Commentary: Improving mental health in Singapore is a long journey

SINGAPORE: The analogy of an overflowing water basin has often been used to illustrate the concept of problem-solving or crisis management in public health. To avoid the water from spilling over onto the bathroom floor, the person connects a hose to the tap to divert the water to the bathtub. Problem solved! Except it is not.

Such an action is the correct first step - it buys time to think of ways to solve the root problem. But how do we turn off the tap, or at least slow down the flow?

Singapore is making significant moves to improve mental health and well-being among residents, with the promise of more resources to meet demand.

In a parliamentary motion on advancing mental health last week, Deputy Prime Minister Lawrence Wong said that Singapore will, by 2030, increase the pool of public sector psychiatrists and psychologists by 30 per cent and 40 per cent respectively, and train an additional 28,000 frontline personnel and volunteers to provide psychological first aid if needed.

This is a welcome move for the mental health community - for this group of professionals and carers have been steadfast through the pandemic and the health demand surges in the post-COVID era. 

At its best, this may be the only solution we need, and we can live happily ever after. More realistically, it buys us time to better examine and address the likely root causes of worsening mental health in Singapore.

YEARS IN THE MAKING

From the sharp rise in mental health issues due to COVID-19 in 2000 to the formation of the Inter-agency Taskforce on Mental Health and Well-being in 2021 and the launch of Singapore’s National Mental Health and Well-being Strategy last year - the parliamentary discourse and debate last week was a fruitful culmination of the issues and the strategies.

A balanced mix of stories and statistics were shared from both sides of the House, and the session concluded with Mr Wong pledging more resources and calling upon all Singaporeans to do more to destigmatise mental health conditions and better support one another. This will be a long journey and we will need continued attention on the progress from the country’s leadership, professional groups and people. 

Singapore’s emphasis on developing programmes, initiatives and capacity for improving mental health and well-being of its people is commendable, and we are making strong progress towards the World Health Organization’s Mental Health Action Plan for 2030 to (1) strengthen effective leadership and governance for mental health; (2) provide comprehensive, integrated and responsive mental health and social care services in community-based settings; (3) implement strategies for promotion and prevention in mental health; and (4) strengthen information systems, evidence and research for mental health. 

Over the past decade, Singapore-based researchers have published many local studies on the risk factors and treatment of mental health conditions, advancing our understanding of the issue. Mental health is also one of seven areas identified as national priorities for research by the National Medical Research Council. We now know a lot more about the risk factors, prevention, early detection and treatment for people at risk or living with mental health conditions.

FIX THE ENVIRONMENT, NOT THE FLOWER

Dr Wan Rizal (PAP-Jalan Besar), who as a member of the Government Parliamentary Committee for Health had filed last week’s motion along with four others, spoke on the stigma on people living with mental health conditions in a parliamentary speech back in 2020. He raised four points: Literacy, accessibility, screening and time-outs - concepts that are easy to remember and key areas that many in the government, professional groups and communities can all contribute towards.

He also shared a quote by inspirational speaker Alexander den Heijer: “When a flower does not bloom, you fix the environment in which it grows, not the flower”. This is an important point that has perhaps been overshadowed by the more pressing response to create the bathtub to prevent the sink from overflowing.

It is heartening to hear the strong emphasis and support on preventive efforts which help to minimise risk of mental health conditions developing - with the efforts in schools, communities and workplaces. We know that health is affected by individual, relationships, community and societal factors, so these efforts are important and spot on because they address not just individual well-being, but also the broader influences of relationships and community dynamics.

COVID-19 and ongoing geopolitical conflicts clearly demonstrate that negative societal factors can contribute strongly to a community’s risk of mental health. Anxiety and depression have spiked globally as a result of prolonged social isolation during the pandemic. People living in conflict zones who witness traumatic events are at higher risk of post-traumatic stress disorder.

Culture and social policies can also have similar effects. A social theory of global health by Robert Merton holds that all social interventions have unintended consequences, some of which can be foreseen and prevented, while others cannot be predicted. As a result, all social action should be routinely evaluated for unintended consequences.

One extreme example is China’s one-child policy, which was implemented in 1979 and only officially ended in 2016. China is now facing a gender ratio imbalance, a falling fertility rate and one of the world’s fastest ageing populations.

HEALTH IS ALSO SOCIAL; PREVENTION IS BETTER THAN CURE

So how do we turn off the tap, or at least slow down the flow? Health is increasingly social, and mental health is a good case study for how risk factors, preventive actions and treatment have a strong social component.

Singapore’s Inter-agency Taskforce on Mental Health and Well-being is co-led by the Ministry of Health and Ministry of Social and Family Development to better enable the task force to better address these issues more holistically. Other countries like Japan, Netherlands and Sweden also acknowledge the strong synergy between health and social, and have taken a different approach to sit health and social together under one ministry. 

Given that much more will be done and committed to improve capacity and resources for mental health services - what would the next steps be for Singapore to improve the mental health of its people?

The adage “prevention is better than cure” comes to mind and Den Heijer’s quote to consider the environment is helpful. To do that, health and social programmes and policies need to be reviewed, researched and considered more holistically. We need to discover new ways to turn off the tap, or at least slow down the flow. 

Dr Clive Tan is an Assistant Professor with the National University of Singapore’s Saw Swee Hock School of Public Health and an Assistant Chief at the National Healthcare Group, working on population health, programmes and policies.