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Table of Contents
REVIEW
Year : 2019  |  Volume : 33  |  Issue : 1  |  Page : 6-12

Mental health care in Singapore: Current and future challenges


Department of Psychological Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore

Date of Submission13-Dec-2018
Date of Decision15-Jan-2019
Date of Acceptance16-Jan-2019
Date of Web Publication28-Mar-2019

Correspondence Address:
Ee Heok Kua
Professor of Psychological Medicine, National University of Singapore, 1E Kent Ridge Road, NUHS Tower Block
Singapore
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/TPSY.TPSY_2_19

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  Abstract 


Objectives: Singapore is a city-state of about 5.7 million in population, having multi-ethnicities–Chinese (74.3%), Malays (13.4%), Indians (9.1%), and others (3.2%). In this review, the authors intended to familiarize the readers with the present state of mental health care in Singapore and to discuss the present and future challenges in service provision in handling psychiatric care and promoting mental health for all Singaporeans. Methods: Through published papers and personal experiences, the authors collected descriptive data on mental health-care service research, psychotherapy, training, stigma, and preventive psychiatry from the published papers and books. Information on recent and future developments was from interviews with clinicians and administrators. Results: There is a steady expansion of mental health-care service, training, and research in Singapore. Community and preventive psychiatry is currently emphasized. There are about 115 practicing psychiatrists in Singapore, giving a psychiatrist-to-population ratio of about 2.6/100,000, which is low compared with other developed countries such as the USA (13.7/100,000), the UK (11/100,000), and Australia (14/100,000). Conclusion: The authors suggest that the focus of mental health care should be on the community and on the Agency for Integrated Care to coordinate the plethora of services by hospitals, clinics, day centers, and nongovernmental organizations. We further stress the need of anchoring the service to a mental or general hospital community care or day hospital beside inpatient care in general hospital or institutions. We also recommend gathering community support, proper use of technology in early detection, referral management, and exploiting the benefits of artificial intelligence for mental health promotion in the future.

Keywords: Carers for the elderly, mental health service research, preventive psychiatry, stigma


How to cite this article:
Kua EH, Rathi M. Mental health care in Singapore: Current and future challenges. Taiwan J Psychiatry 2019;33:6-12

How to cite this URL:
Kua EH, Rathi M. Mental health care in Singapore: Current and future challenges. Taiwan J Psychiatry [serial online] 2019 [cited 2019 Oct 15];33:6-12. Available from: http://www.e-tjp.org/text.asp?2019/33/1/6/255141




  Introduction Top


Mental health care in Singapore, like many British colonies in the last century, started in prison and mental asylum. Today, besides the mental hospital (Institute of Mental Health), there are Departments of Psychiatry in all the general hospitals and psychiatric clinics in the community. The health-care system in Singapore has both public and private providers, and many nongovernmental organizations (NGO's) like religious groups have psychiatric day care services and community rehabilitation centers.

Doctors in primary care can manage minor psychiatric disorders such as anxiety and depression but are generally reluctant to treat psychotic patients. In the Singapore National Mental Health Survey[1], the prevalence of depressive disorder in the adult population was estimated at 8% and in elderly people, it was 5%[2]. Depressive disorder is the most common psychiatric problem in primary care practice.

There is a sense of optimism with the development of new services, for example, rehabilitation, child psychiatry, women's mental health, geriatric psychiatry, addiction medicine, and psychotherapy. However, the perennial shortage of mental health professionals and increasing health-care cost will continue to be challenging problems in the future[3].

The island of Singapore is a multi-ethnic city-state of about 5.7 millions–Chinese (74.3%), Malays (13.4%), Indians (9.1%), and others (3.2%). Cultural and religious beliefs often determine illness behavior and health-seeking tendency of people with mental illness. In a study on illness behavior of 100 ethnic Chinese patients referred consecutively to the psychiatric clinic of the National University Hospital, it was found that 36 patients have also a history of consulting traditional healers[4], and that most of the patients are suffering from depression, anxiety, and schizophrenia. In the Chinese community to consult both the traditional healer and the psychiatrist is common.


