MENTAL HEALTH (CARE AND TREATMENT) BILL

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MENTAL HEALTH (CARE AND TREATMENT) BILL: Order for Second Reading read.

3.02 pm

The Minister for Health (Mr Khaw Boon Wan): Mr Speaker, Sir, I beg to move, "That the Bill be now read a Second time."

This Bill is prompted by the Mental Capacity Bill which the Minister for Community Development, Youth and Sports will shortly take the House through. The Mental Capacity Bill aims to empower individuals to voluntarily plan in advance and appoint a proxy decision-maker for a time when they may lack mental capacity. It will also allow parents to apply to the court for the appointment of a proxy decision-maker for their intellectually disabled children. The Mental Capacity Bill will replace and update Part I of the existing Mental Disorders and Treatment Act.

The Mental Health (Care and Treatment) Bill will in turn replace Parts II and III of the Mental Disorders and Treatment Act. It aims to regulate the involuntary detention of a person in a psychiatric institution for treatment if:

(a) he is suffering from a mental disorder which warrants the detention for treatment; and

(b) it is necessary in the interests of the health or safety of the person or for the protection of other persons that the person be detained.

Many other countries, including the United Kingdom and Australia, have similar provisions for involuntary treatment for persons suffering from mental disorders whose ability to make decisions about medical treatment is significantly

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impaired and who are likely to suffer mental, behavioural or physical deterioration without prompt and adequate treatment. Our Bill will maintain parity with modern best practices to strengthen the safeguards to protect the patients who are involuntarily detained for treatment. For example, regular inspections have to be conducted by visitors appointed by the Minister and a Magistrate's order is required for the detention of a patient beyond a certain period. The improper detention of a person, or wilful neglect or ill-treatment of a patient, will be an offence under the Bill.

Mr Speaker, Sir, let me elaborate on each of the proposed amendments.

Definitions

First, we will replace the term 'mental hospitals' with 'psychiatric institutions'. A part of a hospital (for example, a ward or a department) may now be designated as a 'psychiatric institution' for the reception and treatment of the mentally ill, instead of an entire hospital. This will give us greater flexibility to alter the capacity to meet changing demand in the future.

Procedures

Second, a patient who has voluntarily admitted himself to a psychiatric institution may now be detained pursuant to an order of a designated medical practitioner, if he is assessed to be a danger to himself or others. This is to facilitate prompt treatment. Currently, a detention order may only be made in respect of a person who has not yet been admitted into the mental hospital.

Third, we are reducing the minimum frequency of inspections by visitors appointed by the Minister for Health from once a month to once every three months. This will enable us to set the

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frequency in accordance with needs. For example, where a psychiatric institution has not had adverse reports for a long period, a reduced frequency may be justified. This is a practical step to reduce the load on the visitors. The visitors are, however, required to submit a report to the Director of Medical Services after every inspection. Based on these reports, the Director of Medical Services may then direct the visitors to conduct further inspections as necessary.

Strengthening safeguards

Fourth, after the first month of detention, any further detention, if ordered by two designated doctors, will be capped at a maximum of six months. This is half of the current provision. For detention beyond six months, a Magistrate's order will be required. These safeguards are to ensure that patients are not detained beyond what is medically required.

Fifth, a detained patient who requires treatment for an acute medical condition other than his mental disorder may now be transferred to another hospital, and be temporarily detained there. This arrangement is necessary, as psychiatric institutions may not have the necessary facilities for managing these acute medical conditions. There is currently no such provision in the Mental Disorders and Treatment Act.

Penalties

Finally, we are updating the penalties for certain offences to ensure that they have a deterrent effect and to be on par with equivalent legislation. We are increasing the maximum penalties of fines and imprisonment for offences committed against patients who have to be detained for treatment. These patients are in a vulnerable situation and we need to send

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a clear message that abuse of such patients will not be tolerated.

(a) First, the maximum penalties for ill treating a patient will be raised. Ill-treatment includes physical or sexual abuse, as well as wilful or unreasonable endangerment or neglect of a patient. Currently, the maximum penalty is a fine not exceeding $500 or imprisonment for up to two years or both. The Bill increases this to a maximum fine of $5,000 or imprisonment for up to four years or both. If death is caused to the patient, the penalty will be a maximum fine of $20,000 or imprisonment for up to seven years or both.

(b) Second, the penalty for having sexual intercourse with a patient will be increased from a fine of up to $1,000 or imprisonment for up to two years or both, to a maximum fine of $20,000 or imprisonment for up to 10 years or both.

(c) Third, the penalty for improperly receiving or detaining a patient will be increased from a maximum fine of $2,000 or imprisonment for up to two years or both, to a maximum fine of $5,000 or imprisonment for up to three years or both.

(d) Fourth, a police officer is empowered to visit and inspect a mentally disordered person under the care of a person to ascertain whether or not that mentally disordered person is under proper care and control or is ill-treated or neglected. The Bill enhances the maximum fine for refusing to produce the mentally disordered person for inspection from $1,000 to $4,000.

(e) Lastly, the maximum amount for which a minor offence under the Bill may be compounded will be raised from $500 to $2,000.

Mr Speaker, Sir, the care and treatment of the mentally ill has evolved

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over the years and it will continue to evolve, in the light of experience and medical knowledge. Increasingly, care and treatment for most mentally ill is best done in the community setting. But it is sometimes necessary to detain some mentally disordered persons in a psychiatric institution, to safeguard the health and safety of the patients and to protect the others in the community. In such cases, we have to ensure that the power to detain is not abused.

This Bill updates and strengthens the safeguards for the detained patients under such circumstances. I hope to get the support of all Members for this Bill.

Sir, I beg to move.

Question proposed.

3.15 pm

Mdm Halimah Yacob: Mr Speaker, Sir, I rise in support of this Bill.

The World Health Organisation (WHO) has classified mental illness as a major health issue that will drain the coffers of many countries. In Singapore, too, we see a steady increase in the number of people suffering from mental illness. In 2006 alone, IMH treated close to 33,000 patients for mental illness in its outpatient clinics. A rapidly ageing population has added to the complexity as there are now more dementia cases. It is, therefore, in our interest to ensure that we have a proper legislation in place before the situation worsens.

I, therefore, welcome this new Bill. It is indeed timely for us to review the existing law to ensure that it is up to date and relevant. The Mental Disorders and Treatment Act that this Bill seeks to replace was passed in 1952 and seriously needs updating. According to the WHO, "progressive legislation can be an effective tool to promote access to mental

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health care as well as to promote and protect the rights of persons with mental disorders". However, according to the WHO, "in some countries where legislation has not been updated for many years, mental health legislation has resulted in the violation, rather than the promotion, of human rights of persons with mental disorders. This is because much of the mental health legislation initially drafted was aimed at safeguarding members of the public from "dangerous" patients and isolating them from the public, rather than promoting the rights of persons with mental disorders as people and citizens. Other legislation permitted long-term custodial care of persons with mental disorders who posed no danger to society but were unable to care for themselves, and this too resulted in a violation of human rights".

So, Sir, I was hoping to see a different approach being taken in our legislation in the treatment and care of mentally disordered persons. But I find that the Bill has fundamentally kept the same approach which can be summed up as one that is based on institutional care and is rules based. Quite a large portion of the Bill dealt with giving powers to the Police to arrest mentally disordered persons and powers to the Magistrate and the psychiatric institution to admit or further detain a mentally disordered person for treatment. The Bill also now seeks to increase the fine for family members who fail to provide for the proper care and control of a mentally disordered person.

I am also concerned that while this Bill has strengthened the provisions to protect the public interest through a longer period of detention of a mentally disordered person, there is very little mentioned about protecting the rights of the mentally disordered persons. While I understand the need to protect the public, there is also a need to protect the rights of the mentally disordered persons from unnecessary and prolonged detention that

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will deprive him of his freedom. I note that there is greater clarity now under section 22 on punishments for those who ill treat a patient in a psychiatric institution but more can be done.

While the Bill, Sir, wants caregivers to assume greater legal responsibility for the care and maintenance of mentally disordered persons, there is little support for caregivers in the community to perform their role. Caregivers need greater support as they often suffer as much as if not more than the mentally disordered person whom they are taking care of. While the Bill makes it an offence for caregivers to ill-treat or neglect persons who are mentally disordered, it ignores the fact that the mentally disordered persons are at times the perpetrators of harassment and violence against their caregivers. With the rising cost of medical care, it is certainly not cheap for caregivers to provide for the medical needs of mentally disordered family members when medical care is often needed over a long term period. Caregivers too have a life of their own. They need to work and have other family members to take care of. Often, when there is a mentally disordered family member, caregivers face financial, mental and emotional burnouts.

