NTU Mental Health Introduction 2012

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Are You OK?Mental Health in SingaporeDaniel FungVice Chairman Medical Board IMH

Course ObjectivesUnderstanding mental health Basic knowledge of mental disorders Knowledge of resources available in Singapore

FacultyDaniel Fung Child Psychiatrist Married to Joyce 5 children

References

http://www.imh.com.sg/edu_publications.html

Week No. 1

TopicsLecture 1: Introduction 1.1 Why is mental health important? 1.2 Mental health not illness: Definitions 1.3 Mental health across the ages Lecture 2: The Family 2.1 Family Function 2.2 Family life cycle 2.3 Dysfunctional Family 2.4 Healthy Familes Lecture 3: Development 3.1 Developmental principles 3.2 Developmental delay 3.3 Developmental disorders 3.4 Sleep and its problems Lecture 4 Learning and Mental Health 4.1 What is Learning 4.2. Foundations of learning 4.3. IQ and learning 4.4 Learning disorders Lecture 5: Adolescence 5.1 Physical changes 5.2 Emotional issues 5.3 Sexuality 5.4 Disorders common in adolescence 5.5 Juvenile delinquency Lecture 6: Personality and Problems 6.1 Personality Theories 6.2 Attachment 6.3 Personality Disorders 6.4 Self image and Anorexia Lecture 7: Human Sexuality 7.1 Sexuality definitions 7.2 Marriage and divorce 7.3 Periods of pregnancy 7.4 Postpartum risks MCQ Quiz before lecture

Readings Chapter 1

2

Chapter 2

3

Chapter 3 and 4, 15

4

Chapters 5 and 6

5

Chapters 8 and 9

6

Chapters 10 and 11

7

Chapters 12 to 14

Week No. 8

Topics Lecture 8: Stress 8.1 Definition of stress 8.2 Signs and Sources of stress 8.3 Management of stress Lecture 9: Emotions and disorders 9.1 Normal emotions 9.2 Anger 9.3 Anxiety 9.4 Depression 9.5 Suicide Lecture 10: Alcohol and Substance use 10.1 Alcoholism 10.2 Substance addictions 10.3 Behavioural addictions Lecture 11: Old Age and Mental Health 11.1 Retirement 11.2 Dementia 11.3 Problems of the Elderly Lecture 12: Psychosis 12.1 Schizophrenia 12.2 Bipolar Disorders 12.3 Other psychotic illnesses

Readings Chapter 16 to 18

9

Chapters 19 to 21

10

Chapters 22 and 23

11

Chapter 25

12

Chapter 24

13

Lecture 13: Healing of the Mind 12.1 Psychotropic medications 12.2 Psychotherapy 12.3 Traditional therapies 12.4 Mental Health Services Exams: Essays, Open book

Chapters 28 to 33

IntroductionMental Health Mental Illness Epidemiology of Mental Illness Classification of Mental Illness

Are You Healthy?Health is not merely the absence of disease but a state of complete physical, mental and social well-being .World Health Organization

What is Mental Health?

Defining Mental Health: Mental illnesses are only the tip of the icebergMental Illness

Serious Mental Illnesses: Psychosis, Depression, Anxiety, Dementia, Addiction Disorders, Personality Disorders Minor Psychiatric Morbidity: Adjustment Disorders, Uncomplicated Grief, Situational Reactions

Minor Psychiatric Morbidity

At Risk

Children from dysfunctional families, Individuals with multiple medical conditions, Elderly living alone,

Mentally Healthy

The general population: school children, working adults, young parents, retirees

What is Mental Health?More than just absence of mental illness Balance between all aspects of life

Feelings about ourselves Relationships with others Coping with life Feeling safe and secure

Butthere is no such thing as perfect mental health

Brief HistoryTime Period Ancient civilisation Renaissance period Eighteenth Century Nineteenth Century Twentieth Century Concepts of mental health Mental illness is caused by evil spirits possessed the body and must be driven out Decline in the belief of possession Seen as natural phenomenon - but mental problems seen as irreversible. Scientific inquiry and humanism Need for medical care recognised. Research began and legislation concerning mental health was enacted. The start of the mental health movement. A holistic concept of care and short term care introduced. Goals were to return patients into society, so human service programmes were established. There was a focus on prevention. Biological concepts of mental health strengthened in genetic studies Services Spiritual and religious

Development of specialized care and asylum model of care A reform movement - chains removed. The first mentally ill patient was treated in hospital. Asylums became hospitals for the mentally ill but with long term custodial care. Large state hospitals were built, psychoanalysis developed and community health care centres established.

