The Institute of Mental Health (IMH), formerly known as Woodbridge Hospital (WH), celebrates its 95th anniversary this year. To commemorate the institution's many years of caring for Singapore's mental health, SMA News presents an interview with Dr Chee Kuan Tsee, emeritus consultant and the longest serving psychiatrist of IMH, in which we looked back at the development of both the IMH and psychiatry in Singapore.
The beginnings – WH to IMH
When did it all begin?
WH was built in 1928 and the later-built IMH has continued its functions and services at its current premises in Buangkok since 1993. The public and newer staff will remember only IMH, though WH and IMH are one in continuity. However, that has helped in some way to reduce the stigma surrounding mental illnesses. Such stigma is also diminished by the involvement of volunteers, increased interactions with communities, as well as the improvement of mental health literacy through education and media exposure.
How big was the old WH and how was it structured?
WH occupied a land area of about 145 hectares while present-day IMH occupies about 23 hectares and is surrounded by HDB flats and other buildings. The WH's main building consisted of two storeys. The upper storey was occupied by the medical superintendent's (MS) office, an administrative office and a small common hall. The MS had a "personal secretary" shared with the psychiatrists. She used the manual typewriter initially. There was also a hospital secretary who had a dozen administrative staff under him. The MS, hospital secretary and junior administrative staff each wore multiple hats in multiple roles and functions.
The lower storey was occupied by a female ward, a pharmacy and an outpatient clinic-cum-psychiatrists' offices. Behind the main building, three long corridors were spread out like a fan. On each side of the corridors were 50 dormitory wards along large annexed fields. The central corridor housed both male and female medical wards on each side, where primary care was given to patients with common medical conditions. The patient wards on each side of the corridors consisted of acute and long-stay chronic wards. There was a laboratory next to the medical wards. There was also a forensic ward and a mental defective ward. At the end of the central corridor was the kitchen where worker patients helped and pushed food trolleys to deliver meals to the whole hospital.
Medical officers (MOs) worked in WH as holistic doctors. Among their many duties, the MOs clerked, admitted and discharged acute and relapsed patients, and followed up with long-stay chronic inpatients and outpatients. They also looked after and treated patients with primary medical illnesses. They worked fairly independently and their work included giving electroconvulsive therapy and even performing toilet and suturing of wounds. The MOs were also involved in the rehabilitation of patients with other allied staff. They would present new and problematic patients during clinical ward rounds.
Were there other facilities aside from wards?
Within the WH campus, there were buildings for patients without subsidies or "paying patients", children and adolescents, and the school of nursing. The MS had a bungalow residence for himself and there were also other quarters for staff such as doctors, nurses and attendants.
In front of the hospital beside the canteen, there was a large playing field used by the public and staff for games and sports. We had a lot of fun playing and competing together among all grades of staff and patients.
Where can we find chronicles of Singapore's mental health journey?
There are two notable books on the history of WH/IMH. The first book Till the Break of Day: A History of Mental Health Services in Singapore, 1841-1993 was written by Dr Ng Beng Yeong. It is a well-researched history of mental health services in Singapore covering both the colonial era and post-colonial development from 1841 to 1993.
The National Mental Health Blueprint was enacted from 2007 to 2011 to focus on aspects of mental health such as mental health education and promotion, integrated mental health care, developing mental health professionals and developing mental health research. These efforts are chronicled in the second book, Mental Health of a Nation, edited by Dr Ng Beng Yeong, A/Prof Daniel Fung and other contributors.
These two books provide a comprehensive and detailed history of psychiatry and mental health services in the colonial era and post-independent days, as well as modern psychiatry in Singapore.
What was the discovery in 2014 of a 127-year-old relic about?
In 2014, the co-founder of the Asia Paranormal Investigators Charles Goh unearthed a 75-metre-long colonial wall belonging to the defunct New Lunatic Asylum of 1887. Interestingly, the New Lunatic Asylum was a more humanistic institution for that era. Typically for that period, the standard of psychiatric management was of incarceration and less than humane in nature.