I have a young man, Sir, in my constituency who suffers from severe mental illness. He lives in a 3-room flat with his mother who works as a cleaner to support him. They are on financial assistance as the young man is unable to work due to the side effects from the medication that he is taking, sometimes a problem particularly with the older, cheaper variety that is commonly prescribed. His mother worries about who will take care of him when she is no longer around. I have another family with a son in his 30s also suffering from severe mental illness. Once he jumped down

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from a four-storey building and on another occasion he slided down the rubbish chute, on both occasions after hearing voices. He miraculously survived both episodes. His elderly parents now do not leave home without him. I wonder whether they could be charged for neglect under this Bill as on one of the occasions when the incident occurred, he was left alone at home when one parent was working and the other went to do some errands.

Another gap, Sir, in the treatment and care of mentally disordered people is after a person is discharged from hospital. He gets very little support from the community because there are just not enough step-down care facilities and services. Home care services and support for families taking care of mentally disordered family members at home are also limited. There are not enough community-based programmes to help in the continued rehabilitation of people with mental disorders. The few that exist run by VWOs like the Singapore Association of Mental Health (SAMH), the Hougang Care Centre and the Silver Ribbon, are under funded and under resourced. They need more funding support especially as some of them run residential programmes and the cost of living has gone up. We all know that lack of support to help people with serious mental disorders after their discharge from hospitals often leads to relapses. With every relapse and re-admission into hospital, there is a terrible cost to the Government and society as most mentally disordered people cannot afford private rates.

Sir, the need for accommodation is another pressing issue for those who are mentally disordered. Three-quarters of the 1,600 patients in IMH have been there for at least three months. About 300 have been there for 10 years or more. Even VWOs are finding it hard to cope with the demand. In the Simei Care Centre, which was set up in 2005 to provide short-term

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rehabilitative care to the mentally ill, a number of their patients have stayed on for at least three years. At the Sunlove Home, 70 of the 207 patients have been abandoned by their families. I hope that the Ministry could re-examine the basis of its current funding to some of these shelters for the mentally disordered which is inadequate.

Sir, let me share with this House the Australian example. In 2006, the Australian federal government allocated A$1.8 billion for the expansion of mental services over a period of five years. With this budget, the Australian government will fund 900 personal helpers and mentors to support those with serious mental illness live at home after their discharge from hospital. Carers will help those in need cope with everyday problems such as taking medicines and arranging accommodation. The funding will also expand support for accommodation provided to those with long-term mental illness. There is also funding for respite services for up to 15,000 families who care for relatives with severe mental illness or intellectual disability, with priority given to the elderly. So, Sir, the Australian example shows that they have adopted a much more community based, holistic approach towards treatment and care of mentally disordered persons.

Now, Sir, I would now like to seek some clarifications from the Minister on matters related to the Bill.

Under section 2, mental disorder will now cover not only mental illness but also "any other disorder or disability of the mind". This is very wide as it would also cover mental retardation (also known as mental handicap and intellectual disability) and personality disorders. In most countries, these categories are usually separated. Could the Minister clarify whether it is in the best interest of a person suffering from mental retardation

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or autism, for instance, to be subject to the same regulatory regime as a mentally ill person and be detained for a prolonged period in a psychiatric institution?

Sir, under section 10, a mentally disordered person can be involuntarily admitted into hospital for treatment or even if he admits himself voluntarily, the hospital is given the power to detain him longer. Section 10(5) provides that the hospital can detain him for an extended period of six months, which has been reduced from 12 months – I agree with the Minister – but section 13(3) provides for the mentally disordered person to be detained for up to 12 months if ordered by the Magistrate and this could be further extended. Involuntary detention in a psychiatric institution for a prolonged period has come under scrutiny in many jurisdictions as it restricts a person’s rights and there is also potential for abuse. The WHO recommended that where involuntary treatment is necessary, the patients and their families and/or personal representatives must have a right to appeal to a review body, tribunal and or court against the imposition of involuntary treatment. The UK is one example which followed the WHO's advice as it provides for a Mental Health Review Tribunal to review the appeals of a person detained in a psychiatric institution under the UK Mental Health Act. The Tribunal has the power to order the discharge of any patient who is involuntarily admitted if it feels that there is no need to do so. Could the Minister explain what recourse does a mentally disordered person have under this Bill to ask for earlier release from involuntary detention in a psychiatric institution? Has the balance in the new Bill been tilted too much in favour of protecting the public but which may in fact affect the rights of those with mental disorders? How are the rights of a mentally disordered person protected from arbitrary exercise of power now that the powers of detention have been increased? Would the Minister consider establishing a

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Mental Health Review Tribunal, akin to the UK situation, to provide recourse to persons detained under this Act if they are unhappy with their long detention period?

Sir, as an alternative to the involuntary detention and treatment of mentally disordered persons, could the Minister consider compulsory community supervision or treatment orders which are already commonly found in many developed countries? Such orders decrease hospitalisation and total hospital days when they are accompanied by intensive community-based treatment, which requires substantial commitment of manpower and financial resources, and I admit that. But these are less restrictive and would generally include outpatient treatment, day hospital treatment, partial hospitalisation programmes and home-based treatment. New Zealand, for example, has revised its mental health legislation to accord with the least restrictive principle. Under the New Zealand Mental Health (Compulsory Assessment and Treatment) Act, when a court has ruled that the certification criteria (for involuntary treatment) have been met, “the court shall make a community treatment order unless the court considers that the patient cannot be treated adequately as an outpatient, in which case the court shall make an inpatient order”. The new Bill, Sir, does not provide for supervised community treatments at all as it focuses primarily on institutionalised care which is not the best alternative as prolonged detention infringes on personal liberty whilst not necessarily ensuring the desired outcomes in the treatment of the mentally disordered. Compulsory community supervision and treatment are not only more humane but also provide a more holistic approach in the treatment of the mentally disordered as it complements the other

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treatment methods and provides the much needed community support for those released from institutional care. Could I, therefore, ask the Minister to study the feasibility of introducing compulsory community supervision and treatment?

Sir, under section 5, visitors are now required to inspect a psychiatric institution only once in three months and not once a month as is required under the existing Act. Could the Minister explain how less number of visits would benefit the mentally disordered patients and ensure better protection for them? Also, under the new section 5, the visitors need not inspect every part of the psychiatric institution and see and examine every patient as is required under the existing law. Instead, under the Bill, visitors need to visit only any part of the psychiatric institution or see and examine any patients. Could the Minister clarify how this can be considered as an improvement since visitors are now needed to visit perhaps only a few patients and only some parts of the psychiatric institution?

Sir, under section 7, a police officer is authorised to apprehend any mentally disordered person who “is believed to be dangerous” to himself or to others. Could the Minister clarify what constitutes dangerous behaviour? Could the Minister also clarify what procedures and protocols are in place for the Police to ensure that there are proper safeguards so that the Police can play a constructive and helpful role with respect to people with mental disorders during arrest? Are police officers trained to handle people with mental disorders and how do they assess that a mentally disordered person is indeed dangerous to himself or others?

Under section 8(4), the fine for a caregiver to produce a mentally disordered person for inspection by a police officer has been increased four times, from $1,000 to $4,000. Could the Minister explain the rationale for this four-fold

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increase in fines which would cause tremendous hardship to the caregivers, most of whom are already struggling to provide for their mentally disordered family members? So the question is: would increasing the fine help to address the problem or are we only trying to deal with the symptoms?

Sir, could the Minister enlighten this House on what measures will be taken to increase the number of psychiatrists to put this Bill into effect? There are about 115 psychiatrists in Singapore, giving a psychiatrist-to-population ratio of about 2.6 per 100,000, which is low compared to other developed countries like the USA, which has a ratio of 13.7 per 100,000, the UK (11 per 100,000), and Australia (14 per 100,000). There is also a shortage across the whole range of mental health professionals: psychiatric nurses, clinical psychologists, psychiatric case managers, medical social workers and occupational therapists? Can I ask the Minister what measures are being taken to recruit and train more of these staff as well?

Sir, could the Ministry of Health also focus more on early intervention programmes as early treatment certainly makes a difference? The Early Psychosis Intervention Programme (EPIP) is a good start but more can be done, particularly in schools and at the workplace. In the labour market, one big problem faced by mentally disordered people is the difficulty of getting a job as employers are not willing to employ them. Could they be provided with stronger support and more assistance?

Sir, could the Minister also review the current situation where mentally disordered persons are excluded from MediShield coverage causing them hardship as their illness requires long-term treatment, particularly long-term hospitalisation?

