An elderly woman could not cope and became depressed when her husband was diagnosed with terminal cancer and had to be admitted to a hospice. A young man who was about to pursue further studies grappled with severe anxiety while balancing his work and other commitments. An elderly man with schizophrenia and other chronic medical conditions adhered poorly to his treatment plan because he had mobility problems and a poor understanding of his own condition, and his visually impaired spouse struggled to care for him. These are some of the cases that are presented to social service agencies, primary care providers or the various hospitals' community care teams.
In Singapore, the number of seniors aged 65 years and above will rise from the current one in five to nearly one in four in 2030.1 More people will be living with chronic medical conditions, and these conditions are associated with higher mental health morbidity. Our youths are also facing an increasingly complex and uncertain world, with some finding it difficult to cope. The COVID-19 pandemic has further exacerbated mental health issues in our communities, not least because of increased social isolation.
No health without mental health
The World Health Organization (WHO) defines health as "a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity".2 Dr Brock Chisholm, the WHO's first director-general and a psychiatrist, viewed mental and physical health as being intricately linked and he once said, "Without mental health there can be no true physical health."
Comorbid mental illnesses, if untreated, can affect one's ability to cope with disease and frailty, leading to poorer self-care and suboptimal treatment adherence and outcomes. Conversely, there is also increased physical morbidity and mortality in people with mental illnesses, associated with unhealthy lifestyle factors, medication side effects and lack of access to physical healthcare.
The hospitals' community care teams have been providing interventions for patients with physical illnesses and those living in the community. Frequently, they encounter mental health issues in the patients they serve. Some patients struggle with symptoms but are not keen to seek psychiatric help, while others have difficulty keeping up with follow-up appointments and treatment for both physical and mental health conditions because they are frail or socially isolated.
Earlier detection, earlier care
It helps therefore to focus on high-risk populations by proactively detecting mental health issues early and intervening accordingly. Tan Tock Seng Hospital's (TTSH) Consultation-Liaison Interventions for the Mind and Brain (CLIMB) programme focuses on patients with neuropsychiatric disorders (such as stroke, traumatic brain injury and Parkinson's disease) who may have problems with emotional management, behavioural control, cognition and sleep. The CLIMB programme supports these patients by providing mental health screening, treatment, liaison assistance with healthcare providers and community services, and education for patients and caregivers.
Another useful approach is providing psychiatric support to our hospitals' community health teams (CHTs). TTSH's CHT-Psychiatry service is a collaboration between TTSH's psychiatry department and CHTs to support CHT staff in their day-to-day work, through providing training in basic mental health awareness and intervention skills, and case discussions with psychiatrists on psychiatric management for their patients. This arrangement makes care coordination easier, thus especially beneficial to patients with both physical and mental illnesses requiring interventions from different health and social care providers.
Promoting integration of care
For those seeking help for mental health reasons for the first time, navigating health and social care services can be daunting. Increasing awareness of the resources available and integrating care among different providers would be helpful for these people.
Community Resource, Engagement and Support Teams (CRESTs) and Community Intervention Teams (COMITs) are driven by social service agencies and are important entry points for mental health care and support in the community. They can connect service users with social care, primary care providers or specialist mental health services as needed, and they in turn receive referrals from these services.
CRESTs are community outreach teams that provide screening for mental health conditions and first-line emotional support for people with low mood and anxiety problems or those at risk for dementia. They also help raise awareness of mental wellness through public talks. COMITs are multidisciplinary teams that provide mental health needs assessments, counselling and psychosocial therapy for clients with mental health or dementia needs, and their caregivers.
Primary care providers can also be the first point of contact for those with mental health issues, which can present overtly as mental health symptoms or sometimes manifest as physical symptoms like shortness of breath and palpitations due to anxiety.
Currently, the bulk of referrals to CRESTs and COMITs come from hospitals, social care services, caregivers, and self-referrals. There is a lot of synergy in having hospitals' psychiatric services, primary care providers (ie, GPs and polyclinics' health and mind clinics), CRESTs and COMITs work closely together, either through mental health training, consultations on mental health issues, and/or shared care and referrals. Psychosocial interventions would complement pharmacotherapy in primary care for better clinical outcomes and functional recovery.
Much of what has been done to promote physical health in our communities can also support mental health care delivery. Alongside other hospitals in the National Healthcare Group (NHG), TTSH is building communities of care (CoCs) in the neighbourhoods. These CoCs are localised health and social care networks that aim to meet the health and social needs of residents and coordinate care for those with complex needs. These CoCs comprise CHTs, social service agencies and primary care providers. There are ongoing case discussions in one such network, where physical health, mental health and social issues picked up are discussed together for care planning and coordination.
The case for primary prevention
In some of our neighbourhoods, nearly a third of seniors live alone. Social isolation has many detrimental physical and mental health effects, and it has been said that "loneliness is the new silent killer". This has worsened during the COVID-19 pandemic years, when the impact of isolation on our youths and vulnerable elderly was especially acute.
To stay mentally healthy, it helps to be physically, mentally and socially active, and to manage chronic diseases well. Active ageing centres can provide communal spaces where elderly residents can participate in activities to keep fit and stay socially connected. Primary care doctors can also "issue" social prescriptions for those activities which can help in disease prevention, or to optimally manage chronic physical and mental illnesses. These activities vary between active ageing centres, and could include exercise programmes, healthy eating or nutrition programmes, and social activities for seniors.
NHG also leverages on digital enablers to promote preventive care. Through the NHG Cares mobile app, residents can easily access a suite of lifestyle programmes and social activities organised by healthcare institutions, national agencies and community partners in their neighbourhoods. These activities then help residents to stay mentally and physically fit and active. By taking a short survey in the app about their health needs and activity interests, residents can then choose their preferred activities from the different interest categories.
In summary, early bio-psycho-social interventions can help reduce the impact and distress of mental illnesses on individuals and their families. Hospitals like TTSH can help residents by conducting earlier detection and prevention programmes for at-risk groups, building mental health capabilities among frontline community staff, and working with partners to build up a physical-mental-social care ecosystem of providers. This would help achieve integration of care not just within the field of mental health, but across physical, mental and social health domains.