  Recent Developments in Mental Health Care Top


In recognizing that Singapore has one of the fastest aging populations in Asia and faces increasing demands from work and family life, the Ministry of Health envisioned a holistic approach to mental health. It formulated the National Mental Health Blueprint (NMHBP) in 2006, to promote mental health, build resilience, and reduce the impact of mental illness across the age spectrum. To complement the NMHBP, the Community Mental Health (CMH) Masterplan was introduced in 2012 to expand community-based psychiatric programs and CMH teams (CMHT) to support the shift of institutional care to the community and provide increase accessibility to care.

Programs for the young include:

  • The Response, Early Intervention, and Assessment in Community Mental Health Program has multidisciplinary teams of psychiatrists, clinical psychologists, medical social workers, occupational therapists, and nurses who provide care for school-going children from primary to junior college level and train and support teachers and school counselors. These teams also work with voluntary welfare organizations to support at-risk youth, out-of-school youth, and those from dysfunctional families
  • The early psychosis intervention program provides care for those between 18 and 40 years with a newly diagnosed first-episode psychosis. It has also set up a Support of Wellness Achievement Program for those aged at 16–30 years with at-risk mental states
  • A Community Health Assessment Team reaches out to those aged at 16–30 years before the first episode of mental illness, by raising awareness of youth mental health issues and providing community-based assessments. To support adults with mental illnesses in the community, multidisciplinary CMHT provides home visits and reduce rehospitalizations and length of hospital stays. In addition, there is a helpline and mobile crisis team for crisis intervention when needed. For the elderly, the Community Psychogeriatric Program provides direct care and partners elder care agencies such as day care services, community hospitals, nursing homes, and family physicians to support home-bound elderly with mental health problems such as dementia and their caregivers.


In addition, the extension of mental health services to the community has led to enhanced links with family physicians. The mental health general practitioner (MH-GP) partnership increases GPs competencies in recognizing and providing care for the mentally ill but also right-sites care of those with stable mental health conditions.

For more holistic management of certain high-risk medical and surgical conditions, several mental health teams have been piloted as an integral part of the hospital multidisciplinary teams. Some examples include the women's emotional health service, psychosocial trauma teams, effective mood management after stroke teams, and HIV-psychiatry team.

To support all these initiatives, attention has been paid to workforce development by improving the number of psychiatrists, sponsoring postgraduate training and skills upgrading in mental health care for allied health professionals and nurses, and mental health training for family physicians through a Graduate Diploma in Mental Health offered by the National University of Singapore.


  Mental Health Care Service Research Top


Evaluation of outcome of services is important to ensure mental health care provided is impactful, appropriate, and cost-effective. Health service outcome studies should not be too cumbersome to the service providers or too elaborate that data collection becomes overwhelming. The information collected can assist policymakers to rethink services that can reach out to more people to improve their quality of life. In a community survey, it was found that although the mental health-care services had expanded, many people with psychiatric problems did not seek treatment[5]. As a consequence, many questions have been raised, including stigma, awareness of services, recognizing early symptoms, cost, and literacy. Many people seek help late and this could lead to a poor prognosis. It is equally important to destigmatize mental illness and educate the public on early symptoms and where to seek help.

A study on the prescribing patterns of psychotropic medications[6] has provided valuable information to psychiatrists. This study examined prescribing practices for schizophrenia among 15 countries in Asia using four consecutive surveys conducted from 2001 to 2016. The results were fed back to the psychiatrists to improve their prescribing habits. Antipsychotics were their mainstream treatment, but the first-generation antipsychotics were replaced by the second-generation antipsychotics (SGAs) as the drug of choice along with decreasing use of benzodiazepines and antiparkinsonian drugs. The increasing use of SGAs had also significantly increased metabolic syndrome that was associated with the use of these medications. Compared with the initial study, in the later surveys, monoantipsychotic therapy was common, and the average doses of antipsychotics were comparatively low.

In psychogeriatric service, many patients with early dementia are undetected at the busy primary care clinic. To assist the family doctors, we constructed a 10-item questionnaire, the Elderly Cognitive Assessment Questionnaire, for the detection of cognitive impairment among elderly patients[7]. Some questionnaires, for example, the Mini-Mental state is culturally biased and not appropriate for people with poor education. The ECAG can be administered by a nurse at a busy outpatient clinic and completed in five min.

