|Year : 2021 | Volume
| Issue : 4 | Page : 160-165
Positive psychiatry: A dementia and depression prevention program in Singapore
Ee Heok Kua
Department of Psychological Medicine, National University of Singapore, Singapore
|Date of Submission||28-Aug-2021|
|Date of Decision||02-Oct-2021|
|Date of Acceptance||03-Oct-2021|
|Date of Web Publication||21-Dec-2021|
M.B.B.S., M.D Ee Heok Kua
NUHS Tower Block, 1E Kent Ridge Road, 119228
Source of Support: None, Conflict of Interest: None
Background: There is a dearth of data on positive psychiatry. There should be a greater emphasis on this aspect of mental health in all countries. The emphasis is not just on treatment but more importantly prevention. Positive psychiatry should involve the wide spectrum of mental health professionals including psychiatrists, nurses, psychologists, counselors, art and music therapists, as well as and the public. Methods: In this review, the author summarizes the Age Well Everyday (AWE) program on dementia and depression prevention for seniors conducted by the Mind Science Center, National University of Singapore. The program which started 10 years ago, is supported by volunteers in the community with funding from philanthropists. Results: Interventional strategies in the AWE program include health education, diet, exercise, art therapy, music reminiscence, gardening, and mindfulness practice. Randomized controlled trials have been conducted for all the interventional strategies, and the results are presented. This multi-modal program is a community endeavor and is now adopted by many community centers in Singapore. Conclusion: The AWE program is a nondrug and inexpensive program that can be adapted for other countries. It reflects positive psychiatry and a relevant strategy for the anti-stigma campaign in Singapore. The challenge ahead is translating research results into public health policies.
Keywords: aging, psychosocial intervention, the Age Well Everyday program, the Jurong Aging Study
|How to cite this article:|
Kua EH. Positive psychiatry: A dementia and depression prevention program in Singapore. Taiwan J Psychiatry 2021;35:160-5
| Introduction|| |
In recent years, much discussion exists about positive psychiatry , but research data are meager. This important concept is not just for mental health professionals but also health care policy-makers who plan and allocate funds for services. Mental health professionals including psychiatrists, nurses, psychologists, social workers and other therapists, work downstream care for patients. What is equally important is upstream work to prevent mental health problems in the community. But a lack of emphasis exists on positive psychiatry in most countries worldwide. To consider public policy on mental health is timely, from a preventive perspective to avert the high cost of care in the community.
An emphasis on positive psychiatry also conveys a message of hope to the community and this is of utmost importance, especially in any national campaign against the stigma of mental illness. Psychiatry is often portrayed in the popular media in negative light and the sense of pessimism reinforces the stigma. Research on positive psychiatry can help to de-stigmatize mental illness.
In this review, I cover a model of positive psychiatry for depression and dementia prevention conducted by the Mind Science Center, National University of Singapore (NUS), in Singapore. We are cognizant that translating any model into the larger community means scalability and sustainability. With minimal support, the success of the Age Well Everyday (AWE) program hinges on volunteerism and philanthropy. This model can certainly be adopted by mental health professionals in many other countries. Governmental support to finance mental health programs in most countries around the world is often inadequate and mental health professionals will have to depend on philanthropy and volunteerism.
Our research interest in dementia started 35 years ago in 1986 when the Department of Psychological Medicine of the NUS was invited to join the World Health Organization (WHO) team for the global study of dementia – this team was led by John Copeland from the United Kingdom. The research at Chinatown in Singapore has shown a prevalence of 2.5% for dementia and 5.7% for depression . A memory clinic was organized at the National University Hospital in 1990, and the health professionals included a psychiatrist, geriatric physician, psychologist, nurse, and neurologist . We have massive data from the memory clinic on the clinical aspects of dementia and outcome of management.
The WHO study and experience from the memory clinic gave us insight into the risk factors of dementia and depression . Other studies existed to give evidence supporting the rôle of vascular and related disorders as risk factors of dementia  and the possible rôle of psychosocial factors  including nutrition ,,, as protective factors. The studies also report the association between diabetes mellitus or hypertension and depression ,,.
