HEALTHCARE
Singapore has one of the most successful healthcare systems in the world with services delivered efficiently and effectively. There are 11 public hospital and 10 private hospitals, with one dedicated to mental health. From a 2019 study commissioned by Institute of Mental Health (IMH) we are told that depression and anxiety among youths in Singapore are a worrying trend. There is an urgent need to shore up support for our only mental hospital which we believe is stretched and working tirelessly with what little resources they have in terms of medical staff, funding and facility.
Our concerns about mental healthcare in Singapore centre on the hospitalisation procedures and medication protocols. There can be improvements to how young people are assessed for mental health risks and what are the triage procedures in the hospitals. We wonder if the "default" care for those who present suicidal behaviour admission to IMH? We are especially concerned about the management of medication for those suffering from suicidal behaviour and self-harm. We question the use of antidepressants and care needed to dispense these drugs, especially when given to young children because of the risks of suicidal ideation. How are parents and care-givers briefed and prepared for their role when their loved one requires medication and other interventions.
Finally, we hope that there can be a government-run "half-way" house or step-down care or recovery facility for young people with acute anxiety or depression which is a more supportive strategy than admission to a mental institute? We understand that the Anglican Service centre runs the only Psychiatric Sheltered Home in Singapore for recovering mental patients, but what about young people who require long term rehabilitative care?
HOSPITALISATION
In Singapore the only hospital that offers inpatient care for acute mental illness is the Institute of Mental Health (IMH). This institution has had a long history and has been upgraded with milestone improvements over the many decades. To the government's credit the National Mental Health Blueprint (2006) was developed which incorporated CHAT in 2010 and REACH in 2007 which brought youth mental health into focus. Today those below 18 years are seen at its Child Guidance Clinic at the IMH which works closely with the Ministry of Education.
What makes for good care for young mental health patients and what benchmarks can we use to improve healthcare for our very vulnerable young? These are difficult questions which we have no immediate answers but we know from personal encounters the general boundaries of care which are important, many of which hinge on the manpower resources available to mental health facilities like IMH.
Drawing from various experiences, we observed that :
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Apart from IMH, only National University Hospital, Changi General Hospital, Singapore General Hospital, Sengkang General Hospital and Mt Elizabeth Hospitals would admit patients suffering mental distress, but only if they do not present suicidal tendencies. There is no choice of restructured hospitals for admission. If more hospitals offer inpatient care for mental patients, this can help dilute the stigma of being admitted to a mental facility.
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Higher medical staff to patient ratio will allow more contact time for severely ill patients with consultations scheduled daily or at least regularly several times a week with consulting psychiatrists and/or psychologists or allied support staff. Contact time should be personal, compassionate and safe, offering patients effective care and support.
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There should be separation of care for for patients with differing levels of psychiatric symptoms and diagnosis. The Mood Disorder Unit, staffed by one team of doctors, houses patients suffering from different severity of mental illness, from bipolar to depression. This protocol is the same at the Child Guidance Clinic. Young patients and those first time admissions would be better served in a more homogeneous ward where they might feel safer.
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With a higher doctor to patient ratio, patients would have a higher chance of finding a good fit for treatment with a doctor who suits their temperament and also gender choice. This is particularly important in the efficacy of care and healing process for youth who suffer from psychiatric illness. There will also be enough consultation time for treatment plans to be discussed with family and caregivers, especially if the patient is of a young age.
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Safety within the wards are also of primary concern. With higher nursing to patient ratios, there will be more supervision over the patient's movements and more compassionate interaction between nurses and patients.
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In an emergency situation the mental health triage is very important to provide an accurate initial assessment for whether a person needs further assessment or referral or immediate intervention. Patients should never be administered any medication before medical assessment is done and without discussing a treatment plan with the patient and caregivers. This must be of primary importance in the hospital's protocol.
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Post discharge follow up and outpatient care should form part of the overall treatment strategy for any patient. Ideally, a rehabilitation facility or "safe house" should be made available to support a patient's complete long term recovery.
" My teenage daughter attempted suicide while in the hospital ward. When the nurses saw her with her petechial haemorrhage, they attributed it to a pimple outbreak. Nursing care for mental illness requires specialised training and competencies. "
~ Mrs Tan
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ANTIDEPRESSANTS
There is evidence that the use of antidepressant medication can be an effective part of a comprehensive strategy for patient care. But why and how medication is dispensed, especially to young people and children, is critical to their health and safety. The dispensing of antidepressant drugs like Lexapro, Prozac, Fluvoxamine and Zoloft, must always be cautioned and strictly administered. Warning labels on packaging, patient-caregiver-doctor discussions and supervision guidelines for use must be underscored. We ask the medical community to tighten its practice on dispensing antidepressants for young people as the costs to lives are much too high.
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“Detractors may say that the black box warning on anti-depressants may reduce the youths’ access to mental health care but I say it is imperative that the adverse risk factors be clearly communicated so that young patients can be closely monitored for any worsening of depression or suicidal thoughts by caregivers. Informed consent is key to ensuring patient safety and welfare. Health care professionals have a duty to warn patients of all side effects and the decision is to be made by the patient and caregiver and not the authorities. I paid the high price of not being informed and not being given the chance to make the decision and I lost my son, Zen Dylan Koh to suicide less than 3 weeks after being prescribed the anti-depressant, Lexapro and having his dosage quadrupled within a 10 day period. “
~ Elaine Lek
Among the members of our network, we observed that in Singapore:
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Antidepressants are often prescribed in generic plastic bags in the same way many GPs dispense their own medications. There are no explanations on side effects or warnings written on the bag.
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Even if the the medication comes in the original box package, there is no black box warning in the product inserts, but rather contraindications are embedded within the long lists of side effects.
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Not all doctors give full disclosure of the adverse side effects of antidepressants so as to offer the patient and caregiver clarity before informed consent is given.
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Not all doctors discuss the care strategy nor give advice to the patient and caregiver on the need for close supervision and to look out for worsening symptoms of the depression and increased suicide ideation.
Read
Why we need blackbox labelling on packaging of antidepressants
In 2018, the US Food & Drug Administration had directed manufacturers to revise labelling for antidepressant drugs to include black box labels. They warned that:
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Antidepressants increases the risk of suicidal thinking and behaviour (suicidality) in children, adolescents, and young adults in short-term studies of major depressive disorder (MDD) and other psychiatric disorders.
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Anyone considering the use of any antidepressant in a child, adolescent, or young adult below age 24 must balance this risk with the clinical need.
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Families and caregivers should be advised of the need for close observation and communication with the prescriber.
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Patients who are started on therapy should be observed closely for clinical worsening, suicidality, or unusual changes in behaviour.
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Prescribers or other health professionals should inform patients, their families, and their caregivers about the benefits and risks associated with treatment with antidepressants and should counsel them in its appropriate use.
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It is also recommended that prescriptions for antidepressants be written for the smallest quantity of tablets consistent with good patient management, in order to reduce the risk of overdose.
