PSYCHIATRIC PATIENTS

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PSYCHIATRIC PATIENTS: 2.

Dr Lily Neo asked the Minister for Health (a) whether the Ministry will review the policy of favouring psychiatric patients remaining in the community as much as possible; and (b) whether such a policy is suited to our densely populated city state where there is insufficient psychiatric community support.

Mr Khaw Boon Wan: Sir, how and where to treat a mentally ill patient is a decision for the attending psychiatrist to make. There is a wide range of mental illnesses and many are treatable with prospects of a full recovery. Advances in medical science have led to the general conclusion that prolonged institutionalisation is the wrong approach for the vast majority of mentally ill patients. Instead, good community-based care can result in a better health outcome for the patient, besides rendering a higher quality of life and helping in reintegrating the patient back into society.

Community-based care for the mentally ill is a key recommendation of the World Health Organization and all developed countries, including cities, are moving in this direction.

In Singapore, there are about 25,000 patients with serious mental illness, principally schizophrenia. 10% of them are institutionalised at the Institute of Mental Health (IMH) and psychiatric homes. The rest continue their treatment in the community, often in partnership with the IMH.

While the policy of community-based care is appropriate, successful implementation requires proper planning. First, IMH has to carefully select the patients

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for discharge. They must (a) have responded positively to treatment; (b) have adequate family and/or social support; and (c) be assessed to pose minimal danger to themselves or to others.

Second, IMH will educate the patients and their families on the need to comply with medication and regular follow-up. This is to avoid future relapses.

Third, IMH will formulate an appropriate post-discharge support plan for the patients. Patients are categorised by the level of care, supervision and outpatient treatment that they need. Those with higher risk of relapses are followed up by Community Mental Health Teams led by IMH psychiatrists. They keep in close contact with the patients by telephone and also through regular home visits. Case managers will monitor and alert the doctors if patients default on their follow-up. And if necessary, trained social workers and Community Psychiatry Nurses will make home visits to assess the need for re-admission. For the lower risk cases, IMH runs several outpatient clinics across the island, and has several partnerships with trained GPs who are able to provide follow-up care nearer the patients' homes. Patients are closely tracked to make sure they go for regular treatment and they remain well.

Fourth, IMH runs a 24-hour Emergency Service and attends to patients who require immediate treatment. In addition, there is a crisis hotline and the IMH Mobile Crisis Team can make home visits, if necessary.

Finally, under the Mental Disorders and Treatment Act, the Police are empowered to bring mentally ill persons to IMH for assessment, if they are found or believed to be acting in a manner that is dangerous to themselves or to others.

Our community-based approach is not perfect. I think it is far from perfect, and

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we will continue to enhance it in the light of experience. In particular, we need the support and cooperation of family members and the community at large.

We will further strengthen the community support network. We are devoting more resources to train community partners to support the patients. Every year, more than 600 individuals are trained to increase their awareness of mental health issues and to facilitate early identification of at-risk individuals. Let us all work together to support the mentally ill, to help them get to terms with their illness, comply with the prescribed treatment and achieve early recovery, so that they can have a fresh start in life.

Dr Lily Neo: Sir, in the Minister's words earlier, he said that psychiatric community care in Singapore is far from perfect.

In my own term, I will say it is inadequate. Therefore, what does the Minister plan to do about it and how soon can he implement and address this anomaly?

My second question is: could the Minister make available psychiatric referral in the community for VWOs and grassroots organisations? Because, in general, psychiatric cases in the community do not seek medical assistance by themselves.

Mr Khaw Boon Wan: As I have said, I think our system is far from perfect but I would like to believe that it is much less imperfect now than three years ago, and much, much better than 10 years ago. We are making progress and, honestly, very few countries have reached perfection in treating the mentally ill. It is a real challenge. I discuss and compare notes with my counterparts from other countries, and all tear their hair out over this issue because it is not an easy problem. It requires strong co-operation all round.