What happened to the mentally unwell patients during the Japanese Occupation in the 1940s?
During that period, the Japanese took over the Mental Hospital (former name of WH) and renamed it Miyako Byoin (serving as the Japanese civilian and military hospital) where 800 civilian casualties were treated. Some patients were sent home while about 500 others were moved to St John's Island. Many on the island died of starvation and the survivors returned to the hospital at the end of 1942.
The journey – practising in WH
When did you join WH and who were some of your colleagues?
I started working in WH in October 1967 and have specialised in psychiatry since the end of 1971, after a Colombo Plan Fellowship in London. I have thus been working in IMH for more than 55 years, albeit only part-time now. When I started work, Dr Yap Meow Foo was the first local MS and a psychiatrist with a Doctor of Medicine degree. The titles of CEO, medical director and later chairman of the medical board (CMB) were instituted after we moved to IMH, when many aspects of the hospital including various terminology became commercialised. The most senior psychiatrist then was Dr Wong Yip Cheong, who had a diploma in psychiatric medicine (DPM) and was a member of the Royal College of Physicians of Edinburgh. Dr Wong was also the first lecturer in psychiatry for medical students. He was simply hilarious and inspiring, and his classes were always full.
What was the medical manpower situation like?
When I first joined WH, we had about half a dozen psychiatrists and ten MOs providing psychiatric services for the whole of Singapore. We had over 1,000 inpatients and many outpatient clinics across Singapore at locations such as Bukit Timah, Maxwell, Kallang, Paya Lebar and Queenstown. There were other outpatient clinics added later. The senior registrar and consultant psychiatrists would cover Outram Road General Hospital (now Singapore General Hospital) and the now-defunct Toa Payoh Hospital, seeing "blue letter" referrals and outpatients. Later, the second MS, Prof Tsoi Wing Foo, who was doubly qualified with a DPM and was a member of the Royal College of Physicians, Glasgow (MRCP[G]), moved to the National University Hospital to head the new Department of Psychological Medicine. At that time, each doctor would review around 40 outpatients in two and a half hours at the clinic. Patients literally queued in line to get their prescriptions and move on. One doctor even had the dubious title of the "fastest pen in action".
Was the compound dark and scary? Were there rumours about the hospital being haunted?
Only one MO would be on duty at night covering the admission room, all the wards and Trafalgar Home (which was for leprosy patients), while there was a psychiatrist on call for consultation. The 50 wards which spread out fan-like on each side of the three long corridors were dimly lit. It was quite scary to walk alone at night to answer calls, especially for the women MOs.
There was only one small common room for the doctors. There was a bed for the MO on duty and a table for the doctors to have meals, play chess and read papers. It was the centre for leisure and social activity. The attached bathroom had a cement floor. This doctors' room was rumoured to have been the mortuary or post-mortem examination room during the Japanese Occupation, when WH was used by the Japanese as the civilian and military general hospital.
Which staff were in the multidisciplinary team (MDT)?
At the time, there was only one psychologist, one almoner (which is now known as medical social worker), one pharmacist, one occupational therapist and one laboratory technician. Nowadays, the MDT would include nurses, case managers and more.
What was rehabilitation like for patients? Did they work in the hospital and if so, were they paid?
Besides pharmacotherapy, patients also went for occupational therapy. They were taught carpentry, basketry, rattan work, soft toy making, sewing curtains and light industry skills. There was also farm work and chores such as cleaning, laundry and kitchen work. The View Road Hospital (VRH) was a subsidiary of the WH that overlooked the Johore Strait and it took in stable patients. Some of the patients would go out to work in orchid farms and pet fisheries, and take up odd jobs during the day, then return to VRH at night. They were all paid a small allowance and had their own Post Office Savings Bank accounts. Meanwhile, psychosocial management treatments have become more important in the contemporary era. In a way, the recovery pathway has been a reinventing of the wheel of past rehabilitation with improved manpower and facilities.