Twenty first Century

Smaller hospitals with greater emphasis on community care. Overreliance on medications

Who are Psychiatrists?Not a good example Singapore examples

Who are Psychiatrists?Medical doctors Trained to specialise in mental illness and work with different groups

Adults Children Elderly Specialised disorders

Usually deals with mental illness rather than mental health

Psychiatrists Models

Medical (Disease) ModelDiagnosis Plan of management follows diagnosis

Compare to other modelsCognitive Psychodynamic Social

Who are the Mentally Ill?

The term mental illness that refers collectively to all disorders associated with the mind (mental). Mental disorders are health conditions that are characterized by problems in:

Thinking (Cognitive) Feelings (Mood) Actions (Behaviour)

Individually or in combination associated with distress and/or impaired functioning.

EpidemiologyStudy of the distribution and determinant of diseases and injuries in human populations

Concerned with frequencies and types of injuries and illness in groups of people Concerned with factors that influence the distribution of illness and injuries

Epidemiology of Mental Illness

The current prevalence estimate is that about 20 percent of the U.S. population are affected by mental disorders during a given year. This estimate comes from two epidemiologic surveys:

the Epidemiologic Catchment Area (ECA) study of the early 1980s the National Comorbidity Survey (NCS) of the early 1990s

Mental Health in Singapore

MOH study (1978): 8.4% of the population as suffering from neurosis. The SAMH Study (1989): 17.95% of the population with minor psychiatric morbidity (MPM).

Fones et al, 1998:

Survey of over 3020 subjects (GHQ-28) Point prevalence of 16.6% with MPM ICD-10 diagnoses using the CIDI (Composite International Diagnostic Interview) on 339 subjects in Clementi 12-month prevalence rate for Affective Disorder = 7.8% 12-month prevalence rate for Anxiety Disorders = 9.3%

Mental health in SingaporeWHO Burden of Disease Study 2001

Mental illness contributes to 17% of the combined burden of premature death and living with disability in Singapore

Registry of Births and Deaths

More people die from suicides than road accidents every year

2004/5 National Mental Health Survey

Anxiety & Depression: 6.5% of population Minor Psychiatric Illness: 15.7% of population Dementia: 5.2% of those > 60 yearsSource: National Mental Health Survey 2003/4

Mental Health in Singapore1998(NUH Study)

2003/4(IMH Study)

Depression & Anxiety

No Combined Data

7.1%(Lifetime)

Depressive Disorders Anxiety Disorders

5.5%(12-month)

5.6%(Lifetime)

0.8 -2.5%(12-month, various disorders)

3.4%(Lifetime)

International Studies(WHO 12 month prevalence studies)Anxiety Disorders % USA Belgium France Germany Italy Spain Japan Beijing Shanghai 18.2 6.9 12.0 6.2 5.8 5.9 5.3 3.2 2.4 Mood Disorders % 9.6 6.2 8.5 3.6 3.8 4.9 3.1 2.5 1.7

SINGAPORE

3.4

5.6

International Studies(Utilization of Mental Health Care Services)Serious Cases (% receiving treatment) USA Belgium France Germany Italy Spain Japan Beijing Shanghai 52.3 53.9 63.3 49.7 64.5 Total population (% receiving treatment) 15.3 11.0 12.4 7.8 4.5 7.3 5.7 2.7 3.1

SINGAPORE

49.1

7.5

National Mental Health Survey of School Children

The prevalence of children estimated to be suffering from mental health problems was 12.5% based on parent reports 2.5% based on teacher reports. Internalising Disorders such as anxiety and depression Parents reported 12.2% Teachers estimated 2.2% Based on child reports, the prevalence of children estimated to have an anxiety syndrome was 9.6% and the prevalence of children estimated to have a depressive syndrome was 17.8%. Externalising Disorders such as attention-deficit hyperactivity disorder, conduct disorder and oppositional defiant disorder Parents reported 4.9% Teachers reported 2.4%

Woo et al 2007

National Mental Health Survey of School Children

Overall Problems Male gender (OR 2.1) Low intellectual ability (OR 3.4) Mothers being single, divorced, widowed, deceased (OR 2.9) Internalising disorders Male gender (OR 2.0) Older age (OR 2.4) Low intellectual ability (OR 3.0) Mothers being single, divorced, widowed, deceased (OR 3.6) Externalising disorders Fathers being less educated (OR 3.5) Low intellectual ability (OR 6.5)

Woo et al 2007

Who Is Affected?Globally, 450 million people suffer from mental illness, 70 million people suffer from alcohol dependence, 50 million have epilepsy, 24 million have Schizophrenia, one million people commit suicide everyday and between 10 - 20 million people attempt it

The World Health Report 2001

Who Is Affected?National Mental Health Survey 2004, IMH: Lifetime prevalence rate of depression amongst adults in Singapore is 5.6%.

