SPEECH BY MDM RAHAYU MAHZAM, SENIOR PARLIAMENTARY SECRETARY, MINISTRY OF HEALTH & MINISTRY OF LAW, AT THE MOTION DEBATE ON ADVANCING MENTAL HEALTH ON 7 FEBRUARY 2024

Overview of Mental Health Strategy in Singapore

        Mr Speaker, DPM Wong had explained the operating context that we are in and the approach we are taking as we navigate the issues of mental health in our community. He highlighted an important starting point in our approach - that mental health issues lie on a spectrum, and that this means we need a broad suite of solutions. We also need to meaningfully organise the services and support available so that people have access to the help they need, when they need it.

2.       Allow me to build on this point. Let me start by sharing data that we have from the Singapore Youth Epidemiology and Resilience (YEAR) study, conducted by the National University of Singapore in collaboration with the Ministry of Education. This study showed that while 37% of respondents reported having internalising symptoms like depression and anxiety, only 12% of respondents met the full criteria for at least one of the mental disorders. Furthermore, 6% of respondents who previously met the criteria for at least one mental disorder more than a year ago no longer had the symptoms. This means that while individuals may experience symptoms of poor mental health, they may be due to transient stressors and do not necessarily warrant the same intensity of interventions needed for individuals diagnosed with mental disorders. Receiving care in the community as the first line of support, rather than at hospitals, is therefore more appropriate.

3.       The cornerstone of our National Mental Health and Well-Being Strategy is the Tiered Care Model. It sets the foundation for how our mental health services should be organised, with different care levels depending on the intensity of interventions needed. This ultimately helps us to provide the right care at the right time based on the individual’s needs.

4.       Right-siting of care to the community is part of a much larger shift of mental health care. Countries like Australia, Canada and United Kingdom have implemented a similar model for their mental health care systems. Although more research studies are still being done, existing studies suggest that a tiered model of mental health care delivery, where mental health care can be easily accessible in community settings is a better approach compared to concentrating services in the hospital settings. SMS for Health will speak more on our Tiered Care Model later.

5.       For the Tiered Care Model to be effective, we also need to encourage the right mindsets, allocate resources and build support within the community to empower people. I will therefore be addressing the mental health promotion efforts, community mental well-being initiatives, the affordability of mental health services as well as the manpower needs in providing mental health care.

Mental Health Promotion, Communications, and Engagement

6.        As shared by Dr Wan Rizal when he spoke on the importance of mental health literacy, raising awareness on mental health is crucial in shifting our societal values and attitudes towards making mental well-being one of our priorities. We have made progress in this area as we see improvement in the public’s attitudes towards individuals with mental health conditions. However, we recognise that stigma around mental health issues persist in our society.

7.        Our efforts include encouraging help-seeking and reducing stigma and discrimination against people with mental health conditions through public campaigns and targeted initiatives for youths, seniors, caregivers, women, persons with disabilities and minorities.

8.        At the national level, Health Promotion Board (HPB)’s “It’s OKAY to Reach Out” campaign, and NCSS’s Beyond the Label movement aim to normalise conversations around mental health and encourage help-seeking. These efforts are sustained through social media outreach and online portals. In a post-campaign survey of 800 youths, HPB found that 78% of respondents were motivated to reach out for emotional support when they needed it. HPB’s MindSG offers mental health resources curated by professionals including tools for users to assess their mental health risks, and search for support or services based on their needs. As of 31^st December 2023, the portal has garnered more than 4 million page views, from over 2 million users since its launch in November 2021. The portal will be enhanced progressively to introduce more topics and features.

9.        In schools, HPB offers training for students going through critical transition years, specifically from primary six to secondary one. These programmes are carried out in partnership with schools to equip students with skills to better cope through these transitions. Additionally, in 2023, HPB has trained more than 2,200 students from Institutes of Higher Learning as peer supporters, equipping them with empathetic listening and basic mental health first-aid skills.