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Sir, could the Minister give an update to this House on the progress made by the Inter-Ministerial Committee which was appointed last year with the task of rolling out a roadmap to tackle mental illness? What are the measurables and how have the lives of mentally disordered persons improved? Could the Minister also enlighten this House as to how much of the $88 million that has been set aside to implement this mental roadmap is allocated to funding the various VWOs that are running shelters and programmes for the mentally disordered as they are under-funded and under-resourced?

Sir, in conclusion, this new Bill is but one of the measures that will help to provide for the better care and treatment of mentally disordered persons. However, nothing contained in this Bill can overcome the prejudice, stigma and discrimination that mentally disordered persons face everyday of their lives. It is this stigma that often prevents individuals from seeking treatment early when the chances of recovery are better. It is this stigma that prevents them from landing a job, renting a room or integrating with the rest of society. It is this stigma that often makes them feel like lesser human beings and affects their recovery. To remove this stigma and prejudice requires more than the law. It requires the effort of everyone. For a start, we should start an education campaign to raise awareness and stamp out prejudice and narrow mindedness. I think we owe it to our mentally disordered Singaporeans.

I support the Bill, Sir.

3.30 pm

Dr Lam Pin Min: Mr Speaker, Sir, allow me to begin by quoting Dr Johann Christian Reil, one of the most progressive psychiatrists of his era, in the late 18th century. He said:

"It is difficult to understand the incredible inhumanity with which mentally-sick citizens

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were treated. We incarcerate these miserable creatures as if they were criminals in abandoned jails, near to the lairs of owls in barren canyons beyond the city gates, or in damp dungeons of prisons, where never a pitying look of a humanitarian penetrates; and we let them, in chains, rot in their own excrement. Their fetters have eaten off the flesh of their bones, and their emaciated pale faces look expectantly toward the graves which will end their misery and cover up our shamefulness. Excited patients were locked naked into narrow closets and fed through holes from copperware attached to chains. Beatings were common and defended by shallow rationalisations. Strait jackets and chains attached to walls or beds were used to restrain patients, since the theory was that the more painful the restraint, the better the results, particularly with obstinate psychotics. The unsanitary conditions, lack of nourishment, wounds inflicted by the chains, and application of drastic skin irritants to increase the torment killed a large number of these patients."

Mr Speaker, Sir, what I just recounted were not just fictional stories that could possibly be made into box-office movies, such as the likes of Hannibals or the Silence of the Lambs. Such stories still exist in this day and age, though not to such horrific extent all over the world in mental institutions and homes, whose raison d'etre is to provide the very refuge, protection and care for these vulnerable human beings suffering from mental illnesses.

In a highly stressful urban society like Singapore, we do expect to see more people suffering from some form of mental illnesses. In addition, as more people are living longer, the incidence of the elderly developing age-related degenerative diseases of the brain, such as Parkinson's, Alzheimer and senile dementia, is expected to rise as well. By the year 2050, Singapore would have the

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world's fourth oldest population. The introduction of the Mental Health (Care and Treatment) Bill is not only timely but also an important step in the right direction.

Mental illnesses, such as depression, anxiety, schizophrenia or dementia, are growing problems plaguing many developed countries. In the United States, the Alzheimer's Association estimated that the direct and indirect cost of Alzheimer's disease and other forms of dementia amounts to about US$145 billion annually. A study on Singapore in 2004 estimated that about 5.6% of our adult population suffers from some form of depression. This figure works out to more than 200,000 based on our current population size of four million. This is indeed an alarming figure for our healthcare delivery system to tackle. If not managed properly, the cost overrun could be catastrophic to our national health budget.

Notwithstanding the estimated number of 200,000 people suffering from depression, our Institute of Mental Health only treated a total of 33,000 patients last year, as alluded to by Mdm Halimah. This disparity in number of afflicted and those who sought treatment can be attributed to our Asians' perception of mental illness. Because of the stigma attached to mental illnesses, Asians are reluctant to seek treatment early when confronted with mental illnesses. Asians also have a tendency of somaticising psychological distress as physical pain. Experts in the field are in general agreement that early treatment of mental illnesses is crucial. Hence, I would like to urge the Ministry to engage and train primary healthcare givers, such as GPs, to help identify and provide early treatment, and to refer them to a specialist before the illness deteriorates.

In Hong Kong, mental healthcare faces critical manpower shortage problem

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resulting in compromised quality of care, as well as physical and mental burnout of the caregivers. The situation in Hong Kong is likened to having five lids for 10 boiling teapots. Comparatively, in Singapore, as our population grows, the number of mental healthcare givers needs to correspondingly grow with it. The question to ask thus is, "Do we have an adequate number of mental healthcare professionals?" In the US and Canada, the ratio of professional psychiatric caregiver to the population is about 1:8,000. Whereas WHO recommends that the ratio should be about 1:19,000. According to the Singapore Medical Council's annual report, there are currently about 114 psychiatrists practising in Singapore. Based on WHO's recommendation, we should, therefore, have 210 doctors specialising in psychiatry. We need to act now, given the length of time needed to train the necessary medical professionals to meet these rising demands.

Sir, it is a fact that mental patients are more vulnerable to abuse than their perceived image of "danger". Mental patients, because of the nature of their ailments, are prone to abuse with possibly little recourse. In that respect, I support the harsher penalty imposed for the ill-treatment of patients by healthcare givers as it serves as an effective deterrent against such acts.

Having said that, Sir, let me declare my interest as a member of the healthcare profession. I am a little concerned over the possibility of wrongful prosecution of mental healthcare givers. Mental healthcare providers are exposed to a wide range of patients with mental illnesses, many of whom are of the violent type. For instance, healthcare providers taking care of patients suffering from paranoid schizophrenia are susceptible to violent manipulation. In addition, given their mental state, the injury and ill-treatment

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may be self-inflicted, leading to the wrongful prosecution of healthcare givers. I hope the Ministry can recognise this possibility, no matter how remote, when investigating alleged claims of abuse by mental patients.

Similarly, in the prosecution of ill-treatment, the same predicament faced by family caregivers needs to be taken into consideration, and judicious enforcement necessary.

Usually, seemingly innocent problems are quite common for the elderly with mental illness. Hence, the issue of ill-treatment to people with mental illness, especially family members who are caregivers, needs to be enforced with greater care and sensitivity. For instance, the demented person may complain to others for being ill-treated by not being fed, while in actual fact they had been fed but could not recall recent events because of the nature of their sickness. Family members are already quite stressed out taking care of one of their members with mental disturbances, and may just keel over when confronted with unnecessary investigations into allegations of ill-treatment.

I would like to clarify with the Minister the reason for not stating the penalty for family members guilty of ill-treating mental patients in clause 8 of the Bill. Perhaps, family members who ill-treat mental patients, like Mr Sujit Kumar from Fiji, known to millions around the world as the Chicken Boy, who was confined in a chicken-coop by his family for almost 20 years. It is equally culpable. I understand the need to be sensitive and not to over-burden family members who are caregivers, but it is imperative to send the right signals that we do not condone any ill-treatment of mental patients by anyone. And the Bill needs to be fair in prosecuting any wrong-doers, whether they are healthcare givers, family members or anyone else.

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Sir, I would also like to seek clarifications from the Minister on the following issues:

(1) The Bill amends the maximum detention period of mental patients from 12 to six months, with further extensions requiring Magistrate approval. However, the Bill does not state if there is maximum period for this Magistrate's imposition. I would think that the maximum period is necessary as it mandates a thorough review of the patient's status before a further extension is allowed. Thus, preventing unnecessary prolonged detention of any mental patients.

(2) Clause 15(5) allows a transfer to another hospital for treatment of non mental-related illness. This initiative is good as it allows prompt treatment of the non-medical condition in a better equipped facility. However, one concern is that when deciding on the medical facility for such a transfer, it should ideally be equipped in terms of physical infrastructure to handle such mental patients, especially if they are violent or suicidal.

In clause 10 of the Bill, what is the definition of the designated medical practitioner? Must they be specialists, ie, psychiatrists? If not, can the designated medical practitioner who has the power to sign the order to detain up to one month be a non-specialist and potentially a trainee or junior doctor?

Sir, in closing, let me quote from an American writer, Renata Adler, best known for articles in The New Yorker magazine:

"Nothing defines the quality of life in a community more clearly than people who regard themselves, or whom the consensus chooses to regard, as mentally unwell."

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Sir, with that, I support the Bill.