Many dementia patients are brought to see the specialists only when they have behavioral symptoms such as agitation, insomnia, hallucination, or delusion. We found that the stress level of the family caregivers could be high about 56% of them had the symptoms of anxiety or depression[8]. It is essential in dementia care to look after the needs of the family caregivers with services such as support group, information, and counseling[9].

In a long-term study of schizophrenia in Singapore, the present study confirmed the previous reports that the duration of untreated psychosis is a predictor of outcome in the first-episode schizophrenia, and patients with good outcome had support from their families[10],[11]. In another study at the National University Hospital, we followed up a cohort of first-episode schizophrenia patients[12], and found that no difference exists in outcome for those on typical or atypical antipsychotic medications but those who have sought treatment early or with shorter duration of untreated psychosis (< six months) have the better prognosis.


  Improved Training for Better Mental Health Care Service Top


There is a call for an urgent action to review the clinical training in psychiatry in the editorial, “the future of psychiatry[13].” At a Teachers of Psychiatry (TOP) meeting in Singapore in 2009, Norman Sartorius spoke of “training psychiatrists for the future” and said, “Today's TOP must understand that their plans for the instruction of new graduates must reflect the current state of medicine and society's development and that they must remain sufficiently flexible to follow trends and help future psychiatrists to face and overcome challenges as they emerge[14].” We agree that the future of psychiatry in Singapore would depend on our undergraduate program to inspire medical students to join our ranks.

It is undeniable that the majority of people with mental disorders are not detected; although, they may have been to the health-care service. The under-diagnosis is partly because psychiatry in the undergraduate curriculum and doctors in primary care have difficulties in recognizing the early signs and symptoms. Medical students are often given clinical teaching in the general hospital or mental hospital where cases are of moderate-to-severe degree. However, at primary care practice, the clinical presentations are usually mild, protean, and may not fulfill the criteria of more advanced disorders as stipulated in the diagnostic and statistical manual of the American Psychiatric Association or the international classification of diseases of the World Health Organization. It will be ideal to have the students experience psychiatry at the primary care clinics where they will encounter the early signs of common mental disorders.

Before the 1980s, doctors who wished to specialize in psychiatry headed to the United Kingdom to be trained for the Diploma in Psychological Medicine and later the Membership examination of the Royal College of Psychiatrists (MRCPsych). In the 1970s, the Ministry of Health decided on setting up training programs in Singapore in all medical and surgical disciplines. The specialist training committee for psychiatry was established to oversee psychiatry training in Singapore, and the first trainees were recruited in 1983. The university awarded a master of medicine (Psychiatry) degree, and specialist recognition was by the specialist accreditation board in Singapore. The training program was largely based on requirements of the Royal College of Psychiatrists, the UK. It was initially 3 years and then extended to 5 years. The first 3 years was called basic specialist training, and trainees were expected to complete the master of medicine (psychiatry) examination in year 3. The remaining two years was for advanced specialist training, and the candidates sat for an exit examination consisting of a journal critique, clinical vignette, and a topical case discussion at the end of it.

There are about 115 practicing psychiatrists in Singapore, giving a psychiatrist-to-population ratio of about 2.6/100,000, which is low compared with other developed countries such as the USA (13.7/100,000), the UK (11/100,000), and Australia (14/100,000). To enhance the postgraduate medical training in Singapore, the Ministry of Health decided to introduce the American-style residency program for all medical and surgical disciplines in the 1990s. All hospitals worked to achieve standards and accreditation of the American Accreditation Council for Graduate Medical Education. Psychiatry started its residency training program in 2010. The curriculum for the residency program follows the American Board of Psychiatry and Neurology (ABPN) program and adheres closely to their guidelines, for example, in clinical training rotations, as well as teaching and duty hours. The residency training program is five years, and residents are expected to complete either the MRCPsych or the MMed (Psych) examinations in year 3. They then become senior residents for two more years and sit for an exit examination which has the same format described above and they also need to pass the ABPN consisting of written test with multiple choice questions.

