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|(left) Ms Porsche Poh, Executive Director, Silver Ribbon (Singapore); Ms Ellen Lee, MP for Sembawang GRC; Mr Khaw Boon Wan, Minister for Health; Ms Angelin Pereira, Project Executive, Silver Ribbon (Singapore) and Ms Adeline Chow, Project Executive, Silver Ribbon (Singapore)
Enclosed herewith some comments on mental health issues made by Mr Khaw Boon Wan, Minister for Health, on his blog. For other issues, please visit http://mohsingapore.blogspot.com.
1 FEBRUARY 2011
Healthcare 2011: From Isolation to Integration
I have blogged about the need for mindset change as we pursue a home-centric, patient-centric and wellness-centric approach to healthcare. Much of this mindset change has to come from ourselves who are healthcare providers.
Yet another mindset change which must come from the society at large is our attitude towards a minority in our community who need help integrating into society. Despite public education efforts, stigma still exists in our community. This prejudice against those with certain conditions can lead to discrimination when people are treated less well because of who they are or the condition they have.
I have in mind HIV and mental illness
In the case of HIV, stigma has long been a part of the worldwide epidemic. First, people have a fear of HIV itself, so they shun those living with HIV because of a misplaced fear that they will contract HIV just by being near them.
Second, HIV is often associated with promiscuous sex, gays or drug use, so people make moral judgements about those who are infected with HIV.
The truth is HIV cannot be transmitted by casual contact such as hugging or shaking hands, or by being in close proximity with someone living with HIV. It is not spread through sharing food and drinks. There is no need to fear getting HIV from someone with whom you have casual contact with, whether it be in a home, a school or a workplace. It is also important to remember that HIV does not affect only certain groups of people. It can potentially affect anyone who does not adopt preventive measures.
While we may have deep-seated personal beliefs, we should try to remember that HIV is an infection and people who are infected should be cared for like anyone else living with a chronic illness. We should not continue to perpetuate the notion that it is a "punishment" or "what they deserved".
Why is this important? Because the stigma associated with HIV has been a global obstacle to helping individuals to access HIV testing, treatment and care. Many individuals fear that if they are found to be HIV-positive, they will be abandoned by families, friends, and colleagues. They fear that they will lose their jobs.
This fear of their HIV status being known means that people delay or refuse HIV testing. As a result, they are often diagnosed late, when they have already progressed to a late stage in the infection. This not only compromises their health outcomes, but also means that they may have unknowingly passed on HIV to their sexual partners during the time they were unaware of their own infection.
People living with HIV can and do want to continue working and contributing to society. It is thus important for us to help them remain an integrated part of our community.
We also need to tackle the stigma and myths surrounding mental illness. Like HIV patients, these patients too should be integrated into our community. For instance, depression is not "mad" but "sad", and that means many of us are exposed to the risk of depression.
A growing public health concern, depression has the effect of wearing down the individual’s ability to function and lead a productive, happy life. HPB has been conducting many public education campaigns to promote positive mental health with the aim of building the people’s resistance against mental illness such as depression.
We will further intensify our efforts to break down barriers and encourage help seeking to increase chances of recovering for a treatable disease.
We must change our mindset, from one of "isolating" the ill, to embracing the difference our support can make to those who are unfortunately preyed on by mental illness. For those who are rehabilitating from the illness, a community that is open to integrating them is one which helps them get back on their feet again - whether it is back to school or back to work.
VWOs like Silver Ribbon Singapore, Lejia Society and SOKA Association have led the way with their outreach activities to the community, sharing of successful rehabilitation stories and in engagement of the public. We need more community support.
While we can build more services for the mentally ill, the more difficult and fundamental reform necessary is for society to be more understanding and accepting about mental illness. This requires a mindset change from all Singaporeans.
The journey to recovery for someone who is ill is best travelled with a great dose of understanding, compassion and support from all of us.
28 DECEMBER 2009
Healthcare 2010: State of Mind
More than 172 comments have been posted on Healthcare 2010. Over several weeks, we have discussed many health policy issues, from prevention, to integrated care, to software issues. I thank you all for your ideas.
This week, let’s focus our discussion on mental health, a topic of priority mentioned by many of you. Mental health is indeed a priority for MOH. A large scale, nation-wide survey on Singaporeans’ mental health by IMH specialists is currently underway.
This is not the first time we are conducting such a survey, though this time round the survey is larger in scale and wider in scope. We will try to determine objectively the state of mental health here and gaps in service provision. The findings should help us formulate better policies and programmes.
Mental health is a complex global problem. No country has a perfect system; everyone is learning from one another and sharing valuable experiences.
On the ground, we know that the problem is growing. We come across more cases of those suffering from mental illnesses, and the impact the illness has on family members, caregivers, and sometimes even neighbours.