About 15% of persons with mental illness commit suicide.

About 50% of persons with depression / anxiety disorders in Singapore do not seek help. This is about the same as the estimated 50 - 60% in most developed countries.

Each year about 65 persons accumulate in IMH long-stay wards. By 2020, Major Depression will be the second most important cause of disability worldwide WHO estimate.

Prevalence of schizophrenia worldwide is about 1%.

Basic Facts About Mental IllnessA medical problem often arising from brain chemical changes. Symptoms may change over time Affects not only the patient but the people around them

Causes of Mental Health Disorders

Mental health problems are costly for all

Direct cost of services & treatment Indirect cost

On caregivers (family, society) Trigger for other physical health problemsE.g. Excessive stress linked to heart disease & cancer

Opportunity cost

Lost productivity & employmentE.g. Employees (at 3 major American companies) with chronic symptoms of depression were twice as likely to report missed workdays

= Total Cost of Mental Health ProblemsSome estimates EU US Canada 3-4% of GNP - 45% due to lost productivity 2.5% of GNP - Indirect costs either match or outweigh direct costs in allmental health areas(Source: WHO)

At least $14.4b every yr - $8.1b in lost productivity

THE GLOBAL BURDEN OF DISEASEA comprehensive assessment of mortality and disability from diseases, injuries, and risk factors in 1990 and projected to 2020CHRISTOPHER J.L. MURRAY HARVARD UNIVERSITY BOSTON, MA, USA ALAN D. LOPEZ WORLD HEALTH ORGANIZATION GENEVA, SWITZERLAND

World Health Organization

Harvard School of Public Health

World Bank

100 million new cases of Depression annually 70% aged between 18 and 45 years(estimated figures, WHO)

Depression is associated with the highest Disability Adjusted Life Years (DALY) A measure of life lost, premature death or years lived with a disabilityWHO - World Bank - Harvard University Study

Global Burden of Disease 2020

Murray CJL, Lopez AD, (1996a). The global burden of disease: a comprehensive assessment of mortality and disability from diseases, injuries and risk factors in 1990 and projected to 2020.

Importance of Mental Health

Singapore Med J 2009; 50(5) : 468

Importance of Mental Health

Singapore Med J 2009; 50(5) : 468

Classification of Mental Illnesses

DSM-IV (Diagnostic andStatistical Manual of Mental Disorders, 4th Edition) Latest version is DSM IV TR A publication of the American Psychiatric Association that classifies over 230 psychological disorders into 16 categories. The most widely used classification of psychological disorders.

Classification of Mental Illnesses: DSM-IV

Classification of Mental Illnesses

ICD-10 The International Statistical Classification of Diseases and Related Health Problems, tenth revision The latest in a series that was formalized in 1893 as the Bertillon Classification or International List of Causes of Death.

SchizophreniaEvery year nearly 600 persons in Singapore will be stricken with Schizophrenia.Lianhe ZaoBao & The New Paper Mar 2002

Depression and AnxietyClose to one in 10 Singaporeans suffer from depression or anxiety.Straits Times, 10 Oct 2002

Major depression is now the leading cause of disability globally and rank fourth in the ten leading causes of global burden of disease.The World Health Report 2001

AddictionsGaming, viewing pornography, online gaming and chatting are the four most common addictions of people who use PCs.Computer Times, 5 February 2003

About 750,000 people or about 30 per cent of the 2.5 million Internet users in Singapore may have already become addicted to online pleasures ..Computer Times, 5 February 2003

Eating DisordersAnorexia nervosa is estimated to affect up to one in 100.Straits Times, 23 Jan 2003

StressWork related stress is the second largest occupational health problem in the United Kingdom.Patients First, March/April 2003

One person in every four will be affected by a mental disorder at some stage of life.The World Health Report 2001

Children & AdolescentsTeen suicides: Relationship problems the main causeStraits Times 27 February 2003

46.4% of teens commit suicide due to relationship problems with girl friends or boyfriends or problems with parents.Lianhe Zaobao 14 February 2003

Children & AdolescentsSelective mutism a rare condition where children are able to speak in some situations, like at home, but become mute in less familiar ones, like in school.Straits Times Life! 12 March 2003