Clinician educators are also encouraged to up-skill themselves in medical education and are now given dedicated time to provide training and supervision for residents. The National University of Singapore offers a certificate in medical education which clinicians keen on progressing in a clinician-educator track can complete; many also complete a masters in medical education with various overseas universities, for example, Dundee and Maastricht.

Academic psychiatry in Singapore is growing with quiet aplomb in its own talent and the quest for capacity building will continue. Interest in academic psychiatry is nurtured during traineeship, and there should be a gradual reformation in the curriculum to put a premium on research training–not only basic neuroscience but also health service evaluation. In 2010, a paper by Tor et al.[15] discussed the issues of training future psychiatrists and the need to nurture a research ethos. Such a quantum leap in training will ignite the curiosity of young psychiatrists to explore new paradigms of psychiatric research in the future.


  Family Caregivers of the Frail Elderly Top


A growing concern exists about caring for an increasing number of the frail elderly in Singapore. This concern is not only because of an increasing number of the elderly but also a diminishing number of carers due to the social transformation of the Singapore family. The first study on families of the frail elderly (stroke, dementia, etc.,) in Singapore showed that 20% of carers have depression and anxiety[16]. Those carers who lacked social support have a greater propensity to develop psychological symptoms. Most of those carers lived alone with elderly relatives and were socially isolated. Many of them are also unaware of the available services for the elderly in their community.

The Memory Clinic in the National University Hospital conducted a study on family carers of dementia patients[9]. The interventions included education, monthly support group meetings, telephone counseling, and home visits. At the end of the six months, there is a reduction of the anxiety and depression scores of carers–the study group showed a greatly reduced stress level. About 60% of the control group requested for an aged home for their elderly relative only 10% in the study group. The control group made more visits to general practitioners to consult about behavioral problems like agitation, but none in the study group.

Caring for an elderly person has a high-economic cost. A cost analysis on direct cost only of dementic patients who attended the Memory Clinic showed that the average expenditure per month for each patient with mild dementia is about US$207, moderate dementia US$924, and severe dementia US$628. Policy makers are increasingly aware that family caregiving is not cost-free. Carers incur numerous expenses, including home modifications, assistive devices, special food, high utility costs, and the cost of foregoing paid employment. However, in Singapore, many retirees do not have pensions; they are financially dependent on their children.

In our experience, family caregivers rely more on family support and less on psychogeriatric services. It could be that within the Asian tradition, problems have to be resolved within the family, and to seek outside help is deemed as “failure” or “losing face.” In future, caring for the frail elderly in Singapore will continue to rest on the family. Carers need to seek help outside the home. Support networks typically have the family as the core, but should also include friends, neighbors, and home helps. Community and governmental supports are necessary to alleviate the burden of the family.


  Psychotherapy: Rethinking a Model Top


Models of psychotherapy reflect the cultural and religious milieu in which they are developed. With globalization, the issue of “cultural intelligence” as described by Earley and Mosakowski[17] in 2004 from the London Business School is crucial as economic expansion crosses the national boundary to other continents with very different cultures and customs. Modern psychiatry grows out of Western Europe and the United States. Most psychiatrists in the east are schooled in western ideas of psychiatric practice.

Besides three (psychodynamic, cognitive-behavioral, and supportive) main therapies, many other models exist to include interpersonal psychotherapy, solution-focused therapy, gestalt therapy, narrative therapy, etc. It is important to know what type of therapy fits what type of clients–what works best for them. Commonalities in the different schools of psychotherapy to predict good outcome are a positive therapy relationship, empathetic therapist, and hopeful patient.

Brief integrative personalized therapy

Brief integrative personalized therapy (BIPT) evolves and transcends established schools of psychotherapy and is an attempt to ascertain what therapy is appropriate for particular patient. The emphasis should be on the centrality of personhood. Understanding the cultural mores is crucial in psychological therapy, and cultural issues are explored with affirmation of cultural values. Treatment is not only symptom relief but also to develop coping strategies for the future building resilience or an undefeated mind. The keywords in this process are learn, growth, and resilience. What BIPT hopes is to achieve is a model of psychological balance[18].