Fifteen years ago, in 2006, the idea of dementia and depression prevention in the community was discussed in a meeting with two family physicians Goh Lee Gan and Phibert Chin) and a health care administrator (Ling Sing Lin) in the Department of Psychological Medicine, NUS. This meeting was the impetus which spurred the Jurong Aging Study (JAS), the first research on dementia prevention in Asia.
| The Jurong Aging Study in Singapore|| |
Jurong is an industrial estate on the west side of the island of Singapore. In March 2013, a community mental health program for seniors (60 years or more) was launched with the participation of staff from the Presbyterian Community Services and volunteers. The research base at the Training and Research Academy (TaRA) is in a busy shopping mall called Jurong Point. The finance to build TaRA and the small research team was from a generous donation by the philanthropist, Lee Soon Teck, and the Kwan Yin Hood Cho Temple.
The first phase of the study
The JAS was a project to ascertain whether psycho-social intervention through group activities including health education (HE) and lifestyle can prevent the onset of dementia and depression ,. A cohort of 1,000 seniors living around Jurong Point mall was followed up for five years. Every senior received a physical, mental and social assessment, including blood examination and neuropsychological tests – magnetic resonance imaging (MRI) brain scan was done for those with mild cognitive impairment (MCI)  or dementia .
The study was started with a naturalistic study which comprised 110 ethnic Chinese elderly with subsyndromal depression . All of them attended group meetings once a week for a month and then fortnightly for two more months. Each meeting began with a 20-min talk in Chinese on health issues, including stabilizing diabetes mellitus and hypertension with medications, diet as well as exercise. After the talk, they were divided into four groups for art therapy, tai-chi exercise, mindfulness practice, and music-reminiscence therapy. The four groups were assessed at the beginning, after a month, and at the end of the third month. The scores for depression on the Self-rating Zung Depression Scale  showed remarkable improvement in mood after three months. No remarkable difference existed between the different modalities of therapy . The result was encouraging because it showed that psycho-social therapy improves the mood of seniors and the group approach is acceptable to them. More importantly, they have enjoyed the art therapy, music-reminiscence, and mindfulness practice.
The second phase of the study
In the second phase of the JAS, we did four randomized controlled trials (RTCs) on mindful awareness practice (MAP), HE, art therapy, music-reminiscence, horticultural therapy, and choral singing (CS). Besides neuropsychological tests and rating scales for mood, we also studied biological markers such as brain MRI scanning, telomere length, immunological studies, and assessment of gut bacteria. The followings are major findings:
Mindful awareness practice and health education
Mindfulness meditation is widely practiced and integrated into treatment for many psychological disorders. In Singapore, a well-trained practitioner, Wee Sin Tho, taught a new approach called MAP ,. With a RCT, we compared emotional state through the intervention between MAP and HE, and found that seniors' emotional state of both groups is improved, and that both interventional arms are not different in outcome .
On the MRI brain scan, we found activation in neural activity which is corresponded with improved cognitive functions as assessed on the neuropsychological tests for both MAP and HE . But those who practiced MAP have better brain network efficiency and cortical thickness changes .
Investigating inflammatory biomarkers, MAP showed improvement in levels in seniors with MCI . MAP participants have been found to have decreased high-sensitivity C-reactive protein levels at nine months. The study on gut bacteria showed that cognitive improvement with MAP is associated with changes in gut bacterial profile . The change in telomere lengths in MAP and HE is also quite remarkable, but no difference exists between the two interventional modalities .
Those study results indicate that MAP can remediate cognitive impairment and engender neuroplastic effects delaying cognitive decline. It is also important that MAP is practiced daily or weekly and not monthly.
Music reminiscence and art therapy
Music reminiscence entails listening to popular old songs and discussion of past events and experiences with a therapist in a group. All participants were given ample opportunity for interaction and reflection. Art therapy includes two segments, the creation of an art piece and the subsequent sharing of inner experiences and thoughts. The groups were conducted by qualified instructors and participants in art therapy also visited the National Art Gallery and the NUS Art Museum.
