Types and Relapse Rates of Mental Illnesses amongst Singaporeans

Based on national surveys conducted and Institute of Mental Health (IMH)'s data, the top three mental conditions affecting Singaporeans are dementia, depression and anxiety.

For dementia, relapse episodes cannot be easily determined as the condition will progressively worsen over time. For depression and anxiety, patients experience a relapse when they suffer an increase in the intensity of the illness affecting their daily routine. However, for patients whose daily functions are constantly affected by the severity of the illness, the "relapse" will be less identifiable.

Nevertheless, studies have shown that at least 50% of those who recover from a first episode of depression will have one or more additional episodes in their lifetime. For anxiety disorders, it was shown that the relapse rate for generalised anxiety disorder was about 27% over a three-year period.

Our mental health clinics routinely monitor "no-show" at outpatient attendances especially for high risk groups to ensure that our patients are reviewed regularly and any sign

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of early relapse can be managed in a timely manner.

Detecting signs of relapse early may enable intervention to prevent a full relapse or reduce its severity when it occurs. As family, friends and neighbours are closest to those with mental conditions, they are in the best position to detect warning signs, for instance, change in behaviour, disordered thinking or missing appointments that indicate a potential relapse. In this respect, IMH and the Agency of Integrated Care (AIC) have been working with grassroots organisations and their volunteers to: (a) increase mental health knowledge and skills so that they are able to recognise early signs; and (b) link residents who are displaying warning signs to appropriate mental health, general health or social services. As at the end of fiscal year 2013, AIC has engaged 12 constituencies, trained over 300 grassroots leaders and volunteers and assisted 190 residents.

Four community support teams led by Voluntary Welfare Organisations (VWOs) have also been set up through AIC to conduct home visits for clients identified by community partners, such as Family Service Centres (FSCs), Senior Activity Centres (SACs) and Town Councils, who may require more thorough assessments.

Additionally, AIC has worked with various VWOs to set up seven community engagement and support teams within SACs to identify elderly who may suffer from dementia or depression. These teams facilitate early recognition and provide basic emotional support to clients and caregivers. The seven teams have reached out to over 21,000 clients as at the end of fiscal year 2013. For those who require more intervention, for example clinical care, psychotherapy, these support teams will then refer the patients to the specialist-led or allied health-led multidisciplinary teams in the community based on their needs.

I thank the Senior Minister of State for the reply. I have three supplementary questions. First, given that non-compliance is very common in patients with mental illness and chances of relapse are high, what is being done and can be done to ensure that discharged patients stick to their routine drugs? Next, what is the current psychiatrist-to-population ratio today and are we able to cope with the number of people suffering from mental disorders? Lastly, what can the Ministry do to promote more providers of community-based mental health services and make them more accessible to better support people with mental disorders, so that they can be better supported and re-integrate into society?

Thank you. For the first question about non-compliance and how do we try and ensure compliance by discharged patients, as I had noted in my reply earlier, our mental health clinics routinely monitor these "no show" patients or our outpatient attendances, especially for the high-risk groups to ensure that our patients are reviewed regularly and any sign of early relapse can be managed in a timely manner. For these "no show" cases, the case managers will follow up with phone calls to check if the patients are well, to fix the next appointment where possible and to do brief assessment over the phone to understand why the patients are not showing up. If they still remain uncontactable, the case managers could conduct home visits.

In addition, IMH is enhancing its capability to track over 11,000 patients discharged with two diagnosis – schizophrenia and delusional disorder which carry higher risk of default and disturbed behaviour; and another 1,000 selected outpatients tagged to be high risk due to their previous history of dangerous behaviour.

IMH then ensures that these tracked patients comply with follow-up treatment through telephone case management and home visits where necessary. IMH's mobile crisis team is also deployed to de-escalate crisis situations and assist in bringing patients for inpatient treatment if required. Through IMH's enhanced tracking of these patients and follow-up, over 91% of patients tracked so far, have attended first appointment after discharge.

For the second question about the psychiatrist-to-population ratio, as of 2013, there are 3.5 psychiatrists per 100,000 population. The national training supply for psychiatrists has been producing about seven to eight psychiatrists each year for the last three years. But in order to support the projected demand for mental health services required, the training supply for psychiatrists has been increased to an average of about 14 to 15 each year. With this increased in training supply, the psychiatrists in public sector have increased from about 89 to 130 – or around 46% – from 2009 to 2013. This growth in training supply should be sufficient to meet the service needs.