In public hospitals, providing one-hour psychological therapy is a luxury of time. The challenge is how to deliver a service in 15 or 20 minutes and what psychological therapy techniques are appropriate. The rise of academic psychiatry[19] has prompted a need to reexamine how we practice psychological therapy. We should tailor therapy to fit a particular patient and not to provide the same therapy, for example, cognitive-behavioral therapy or psychoanalytic therapy, for every disorder. Can it be more “personalized”?

Psychotherapeutic integration is motivated by a need to view beyond the restricted single-school approach. Integration means intent to increase therapeutic effectiveness by looking beyond a monistic approach. Psychological therapy is often not practiced in isolation, and sometimes there is a need to combine with psychopharmacotherapy to ensure improvement. An outpatient naturalistic study comparing elderly depressed patients on antidepressant medications plus psychotherapy versus psychotherapy showed that 72% of patients on the former regime recover compared to 62% on psychotherapy alone[20]. Medication improves depressive or anxiety symptoms and facilitates psychological therapy. Conversely, psychological therapy improves therapeutic relationship and encourages medication compliance.

With complex clinical problems, a single interventional method may not be possible. In BIPT, a spirit of openness to new ideas exists and not to operate from within one particular theoretical framework. For example, a patient with alcohol dependence will need medications in the detoxification phase of 3–4 weeks to overcome withdrawal symptoms, followed by psychoeducation to help him understand the dangers of excessive drinking, and may be cognitive-behavioral therapy for insomnia. If there was a history of childhood trauma, psychodynamic therapy may be helpful, and the patient also attends group therapy and family therapy. In essence, psychological therapy has to be personalized, and BIPT is a clinical approach to individualize therapy for the person.

There are a large number of persons with “subclinical” mental health problems, and this could lead to reduced productivity, low quality of life, and distress. Providing brief supportive therapy combining with other techniques such as cognitive-behavioral therapy or mindfulness therapy can help alleviate emotional distress. Today, mindfulness therapy is also taught in schools and workplace to help relieve stress; it is gaining interest among the many elderly to help alleviate tension and psychological distress. Compared with psychodynamic therapy, BIPT is more structured, and directive, but not dogmatic. An emphasis also exits on healthy lifestyle; many patients often ask about what food to avoid or consume, “tai-chi” exercise, etc.

It is undeniable that brief therapy and integration are the psychotherapeutic zeitgeist of the 21st century in Asia. Psychological therapy is organic, and it will continue to grow and evolve. BIPT can equip a person to cope with life stressful personal situations and to improve interpersonal relationships.

Peer counseling

Because of a dearth of mental health professionals, we felt it would be appropriate and necessary to train retired teachers, doctors, or nurses as peer counselors for the depressed elderly, especially those with mild depression and no suicidal ideation. The consequences of untreated depression include suffering and despair, increased medical morbidity and use of medical services, inappropriate institutionalization, as well as caregiver burden.

A course to train senior citizens as counselors was introduced. Martha Chiu, a senior clinical psychologist from Stanford University, and I planned the program[21]. Components of the course include lectures on topics such as aging, relationships in old age, etiology and symptomatology of depression, bereavement, cultural issues in illness and therapy, crisis intervention, ethics and techniques of counseling. Skill learning is from demonstration by course leaders, role play, video feedback, and experiential group.

The course emphasizes on the relief of emotional distress using psychological methods and the primacy of communication in the healing or therapeutic relationship. The counseling helps identify and modify cause and consequence of behavior of the elderly person that created distress. Correcting faulty cognition would enhance self-confidence and social competence. The counseling helps explain the condition, clarify methods of improving, or deal with the problem, and provide an opportunity for catharsis.

The three-month short course was organized fortnightly and there were regular feedback and review with 24 trainees. The trainees were volunteers in day centers, and the program helped enhance their skills and self-esteem. We met those trainees regularly to mentor, and to assist them in their patients.

Many senior volunteers help man by the telephone counseling, provided by the Singapore Action Group of Elders, an NGO. This service is one of the factors which has led to a decline of the elderly suicide rate in Singapore[7].


  Combating the Stigma in Singapore Top


As in most countries, the pernicious stigma of mental illness is a major issue. An anti-stigma campaign, “changing hearts and minds,” has been launched and there is cooperation with the mass media with regular columns in the daily papers and air time on the radio and television for mental health programs. Some NGO's like the Singapore Association for Mental Health, have been active in organizing mental health awareness programs for the public[22].

