The 2016 Singapore Mental Health Study (SMHS) showed that one in seven people in Singapore has experienced a mood, anxiety or alcohol use disorder in their lifetime. Compared to the same study done in 2010, there was a slight increase in the lifetime prevalence of mental illnesses. However, the proportion of the people with mental disorders who were not seeking help remains high and a significant treatment gap remains.1
Several reasons have been put forth for this treatment gap and stigma is one of them. Despite efforts to combat the stigma of mental illness, it is still daunting for many people to admit that they have a mental illness and seek treatment for it. Mental health literacy needs to be improved and quality mental healthcare has to be accessible, especially in a setting with less stigma attached.
Even though primary care in Singapore represents the first point of contact for most patients in Singapore (with 20 polyclinics and about 1,500 private GP clinics distributed all over the island), many patients (and pre- patients) may not associate mental health treatment with their family doctors, whether in public or private practice. Among those with a mental disorder who sought help, more than 40% consulted a psychiatrist, whereas only 20% went to see their primary care physicians, according to SMHS 2016.
Mental health services in the primary care setting
Since 2010, there has been significant effort to equip primary care physicians to be competent and confident in assessing and treating patients with mental health concerns.
The Assessment and Shared Care Teams (ASCATs), funded by the Agency for Integrated Care, were started in 2010 to address the treatment gap issues. As mentioned above, there was a sizeable number of persons with mental health issues who did not want to seek help with hospitals due to issues of stigma. As a result, many persons remained undiagnosed and untreated, and they tended to present with more severe symptoms by the time they sought help. As such, there was a pressing need to bring mental health care into the community so that needs can be identified and attended to early.
The new model of care, delivered through ASCATs, sought to provide mental health assessment, treatment and support in the community, through polyclinics, private GP practices and social service agencies. The vision then was to develop a mental health integrated network that enables adults residing within the region to access holistic and patient-centred mental health services.
The first ASCAT was set up at Khoo Teck Puat Hospital in 2010 to serve the mental health needs of the population living in the north of Singapore. This was followed by the second team set up at Ang Mo Kio (AMK) Polyclinic to perform psychiatric assessment and follow-up treatment for patients with mild to moderate mental health disorders, such as those with depression, anxiety and sleep issues. Since 2012, four more ASCATs were formed. ASCAT@Central at the Institute of Mental Health (IMH) would support the entire central region of Singapore. The team at Changi General Hospital supported the east, and the two ASCATs at National University Hospital and Ng Teng Fong General Hospital, respectively supported the western region of Singapore. Even though each ASCAT team has relative autonomy on how they engaged the patients and community partners, the mission for each team was the same – to bring mental health care to the community.3
IMH developed and launched its ASCAT programme in 2012. One of its core functions was to provide training for primary care practitioners in the form of didactic lectures, case supervisions and co-consultations for both polyclinics and family medicine clinics (FMC). Psychiatrists were also available to provide tele-consultation at any time for the primary care doctors.
AMK Polyclinic and Hougang Polyclinic have set up mental health clinics (termed Health & Mind Clinics, or HMCs for short) which see patients with conditions such as depression, anxiety disorders, adjustment disorders and insomnia. When these services first started, psychiatrists from IMH would sit in with the family physicians (FPs) to provide supervision for their mental health patients. These FPs were identified based on their interest in mental health, and it took three to six months of such training for them to be confident and competent to independently evaluate and treat the range of patients with mental health issues presenting to the polyclinics. If these FPs identify that their patients require further evaluation and treatment at a tertiary level, patients will be given fast-track access at IMH. (At the time of writing this article, Toa Payoh Polyclinic has also begun training their FPs to start a HMC.)
Apart from polyclinics, ASCAT@ Central has also trained doctors from Unity FMC to attend to patients with mental health issues. Unity FMC runs weekly dedicated clinics where a psychiatrist would sit in with the GP to see patients, both existing and new, with mental health concerns. Once the patient is evaluated and has a treatment plan, he/she will continue their follow-up with the FMC. If the FMC doctor identifies that the patient needs tertiary level care, the patient will get expedited appointments at IMH. Similarly, FMC doctors can consult their psychiatrist colleagues at any time if they encounter issues with their patients.
ASCAT@Central also engages non-medical partners such as community intervention teams, Family Service Centres and other social service agencies through training initiatives, such as workshops and case conferences, so that they are better equipped to care for those with mental health problems within the community. Many of these community partners work closely with GPs and hospital-based mental health services to support patients through their time of distress and crisis. They also run case management, therapy sessions and provide caregiver support for those in the community.
More to be done
The intention of this mental health network is to provide patient-centred quality care in the most appropriate and accessible settings. Through the partnerships, more serious and complex cases can be easily escalated to the tertiary mental health services, while stable patients can be right-sited to the community partners. The need for mental health services in Singapore is only projected to grow. We have made progress over the years but we can certainly do better. Increasing the competency and capacity of primary care and other community partners is only one part of the solution. Other aspects that need to improve include mental health education, reduction of stigma and strengthening the resilience of the population.
Note
- There are currently five ASCATs in Singapore. The ASCAT set up to support AMK Polyclinic was incorporated into the current IMH ASCAT@Central in 2012.