Singapore’s Institute of Mental Health offers a comprehensive range of psychiatric, rehabilitative, and psychotherapy services for the country’s population. CEO Associate Professor Daniel Fung discusses their work to transform mental illness treatments, why telemedicine will succeed, and how it plans to address population health by moving upstream to identify the at-risk and prevent illness.
I see Singapore as a melting pot of trials, where you can prototype and test out things because we are small and connected
Daniel, could you begin by giving our audience a brief introduction to yourself and your work at the Institute of Mental Health (IMH)?
I did my training in Singapore, earning my medical degree from the National University of Singapore, which at the time was the only medical school in the country. I also spent a year in Toronto at the Hospital for Sick Children, where I did my subspecialty in child psychiatry. I have worked with children in the public sector ever since.
I became the chief of the Department of Child Psychiatry and, after six years, I was named chairman of the Medical Board, which is essentially the chief psychiatrist of the hospital, and finally promoted to CEO after that. I am a medical person with the administrative task to look after this tertiary psychiatric hospital, the Institute of Mental Health. The hospital used to be called Woodbridge Hospital, and it was temporarily used as a military hospital by the Japanese during World War 2 when the Japanese occupied Singapore and the Malayan peninsula. IMH celebrated its 90th year in 2018.
Rebuilt in 1993 in a small section of the original site, the hospital is a modern tertiary psychiatric facility with 2,000 beds, which make up 90 percent of the total psychiatric beds in the country. We have patients that have been with us for over 40 years, since the days of the old hospital where the care model was more custodial in nature. We have since moved into a recovery model in which we try not to have patients stay long term with us. The average length of stay now is about two to three weeks. Even though Singapore, like many other countries, has fairly coercive mental health laws, we are trying to move away from such laws. The laws exist to protect people with mental illness as well as the public from some of the risks that severely mentally ill patients can pose.
As head of the most important mental health institution in Singapore, how do you see the treatment of mental illness evolving?
A real mental illness that needs treatment is a brain disorder that requires mental health professionals and evidence-based treatments. The lifetime prevalence of mental illness in any part of the world is about 20 percent; we did our own prevalence study and found 13.9 percent in Singapore.
We believe that moving forward, mental illness should be treated very much like physical illness. Obviously, there are safety considerations, but we must make sure that patients are treated well and in a humane way. We want to make the acute treatment shorter and develop more intensive therapies with programs that allow for recovery and reintegration into the community. It has been six years since we started our specialist program where we train peers, along with the nonprofit National Council of Social Service, to identify recovered individuals with lived experience of mental illness to participate in the recovery process of others.
We also focus on engaging the community to bring mental health services out rather than into the hospital; we focus on workplaces, schools and community agencies. We want to talk about recovery, not cure, so we need to be able to provide a suite of support across the spectrum from hospitals all the way into community and workplaces.
At the same time, we must fight the stigma issue. Now, mental health is broader than mental illness. Mental health is not just the absence of mental illness but rather a state of wellbeing, an approach similar to Bhutan’s, which uses the happiness index as a way to gauge the nation’s mental health.
Can you explain how serious the burden of mental illnesses is in Singapore and some of the specific characteristics of the mental health landscape where you sit?
The burden of mental illnesses in Singapore, like the rest of the world, is really in the younger population. Although the Singapore Mental Health Study conducted by IMH in 2016 looked at people 18 years and above, it was very clear that most of the onset of illness actually is in the adolescent age group, and in some cases, even in late childhood. And although it does not often result in death, unless there is a suicide, it does have a significant toll on families and society because of the chronic nature of the illness. If untreated, it becomes a social issue.
However, one of the things that gives the country an advantage is the fact that we do not have homelessness because of laws like the Destitute Persons Act, which tries to make sure people do not live on the streets. Chronic mental illness if not properly followed up may end up in the homeless population but we prevented that.
Another interesting fact is that the prevalence of schizophrenia in Singapore is lower. There are several reasons for that, but the fact that we don’t have as much penetration of substance use and abuse helps. It is protective because substances do affect the brain. We have been careful not to use the judicial route to confine people with mental illness in prison to get them treated unless they have offended and even then, we try to manage and provide support for their treatment.
Our efficient national electronic medical records system rounds everything up. I think digitalization technology has made a difference. The recent Healthcare Services Act does take into account things like telehealth and telemedicine. For example, telepsychiatry would be much faster and the adoption easier because there is a regulatory framework. It will be similar to the modern banking system, which operates digitally but the traditional system has not changed, it is just digitized. Healthcare is being digitized now, in the traditional sense of the word, and artificial intelligence will help improve it.
Do you think COVID-19 and the switch to remote working and telehealth could be an inflection point towards digital medicine?
The pandemic and the lifestyle changes that followed certainly have pushed telepsychiatry forward. Thanks to the adoption of technology and its low cost, doctors can see patients instantly and in remote areas.
The real issue is the mindset. Southeast Asia actually has many prototypes and pilot programs on telemedicine but none of them has gone mainstream because there is a mindset you have to overcome. We have to evolve and accept changes in traditional medicine. Part of the problem has to do with digital migrants like ourselves; people want to see their doctor, touch his or her hand. Nonetheless, we are close to the inflection point, the tipping point that will allow us maybe to take on AI.
Sitting in one of the most, if not the most, developed countries within your region, how do you assess the openness and ability to spend on technology and research in Singapore?
We want to be able to develop a model that we can then replicate and share. One of the advantages is the high penetration of mobile devices in the region; that is where I suspect that many of the disruptive technological advancements in medicine will come from, along with wearable technology. I am hopeful that everything will be technology-enabled in the future. The problem, of course, is the pushback with security, privacy concerns and the use of data. I see Singapore as a melting pot of trials, where you can prototype and test out things because we are small and connected.
The practice of medicine will dramatically change, but this is only one piece of it. I think the other part is the population health, trying to go upstream and prevent illness in the first place. I guess we have to change the way we work.
In terms of research, the IMH has a dedicated team looking at clinical research in the traditional sense. We are trying to implement the use of using data to help us understand diseases and predict efficient models of care. That means predicting when someone might relapse or even predict who is likely to develop mental illness early in the lives so you can interrupt that trajectory. You need data for this, you need to coordinate in to bring that data together.
The National Healthcare Group is looking at what we call health intelligence, which is trying to make sense of the data we already have. The data is more readily accessible since it has gone digital. We also need to do this in the public and the non-profit sectors. We have a vast amount of information available, but we have to make sure it is not siloed away, unused.
I have the hope that one day, people will have full ownership of their data, they carry it with them and are able to share it how they wish. Like a safe deposit box in a bank where the bank has one key and the customer another key and both are required to open it. Of course, it is still a dream, but we are forming the foundations for some of this.