Even with adequate services available, there tends to be a delay in seeking treatment because of the stigma associated with the mental hospital. This will consequently affect treatment adherence, prognosis, employability, and quality of life[23].

The patient will be in dire straits and this may burden the family carers and the community–the economic cost of chronic mental illness on the patient, family, and state can be phenomenal.

The 2007 Lancet series on Global Mental Health documented the scarcity, inequity, and inefficiency of mental health services in many countries[24]. If you read between the lines, you could detect an impassioned cri du coer about the pervasive stigma of mental illness. A paper on the stigma of mental illness in Singapore has been published by the Department of Psychological Medicine, National University Hospital[25]. The seminal study provided evidence-based data on the issues surrounding stigmatization and found that about 47% of schizophrenia patients (n = 48) and 33% of depressed patients (n = 88) feel ashamed of the illness. 40% of the former group and 10% of the latter are rejected for insurance coverage, that among psychiatrists and nurses, about 60% have experienced ridicule by friends, and that 30% are discouraged by their families from pursuing a career in the mental health field.

The diagnosis of mental illness has collateral damage regardless of whether the patient is treated in a mental hospital or general hospital[26]. Psychiatric patients should be accorded the same dignity and compassion many people with physical disabilities such as stroke or cancer have comorbid anxiety and depression which are often not addressed[27],[28]. We speak of asthma with a respectful voice, but mental illness stirs up intense emotion – it is beyond peradventure, the pain of the mind is worse than the pain of the body.

The history of psychiatry in Singapore is germane to the current debate on stigmatization as documented in the recent report[28]. Just like tuberculosis in the past, psychiatric patients in many countries are still sequestered in asylums away from the populace, and mental health professionals who work there are also tainted by the stigma. Certain misconceptions have gained currency, and there is a tendency to associate mental illness with violence and traduce the suffering of those afflicted. The true stories of some patients in Singapore who struggled with mental illness and the stigma which haunted them have been published in a novel, an undefeated mind[29].

It is undeniable that the future of psychiatry as a profession hinges not only on public policies, service demands, and training programs but also the stigma of mental illness which discourages recruitment of doctors and nurses into the specialty[3],[13].

The Age Well Everyday (AWE) program is a new strategy in the destigmatization campaign in Singapore. The program is under the aegis of the National University of Singapore Mind-Science Center and advocates nondrug psychosocial interventions with an emphasis on health education, including mental health. An innovative platform is available to discuss mental health and illness in the community. The AWE program is now introduced to nine community centers around the island[22].


  Preventive Psychiatry Top


Besides expanding mental health-care services, to build preventive strategies is equally important to tackle risk factors and the early detection of cases. The downward trend in the elderly suicide after 1996, has demolished the myth that suicide is not preventable[7]. The government has initiated a national effort to examine and address the problems of the elderly; this effort includes identifying issues related to the needs of the elderly such as housing, health care, and community support. This holistic approach addresses the multi-faceted problems of the elderly, including loneliness, depression, financial, and caregiver issues, to improve the quality of life of the elderly.

We should continue to strengthen the education of the primary care doctors and health-care workers to facilitate early detection. We should also continue training more individuals in the specialized care of the elderly and work toward a multidisciplinary team approach with good continuity of care in the community. More importantly, we should look into preventive psychiatry, which includes identifying at-risk individuals in the community.

With the greying of the population in many countries, a global concern exists about the rising tide of dementia. Drawing from our clinical experience at the National University Hospital Memory Clinic, which started in 1990, we found that the quality of life and life expectancy of dementia patients can be enhanced if chronic illnesses such as diabetes mellitus and hypertension are stabilized, together with lifestyle changes, including diet, exercise, music reminiscence, and art therapy. We do not presume that we can prevent all cases of dementia but if we could reduce the incidence or delay the onset by a modest 10% that will be a great success. It is estimated that every year, there are about 2,500 new cases of dementia in Singapore and if 10% can be prevented that is equivalent to 250 cases – the cost-benefit of care will be tremendous for the family and public health service.