With regard to the third question about better support for patients who have discharged into the community, who may be in remission: first of all, the Community Mental Health Masterplan that was developed in 2012 was developed to ensure patients who no longer require institutionalised mental healthcare, are well supported in the community. One of the ways we are achieving this is by developing new community-based mental health services to improve access to mental healthcare. Some of the recent key services that we have initiated include the one I had just mentioned, enhancing discharged and after care services, where IMH is enhancing its capability to track patients and to follow up; improving

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capability of service providers in community and primary care so that mental health services can be more easily accessed. We do this with two specialist-led and three allied health-led multi-disciplinary teams that have been set up. They support mental health professionals, including over 80 General Practitioner (GP) partners, in caring for mental health patients within the community. These community teams will provide clinical care, psychotherapy and education to support the patients, their caregivers and the general public. These teams have supported over 2,000 patients as at the end of fiscal year 2013.

Thirdly, enhancing support and capability of community partners. I have touched on that – working with the grassroots organisations, training them so that they can recognise some of these potential relapse cases and then, linking them to the appropriate services.

Lastly, enhancing our crisis response. IMH operates a 24-hour mental health helpline which will provide immediate support and advice for patients, caregivers and community partners. You can access it through some of our community partners, such as the Family Service Centres.

Thank you, Mdm Speaker. In order to provide better support to the community for psychiatric patients, may I ask the Senior Minister of State whether there can be provision of more healthcare workers, nurses or psychiatrists to give early detection care, follow-up and treatment to the psychiatric patients in the community which is pretty lacking at the moment?

As I have noted earlier in my reply, we have ramped up the supply of trained psychiatrists and the increase over the years has been about 46% between 2009 and 2013. We think that this should be sufficient. In addition, of course, we need to train nurses, as well as allied health professionals, for this.

I have also said that in order to be able to avail such services to the community and care for these patients in the community – try and prevent relapse – we have taken a multi-prong approach, various initiatives. I have actually elaborated on some of them earlier in terms of IMH enhancing its own capability for after care services for these patients, especially the high-risk patients.

In fact, mental health clinics that are providing such services are also keeping a close track on the "no show" patients, as I have also said earlier. There are other initiatives, for instance, having community support teams – specialists, allied health teams, specialist-led

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or multidisciplinary-led teams – that can be accessed by the community for interventions.

Mdm Speaker, I would like to ask the Senior Minister of State two supplementary questions. Does MOH have statistics on children and young people with mental health issues? Also, given the importance of community support and acceptance, how are these children and young people supported and integrated into schools and the community?

I do not have the statistics for the number of children with mental health problems. Perhaps, the hon Member might like to file another Parliamentary Question on it.

With regard to integration in schools and the community, I think IMH is mindful of this, and that is the reason why, as far as possible, we do not encourage institutionalised care and we try and integrate them back into the society in terms of having close follow-up through support services within the community, like mental health clinics within the community, so that they do not have the stigma. They do not have to go to IMH. They could also access community-led teams that can support them, if needed, with home visits and so on.

Thank you, Mdm Speaker. A supplementary question, please. For the low-risk patients who have been discharged, ultimately, I think the aim must be to integrate them not just back into the community but also into the workplace. Are there also work integration programmes and counselling and such sessions that have been designed to guide them through and also guide their colleagues and employers so that they could more successfully integrate back into the workplace?

Yes. IMH itself has a programme to help these patients find jobs – train them, prepare them and to find jobs. Just over the weekend, I actually attended an event run by a charity group, Mindset, which is working with St Andrew's Community Services who has employment support schemes to help these ex-patients and patients in recovery re-integrate back into society in terms of upgrading their skills, and provide them with relevant skills to enhance their employability and also help them find jobs.

A quick follow-up question. I am heartened to hear that there are work support schemes for the patients. But what about the employers and their colleagues? Quite often, the environment will become too stressful because people do not quite understand how they function and what works for them. So, whether there are also schemes in place to help employers and their colleagues understand how to deal with such a patient.

The other aspect of the work, for instance, of these employment support services by St Andrew's Community Services, is also about working with the potential employers and helping them to see how they can work together, perhaps even redesigning the job processes and so on, to accommodate the prospective employees.

HPB also has mental health programmes that we encourage employers to implement at the workplace, for not just potential employees but existing employees as well.