3.41 pm

Dr Ong Seh Hong (Marine Parade): Sir, allow me to tell a story from a popular movie from Hong Kong some 20 years ago. The title of the movie was " tian cai yu bai chi ". Literally translated into English, it reads "The Genius and A Fool". The scene that I remember revolved around a mental hospital and the dialogue between a mental patient and one of the main actors.

This patient was squatting and holding a fishing rod over a bucket of water. He was asked what he was doing and replied that he was fishing. The protagonist then asked him how many fish he had caught that day. The patient replied, "Are you crazy? This is just a bucket. How to get any fish? I may be mental, but I am not stupid!"

Although this episode is fictitious and culled from a movie, it does illustrate the difficult task of defining what mental illness is. It also highlights one thing, ie, all mental patients – or the more politically-correct term is patients suffering from mental illness – are human beings too, like you and me. They have their feelings, wits and ability to think. Although they may be deluded and hearing voices when they become unwell, they can be treated and become rational. Certainly, they are not stupid.

Sir, I would like to declare my interest as a practising psychiatrist. Mental illnesses cover a broad area of human ailments. It is a problem that can afflict the young, the old and the not-so-old. A child going to school for the first time might suffer from school refusal, which is considered a form of mental illness. A person hearing imaginary voices is suffering from mental illness. So is an elder person who has degenerative brain diseases presenting behavioural problems

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and/or deteriorating memories. Another person not being able to sleep without an increasing dosage of medication may also suffer from some form of mental illness. In such instances, medication may worsen the patient's condition when the patient actually needs ultimately to be weaned off the medication to be on the road to recovery. So it is a thin line after that between a medical problem and a psychological problem.

Sir, the Bill seeks to protect the mentally ill but fails to be clear about the definition of the area of mental illness to be covered. This point was also brought up by Mdm Halimah. In fact, the onus appears to be lop-sided, weighing on the psychiatrist to set out the parameters of what mental illness is. Therefore, given the many varied types, it would be overly onerous. I hope the Ministry can be clearer in its definition of the type of mental illness that the Bill seeks to address. Moreover, the proposed Bill involves only doctors in the decision-making of applying this detention order or order for involuntary treatment in the hospital. In the UK, Australia and a number of other developed countries, these detention orders are often made

jointly by a psychiatrist and a social worker. I urge the Ministry to consider adopting a similar approach. Having such an approach will allow a more rounded and informed decision when an application is made. The social worker will balance the views of the psychiatrist and they will have to ensure that the patient's social and family backgrounds have been investigated and considered before any order can be applied

Next, I would like to touch on the problems of patient-therapist relationship. Confidential relationship between patient and therapist or psychiatrist is different when it concerns people with mental illness. Unlike the usual patient-doctor relationship – where patient confiden-

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tiality overrides most other considerations – when it concerns mental patients, we are on a slippery ground. In this Bill, I hope we can be clear where we stand. Do we make a clear stand now and debate in this House, or do we wait until something similar to the Tatiana Tarasoff's case before we act?

Allow me to narrate briefly what happened to this Tarasoff's case. This is a case of Tarasoff vs the Regents of the University of California . The family of Tatiana Tarasoff sued the Regents of the University of California for failing to act after Mr Poddar confided to his psychiatrist, Dr Moore, that he intended to kill Ms Tarasoff. Dr Moore diagnosed Mr Poddar as suffering from paranoid schizophrenia, then ordered Mr Poddar's detention, but was overruled by his supervisor. Mr Poddar plotted, waited and when the opportunity arose, he ended up killing Ms Tarasoff.

The California Supreme Court made the landmark ruling that a professional mental health body has an obligation not only to the patient, but also to the individual whom the patient specifically wanted to harm. The California Supreme Court ruling has not been accepted all over the United States, but has influenced many other judiciaries as well. In our case, since the Bill is being presented in this House, it might be in our favour to deliberate and debate it to reach a consensus. It would not be fair to leave it to our judiciary to second guess our intent. Do we take the majority stand that the communication between patient and therapist must yield to the extent where disclosure could avert essential danger to others? Or do we take the stand that the protection privileges of the patients rule supreme? This is an important issue which unfortunately the Bill does not seem to address. I would like to see the Health Minister present his learned views and then let the House debate on this issue on the sacrosanct rights of a patient.

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While we are still on this subject, I am concerned, on the other hand, about the lack of security of mental patients' rights and welfare. I echo the call by Mdm Halimah. To protect the rights of the patients, we must adopt a balanced approach between protecting public interest and maintaining the dignity of and respect for the patient. Just as while bacteria are not visible to the naked eye it does not mean that it is not present. Similarly, the absence of abuse of mental patients does not mean that it does not happen either. Given the inability of mental patients when they are unwell to control over their mind, and as an extension, ability to protect themselves, mental patients' right has to be clearly safeguarded. For example, when a patient is involuntarily institutionalised, patients should retain the right to be visited by the family, the right to legal counsel and the right to appeal against involuntary institutionalisation. The recourse to appeal needs to be immediate and not allowed to drag on.

Sir, mental illness is unique from other physical illnesses. Hence, if a patient has an acute mental illness, and especially since he is still lucid or during his lucid moment, his appeal against institutionalisation ought to be heard and considered immediately. To this end, the United Kingdom's Mental Health provision for a Tribunal could be exemplary for us.

I would like to relate another story, Sir. It was told to me that a cheerful young boy working as an office assistant had an acute stress-induced nervous breakdown when he was travelling with his office colleagues to New Zealand. He ran away from his hotel room in the middle of the night, ostensibly waiting for his flight to take him home. While waiting all alone in the airport, he started to display his clothing all over the floor. The police found him, brought him back to the

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hotel and the next day, he was brought to the psychiatric hospital where he spent the night. The boy related later that when he was in the hospital, he begun to regain his own composure and was calmer after the hospital had given him some medication. He was normal but they insisted on retaining him overnight in the hospital, together with other more seriously-ill mental patients. He went through a terrible time and no one would listen to him that he was well.

Sir, not all mental patients are alike and most mental patients are not a threat to society at large. Therefore, there must be a recourse to appeal and communications with the mental patient must always be maintained and established. I recognise that the Bill does attempt to provide some form of external audit. But if someone has been detained on a six-monthly order, waiting for six months is cold comfort to cases like the boy I have just mentioned. It might be too late for the boy. He would have been frightened by the terrible experience of living in a mental hospital and "gone mad" literally. The law must guarantee that immediate appeals and communications are allowed. Both England and Scotland made amendments to their Mental Health Act that, amongst other things, weigh heavily on protecting the rights of mental patients. In particular, both England and Scotland allow for the formation of a Mental Health Tribunal as the forum to hear cases to decide on compulsory treatment order.

Sir, there is another role of the Mental Health Tribunal. It is important in determining the type of treatment, the rights of the patient as well as when the patient can be taken into a hospital against his will. Let us talk about the treatment. In light of the different possible treatments that a psychiatric patient can be subjected to, for example, electro-convulsive treatment (ECT) or neurosurgery for mental disorder (NMD), it is all

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the more important for the rights of the patient to be safeguarded. I think the Bill is not clear on this count. These provisions are not new and they are easily available. I rather not second guess the Ministry of Health's intention to deliberately leave this out but look forward to hearing from the Minister in his explanation. I also urge the Minister to consider taking the same approach of having a Mental Health Tribunal.

Another major obstacle faced by mental patients is stigmatisation. To quote our distinguished Minister for Health, Mr Khaw Boon Wan, he said that it is as bad as the undesirable label given to ex-convicts. Like ex-convicts, mental patients may recover from their illness. Like any medical illness, they are mostly treatable with medicines or different types of psychotherapy. However, social stigmatisation has no cure. They tend to stem from ignorance, and sadly, there is a lot of ignorance surrounding mental illnesses. The findings of a recent survey support this generally accepted misnomer that mental patients are "dangerous".

Sir, this is further from the truth. The mentally ill are no more violent than those who suffer no mental illness. If you look at those persons who have committed the violent crimes, in fact, many of them are otherwise normal people with no mental illness. But Singaporeans are no different from many people all over the world in thinking that the mentally ill are dangerous people. We generally think that they are dangerous to normal people and, hence, need to be segregated. The myth that mental patients are prone to violence is probably perpetuated by the media. So this results in stigmatisation which is worse than the disease itself. Unfortunately, this Bill does not even attempt to deal with the terrible stigmatisation that mental patients have to bear.