A RCT evaluating the impact of art therapy versus music reminiscence showed improvement in mood and cognition for both groups. But art therapy showed a more remarkable improvement in memory domains compared to music reminiscence ,. Art therapy can engender cortical changes even when executed as a low-intensity intervention over three months . It must be emphasized that the seniors enjoyed both the music reminiscence and art therapy.
CS is common and popular community social activity around the world. The idea of a scientific study with brain imaging was mooted by Maurine Tsakok, a former professor of obstetrics and gynecology. The effects of CS on cognition were studied in a RCT comparing a group of 47 seniors with MCI and another 46 ones with MCI assigned to HE. It was conducted over two years and participants attended one hour weekly CS and HE. The cognitive score for those in the CS group improved more than that in the HE group. But no difference exists between the two groups comparing biomarkers of MRI brain scan and immunosenescence. The results support the rôle of CS in improving cognitive health in aging .
In collaboration with the National Parks, the team conducted a RCT to investigate the efficacy of horticultural therapy or gardening to improve the mental health of another subsample of seniors. A total of 70 participants were divided into two groups – treatment (horticultural therapy) and control (on waiting list). After three months, the seniors in the horticultural therapy (HT) group do better than the control group in the scores for life satisfaction, memory and psychological well-being, but the difference is not remarkable. The remarkable finding is for positive relation, meaning social connectedness and trusting relationships ,. An interesting finding of relevance in preventive medicine is the enhancement of body immunity with lowering of pro-inflammatory proteins ,,.
The JAS five-year follow-up study [Table 1] was presented at the 2020 World Congress of Psychiatry, held in Bangkok, Thailand. In the original cohort, we had 1,000 senior participants. The prevalence of depression was 7.33%, anxiety 1.58%, and dementia 1.88%. After five years with the psychosocial interventions, we could only trace and re-assess 644 subjects. Of the remaining 373, there were 36 who were still working and declined an interview, 14 passed away, 110 migrated or shifted home, 26 were too physically ill with cancer or stroke and declined assessment, and 170 refused the second interview. On re-assessment of the 644 seniors, the prevalence of depression is 4.47%, anxiety 0.96% and dementia 2.87% [Table 1]. The rates for depression and anxiety have improved, but the rate for dementia is increased slightly. Without the interventions, the prevalence of depression, anxiety and dementia would be higher - especially that for dementia which would increase as the cohort got aged. We observed that the seniors began to bond and because of an increase in social connectedness they feel less isolated.
|Table 1: Prevalence of mental disorders in the study senior participants in the Jurong Aging Study (N = 644)|
Click here to view
The results of the JAS were discussed in the local newspapers and public seminars attracting interest among seniors in Singapore. It has now expanded to more community centers in Singapore as the AWE program.
| The Age Well Everyday Program in Singapore|| |
The AWE program [Table 2] exemplifies the ecology of resilience – a community helping enhance the resilience of seniors through voluntarism and philanthropy in Singapore. The tagline of the AWE program is “preventive medicine of the community by the community for the community” . It is a structured and evidence-based program with measurable outcome. The aims are to promote seniors' mental health and keep their depression and dementia at bay.
To expand the program to other community centers we are fortunate to collaborate with the People's Association, which manages over 80 community centers in Singapore. There are now eight community centers with the AWE program and more are coming on board. The training of volunteers started five years ago at the National University Hospital over five weekends. The AWE program has three components: HE, MAP, and exercise. Music-reminiscence and art activities are included in the HE section for cognitive stimulation [Table 2]. Three centers have introduced HT or gardening with assistance from the National Parks. The program is conducted by volunteers from the community and staff from Yong Loo Lin School of Medicine, NUS. The funds to finance the AWE program are predominantly from public donations.
As in the JAS, a collateral benefit of the program is the enhancement of social connectedness. We observe that seniors in the program have made new friends in their neighborhood and the young old (65–74 years) are assisting the old-old (75 years or older) who are frail. A sense of compassion has emanated in them – something we did not anticipate.