10.      At workplaces, HPB trains management staff and conducts workshops to enable people to better cope at work and support their colleagues. In 2023, more than 55,000 working adults have benefitted from HPB’s mental wellness programmes. Besides HPB-led initiatives, the Workplace Safety and Health Council also launched the “Take Time to Take Care” campaign to remind employees to look after their own and their colleagues’ well-being. 

11.      In the community, Well-Being Circles have been established across various neighbourhoods to raise awareness on mental health and available resources, and to empower citizens with skills to look after their own mental well-being as well as that of others. We will continue to encourage the formation of more Well-Being Circles so that more in the community will have access to the support when they need it.

Community Mental Well-Being Efforts for Youth, Seniors, Caregivers, Women and Minorities

12.      Apart from community-wide efforts in mental health promotion, there are also several initiatives that target specific groups.

Youth

13.      According to the 2022 National Population Health Survey (NPHS), youths aged 18 to 29 formed the largest proportion of people with poor mental health in Singapore. Currently, we have community mental health teams known as CREST-Youth and Youth Integrated Teams (or YITs) dedicated to support youths with mental health needs. CREST-Youth reaches out to youths and parents to promote early identification of mental health symptoms, and provide basic emotional support. YITs carry out mental health assessments and provide psychosocial interventions for youths who need more intensive support.

14.      As of September 2023, we have four YITs that have supported over 3,000 youths and parents, and eight CREST-Youth teams that have reached over 87,000 youths and parents. By 2030, we will be expanding to 15 YITs and CREST-Youth teams each, across the island.

15.      In addition to these community mental health teams, the Response, Early Intervention and Assessment in Community Mental Health (REACH) teams work closely with schools to provide mental health assessments and interventions for students aged 6 to 19. CHAT, another mental health service which supports youths aged 16 to 30, has assessed over 7,000 youths at risk of developing mental health conditions as of September 2023.

16.      To support youths at risk of suicide or severe self-harm, an intermediate residential facility will also be developed. Not all youths who present with suicidal behaviour suffer from mental health conditions. Instead, they may have experienced social stressors such as having difficulties coping with schoolwork and being bullied. Therefore, this facility will cater to this group of youths, aged 10-19 years old, to support them within a safe environment.

17.      In the facility, youths will be supported by a multi-disciplinary team consisting of psychiatrists, psychologists, social workers, nurses and live-in care staff. Services provided will include: (i) identifying the needs of youths in crisis; (ii) providing psychosocial interventions, such as counselling and supportive medical attention where necessary; and (iii) facilitating the transition of youths with support from community partners before they are discharged.

18.      In the course of supporting the mental health of our youths, there have been ground feedback on the need for parental consent for children and youths below 21 years old, which could hinder their access to mental health support. I thank the Members who have raised this issue earlier. We recognise the importance of youths’ continued access to mental health services, and I appreciate Ms Rachel Ong’s earlier suggestion of having tiered guidelines for the requirement of parental consent on mental health services. In this regard, I would like to lay out several considerations that MOH is reviewing as we navigate this issue. These include balancing the need for (i) youths’ access to appropriate treatment, (ii) the involvement of the family and social support in youths’ care journey, (iii) protection of the youths in view of the risks associated with treatments, and (iv) the level of maturity and understanding of the child. Above all, our priority is to ensure that any approach undertaken is in the best interest of the child and that they can receive mental health care timely. We are studying this issue and exploring meaningful options to address it.

Seniors

19.      Several MPs like Mr Yip Hon Weng and Ms Nadia Samdin spoke about the need to do more to support seniors with mental health needs. Currently, seniors are supported by the Community Outreach Teams (CREST), to identify their mental health needs and provide basic emotional support and referrals to appropriate service providers. In addition, Active Ageing Centres (AACs) work with CREST providers in serving as community nodes to conduct activities that engage and connect seniors with the community. We have 73 CREST teams islandwide, of which 65 teams can support seniors at-risk of mental health needs.

