East Asian Arch Psychiatry 2015;25:168-174

ORIGINAL ARTICLE

Dr Ka-Man Cheang, MD (UKM), MRCPsych (UK), Department of Psychological Medicine, Khoo Teck Puat Hospital, Singapore.
Dr Christopher CS Cheok, MBBS, MMed (Psych), Department of Psychological Medicine, Khoo Teck Puat Hospital, Singapore.

Address for correspondence: Dr Ka-Man Cheang, Senior Resident, Department of Psychological Medicine, Khoo Teck Puat Hospital, Singapore. Tel: (65) 6602 2216; Fax: (65) 6602 3646 / 6602 3647;
Email: kaman.cheang@mohh.com.sg

Submitted: 15 December 2014; Accepted: 6 May 2015

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Introduction

The year 1928 marked the beginning of the mental health service in Singapore.¹ It began with a large asylum that provided mainly custodial care, and where the mentally ill were managed by a handful of expatriate medical pioneers and nurses. Drugs were limited and hospitalisation lasted for years. The scene has changed tremendously over the last 6 decades. Today the mental health service in Singapore is largely provided by the public sector with contributions from private and voluntary organisations. It provides a comprehensive and integrated programme comprising hospital-based and community-based treatment programmes with the objectives to promote good mental health for everyone and to provide the best possible treatment for those afflicted with mental illnesses of all types. The move to further enhance community-based interventions had its early beginnings with the conception of the Ministry of Health Community Mental Health Masterplan (2012- 2017) that aimed to build novel services for the community. The Masterplan envisions the development of Assessment Shared Care Teams (ASCATs) and Community Intervention Teams (COMITs) to build the capacity and capability for psychiatric care to be delivered outside the hospital in the community.

The Concept of THRIVE (Total Health Rich In Vitality and Energy)

The Total Health Rich In Vitality and Energy (THRIVE) is 1 of the 2 pioneering ASCATs. At the onset, the THRIVE- ASCAT’s strategic goals were to fulfil unmet needs and deliver novel services that leverage on technology. Rather than just increase the capacity of the existing services, the THRIVE-ASCAT focuses on building new capabilities and then increasing capacity. The goals of THRIVE-ASCAT are manifold. A key goal was to build a regional platform for the North of Singapore to network mental health services, community-based social services, government agencies and voluntary welfare organisation (VWO) as well as non-governmental organisations (NGO). A second goal was to build a tiered system to provide a spectrum of care catering to a wide variety of patients. Primary care starts from the general practitioner supported by COMITs and VWOs; secondary care is provided at Khoo Teck Puat Hospital (KTPH) and tertiary care at the Institute of Mental Health (IMH). Third, the internet is used to deliver self- directed psychological therapy to help-seeking and non– help-seeking individuals; educating the public and using traditional and social media to engage the public and change their perception of mental illness. Fourth, it is important to train professional colleagues, governmental and community agencies, and the public in mental health issues to reduce the stigma of mental illness.

Planning for a Programme

Planning for an ASCAT requires an understanding of the needs of the stakeholders balanced against evidence- based strategies. The key stakeholders identified include AIC (Agency for Integrated Care, under the Ministry of Health), VWOs, and NGO in the North of Singapore; and most importantly, the patients and their families. Hospital management and the general public are also key stakeholders.

A total of 200 members of the public were interviewed using standardised paper and internet surveys to understand their mental health help-seeking attitude. Open-ended questions were directed to elicit the main source of information utilised for issues related to mental health, and the characteristics of mental health services that are valued by an individual. The internet is the preferred information portal. The public values mental health services that are accessible and convenient to them, e.g. short waiting time for medical appointment, services that are close to place of work / home or available after standard working hours. In addition, the THRIVE spoke to various members of the NGO and VWO community to understand their needs. Some key issues were identified following interviews, surveys, and focus group discussion. The existing professional links between community, governmental agencies in the North and the hospital were weak. The VWOs and NGO valued efforts to strengthen these ties in the form of training opportunities and networking among the stakeholders. There was also a need to provide a comprehensive range of services in the community and at the hospital to help the mentally ill, especially when the majority do not actively seek help.