A future challenge of this community-led preventative health-care program is to ensure sustainability. We have teamed up with our strategic partners, Singapore University of Social Science and Stroke Support Station, to introduce an e-portal for training volunteers. We have trained over 200 volunteers who will have a crucial rôle in the community centres near their homes. Many of these volunteers are retired teachers, doctors, nurses, home-makers, etc.
It is heartening to note that interest in dementia prevention and the AWE program has been generated in Asia from our research publications and lectures in Association of Southeast Asian Nations (ASEAN), Japan and China. The AWE program was presented at the Congresses of World Congress of Psychiatry in Mexico City, Mexico in 2018 and Bangkok, Thailand in 2020.
| Nature and Mindful Awareness Study|| |
As a consequence of the successful research outcome of the therapeutic horticulture project in the JAS, a Therapeutic Garden was established in HortPark - there are plans to build eight more Therapeutic Gardens around the island. Recently the vision of a City in Nature as articulated by the government has stirred interest in the green environment. Green urbanism is a vital aspect of a resilient and liveable city ,. Singapore is blessed with verdant parks, and biophilia is a source of positive feelings contributing to a better quality of life. Parks and forests enliven us. People in Singapore promote not just their health, but also social interaction among themselves and help create a sense of community.
The Nature and Mindful Awareness Study (NaMAS) was a qualitative study with 20 participants - 12 men and 8 women (mean age of 65.5 years). The participants (mainly retired doctors, senior civil servants, bankers, etc.) walked mindfully together for 10 consecutive Saturday mornings in the rainforest of the Singapore Botanical Gardens. At the end of the study, two thirds of the group had slight or good improvement of their common physical health problems such as backache and arthritis. The post-walk chat on diet and medications benefited all of them in controlling or preventing onset of diabetes and hypertension. Mental health assessment in the beginning of the study with a modified General Health Questionnaire, showed the majority scored 1–2 points (80%) with minor sleep difficulty and anxiety - only one scored 3 points and improved on assessment at the 10th week. They experienced better social health and helped build the group cohesiveness which was the foundation of the success of NaMAS. The group culture fostered a sense of belonging, acceptance, and positivity. After 10 weeks of mindful walking together, there was bonding within the group – members became more supportive and caring of each other. With social connectedness, a sense of compassion and empathy emanated among them .
NaMAS has shown that mindful walking in the park and rainforest is good for physical, mental, and social health. A spontaneous interest in nature, especially the rainforest has grown within the group. They are attracted to the flora and fauna of the Singapore Botanical Gardens, including trees, birds, and insects. It had also stirred a sense of altruism and this is most obvious during the COVID-19 pandemic when a genuine concern exists for each other. The study has a collateral benefit – an interest in the rainforest among the participants and the need to protect it for the future of humanity. There are plans to introduce the NaMAS program to more people, especially those in the other AWE community groups and schools in Singapore.
| Community Health and Intergenerational Study|| |
A common theme raised during our discussion with seniors in the AWE program is the care of the frail elderly. Most of them prefer to live in their own homes and not in geriatric homes or institutions. “Aging-in-place” is now in the national conversation and agenda. We have started a new research at the Hannah Day Center near the NUS to study the concept of aging-in-place in a public housing estate with intergenerational bonding and community support.
Conventionally, Asian culture has a collectivistic orientation and a core component of collectivistic ideology is a strong concern for one's kin and the expectation of supporting one another. This was the ethos when the early immigrants came to Singapore from China, India, or Indonesia. Social engagement and support are important factors that contribute toward multiple health outcomes - family much support being a critical component of the social network. Targeted interventions can also be delivered to selected groups of individuals in a study design that is fast gaining popularity – the cohort multiple RCT (cmRCT) as shown in the JAS.
In the Community Health and Intergenerational (CHI) study, about 1,000 seniors and their families living in the vicinity of the Hannah Day Center were surveyed through inviting to participate in this cohort study. Evaluations included cognition, psychological well-being, physical health, frailty, social identity and connectedness, attitudes to aging, and health behaviors (lifestyle and dietary habits). Selected neuroimaging and biomarkers will be performed for individuals found to be in the at risk groups (pre-frail, MCI). Intergenerational influences would be evaluated and environmental influences (urban environment and liveability) will be assessed.