NTU HP803

Spectrum of Care1. Universal Promotion of Wellbeing & Prevention-Create supportive environments -Nurture personal coping skills

2. Targeted Prevention & Early Intervention-Significant life events -Income & family status

3. Standard Treatment

Mentally well

At risk

Minor morbidity

Mentally ill

6. Universal Prevention & Destigmisation

5. Targeted Reintegration & Relapse Prevention

4. Continuing Care

TreatmentA combination of psychotherapy, medication, and socio-occupational intervention. The Mental Health Team Psychiatrists Nurses Psychologists Medical Social Workers Occupational Therapists Physiotherapists

Governance: Mental Health PolicyWHO Regions Africa Americas Eastern Mediterranean Europe South East Asia Western Pacific World Countries with MH policy 19/45 18/32 13/19 38/52 7/10 15/26 110/184 Percent with MH policy 42.2 56.3 68.4 73.1 70 57.7 59.8 Population Coverage 60.1 88.1 84.8 90.8 31.8 94.9 71.5

Singapore

Mental Health Blueprint 2006

Mental Health Policy

Financing

7.1%

Singapore Percentage of health budget allocated to mental health

Mental Health Human ResourceWHO Regions Africa Americas Eastern Mediterranean Europe South East Asia Western Pacific WorldPsychiatris ts Other doctors Nurses Psychologi sts MSW OT

0.05 1.57 0.9 8.59 0.23 0.9 1.27 3

0.06 0.72 0.31 1.14 0.19 0.81 0.34 60.9

0.61 3.92 3.18 21.93 0.77 7.70 5.8 535.8

0.04 1.29 0.48 2.58 0.03 0 0.3 1.74

0.03 0.39 0.46 1.12 0.01 0 0.23 4.76

0.31 6.37 4.35 17.21 0.04 2.86 2.65 3.92

Singapore

Median rate per 100,000 population

Mental Health Outpatient Facilities

0.22

Singapore Outpatient mental health facilities per 100,000 populati

Mental Health Facilities: Beds

1.36

Singapore Psychiatric beds in general hospitals per 100,000 populaSingapore has 1976 psychiatric beds in the only psychiatric facility

Myths and FactsPeople with mental illness are violent and dangerous.As a group, mentally ill people are no more violent than any other group. In fact, they are far more likely to be the victims of violence than to be violent themselves.

People with mental illness are poor and/or less intelligent.Most mentally ill people have average or above-average intelligence. Mental illness can affect anyone regardless of intelligence, social class or income level.

Myths and FactsMental illness is caused by a personal weakness.A mental illness is not a character flaw. It has nothing to do with being weak or lacking will-power.

Mental illness is a single, rare disorder.Mental illness is not a single disease but a broad classification for many disorders - anxiety, depression, schizophrenia, personality disorders, eating disorders, organic brain disorders

Myths and FactsPeople who are depressed could just snap out of it if they tried hard enough.Depression has nothing to do with being lazy or weak. It results from changes in brain chemistry or brain function, and medication and/or psychotherapy often help people to recover.

Depression and other illnesses, such as anxiety disorders, do not affect children or adolescents. Any problems they have are just a part of growing up.Children and adolescents can develop severe mental illnesses. Left untreated, these problems can get worse.

Myths and FactsAddiction is a lifestyle choice and shows a lack of willpower. People with a substance abuse problem are morally weak or "bad".Addiction is a disease that generally results from changes in brain chemistry. It has nothing to do with being a "bad" person.

Mentally ill people cannot lead productive lives.FACT: People with a mental illness who are properly treated with therapy and/or medication can live full, enjoyable and productive lives.Source: Canadian Mental Health Association, PRNewswire,

Pressures on mental health will grow Social changes

Lifestyle changes

Nuclear families, broken marriages high personal and societal expectations at home, school, work

Source: Kessler et al 2003

Work environment

rapid changes & development , job uncertainty

Threat of national crisis and disasters

SARS, Avian flu, terrorism

Mentally resilient people underpin our efforts to build Land of Opportunity & Strong Society

Ageing population e.g. dementia among elderly

Stigma"crazy", "cuckoo", "psycho", and "wacko" - words that keep the stigma of mental illness alive.

These words belittle and offend people with mental health problems.

Doing Your PartWe can all help to change community attitudes by:Learning to see mental illness like any other health problem. Learning more about the illness so we can understand why the person behaves strangely. Showing friendship and support to friends, relatives, neighbours or colleagues who are affected by mental illness. Encouraging people who are mentally ill, or their families, to seek help.

Most people with mental illnessescan live at home, hold a job and function as contributing members of society.

Questions?