Singapore: World-Class Mental Health Care faces Cultural Obstacles

IMH 

A Brief Overview – The Institute of Mental Health of Singapore (IMH)

The IMH provides formidably a wide range of general and specialized services to the Singapore public addressing as target groups children, adults and the elderly.

Assessment for children includes developmental problems, disruptive behavioral problems, emotional problems as well as sleeping- and eating-disorders and pathological video-gaming. For treatment pharmacotherapy, CBT, individual and group-therapy as well as play-therapy are being offered among others. Specialty services include a neuro-behavioral clinic offering Autism and ADHD services, a mood and anxiety clinic as well as ‘Forensic Rehabilitation, Intervention, Evaluation & Network Development Services’ (FRIENDS) assisting young offenders, victims of child abuse and children involved in complex custody disputes. Assessments for adults include anxiety and mood disorders, OCD, insomnia, psychosis and schizophrenia, depression, addictions and forensic assessment. Treatments include pharmacotherapy, medical social work (counseling, psychoeducation, group therapy, home – and school-visits), psychotherapy, rehabilitation and physiotherapy.  Specialized services offer addictions management, mood disorder service and an Adult Neuro-Developmental Service. Provisions for the elderly extend to adjustment disorders, dementia, grief and loss issues and stress from physical illness. Treatments for elderly patients are also offered as home-based services.

The IMH has made a commitment to evidence based assessment, has formed global alliances with leading medical universities and training institutes and employs approximately 120 doctors (IMH, 2012). The Singapore 5.3 million multi-ethnic population that the IMH serves has a 98% literacy rate in English (Chong et al., 2012) and is composed of 76.8% Chinese, 13.9% Malay, 7.9% Indian and 0.9% others.

The problem with addressing diversity

Diversity is not compromised by the IMH’s exemplary online presence in English language since most of the population speaks English, but more by the fact that Internet-use is relatively low for the majority of the population at a mean age of 43 years and only ranks high for online participants between 25-34 years of age, which make for only 32% of the population (Chong et al., p.129). A second issue with diversity is that specific issues of mental health care needs of minorities do not appear in publicized materials, most likely to avoid being accused of racial bias. Curiously enough, the video-portraits on the IMH website (‘Heroes’, ‘Zul’, ‘Amira’, ‘Ali’, ‘Putri’) feature predominantly Malay but no Chinese or Indian clients with mental health disorders. Among all ethnicities MDD (Major Depressive Disorder) is the most common mental disorder, followed by anxiety disorders and OCD (Chong, 2012, p. 64).

Additional action required to become more thorough in addressing populations

Despite world-class facilities and a wide range of specialized services most Singaporeans shy away from using professional help regardless of ethnicity. Only 2.6% out of 16.9% of the population that qualifies for receiving mental health services, based on a nation-wide GHQ-28 assessment (Chong et al., 2012), have contacted public caregivers. Of those scoring high on the GHQ only 10.4% consult the IMH. The study by Chong and colleagues revealed that for mild to moderate impairment need-factors override predisposing and enabling factors (Chong, p. 158). Singaporeans tolerate suffering unless they are compelled to seek help.  Chinese, Malay and Indian communities are indeed rooted in deep superstitious beliefs. Many Malays for example preferably consult their spiritual healer (‘Bomoh’). Many Chinese clients believe in the possession by spirits causing them to behave abnormally (22% of patients) while 36% consulted a temple medium prior to seeking professional help (Ng et al., 2003, Kua et al., 1993). GPs were also consulted more frequently than professional counselors provided by the government (Chong, p. 158), posing the question of a bias towards governmental help. Besides superstition and general reluctance, stigma surrounding mental illness is great in Singapore (Chee et al., 2005, p.653). The fear of ‘Loosing face’, to avoid compromising at all costs the flawless appearance of a projected public persona (Dong et al., 2013), still ranks as a supreme value across Asian populations. To address the Singapore public more efficiently traditional spiritual healers and GPs may need to be invited to be trained to consult and advise on mental health care, be it as a referrer or as integrated members of the ‘care team’. Qualitative research investigating the motives behind stigmatization of mental illness would need to be conducted to address the widespread avoidance of services across ethnicities in Singapore.

Conclusion

Singapore suffers from a mismatch between first-class health-care provision and adaptation to exiting cultural frameworks (Castro et al. 2010, p.216) leaving more than 80% of qualifying clients not provided for. Currently there is little qualitative research available on evidence-based community strategies (Cohen, 2011) addressing the cultural issues of widespread superstition as well as the stigmatization of mental health disorders in cultural discourse.

References

Castro, F. G., Barrera, M., Jr., & Steiker, L. K. H. (2010). Issues and challenges in the design of culturally adapted evidence-based interventions. Annual Review of Clinical Psychology, 6, 213–239.

Chee, C., Ng, T., & Kua, E. (2005). Comparing the stigma of mental illness in a general hospital with a state mental hospital: a Singapore study. Social Psychiatry And Psychiatric Epidemiology, 40(8), 648-653.

Chong, S., Abdin, E., Vaingankar, J., Heng, D., Sherbourne, C., Yap, M., Subramaniam, M. (2012). A population-based survey of mental disorders in Singapore. Annals Of The Academy Of Medicine, Singapore, 41(2), 49-66.

Chong, S., Abdin, E., Vaingankar, J., Kwok, K., & Subramaniam, M. (2012). Where do people with mental disorders in Singapore go to for help? Annals Of The Academy Of Medicine, Singapore, 41(4), 154-160.

Chong, S., Mythily, Deurenberg-Yap, M., Verma, S., & Swartz, M. (2008). Performance measures for mental healthcare in Singapore. Annals Of The Academy Of Medicine, Singapore, 37(9), 791-796.

Cohen, A., Eaton, J., Radtke, B., George, C., Manuel, B. V., De Silva, M., & Patel, V. (2011). Three models of community mental health services in low-income countries. International Journal of Mental Health Systems, 5(1), 3–12.

Dong, P., Huang, X., & Wyer, R. (2013). The Illusion of Saving Face: How People Symbolically Cope With Embarrassment. Psychological Science, August 12, 2013

Institute of Mental Health (IMH, Singapore). (2012). Retrieved from http://www.imh.com.sg/

Kua, E.H., Chew, P.H., Ko, S.M. (1993). Spirit possession and healing among Chinese psychiatric patients. Acta Psychiatrica Scandinavica 1993; 88-447-450

Ng, T., Fones, C., & Kua, E. (2003). Preference, need and utilization of mental health services, Singapore National Mental Health Survey. The Australian And New Zealand Journal Of Psychiatry, 37(5), 613-619.

2 thoughts on “Singapore: World-Class Mental Health Care faces Cultural Obstacles

    • Hallo Kelvin,

      I am the author of the article and you are welcome to re-blog the post.
      The reference to Hesse’s ‘Steppenwolf’ is a very suitable choice.

      My Kindest Regards!

      Joana

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