20.      We understand that some seniors may be reluctant to seek help or accept support for their mental health needs due to stigma. As part of their outreach efforts, Silver Generation Ambassadors who come across these seniors would also share about mental health resources in the community and encourage them to seek help. We are glad there are also community initiatives carried out by Members in their respective constituencies that reach out to these seniors.

21.      We are also looking at mental well-being issues of our seniors and tackling the social phenomenon of loneliness as part of the holistic Age Well SG strategy announced last November.

Caregivers

22.      For caregivers who have or are at risk of developing depression, anxiety and burnout due to their caregiving role, there are Community Outreach Teams (CREST) that provide dedicated support. These teams support caregivers in self-care, stress management and future planning, such as making a Lasting Power of Attorney and Advance Care Planning. Where necessary, they will also link caregivers with counselling services and peer support groups, like the Caregiver Support Network. As of September 2023, there are 6 Caregiver Community Outreach Teams and over 2,300 caregivers have been supported.

23.      AIC also administers the Caregiver Training Grant which provides subsidies for caregiver training, including psychosocial management of behavioural issues.

24.      For caregivers who need short-term support to have their loved ones taken care of, some MOH-funded psychiatric nursing homes offer the Nursing Home Respite Care programme, which provides eligible clients with short periods of stay typically ranging from a week to a month. Such arrangements allow caregivers some time off, with the assurance that their loved ones are safely cared for in the nursing home.

Women

25.      I thank Ms Hazel Poa and Ms Hany Soh for their suggestions on support for postpartum women and their spouses. Several efforts are ongoing to support the mental health of women. For example, the National University Hospital (NUH) Women’s Emotional Health Services (WEHS) provides both antenatal and postnatal mental health screening, as well as  individualised treatment interventions for women who need more support. The NUH WEHS team also works closely with community partners and social service providers to coordinate and provide continuity of care to those who need it. Similarly, the Postnatal Depression Intervention Programme in KK Women’s and Children’s Hospital (KKH) provides routine postnatal depression screening for all pregnant women, and those with depressive symptoms will be referred to the appropriate services available. Mental health services, including mental health screening for mothers, are also available in polyclinics.

26.      To support fathers and spouses, NUH will be extending its mental health screening and support to them. The programme allows for early intervention, case management and multidisciplinary treatment.

27.      In 2020, the KKH Psychosocial Trauma Support Service (PTSS) also began providing trauma-focused assessments and interventions to women experiencing psycho-emotional difficulties that arose from traumatic incidents.

Persons with Disability (PwDs)

28.      I thank Ms Nadia Samdin for her suggestions on meeting the holistic health needs of persons with disabilities (PwDs). MOH is committed to working with partners to deliver holistic care for PwDs. To address their healthcare needs, MOH works with community partners to provide the Home Personal Care service, which offers a range of services including assistance with personal hygiene, housekeeping and simple maintenance exercises.

29.      Over the past years, we have also (i) collaborated with the College of Family Physicians Singapore to offer a Family Practice Skills Course to equip general practitioners in caring for persons with intellectual disabilities; and piloted (ii) a Community Integrated Health Team in partnership with a social service agency, as well as (iii) a specialist outreach team from the Institute of Mental Health, to offer home- or community-based care for persons with intellectual disabilities who have complex health needs. We will continue to build these capabilities in the community to support more caregivers and families of PwDs.

Malay/Muslim Community

30.      In the Malay/Muslim community, we have organisations like Club Heal, which has championed mental health issues for years. New initiatives are also in place. I lead M3’s Focus Area on Community Health, which was introduced last year. M3 is a collaboration between the Islamic Religious Council of Singapore (MUIS), MENDAKI, and MESRA. The newly introduced Focus Area on Community Health, aims to promote healthy lifestyles and empower residents to spearhead ground-up efforts within their own community, including efforts on mental health and well-being. In towns like M3 @ Jalan Besar, youth peer support groups have been set up and the community is rallied to co-create solutions. We will continue to roll out such initiatives to enhance residents’ mental well-being in the different towns.