Let me give you another survey. In a recent survey in the United Kingdom

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Parliament, published in July 2008 by the Royal College of Psychiatrist, the survey covered 94 MPs, 100 Lords and 151 parliamentary staff in the UK. It is very telling of the downside of stigmatisation. The report conducted by the All-Party Parliamentary Group on Mental Health showed that 27% of those surveyed had reported some form of personal experience of mental health problem. However, it is not surprising also to learn that one in three of them feared hostile public reaction which prevented them from being open about their mental health problems. British Members of Parliament stand to lose their seat for life if they are sectioned under the Mental Health Act for six months or more. While there is understandable reason for the British MPs to hide their mental health problems for obvious reasons, I think what is more important is that the social stigmatisation is also stopping them from seeking treatment. This is a big problem, if left unattended and will cost our society even more. So, therefore, we need to have public education.

Sir, I acknowledge that it would be an uphill task to try and address the social stigmatisation issue but given the terrible cost we would have to bear, we need to deal with them head on. For starters, we could begin with greater public education on the ignorance surrounding mental illness. We need to inform the general public that mental illnesses are treatable. It is estimated that 1% of any given population may suffer from schizophrenia. Just now, Dr Lam also quoted a report in 2004 which estimated that about 5.6% of our population suffers from depression and this will work out to about 240,000 of our population.

One of the common problems among people with mental health problems is when it comes to applying for jobs. Usually, there is a column requiring them to declare whether they have any mental

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health problems. In dealing with my patients in a psychiatric clinic, I see that this is a constant struggle for many of them because I suspect that if they truthfully declare that they have some form of mental health problems, it is very likely that the prospective employers would not even consider shortlisting them for interview. This may mean that a quarter million people may lose their job or become unemployed. And also because of this stigmatisation, many people are not seeking the necessary treatment because if I go and see a doctor and I have been diagnosed as suffering from depression or schizophrenia, the label will stay with me. If I never see a doctor, I never know that I have this illness, I would never have to declare it. So it compounded the problem even more. I think we should educate our people to let them know that delayed treatment is not to our advantage. Early detection and treatment, like Mdm Halimah suggested, will help recovery and prevent illness from developing into a crisis. So I support the Government's efforts to engage a primary health provider for early identification and treatment of mental illness, and nipping it in the bud before it becomes more serious. It would go a long way to help us from engaging a bigger medical bill.

One common problem of people with mental illness is that mental illness is a chronic condition. Besides the right dose and right type of medication, the patient needs to be followed up regularly by the psychiatrist and be given support by a network of social workers and many other agencies. However, our experience shows that a significant proportion of the patients defaulted on the treatment for a variety of reasons after they are discharged. And what will happen is that they will relapse and often result in re-admissions. This is what we call a revolving-door syndrome. I think there is one way that we can avoid the revolving-

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door syndrome by introducing a community treatment order, as proposed by Mdm Halimah.

I therefore, also urge the Ministry to ensure that patients get their regular follow-up and continue with their treatment after they are discharged from the hospital, and to provide for a Community Treatment Order to ensure continual treatment after they return back to the community. Both caregiver as well as immediate families have the responsibility to ensure that mental health patients continue with their treatment. The community support services also need to be beefed up as well. If the law fails to safeguard continual treatment and medication of the patient, the patient will be released soon after they show some sign of recovery, staying away from medication and, especially when the money is tight, they would relapse and revolve back, this time probably more serious than the last, to the hospital.

In the Community Treatment Order, we must also ensure that there is a clear involvement of social workers and all the community support services. This is because many of our patients with mental illness also face a whole range of social problems when they attempt to reintegrate back into the society. Not only discrimination of jobs, they may also have problems of housing, family relationship and financial difficulties. Therefore, this multi-agency and multi-disciplinary approach is crucial in the long-term care of the patients.

Finally, I would like to urge the Ministry to consider free continuous treatments for psychiatric patients. Because a recurring mental patient, is of little economic value to the State. It is of even little significance to his immediate family. In preparation for the play "Off Centre", Mr Alvin Tan of the Necessary Stage, interviewed some recovering mental patients, and reported that all did

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not want to reveal to him their occupation. They fear that if the truth comes out, they might lose their job. It is a fact that most employers are reluctant to employ people with mental illness. Mental patients would be even more resented by their family members if, in addition to losing their economic value, they are a financial burden to their family and that may prevent the family from wanting to support them for treatment. In this regard, I think we may be better off providing free treatment to these patients so that we can maintain them well in the communities, so that whether they can work or they cannot work, they have a more meaningful life without having to be re-admitted repeatedly – it is like a revolving-door syndrome.

Sir, with these comments, I support the Bill.

Mr Speaker: Order. I propose to take the break now. I suspend the Sitting and will take the Chair again at 4.30 pm.

Sitting accordingly suspended

at 4.07 pm until 4.30 pm.

Sitting resumed at 4.30 pm

[Mr Speaker in the Chair]:

MENTAL HEALTH (CARE AND TREATMENT) BILL: Debate resumed.

Mdm Cynthia Phua (Aljunied): Mr Speaker, Sir, I would like to begin by commending our Health Minister Mr Khaw Boon Wan for introducing the Mental Health (Care and Treatment) Bill, which is timely especially when mental dementia may be more prevalent with an ageing population.

With an increasing number of people being afflicted by psychological problems, concerns about legal implications and

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social issues with the regard to mental illness have been surfacing. The Bill is a farsighted move in drawing up a framework to provide clarity in the event of any legal disputes involving those who may be mentally ill, and in ensuring such patients are identified and given appropriate health care and attention.

However, to effectively provide support for the mentally ill, much more can be done. Although mental patients are able to turn to medical care from local hospitals and health institutions, they receive little in terms of social support. On the other hand, those who are suffering from physical health problems, such as cancer victims and the physically disabled, have the options of seeking medical and social assistance from welfare organisations that are established to take care of their ailments. This is a situation of disparity that needs to be addressed.

Few welfare organisations cater to the needs of the mentally ill. I believe there are sub-specialties in counselling and that one who is trained in psychological counselling may not be suitable to handle cases that require someone trained in psychotherapy. Hence, though some volunteers are trained in counselling skills, this does not equip them to deal with a whole spectrum of cases including involving those who are mentally ill. We must be able to train our psychological counsellors in the community to identify mental health patients and refer them to trained mental health professionals. Presently, in the community, there are very few trained mental health professionals. We need to speed up the effort to encourage this pool of professionals.

We need to increase the awareness that mental health can improve with prompt treatment, as in the case of cancer. More often than not, mental patients find themselves in the dilemma of

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whether to seek medical treatment or not. Some may find medical fees unaffordable. Some do not recognise the severity of their symptoms. Yet others keep mum about their predicament and avoid the hospital for fear of negative labels. Worse will be those who turn to pseudo counsellors who mislead them, and strip them off their life savings.

Once they are receiving treatment, they also require support to get their life back on track. So we need to organise strong support groups in the community to give post-treatment support. This is where I urge the Government to look into training a talent pool of perhaps volunteers by giving them opportunities to undergo basic training in areas that are pertinent to understanding and supporting mental illnesses. I think this is especially so for family members because they are caring for the patients day and night. Personally, when I was young, I was living, for a short period, with a mental patient and it was really very torturing and very hard on the family to care for the patient day and night. At times, when there is no medication, either because there is no financial support or the patient refuses to take the medication, the patient goes on a cyclical mood. And that is where aggressiveness comes in, there is a real need for community support in terms of even police intervention, and this is where I feel that even the Police could be involved in certain areas as well.

In Singapore, special attention needs to be given to the elderly, who constitute a large group among those with psychological problems. Last year, suicide rates among those aged 65 years and above took a leap from 69 in 2006 to 87. A large number of these suicide cases may be attributed to psychological issues. Training for counsellors to handle this group should also include lessons in local dialects so that they can communicate

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with the elderly, most of whom do not speak Mandarin, for example. This will also enable volunteers to become confidant to the elderly and alleviate their loneliness.

Lastly, I urge the Minister to look into how we can prevent people from abandoning the mentally-ill at the hospitals or institutions. Given modern technology, we should impose a system whereby the next-of-kin, guardian or family members must be tracked so that they look after these patients. Without family support, their chances of recovery and returning to society would be worse.

4.36 pm

Assoc. Prof. Kalyani K Mehta: Thank you, Mr Speaker, Sir for granting me permission to speak on this Bill.

In Singapore, one in six persons suffers from some form of mental health problem. While the current percentage of 16%-18% is lower than many developed societies like USA, where the corollary is 26%, the finding from the National Mental Health Survey has propelled the Ministry of Health to carry out a Blueprint or Master plan for the next five years. The introduction of this new Bill which replaces the earlier Mental Disorders and Treatment Act 1985 has been long overdue. For far too long we have devalued people with mental illness, and there has not been proper protection, whether medical or legal, of mentally ill persons. Stigmatisation of people who belong to this category was prevalent in the past as seen in the derogatory reference to Woodbridge Hospital as the 'mad persons' hospital. Even today, a person with a history of mental ill health would have difficulty in seeking employment.