The CHI study is an ambitious multidisciplinary research program including specialists from psychiatry, cardiology, dentistry, orthopedics, ENT, nursing, statistics, genetics, ophthalmology, nutrition, traditional Chinese medicine, immunology, radiology, public health, epidemiology, pharmacology, family medicine, anthropology, sociology, psychology, and architecture.
The aging-in-place theme will explore family interaction to enhance bonding and community support from volunteerism. This research is still in progress. A family bonding study is headed a statistician Wilson Tam and a volunteer by psychiatrist Johnson Fam. There is also a program for seniors to train them to provide basic counseling in a project called “Where there is no psychiatrist.” This program is led by a nurse Shefaly Shorey. The studies are delayed unfortunately because of the COVID-19 pandemic.
| Conclusion|| |
There should be a paradigm shift in planning mental health policy to focus on not just the provision of services for treatment, but more importantly on prevention or positive psychiatry. The AWE program is a nondrug approach with community support. If inexpensive psychosocial activities can be implemented, the cost-saving in future years will be enormous not only for the family but also the health authority.
With the graying of the population in many countries, a global concern exists about the rising tide of dementia. We do not presume that we can prevent all dementias. But if we can reduce the incidence or delay the onset that will be a marvelous success. Every year in Singapore, about 2,500 new persons with dementia have been estimated, and if 5% can be prevented that is equivalent to 125 persons.
The psychosocial intervention in the AWE program has a positive effect on the rates of depression, anxiety, and dementia after five years. Using culturally appropriate and locally relevant activities have contributed to the program acceptability among the seniors. In progress is a study on Chinese brush painting helmed by psychiatrist Chee Tji Tjian and a study on dancing by a nurse Vivien Wu.
Because of the change in the family structure, more Asian elderly people will be living alone in future. Building social support system in the community to enhance social connectedness is critical.
Now a project has been introduced to use smartphone for seniors in the community to help prevent a sense of loneliness especially for many living isolated lives in the city. The “new old” and aging baby-boomers today are more familiar with smartphone, and this can be exploited in future research for the prevention of mental health problems.
In the Singapore context, the AWE program has a rôle in nation building in encouraging seniors of different ethnicities to meet and interact. During British colonial administration the island was sectored according to ethnicity by the divide-and-rule strategy. Hence there are Chinatown, Malay Village and Little India in Singapore. Geographical division of the ethnic groups is encouraged to have suspicion and animosity among them. In the AWE program, the community centers are led by volunteers who may be an Indian, Chinese or Malay. There is social interaction among them and they learn the rich cultures of other people in this cosmopolitan island. Enhancing social cohesion is important to ensure harmony in a multi-ethnic community.
Positive psychiatry is gaining momentum in many countries. In Singapore, the Mind Science Centre of the NUS is embarking on other innovative programs for youth mental health. One such program is the introduction of NaMAS to school children, university students and working adults. Impactful programs in the community will also elevate public perception of mental health and help eliminate the stigma – this in essence is positive psychiatry.
| Acknowledgments|| |
I thank all our donors and volunteers from the NUS, People's Association, National Parks Board, Presbyterian Community Services and Singapore Action Group of Elders (SAGE) Counseling Center. I also thank Wee Sin Tho and Gek Hua, Rathi Mahendran, John Wong, Feng Lei, Ng Kheng Siang, Yu Junhong, Goh Lee Gan, Lau Tang Ching, Jonathan Wong, Wong Lit Soon, Jiang Minjun, and Fadzillah Nur Mohamed Abdullah for their contributions.
| Financial Support and Sponsorship|| |
The Jurong Aging Study in Singapore (JASS) was funded by Lee Kim Tah Pte Ltd., Lee Soon Teck, Kwan Im Thong Hood Cho Temple, Buddhist Library, and Alice Lim Memorial Fund.
| Conflicts of Interest|| |
Ee Heok Kua, an international advisory board member at Taiwan Journal of Psychiatry, had no rôle in the peer review process or decision to publish this article.
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[Table 1], [Table 2]