Armed with context-specific needs, the THRIVE carried out a literature search on PubMed focusing on the areas of community-based interventions, psychiatric epidemiology, and internet interventions to further inform the THRIVE’s intervention strategies. Selection of journal articles was based on impact factor, accessibility, and suitability to the local context. Stepped care models have been adopted in several international evidence-based clinical guidelines in the last 10 years.^2,3 There is a growing body of evidence that advocates a stepped care approach in a diverse range of common mental disorders.^4-13 Its core principle of first delivering low-burden treatment, followed by careful patient progress monitoring to step patients up to more intensive treatment led to considerable implementation diversity when services attempted to work in this manner.⁶ According to the Singapore Mental Health Study conducted in 2010, more than two-thirds of patients with mental illness in Singapore do not seek help from traditional mental health care providers.¹⁴ In order to reach the non–help-seekers who are likely to utilise the internet for information or help, we examined the literature on internet interventions. Self-help interventions were superior to no help for anxiety disorders and depression. Internet-delivered cognitive behavioural therapy for anxiety disorders and depression has been reported to be as good as face-to-face interventions.^15-19 In addition, the practice of the principles of positive psychology has been shown scientifically to improve mental wellbeing.²⁰

Care Model, Service Structure, and Design

Recognising that clinic-based services were well established compared with community-based services, key goals of the THRIVE are to build services aimed at prevention programmes and helping those who do not wish to seek help. The care model stratifies the population into subgroups: the well group; the at-risk group stratified by help-seekers and non–help-seekers; the ill group with mild, moderate and severe categories; and community stakeholders.

The well group in the community represents about 90% of the population. The key intervention planned for this group was public education about mental illness and resilience building by application of positive psychology principles. Achieving Happiness In Singapore (AHIS) is an 8-week self-help programme developed using the principles of positive psychology and distributed in print and e-book formats. The AHIS programme comprises a fact book and 4 worksheets to help people build loving relationships, change unhelpful thinking patterns, and identify their values. A book titled “Handbook of common mental illnesses in Singapore”²¹ has also been written to educate the public about mental illness.

For those who are at risk of mental illness, mental health information is provided on the THRIVE website.²² For mild mental illness, care is provided by Clarity, COMIT, and general practitioners for those who want to seek help. Self-help programmes have been designed for those who are non–help-seeking. For mental illness of moderate severity, help-seekers are provided with outpatient psychiatric care at KTPH, complemented by Clarity, COMIT, and rehabilitation at Community Rehabilitation and Support Services (CRSS)–Yishun. The THRIVE website also hosts self-help materials for those who are non–help-seeking. For severe mental illness that necessitates inpatient care, services are provided at the IMH.

Clinical Care

The THRIVE adopts a step-care approach delivered by non-specialist doctors. This increases the capacity for mental health consultations. The psychiatry clinic is functionally divided into the THRIVE-Clinic and the Specialist Outpatient Clinic. All new patients referred to KTPH Psychological Medicine are reviewed by specialists. Thereafter, those with a Global Assessment of Functioning (GAF) score of 61 to 100 (mild to moderate severity) are managed by non-specialists using clinical protocols and supervised by specialists. Those with a GAF score of < 61 (moderate to severe illness) are managed by specialists. Using this system, the median waiting time for psychiatry appointments is 10 to 17 days while urgent cases can be seen within 3 days.

Developing Case Management

Case management services have been developed in many clinical services in medicine both locally and overseas. The THRIVE introduced case management services for moderate-to-severe cases who require multiple services such as psychiatry consultations, rehabilitation, psychology, and social work. Case managers contact patients at least once a month, but additional contact can be provided on a case-by-case basis. Case managers help to coordinate care with community partners, monitor treatment compliance, and provide caregiver emotional support and psychological support for patients in crisis. There are 2 case managers in the THRIVE team.

Using the Internet to Complement Clinical Care

The internet is an effective medium to complement traditional clinical care. The THRIVE website hosts interactive psycho-education programmes, reading materials, a regional services directory, caregiver handbooks, and self-help Cognitive Behaviour Therapy programmes for a wide range of common psychiatric disorders.²² Patients, family members, and caregivers find the website useful for information and learning skills. The website receives over 30,000 hits per month with over 16,000 pages views per month.