To illustrate, allow me to describe an empirical study conducted in Singapore by a Master's level Social Work student from

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National University of Singapore. He found that schizophrenic patients were so afraid of being identified by their employers as being mentally ill that they religiously kept their appointments with their doctor, and were conscious of taking their medicines as prescribed. Hence, they lived in fear of being disclosed, and instead of advocating for better treatment by society, they kept their shroud of secrecy to hold on to their jobs. A similar study using similar research instruments, found that in contrast to the Singaporean patients, their American counterparts were more active in advocating for themselves, and did not live in fear of being identified as mentally ill. One positive outcome identified by the researcher was that Singapore patients tended to be more compliant as far as medication is concerned as compared to their American counterparts! The study made me wonder whether we could work towards a situation when schizophrenic sufferers would feel accepted by society and have a positive rather than a negative motivation to comply to medication.

In the last 10 years, the legal sector has made some progress in their recognition of the needs of the mentally ill when they appear in court. Chief Justice Chan Sek Keong, who introduced the Community Court in June 2006, introduced relevant policies as to how the mentally ill and disabled should be tried in court. His progressive thoughts in this arena are commendable.

The Mental Health (Care and Treatment) Bill is comprehensive in that it deals with the apprehension, treatment, removal and transfer from a psychiatric institution; maintenance and liability, punishment for offences against mentally disordered persons as well as for improper detention of them. It is more reactive and protective of the physical well being of the mentally ill.

Mr Speaker, Sir, I have the following concerns about the Bill.

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Firstly, not enough attention is paid to the psychosocial treatment of the abuser after he or she has been fined and punished for ill-treatment and/or neglect of the mentally disordered person. Just as we have mandated counselling for the domestic violence abuser, similarly, informal and formal caregivers may also need counselling and support to improve themselves or even show remorse for their past deeds. Caregivers, who have intentionally or unintentionally neglected or ill-treated the mentally disordered person, usually have been burnt out by the stress of caregiving which could have been for lengthy periods, eg, 20 or even 30 years. They need help too. In order not to overstretch the manpower of the Medical Social Services Departments, such abusive caregivers could be referred for counselling at the Family Service Centre nearer their homes.

My second concern is that mentally ill persons may be detained or institutionalised against their will. The reasons for detention have to be the health and safety of the mentally disordered person as well as the safety of other persons. The period of detention should not exceed six months. I would like to ask the Minister for Health whether there will be a channel for review of detention. Are there plans to develop a Code of Practice to guide any family members who may wish to seek a review of the detention order? To whom should such a request for review be directed? For comparison purposes, the British have developed a document titled "Deprivation of Liberty Safeguards" or DOLS in June 2008, which provides such information. It is reasonable for concerned family members to seek a review and they should be entitled to a full explanation, as mentioned earlier by my honourable colleague, Mdm Halimah.

Another related third concern is that of inadequate manpower to cope with the

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additional clientele in psychiatric institutions. With the broader powers assigned to police officers for the removal of mentally disordered persons, it is to be expected that the numbers admitted to the psychiatric institutions will increase dramatically. If the population of allied health workers such as counsellors, medical social workers and psychologists does not commensurate with the expansion of services, we could face insurmountable problems. I would like to ask the Minister for his plans on the rapid expansion of the sector of allied health professionals such as nurses, psychologists, medical social workers, counsellors, and the like. If our local expertise is inadequate, will our dependence on foreign labour be accelerated as a result?

It is a well-thought-out strategy to introduce the Mental Health (Care and Treatment) Bill and the Mental Capacity Bill together as they deal with connected issues. The Singapore Government is to be applauded for taking the issues of the mentally ill and disabled very seriously. It is not only imperative politically, but also morally and philosophically, for a government to support its marginalised populations and facilitate their growth and protection. By example, our Government is giving the message that the mentally disordered persons deserve a better deal in life, and better services, which they may have been deprived of either by choice or circumstance. The inspection of psychiatric facilities by a Board of Visitors every three months is also necessary to maintain the institutions' high level of quality of care.

On a broader level, we need more evidence-based research to identify the causes for the rise in mental illness in our population. Does the Ministry have any plans for conducting such research? If yes, can the Minister please elaborate? Prevention is the better route, both

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economically as well as in terms of productivity; some forms of mental disorders are hereditary and it is hoped that our Singapore Genome Project may help in future to curb such sources of mental illness. Alzheimer’s disease is one such mentally debilitating disease.

On this note, I support the Bill.

Mr Ang Mong Seng (Hong Kah): ( In Mandarin ): [For vernacular speech, please refer to Appendix A.] Mr Speaker, Sir, mental disorder is one that is not easily detectable. According to my understanding, even the doctor and psychiatrist agree that two doctors will never get the same diagnosis for a psychotic patient.

I would like to ask the Minister how does MOH define mental disorder. For instance, making gestures in public, making indiscreet remarks, sloppily dressed, or scolding people for no reason – is this considered a case of a mentally deranged person? The person might not have vandalised, or hurt anyone. However, a mentally deranged person can vandalise public property, he cannot refrain from dangerous behaviour, and can inflict harm on another person. But according to the proposed amendment, the police officers will only transport the mentally deranged person to the hospital for treatment in the event a member of the public lodges a complaint. But members of the public are usually not proactive and they will not call the police. If these psychotic patients are not treated in time, their illness will get worse.

Therefore, I propose that we empower our police officers with the authority that in the event they encounter mentally deranged persons, they can "invite" them to the hospital for examination. If the patients’ condition is not too serious, the family members can take care of them, make sure that they receive treatment periodically, so as to prevent it from worsening. For those with a critical

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condition, the Government should make it mandatory for them to receive treatment.

Singapore is facing a greying population, and we know that dementia is one very common case of mental disorder. If you have watched Jack Neo’s movie "Money No Enough II", in one part of the movie, the elderly mother has dementia and she repeatedly asked her son, "Have you eaten?". This has caused misunderstanding between the mother and son, and we can see that dementia has similar symptoms as that of mental disorder.

Therefore, I would like to ask the Minister, under the proposed changes, will there be any negative impact on the elderly who have dementia? My worry is that some parents might abuse the system and they get the police officers to send their old folks for examination, or compulsorily admit them into psychiatric institutions. This may cause family discord and could be detrimental to our Government’s family policy. In this regard, how can the Ministry ensure that all these dementia elderly are not treated as psychotic patients?

*Cols. 173-174.

4.48 pm

Mr Khaw Boon Wan: Mr Speaker, Sir, let me thank Members for rendering their support to this Bill. Members have spoken very passionately on this subject and I have noted all their feedback and suggestions.

As noted by Members, mental disorder covers a very wide range of mental illnesses, and that is why most legislation, including ours, have to define "mental disorder" very widely. Mdm Halimah, Dr Ong Seh Hong and, just a while ago, Mr Ang Mong Seng seem to prefer a clearer, presumably, tighter definition. But the objective of this Bill is to ensure that those mentally ill patients who require

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institutionalised psychiatric care are accorded prompt treatment. Not all mentally ill need to be institutionalised. In fact, only a small minority do. Mdm Halimah and Dr Lam highlighted this point a while ago. So all patients have to be assessed and a medical judgement made. We think this is best achieved by allowing the attending doctor to make such an assessment rather than trying to hard-wire the various possible mental disabilities into the legal definition. But because mental disorder covers a wide range of mental illnesses, the stereotype image of the mentally ill is most unfortunate, incorrect, unfair and unhelpful. A senior doctor once commented, probably half in jest, that to different degrees, we are all mentally ill. In fact, he probably meant it quite seriously.

The fact is that most mentally ill patients can carry on a productive life, especially if they comply with the doctor's medical prescription. They do not need to be institutionalised. Even for the small minority who require institutionalisation, extended institutionalisation is now the exception rather than the rule. This is the result of better medical knowledge and advancement in mental healthcare. Unfortunately, society's perception of the mentally ill remains largely archaic.