The first study on dementia prevention comprised 110 Chinese Singaporean elderly with mild depressive symptoms and mild impairment of cognition. This was a naturalistic study. Each meeting began with a 20-minute talk on health issues, including stabilizing diabetes mellitus and hypertension with medication, diet, and fall prevention. After the talk, participants were divided into four groups for art activities, tai-chi exercise, mindfulness practice, and music reminiscence – this session lasted 30 min[30],[31]. After the first month, the investigators found that improvement shows in the group on music reminiscence in depression and anxiety scores, that improvement is obvious in all the four modalities by the third month, that 22% of study participants improve in cognition (memory, concentration, and orientation) after a year, and that 24% of them remain stable[31],[32].

There were four randomized controlled trials on mindfulness awareness practice, art activities and music reminiscence, choral singing, as well as horticultural therapy. Besides neuropsychological tests and rating scales for mood, we had biological markers such as brain scans (magnetic resonance imaging), telomere length, oxidative stress tests, immunological studies, and assessment of gut bacteria.

To extend the dementia prevention to other community centers, we have collaborated with a community organization called the People's Association. The training of volunteers started two years ago at the National University Hospital over five weekends. The AWE program has three components, namely, health education, mindful awareness practice, and exercise. Music reminiscence and art activities are included in the health education section for cognitive stimulation. There is cogent evidence that psychosocial interventions can benefit the mental health of elderly people. A collateral benefit of the study was the improvement in their social connectedness.

The Mind-Science Center at the National University of Singapore started in 2017 and aims to conduct research to enhance cognitive performance of people across the lifespan, prevent cognitive impairment in the elderly and develop psychosocial (nondrug) interventions that promote resilient living and active aging. The seeds of independent and successful adult life are laid down in adolescence, and to create opportunities for youths is necessary to maximize their potential and enhance their contributions to society. Understanding and developing resilience in the aging population are also a vital research agenda for human resource and national development – the concept is an active mind in a healthy body. The Mind-Science Center is a platform for not only preventive psychiatry but also destigmatization of mental illness[22].


  Future Mental Healthcare Services Top


The focus of mental healthcare should be in the community, and there is an effort by the Government's Agency for Integrated Care to coordinate the plethora of services by hospitals, clinics, day centers, and NGOs. Anchoring the service to a mental or general hospital may invariably lead to institutionalization, sluggish bureaucracy, and dislocation of family contacts–there will be the inevitable stigma of a mental institution and anxiety of abandonment.

A day hospital in the community can be the nucleus of future mental health-care service with psychiatrists, nurses, psychologists, and other mental health therapists working as a team–this will facilitate referral and save cost. Being in the community and near the people will encourage referrals from primary care doctors. With referrals from the general hospital, the day hospital can provide step-down care program, and this will reduce the burden of bed shortage in many acute hospitals.

Galvanizing community support is critical to ensure the success of the mental health-care service. However, there is a woeful shortage of mental health professionals; it may be necessary to encourage voluntarism among students, working people, and retirees, who can be trained to provide emotional support and to assist some of the community mental health-care activities.

The potential of technology in the early detection, referral and management should be emphasized. We can have e-counseling to provide support for many patients and their caregivers. There are now apps to monitor mood and teach relaxation techniques. Exploiting the benefits of artificial intelligence for mental health promotion will be crucial in the future.


  Conclusion Top


The challenges in providing mental healthcare in the future are not only setting up more community services but also combating the stigma of mental illness. The national effort to lower suicide and attempted suicide rates should continue. Curricular adjustment in the medical course to emphasize on primary care psychiatry is essential.

Health service outcome studies should be introduced in mental healthcare to ensure good quality of care for patients to prevent deterioration into chronicity. The Mind-Science Center is a new paradigm in preventive psychiatry to nurture mental resilience.


  Financial Support and Sponsorship Top


Nil.


  Conflicts of Interest Top


There are no conflicts of interest.



 
  References Top

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   Abstract
  Introduction
   Recent Developme...
   Mental Health Ca...
   Improved Trainin...
   Family Caregiver...
   Psychotherapy: R...
   Combating the St...
   Preventive Psych...
   Future Mental He...
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   Financial Suppor...
   Conflicts of Int...
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