Results of Clinical Programme

The outcomes of the programme were measured using a variety of indicators. These indicators were required for service evaluation and requested by the funding agency. Informed consent was obtained from the patient and data were anonymised. Service load indicators included total number of patients seen and clinical indicators included the GAF (clinician-rated) and the Sheehan Disability Scale (SDS, service user–rated). Both GAF and SDS scores were collected at the start of the service and after 6 months or at separation from service.

Clinical Indicators

The GAF is a clinician-rated 100-point scale and measures the functioning of a person. Higher score reflects higher functioning. The SDS assesses functional impairment in 3 domains: work / school, social, and family life. It is a self- report tool and each domain is rated on a 10-point visual analogue scale. Disability is scored by the total score of all 3 domains and ranges from 0 (unimpaired) to 30 (highly impaired).

The THRIVE saw a total of 201 newly referred cases over a 17-month period. Male and female patients were in nearly equal distribution (M:F=1.01:1). The mean age was 36.9 years (range, 13-83 years). The ethnic background of the patients was as follows: 80% Chinese, 8.5% Malay, 7% Indian, and 4.5% others. These demographics of the patient population are representative of the Singaporean population.²³ A large proportion of patients were diagnosed with depressive disorders (40.3%) followed by anxiety disorders (28.9%), insomnia (10.4%), psychotic disorders (5.5%), and others (14.9%). Statistical analyses were carried out using the Statistical Package for the Social Sciences Windows version 18 (SPSS Inc., Chicago [IL], US).

Paired t test was used to compare the various components of SDS and GAF scale pre- and post-clinical intervention at 6 months’ follow-up. The reduction in the SDS domain scores and the overall increase in GAF scale scores reached statistical significance, indicating improvement in the patients’ functional status following treatment.

A general linear model was used to determine demographic factors including age, gender (male / female), ethnic group (Chinese, Malay, Indian, others), and diagnostic group (depressive disorders, anxiety disorders, insomnia, psychotic disorders, others) that would predict change in the SDS (by component) and GAF scale. To correlate functional improvement, post-intervention scores were subtracted from pre-intervention scores for SDS components. For GAF scale, pre-intervention scores were subtracted from those post-intervention. Chinese ethnicity, depressive disorders, and male gender were selected as comparators as these were the largest group in their respective categories.

Malay ethnicity significantly predicted changes to score in 4 of the SDS components: (a) improvement in work life (p < 0.001); (b) improvement in social life (p < 0.001); (c) improvement in family life (p < 0.001); and (d) reduction in the number of days lost (p < 0.001) [Tables 1-3]. Indian ethnicity significantly predicted reduction in the number of days unproductive at work (β = 1.4, p < 0.05). The results should be interpreted with caution as the number of patients from these 2 ethnic backgrounds constituted only 15.5% of the entire group.

Insomnia (p = 0.03) and other diagnoses (p = 0.001) significantly predicted reduction in GAF scale score post- intervention (Table 4). Reduction in GAF scale score reflects decreased functional status post-intervention. Indian ethnicity and other ethnic groups similarly predicted a reduction in GAF scale scores although it did not reach statistical significance. These results should also be interpreted with caution given the small number of patients in each group.

The Network

In the North community, CRSS-Yishun, Clarity Singapore, and National Healthcare Group (NHG) Polyclinics were identified as key mental health partners. The CRSS-Yishun is a VWO that provides psychiatric rehabilitation and Clarity Singapore is a VWO that provides psychotherapy. The NHG Polyclinics refer patients with psychiatric illness to the THRIVE. The Singapore Armed Forces was another source of referral. The Singapore Police Force was also a partner as they meet residents with dementia and other serious mental illness. Family Service Centres provide social work services and counselling to residents. Many families with social problems also have mental health issues. As students face considerable stress from education and peer influence, schools and tertiary education institutes also found value in collaborating with the THRIVE. Partners identified the following gaps that were regarded as high priority areas: (a) training in mental health issues; (b) access to an emergency consultation with a mental health professional when the need arises; (c) easy and quick access to a psychiatric clinic; and (d) discussion and collaboration in complex cases. A total of 25 agencies work jointly with the THRIVE in the North of Singapore and all expressed satisfaction with the collaboration with the THRIVE.

New Programmes to Meet the Needs of Our Partners

Wonderful Wednesday

To meet the needs of training, the THRIVE developed the Wonderful Wednesday programme. Wonderful Wednesday is organised once a month and provides a half-day training in a particular area of mental health. In the first hour, there is a lecture about a mental health issue. In the second hour, one of the partners presents a successful case for discussion to illustrate the various ways to manage a complex case in the community. In the third hour, there is an opportunity for any partner to discuss a difficult case currently being managed.