As noted by Dr Ong Seh Hong, a recent study by IMH found that more than one in three Singaporeans believed mentally ill patients to be dangerous. About half of the respondents felt that the public should be better protected from people with mental health problems. The stigma runs deep, as noted by several Members. The majority of the respondents believed that mental health problems could afflict anyone, including themselves. But about half would not want anyone to know about it, if they were to suffer mental health problems, and that is why many continue to delay treatment to the detriment of their own health. And this is not unique to Singapore. Dr Ong quoted a

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similar study in the United Kingdom. So, clearly, we have much to do. We have to work harder to correct the misperceptions, destigmatise mental illness, promote mental health and ensure that the patients receive prompt care in the appropriate setting, whether it is in a hospital or in a community.

Mdm Halimah, Mdm Cynthia Phua and Dr Ong highlighted the benefits of educating the public about mental health. I totally agree. Early treatment and detection aid recovery and prevent the illness from getting worse. These are the issues we need to address through community-based mental healthcare programmes. Medical experts agree that community-based care is the way forward in improving the standards of care for the mentally ill by focusing on rehabilitation and integration of the patient into society as far as possible. There is evidence to suggest that aggressive community management of persons with mental illness can result in improvements in the quality of life, greater acceptance of treatment and reduction in hospital readmissions.

Last year, my Ministry launched a five-year programme to help enhanced mental health. So we are now into year two. There are four key thrusts – improve public education on mental health, develop community-based mental healthcare services, increase manpower and enhance research capabilities in mental health. I think we are all on the same wavelength here, based on what Members have spoken.

Two-thirds of the fund would seek to expand the community's resources for persons with mental illness. This includes developing partnership with GPs, community mental health teams and integrated medical psychological teams. The community mental health teams

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target four significant groups - school-going children, adolescents, adults and the elderly. They provide clinical services which include diagnosis, treatment and support to persons with mental health conditions in the community. They also provide training to front-line staff in a community agency as well as carers, a point raised by Mdm Cynthia Phua. The targeted agencies include eldercare services, VWOs, grassroots organisations and schools to teach them to detect possible mental health problems in their clients and educate them on the follow-up steps that they should take.

Early detection and intervention programmes ensure that persons who have just developed mental disorder can reintegrate into the community as soon as possible. With good clinical care and strong support in the community to ensure good compliance with follow-up treatment and rehabilitation, the mentally ill in the community can be managed much more effectively. About $18 million is set aside for public education to increase awareness of Singaporeans about the importance of mental wellness and what they can do to maintain it. Like all things, a preventive approach is best. If we wait until it is too late, it is really too late. We can try to remedy and rectify, but it is never satisfactory and full recovery is almost impossible. The Health Promotion Board will implement its health promotion activities across a variety of settings, such as schools and workplaces, targeting Singaporeans at various stages of life.

I agree with Mdm Halimah and Dr Ong that society needs to help the mentally ill in many areas, including trying to secure employment. IMH has a job club programme to facilitate the employment of persons whose mental disorders have stabilised by providing rehabilitation and skills training. I believe strongly in this, but I know how uphill the task is. I have looked at the "Yellow Ribbon" programme

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which tries to help the ex-convicts secure jobs. It started off difficult, as usual. But after 10 years, it had achieved quite good results. I challenged our people in IMH and the Ministry of Health to try to do something similar, though knowing that getting employers to accept ex-convicts is probably easier than the ex-mentally ill; a lot has to do with social stigma, which many Members have talked about. Society tends to generalise that all mentally ill are identically of the extreme, when in fact these are the small minority. Many can be stabilised and rehabilitated and can function like you and me. So we need the support of many to make this work, ie, employers, fellow employees, family members, community rehabilitation organisations as well as agencies like the Workforce Development Agency (WDA) and CDCs. Through these initiatives, we seek to train more GPs to better manage their mentally ill patients, avoid hospitalisation, reduce length of hospital stay, increase public awareness of the importance of public mental health and knowledge of coping strategies as well as improve the level of functioning of the mentally ill patients.

I agree with Mdm Halimah and Prof. Mehta that we need to ramp up our manpower in a big way to support mental healthcare. We need many more trained professionals who can manage persons with mental illness effectively. Mental health or psychiatry has now been incorporated into the basic training of medical doctors, nurses and therapists. We support post-graduate training and specialisation in mental health for healthcare professionals through training awards and scholarships.

As Members noted, there are now 116 registered psychiatrists in Singapore. Too few! We have to ramp up the number. I am quite glad to note, just before coming here, that right now, we have 50 trainees in the pipeline. We are definitely going to increase the number to at least 200 by

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2015. It can be done. If we need to augment with foreign recruits, we would do so. This would raise the psychiatric population ratio to about 4:100,000 – still low compared to many other countries, but a significant improvement compared to today. But we have to take a multi-disciplinary team approach, relying not merely on psychiatrists. $15 million has been set aside to develop mental health manpower through the training of nurses, clinical psychologists, occupational therapists, medical social workers and many more, as noted by Mdm Cynthia Phua.

Mental health scholarships, awards and other skills development opportunities are also being offered. GPs can do more, as our key partners in managing patients with more stable and less severe mental illness in the community. Hospitals are training our GPs and engaging them in close working partnership to deliver continuing mental healthcare in the community. A new graduate diploma in psychiatry for GPs will also be launched. The family medicine training programme which prepares our young doctors to become GPs now includes a core posting in psychiatry. That probably helps explain the big increase in the number of trainees in psychiatry.

There are nearly 500 nurses who have specialised training in mental health today. We will support more nurses for skills upgrading. This year, 35 nurses have been awarded scholarships to do so. And from this year, 15 new fellowships will be offered annually for allied health professionals to pursue skills upgrading or postgraduate training in clinical psychology, occupational therapy, medical social work and other mental health areas.

Prof. Kalyani Mehta asked about clinical research. Yes, this is also an area of emphasis. Out of the five-year programme funding, a small though significant sum is set aside for research,

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to particularly pay attention to applied research; how we can reduce hospitalisation stay, how we can avoid re-admissions to hospitals, and other related areas. Over all, my Ministry will continue to review these measures, study the experience elsewhere, whether it is Australia or New Zealand, and improve ours so as to enhance the care and treatment of the mentally ill here.

Let me now address some specific queries on the Bill. Dr Lam asked whether non-psychiatrists, including potentially untrained junior doctors, may sign the orders to detain patients for care and treatment. The answer is no. Clause 2 of the Bill states that only a doctor working in a psychiatric institution and who is designated in writing by my Ministry may sign such an order. And, obviously, we would only authorise doctors who are competent and have been properly trained.

Several Members were concerned about patients being subjected to unnecessary or prolonged detention. This is a valid concern. Mdm Halimah and Dr Ong called for a Mental Health Review Tribunal to hear appeals by patients and their families. Mdm Halimah asked for stronger protection of a patient from the arbitrary exercise of the power of detention, now that it has been increased. Dr Lam asked if there is a maximum period of which a Magistrate may order a patient's detention. Let me clarify that, as compared to the current Act, this Bill does not increase the power of detention or the length of time for which a patient may be detained. On the contrary, this Bill is to reduce the power of detention. The maximum period of detention, for example, is now halved. Let me stress that not all mentally ill patients can be detained by us. We must fulfil two conditions:

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(1) That his condition requires in-patient treatment. If he does not require in-patient treatment, there is no reason to exercise this Act; and

(2) That detention is necessary in the interest of his own health and safety or for the protection of other persons.

So, both criteria must be valid before we can exercise this power. And there are checks and balances in place to ensure there is no abuse. For instance, the need for detention is reviewed regularly by a multi-disciplinary team treating the patient, as well as by the Visitors Board. The Visitors Board comprises lay persons and doctors who are not working at a psychiatric institution. As an added safeguard, applications for detention of up to 12 months at a time can only be made by these external visitors, after reviewing the institution's report and personally inspecting the patient. The visitors' application is then carefully scrutinised by the Magistrate who then decides whether to make such a detention order. Apart from these safeguards, applications may be made to the High Court for a review of any detention to challenge the lawfulness of a detention. Once a patient is assessed as no longer posing a danger, he will be discharged from detention immediately.

As this is not a new power, let us see what has been our actual experience. Last year, for example, IMH had more than 3,000 admissions under the Mental Disorders and Treatment Act. But of these, only five cases required further detention beyond one month. In fact, only 5% of these cases require detention beyond three days. So, the bulk of the detentions are for less than 72 hours. A Magistrate's Order for extended detention is also rare.

I believe the current measures are adequate, based on actual experience. We will study best practices overseas to

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see whether additional safety nets, such as the tribunal that Members mentioned about, should also be put in place. I will keep an open mind on this particular issue.