The lifework – personal thoughts
Who did you look up to and why?
The psychiatric departments were divided into three units each with a head and a few MOs. A special mention needs to be made of Dr Teo Seng Hock's contributions. Like Prof Tsoi, he was also doubly qualified with a DPM and an MRCP(G). He was the longest serving MS for 17 years and wore many hats. As the head of Unit II, he was the equivalent of the present CEO, CMB, chief operating officer, chief financial officer, chief human resource officer, etc, all combined. The hospital secretary shared these roles and functions with Dr Teo collaboratively. In addition, he was the director and chief examiner of the NUS postgraduate psychiatry course for the Master of Medicine Degree in Psychiatry. We started our own psychiatry training and awarding of the local qualification in the early 1980s. This stopped later when trainees started sitting for the standardised UK Member of the Royal College of Psychiatrists examinations.
Dr Luisa Lee, the first and only female CEO of IMH, was responsible for the smooth logistic transfer of patients from WH to IMH in 1993, with the help of the Singapore Armed Forces. It must be added that Dr Teo, under the direction of the late Dr Kwa Soon Bee, then Permanent Secretary and Director of Medical Services of the Ministry of Health, played an important part in the building of IMH. Dr Teo, Dr Ong Thiew Chai (now in Tan Tock Seng Hospital) and some architects went on many overseas trips to observe and study different mental hospitals. During the 1970s and 1980s, developed countries were in the political process of abolishing large mental hospitals to transition to small units in general hospitals and community psychiatry. Singapore went against the trend to build a 2,000-bed IMH. Dr Teo's emphasis then was to have more spaces for patients, such as the day care centre and rehabilitation activity centres for both inpatients and outpatients. These spaces have since been re-allocated for use by staff. By 2013, the additional Annex building had become necessary for the growing number of staff. Nevertheless, IMH has become a showpiece and object of envy to foreign visitors.
How has the practice evolved over the last 95 years?
Both medicine and our patients have changed enormously. Diagnostic procedures and latest treatments have been escalating in cost. We are depending more and more on laboratory and radiological investigation, use of machines, digital technology and artificial intelligence (AI). Our patients are also evolving. In the early days, we hardly saw patients with eating disorders, self-cutting harm tendencies, personality disorders or drug addictions. Now, these disorders are a great challenge to manage. In the earlier days, we saw the cultural syndromes of koro, trance states and spirit possessions, which are all almost absent now. Bettereducated families have become more demanding and aggressive as well as being more Internet-savvy. The modern AI could lead to the reverse cloning of man, as AI technology depends on the downloading of human knowledge from human users.
Specialisations in medicine have divided the body into parts and each part into further subspecialties. Psychiatry, likewise, has divided the mind into different mental functions. In the past, one doctor looked after many patients, but now many specialists manage one patient.
Does becoming a doctor equate to having glamorous life?
In the old days, doctors used to enjoy respect, status and a good life. But with the commercialisation of all things in life, the lustre of the medical vocation has been diminished. Being able to have a good life or lifestyle has been affected. Much of our hard-earned income goes to the landlords and our overheads, similar to the financial situation of hawkers. When morals and ethics are carelessly compromised, respect and status are also lost.
In the training of young psychiatrists or doctors, we need to go back to our medical pledge and vocation calling. Spouses and families need to be understanding and united when faced with life changes and the attraction of material success. We should live in accordance with what we can afford and be morally upright instead of aspiring to achieve certain lifestyles at all costs. We should first aim to be a holistic doctor before considering specialising.
What golden advice would you give to fellow doctors?
The adage of "to cure sometimes, to relieve often, and to comfort always" is still wise and relevant. Also, another saying to remember is "first do no harm" – to do no harm to anybody by what we do, no harm to the mind by what we say, and no harm to the pocket by what we charge. There can still be satisfaction and pride when we practise with competence and compassion. Just as IMH's tagline goes: Loving Hearts, Beautiful Minds.
Aerial view of the old Woodbridge Hospital
Patients doing carpentry work