Collaboration with Singapore Police Force

Regular discussions were held with the Singapore Police Force to understand their needs. A microsite was developed to help frontline officers identify and understand the problems of serious mental illness. The THRIVE also provided advice and support to the police whenever they were concerned about a resident with behavioural problems. These were usually patients with addictions, bipolar disorder or schizophrenia who had defaulted from treatment and were experiencing a relapse.

Day Care of Community Rehabilitation and Support Services–Yishun

An innovative pilot service was developed with CRSS- Yishun to provide day care services for patients in the acute phase of a relapse in lieu of hospitalisation. Strict referral and severity criteria were formulated for this programme. Caregivers can resume their daily work while their loved ones are cared for.

Management Consultations with Clarity Singapore for Service Development

The THRIVE provided advice to Clarity Singapore for service development. As Clarity Singapore is a young organisation providing psychotherapy, the THRIVE helped Clarity Singapore to formulate their service policies and clinical standards. The THRIVE also provided case consultation and case supervision for their psychotherapists.

Other Collaborations

The THRIVE collaborated with Republic Polytechnic to promote mental health awareness during World Happiness Day in 2013. At Pathlight School for students with autism, the THRIVE helped parents understand issues when children with autism enter National Service.

Mental Health Promotion, Reaching the Non–help-seeking, and Building Resilience

An essential part of a community mental health programme is mental health promotion, education, and prevention. The morbidity of mental illness in every community is high and resilience and prevention programmes are necessary to reduce the impact of mental health problems on the person and his community.

Helping the Non–help-seekers

Recognising that technology can bridge the gap for non–help-seekers, the THRIVE developed self-help programmes based on cognitive behavioural therapy that is freely available to the public. Programmes for major depression, panic disorder, hyperactivity, obsessive- compulsive disorder, and generalised anxiety disorders were developed. Overall, in the first year, there were over 30,000 hits per month to the website for our education and intervention programmes. There are on average over 16,000 page views per month.

The THRIVE also produced 2 iOS applications to serve the public. “Axiety” is an iPhone application for panic disorder while “Thought Buddy” is an application to help people monitor their thought patterns. Thought monitoring is beneficial in the treatment of anxiety and depression.

Achieving Happiness in Singapore

Research shows that happiness can be taught and increases sense of wellbeing. The THRIVE adopted the principles of positive psychology to promote wellbeing and happiness in people. Positive psychology teaches that happiness can be achieved by developing a sense of gratitude, building strong relationships, volunteering, discovering and living your values, and experiencing positive emotions in daily life.

The AHIS consists of a knowledge booklet to teach people about positive psychology, an 8-week programme to help people change their lifestyle and 4 worksheets to teach learners about an aspect of positive psychology. The 4 worksheets cover finding one’s values, changing unhelpful thought patterns, and getting rid of past hurt and building loving relationships. The AHIS is currently the most successful product produced by the THRIVE. Organisations have requested copies of AHIS for their staff and the public have given favourable feedback on the content. Overall, over 25,000 copies of AHIS have been distributed to the public.

Public Outreach, Public Education

Public outreach is an important facet of a community programme. The THRIVE organised more than 15 public engagements to speak about a variety of mental health issues. Overall, more than 2000 individuals have attended our programme that included talks on depression, anxiety, wellness and happiness and understanding mental illness. To complement our lectures, a book titled “Handbook of common mental illnesses in Singapore”²¹ has been produced to educate the public: 3000 copies have been printed and are available in bookshops in Singapore.

Future Work

In the next 2 years, the THRIVE will focus on expanding internet-delivered care; developing internet interventions for youths suffering depression and anxiety disorders; and increasing mental health literacy of the public in the north of Singapore. In 2014, phone support and expedited case referrals were provided for urgent cases referred from Yishun and Woodlands Polyclinics.

Conclusion

The first 17 months of the THRIVE focused on the development of a clinical programme, establishing a network of agencies that would interact with patients and a public outreach programme that would increase mental health literacy and wellbeing in the community. Leveraging on technology and using evidence-based interventions, the THRIVE has been able to reach people in the community through various products and services.

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