Mdm Halimah expressed concern that a reduction in the minimum frequency of visitor inspections might affect the protection of patients. Let me assure this House that the protection for detained patients will not be compromised. The amendment refers to the minimum frequency of visits. So it does not prevent visitors from conducting more frequent checks. We have added a provision which allows the Director of Medical Services to order additional visits if he deems necessary. The visitors can also make surprise random checks at any time. The visitors have a comprehensive list of tasks to perform whenever they conduct an inspection. Besides inspecting the institution, they also have to carefully review the overall well-being of the detained patients through observations and interviews. In addition, they need to evaluate patients detained by court order under the Criminal Procedure Code, make recommendations on patients' fitness for discharge from detention or from a remand to an open ward.

Mdm Halimah and Mdm Cynthia Phua spoke on continuing care for psychiatric patients after their discharge from hospitals, and this is clearly necessary. Last year, my Ministry provided about $7 million of subsidies to support such long-term care for psychiatric patients. This will not be sufficient, going forward. Our approach is to ensure that a wide range of community-based services are available to help these patients. We will invest more resources to expand the sector as demand increases.

Mdm Halimah and Dr Ong have asked us to study the feasibility of supervised community treatments. Mdm Phua also called on MOH to support the

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management of these patients in a much more aggressive way in the community, and we will try to be aggressive. Mdm Halimah referred this House to the New Zealand Mental Health Compulsory Assessment and Treatment Act. If a patient can be treated in a community and does not pose a danger, then he cannot be detained. Detention is a major step and that is why we set the threshold high. But countries, such as New Zealand, have gone further. Under the New Zealand scheme, two kinds of compulsory orders may be made.

The first is an in-patient order which is similar to our Bill, when detention and in-patient treatment are considered absolutely necessary.

The second is community treatment order, where a patient can be adequately and safely treated on an outpatient basis and he is ordered to undergo treatment in the community. Mandatory community treatment is therefore a complement to compulsory in-patient treatment and an extension of legal coverage. It is not an alternative.

My Ministry is committed to ensuring that patients with mental disorders are treated in the least restrictive way possible. Like any other illnesses, such patients and their families should be encouraged to seek help, whether in the community or in a hospital. Detention is really a last resort, when a patient poses a risk to himself or to others. Even when detention is necessary, there is a provision in the Bill to grant the patient leave from the institution. This is one mechanism to transit patients back to the community even before formal discharge, when the risk to themselves or the community is reduced.

Our intent is clear. It is to shift the focus of caring for the mentally ill from the institution to the community. If a patient does not need to be detained, then

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we think it is best to emphasise voluntary treatment and community self-help, rather than resort to legal compulsion. That is why we promote voluntary community mental health treatment programmes rather than extend the law to make community treatment compulsory.

Nevertheless, I keep an open mind. We will closely monitor the progress, outcomes and the effectiveness of our own programmes and compare them with the experience in New Zealand and elsewhere. We can then decide if we need to extend the law to provide for community treatment orders. But, meanwhile, we step up and strengthen the community services. There is a gap and let us plug the gap first. We will think about the law later.

Mdm Halimah asked for MediShield to cover mental illness, while Dr Ong suggested that treatment be free. With Medifund, some mentally ill do not pay anything. So, it is free for them. But they have to be properly means-tested to avoid any abuse. MediShield does not cover mental illness because its premiums have not factored in such a liability. If MediShield is to cover mental illness, these premiums will have to be raised. But I have mentioned before that I keep an open mind on this particular idea. At some stage, when we are going to revise MediShield again, we can think about this particular idea.

Mdm Halimah was concerned that increasing the maximum penalty in clause 8 of the Bill will cause hardship for caregivers. Under clause 8(3), a police officer is empowered to visit and inspect a mentally disordered person to ascertain whether or not he is properly cared for or whether he is being ill-treated or neglected. A caregiver commits an offence only if he refuses to allow the police officer access. I believe it is

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necessary to enhance the penalty for such an offence so as to protect the patients in the community.

Mr Ang Mong Seng was worried that family members may abuse the elderly with dementia by complaining to the police so that these elderly persons can be arrested and removed from their homes. If so, this will indeed be a very sad development for our society. The police will not detain any person indiscriminately based solely on complaints. They will conduct a thorough investigation and assessment of the situation. On the other hand, if the investigation turns out that the family members have ill-treated their mentally ill relatives – a scenario painted by Dr Lam just now – they would have committed an offence, not under this Bill but under the Penal Code, and will be taken to task. In any case, each case will have to be looked at individually and we should not jump to any hasty conclusion or moral judgment. It is easy for outsiders to criticise a family member living with a mentally ill 24 hours a day, seven days a week. As Mdm Halimah, Mdm Cynthia Phua and Prof. Kalyani Mehta have noted, sometimes the family members will need strong support and treatment too.

Mdm Halimah asked what constitutes dangerous behaviour, whether police officers are trained to handle persons with mental disorders and how they assess that a mentally disordered person is indeed dangerous to himself or others. Dangerous behaviour may include arming oneself with a knife or other sharp object, threatening others, or putting oneself in a precarious position, for example, climbing out of the window to stand on the parapet. In dealing with such situations, the police will bring the mentally disordered person into safe custody first before referring them to medical assessment and treatment. The police have proper procedures in place to handle such persons. These procedures will guide

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officers on the course of actions to take, to assure, to pacify and to persuade the person to go for medical treatment. Where force is required as a last resort, to disarm the person or to bring him into custody safely, these procedures further specify that such force shall only be sufficient to overcome the threat or resistance. In short, police officers do receive training in handling persons with mental disorders.

Mr Ang Mong Seng asked if the police can be more proactive in getting patients, behaving strangely before they become violent or dangerous, to seek treatment early. We certainly should try, whenever we come across such cases, to alert the medical officers and hospitals so that we can start early treatment or diagnosis. But I hope we can do it in a way which will not reinforce the flawed stereotyping of the mentally ill. Some of this social nuisance does not equate to dangerous behaviour. It simply means that the person is unwell

and we should find the root cause to it. Is he getting enough support and care from his family, compliant with his treatment or experiencing a relapse? Let us all, as family members, neighbours and fellow Singaporeans, lend a listening ear and a helping hand. Society can play a greater role in supporting the needs of the mentally ill. Police assistance can be sought, however, if the public thinks that the nuisance is persistent and it poses a danger to himself or others.

I thank Dr Lam for expressing concerns about the welfare of healthcare givers working in psychiatric institutions but we are used to dealing with such occupational hazards. The IMH has a framework in place to deal with cases of assault on staff.

Clause 15(5) of the Bill allows the transfer of detained patients to another hospital for treatment of non-mental related illness. Dr Lam was concerned

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that the receiving hospital's facility might not be adequate. We will work with the hospitals to ensure that they have the necessary capacity and capability to manage these patients.

Dr Ong highlighted the 1976 California Supreme Court ruling of Tarasoff vs Regents of the University of California and asked for a debate on this issue. While I agree that the California case threw up an important issue, I doubt this is the occasion to debate it. I do not think it is appropriate to legislate on a psychiatrist's duty of care towards third parties in this Bill. Without detracting too much from the debate on this Bill, let me just say that the doctor-patient confidentiality is fundamentally important but it is not absolute. There may be very compelling situations where countervailing public interests may justify disclosure. This is also recognised in the Singapore Medical Council's ethical code and ethical guidelines.

Mr Speaker, Sir, my Ministry will continue to work with other ministries and agencies on this nation-wide mental healthcare programme. My Ministry cannot do this alone. Under this programme, we will pro-actively care for patients across a wide spectrum of mental health conditions. The focus is prevention, early treatment for those who suffer from mental health conditions, get them back on their feet with continuing care in the community wherever possible. While the Government will work hard on this, the society at large has to work even harder on changing mindset, ie, employers, fellow employees, fellow Singaporeans, family members, neighbours. The mentally ill need our help, our sympathy, our empathy. Try to put ourselves in their shoes. If you continue to stigmatise mental illness, treat all of them like psychopaths, we will only make their conditions worse and their recovery more difficult.

I, therefore, join Mdm Halimah, Dr Ong, Mdm Cynthia Phua and all the

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Members who have spoken, to appeal to all Singaporeans to join us to help these unfortunate patients. But for a small minority of these mentally ill, their psychiatric problems necessitate their involuntary admission, care and treatment in a psychiatric institution. This is to ensure their personal safety, health and to protect other persons in the community. Hence, we need this Bill and, once again, I thank the House for their strong support.

Question put, and agreed to.

Bill accordingly read a Second time and committed to a Committee of the whole House.

The House immediately resolved itself into a Committee on the Bill. – [Mr Khaw Boon Wan].

Bill considered in Committee; reported without amendment; read a Third time and passed.