31.      Mr Speaker, please allow me to say some words in Malay.  

32.      Kesedaran tentang isu-isu kesihatan mental dalam masyarakat Melayu-Islam sudah semakin meningkat. Kita beruntung punya organisasi seperti Club Heal yang telah menperjuangkan usaha ini buat bertahun lamanya. Penting untuk kita terus menguatkan usaha dan membina sokongan dalam masyarakat. Sebahagian daripada Strategi Kesihatan Mental dan Kesejahteraan Nasional, adalah usaha memastikan adanya sokongan dan inisiatif-inisiatif yang mudah didapati dalam Masyarakat kita.

33.      Saya memimpin Bidang Tumpuan kerja M3 berkenaan dengan Kesihatan dan kesejahteraan masyarakat. Ianya diperkenalkan pada tahun lalu. Tumpuan baru ini bertujuan untuk mempromosikan gaya hidup sihat dan memperkasa penduduk untuk menerajui usaha dalam komuniti mereka sendiri. Salah satu tunggak usaha ini adalah menangani isu-isu kesihatan dan kesejahteraan mental dalam Masyarakat kita.  

34.      Saya mengalu-alukan usaha di bandar seperti di M3 @ Jalan Besar yang diterajui oleh Dr Wan Rizal. Kumpulan sokongan rakan sebaya bagi golongan belia telah ditubuhkan dan komuniti diajak untuk sama-sama mencipta penyelesaian. Kita akan terus melaksanakan inisiatif seumpama ini untuk meningkatkan kesejahteraan mental penduduk di serata Singapura.

Mental Health Financing  

35.      Let me touch on the affordability of mental health services. In this regard, we have made efforts to reduce out-of-pocket costs through various schemes available.  

36.      For outpatient mental health treatment offered at polyclinics and public specialist outpatient clinics, eligible patients can receive subsidies of up to 75%. Additionally, individuals who hold CHAS, Pioneer Generation and Merdeka Generation cards are eligible for subsidies of up to $540 per year for mental health conditions including depression, anxiety disorders, bipolar disorder and schizophrenia under the Chronic Disease Management Programme. These subsidies are available at public specialist outpatient clinics, polyclinics and participating GP clinics. Patients can also use up to $500 or $700 from MediSave each year, depending on the complexity of their condition, at selected clinics. For patients aged 60 years and above, they can use an additional $300 each year from their Flexi-MediSave to offset out-of-pocket payments for their outpatient mental health treatment. Patients may also receive subsidised or free counselling services provided by various community service providers.

37.      For inpatient services, all Singaporeans and Permanent Residents are covered under MediShield Life, regardless of pre-existing conditions. Patients who require inpatient mental health treatment can claim up to $160 per day, capped at 60 days per year, from MediShield Life, and up to $150 per day from MediSave, within an annual MediSave limit of $5,000. MediShield Life and MediSave claim limits are regularly refreshed to ensure that they remain sufficient to cover 9 in 10 subsidised bills.

38.      On top of MediShield Life, Integrated Shield Plans (IPs) and other private health insurance plans may provide additional coverage for mental health treatment. Today, all IP insurers offer plans that cover inpatient mental health treatment, and the amount of coverage is decided by the insurers.

39.      For lower-income Singaporeans who require more financial assistance to pay for their remaining healthcare bills, they may apply for MediFund, which serves as a safety net for needy Singaporeans. No Singaporean will be denied access to appropriate healthcare due to their inability to pay.

40.      I share Dr Tan Wu Meng’s concern regarding denied access to private insurance for persons with mental health conditions.  Several other Members have also raised this concern. This should be considered within the larger context of our healthcare financing system where all Singaporeans are eligible for subsidies and are covered under MediShield Life, which is a national risk pool which helps to ensure its sustainability. On the other hand, IPs and other private health insurance products are optional. Private insurers may exclude pre-existing conditions from coverage upon underwriting, including mental health conditions informed by actuarial and commercial considerations. Such a process allows insurers to ensure their insurance risk score remains sustainable as they otherwise have to increase premiums for all policyholders. Depending on the underwriting assessment frameworks, insurers may still offer coverage to applicants with pre-existing conditions but with exclusions or higher premiums. It allows this group of applicants to still benefit from some coverage without adversely affecting other policyholders.