Mental illness covers a wide range of illnesses and is not all about schizophrenia or depression. Most are mild and reversible with suitable medical intervention. Unfortunately, stigma against mental illness has discouraged some from coming forward until the illness has become severe and harder to treat. HIV patients face the same sort of stigma and problems.
We need to change society’s attitude towards the mentally ill. As Antoinette Soh and Porsche Poh pointed out, mental illness should be seen as a disease just like diabetes or high blood pressure, with patients encouraged to seek help early rather than worry about the stigma associated with the illness. For the mildly mentally ill, they can, with medical support, live quite normal lives, working and bringing up children. Without society’s support, for instance by a willing and understanding employer or supportive schooling environments, they face hardships which often make medical recovery even more difficult. Just last week, a mother of a child with some mental illness emailed me about her difficulty with the teachers in her child’s school. She sought my help to transfer her kid to a more supportive school.
Mental illness is also about addictions: alcohol, drugs, chemicals, computer games, gambling, etc (even Tiger Woods’ addiction problem?) Modern lifestyles will continue to throw up such medical challenges, imposing new medical burdens. I don’t see this problem subsiding.
Dementia is another mental illness that will only grow as more Singaporeans age. I have been visiting some of these elderly dementia patients at their homes and observing how they are being cared for by home nurses and IMH community psychiatric teams. Where good and adequate care is available, both patients and family members can get on with life normally. Where care is not available, each day is a challenge, worsening the patient’s medical condition.
On the other hand, the problem of a poorly adjusted mentally ill patient is sometimes a source of neighbourly disputes. We occasionally come across such cases at MPS. Media reports on the recent "killer litter" case at Seng Kang suggest the offender may be mentally ill. Whether this is true or not, such cases will surely cause society to further stigmatise sufferers of mental illness.
The affected neighbours plead with the Government to lock up such patients. But is this the right solution? Some institutionalisation is inevitable for those with severe risks of violence and who pose a danger to themselves and others around them. But many cases are mild and with suitable community support and medical advice, can live normal lives in the community. Locking up such cases will prevent them from recovering.
We have been addressing these issues earnestly in recent years. MOH’s Permanent Secretary chairs an ongoing high level, inter-agency committee on mental health. In 2007, they formulated a Mental Health Blueprint to close some of the gaps. We backed up the Blueprint with $88 million of new funding. More recently, we raised their budget further, by another $35 million, to scale up several successful pilot projects.
We know that we are still far from perfection but we are determined to enhance the system where feasible. Several projects proposed in the Blueprint will be expanded next year, to benefit more patients. An important emphasis is on scaling up community mental health services, including home visits where it is practical to do so.
We know this is a marathon, where success and progress will be measured by new milestones crossed, knowing that the goal post is still further ahead. But we know we are going in the right direction.
To quicken the pace, we need to rope in more GPs to help look after their patients who have stabilised. We also need more skilled healthcare professionals with passion about this cause. Not just more psychiatrists (as we will never have enough), but also more allied health professionals, including Advanced Practice Nurses, psychologists, counsellors, even art therapists (as I discovered during my recent visit to LASALLE).
We will also have to refine the funding model. Currently, most of the patients are heavily subsidised and access to care is available to all. Medisave has now been extended to cover the outpatient treatment of the two most common mental illnesses: schizophrenia and severe depression. MP Halimah has been calling for the extension of MediShield to cover mental illness. I am sympathetic to her call but will have to wait for the economy to recover fully as extended coverage will necessitate premium adjustments.
Equally important is the "prevention" approach that we discussed in detail three weeks ago. This means greater awareness of mental illness, early detection of its symptoms, and learning to cope with mental stresses. For the seniors, mental and physical wellness requires an active social life and healthy lifestyle of community engagement. Minister Lim Boon Heng is leading the crusade to get all seniors to come out of their apartments, make friends, socialise and engage in meaningful social and physical activities. Such "active ageing" is most important.
Before I end this blog, let me highlight two IMH programmes that we intend to scale up next year:
First, the Aged Psychiatry Community Assessment and Treatment Service (APCATS) ensures that homebound elderly with mental illness receive proper care at home or in step-down facilities like nursing homes. I recently accompanied the IMH team on its round of APCATS home visits and came away impressed.
Second, Community Mental Health Teams serve mentally stable outpatients of IMH. The focus is on empowering these patients to live at home, even as they continue with their medications and treatment. In the event of a crisis, families and caregivers have quick access to a counselor via a dedicated, 24-hour helpline. For serious cases, IMH dispatches a team to the home and if necessary, ferries the patient to IMH for readmission. This service has helped reduce the number of Emergency Department visits and hospitalisations for some of the patients. By the way, the IMH Helpline is a public line - anyone facing a mental health crisis may call the helpline for immediate assistance and advice by qualified counselors.
As we think through these problems, we will pilot other ideas and scale up those which work. For the next few days, do share with us your views or observations on this important subject. I thank you in advance.
Finally, let me wish all a Happy New Year. May 2010 be a year of peace, prosperity and happiness for all.