Acute cases are always easier to handle. If you come in with a heart attack

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or whatever, a few days' stay in a good hospital with high technology, you get treated. But much of the life-long chronic diseases require support and often behavourial changes, both of the patient as well as the family. It is really a marathon, and we judge ourselves and encourage each other on by hoping that this year is better than last year, and next year will be better than this year. So, I think there will always be progress and we will push in this direction.

For the last few years, I have paid some attention to this area because I worry a lot about this particular topic. Members may be aware that I formed an inter-agency committee – an Inter-Ministerial Committee chaired by my Permanent Secretary – and they have been at work with the professionals from the Ministry of Education, Ministry of Home Affairs and all related Ministries. It is an ongoing committee. They had put up recommendations a couple of years ago and we were able to get the support of the Ministry of Finance for an injection of new money. And this year when they reviewed it, they asked for more resources to plug certain areas of gaps, and the Finance Ministry was, again, very supportive. So, I think we are making progress.

Like Dr Neo, I would like to hope that we can move faster but critically is we also need the support from society at large, in particular, society's attitude towards the mentally ill. It is easy for us to talk about destigmatisation but it is real. I have been trying to help some VWOs because I was inspired by the Yellow Ribbon project for ex-convicts. With the help of the Ministry of the Home Affairs, I think they have achieved a lot in the last few years in changing attitude and getting employers to recruit some ex-convicts, and I have visited some of those shops, restaurants run by ex-convicts and I was

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very warmed by what I saw. A few years ago, a few of us wanted to help the ex-mentally ill in similar fashion; but it is an uphill task. Still we have to push it otherwise we will never make progress.

I am not so sure what is psychiatric referral in the community – meaning that they can refer directly?

Dr Lily Neo: Standard call for help with medical; psychiatric nurses; psychiatrists come and assess patients.

Mr Khaw Boon Wan: I thought the answer is "yes". In the past, no, but I think they now have 24-hour hotline for such access, including referrals from grassroots leaders. Of course, there must be a network and prior contact made. We train them, so that they know what numbers to call. If necessary, they will send nurses down to visit. So, we would do all this.

Mr Speaker: Ms Denise Phua, last question.

Ms Denise Phua Lay Peng (Jalan Besar): I thank the Minister for his clarification and his plan to implement the inter-agency committee on mental illness.

I would like to ask the Minister to clarify what key gaps were identified; what strategies were proposed; what resources were given; and the KPIs that this inter-agency committee has come up with. This is because I still see quite a number of the patients not just in my district but in other MPs' as well and sometimes help comes a bit too late for some of these patients or ex-patients who are deemed as "at risk" in the neighbourhood.

Mr Khaw Boon Wan: I cannot remember all the details because it is

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quite a thick report which they published. I remember my Permanent Secretary held a press conference just a few weeks ago when they asked for a second round of additional resources. I cannot remember all the details because it was quite a comprehensive report, going through all the key areas and systematically trying to plug all those gaps.

But I do remember some major highlights in the report – society's attitude, destigmatisation, more public education. That is why I was personally quite concerned about recent incidents involving mentally ill patients. When I read the news, it bothers me because I think, inevitably, it will push our work backwards on trying to change public attitude and raise acceptance of the mentally ill. No doubt, there will be some which are in acute difficulties and require professional help but the vast majority of the mentally ill are like you and me, in that they can carry on their lives if we give them a chance.

Dr Lily Neo: Can I seek more clarification, Mr Speaker?

Mr Speaker: Just a clarification, no question.

Dr Lily Neo: No more questions, just one clarification on what the Minister said earlier.

Mr Speaker: Make it quick, please.

Dr Lily Neo: Thank you. He said that the majority of the psychiatric cases are not hospitalised, in fact, 90% of the schizophrenic cases. May I ask the Minister, in view of our insufficient care in the community for such patients, is it not better to tweak our policy presently so that these patients in the community are not without insufficient care, which may harm themselves, their family members and the community?

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Mr Speaker: A short answer, please, Mr Khaw.

Mr Khaw Boon Wan: A short answer is we will leave this to the experts. We are not experts and they will assess by risk categorisation as I articulated in my reply just now. Those who require institutionalisation, they will be institutionalised.