41.      MOH and the Monetary Authority of Singapore (MAS) fully expect all insurers to deal fairly with their customers. Insurers are expected to carry out an objective assessment of every application based on reliable information or data relevant to the risks being insured. Insurers should not indiscriminately reject an application solely on the basis of declared personal information, including mental health conditions. Where an application is rejected or approved with higher premiums or additional conditions, insurers should properly explain to the customer the basis for the underwriting decision. MOH and MAS take this seriously, and MAS will take action against insurers whose practices are in breach of its regulations or guidance. MOH and MAS will review this issue and consider how insurance coverage for persons with mental health conditions can be improved.

42.      I also thank Dr Tan for highlighting the Forum Letter by Ms Tan Hui In. MAS does not have records of her feedback in its complaints database. If Dr Tan has additional info to share about this specific case, he can share it with MAS and MAS can promptly look into it with the relevant insurers, if the complainant consents to it. Members of the public with similar feedback can also write to MAS, and MAS will investigate accordingly. On the feedback of long waiting times to access mental health treatment services, MOH will similarly look into this issue.

Manpower for Mental Health Care

43.      Let me move to the point on manpower for mental health care. One of the key considerations is the adequacy of mental health professionals, including psychiatrists and psychologists.

44.      As of 2022, there were 203 registered psychiatrists and 212 psychologists in the public sector. To meet the anticipated increase in demand for mental health services, the Government aims to increase the number of psychiatrists by about 30% to 260, and the number of psychologists by about 40% to 300, in the public sector, by 2030. However, solely increasing the number of psychiatrists and psychologists will be insufficient and unsustainable to meet increasing demands for mental health services. This is also one of the reasons why we have developed the Tiered Care Model.

45.      With the Tiered Care Model, more patients will receive timely care in the community, provided by appropriate mental health professionals such as counsellors. This will allow psychiatrists and psychologists to focus on patients with more complex mental health needs. We are thus committed to continue to raise the capability and capacity of our community service providers, while monitoring the changes in demand for mental health services to ensure continued adequacy of manpower required for mental health care.

Closing

46.      Mr Speaker, issues surrounding mental health has garnered attention globally, and in Singapore. I am encouraged by the efforts and progress we are making as a nation in tackling this extremely important and challenging area. In particular, we have made advancements in integrating various aspects of our social, education and health sectors.

47.      To illustrate, let me share the story of Mr Chee Soon Weng. Mr Chee was an experienced teacher and managed students with challenging behavioural issues. This took a toll on his mental health, and over time, he suffered from comorbid anxiety and depressive disorder. As a result, Mr Chee transited from a student-facing role to an administrative and research position at work. At home, he also encountered issues with his family due to his mood. He then approached the Methodist Welfare Service’s Family Service Centre under the Ministry of Social and Family Development (MSF), who identified his mental health needs and referred him to one of our COMIT Anglican Care Centre teams for support. Through weekly counselling and psychoeducation on symptoms and treatment plans, Mr Chee made significant progress in his mental health. Today, Mr Chee is coping well with his new position at work and his relationship with his family has also improved. Mr Chee’s story underscores the importance of integrating social service and health sectors to enhance mental health care for individuals.

48.      In closing, I would like to record my gratitude to Members who have raised this Motion. It has given us the opportunity to highlight the mental health efforts that we have developed and implemented through the years, as well as hear various feedback and suggestions on how we can do more. I would also like to take this opportunity to thank all our community service providers for their unwavering dedication and their instrumental role in implementing these initiatives on the ground. The Government is committed to continue working with the healthcare clusters and community partners to develop and review our strategies to uplift the mental health of our nation. I support this motion.