Put mental health on a par with physical health, S'pore doctor says

SINGAPORE - As a psychiatrist I treat individuals with mental health problems.

I also try, in the words of the preeminent psychiatrist and former editor-in-chief of the American Journal of Psychiatry Nancy Andreasen, "to think about them within the context of the social matrix in which they live, to skilfully elicit a 'life narrative' that summarises their past and current experiences, and to use that information in order to understand how their symptoms arise and can be treated… and to try to help them become healthier".

I used to think I did that well enough.

Some time ago, however, I had a patient who suffered from schizophrenia. As part of a routine medical examination, I discovered that his blood pressure was high, as were his cholesterol levels. Following our usual practice, I wrote a referral and sent him to a polyclinic for further management.

But when I saw him next, he had not gone to the polyclinic as instructed, and his blood pressure was even higher. Feeling somewhat annoyed, I repeated my mini lecture on the dire consequences of remaining untreated and the absolute necessity of him getting medical treatment from a doctor at the polyclinic. I, on the other hand, would focus on his psychiatric problems.

Calmly, he explained that it would mean an additional trip and long waiting time at the clinic. This would cost him more in terms of transport and, as a daily rated worker, he would also lose income. It would be far better, he said, if I would treat him for these conditions since he had long been one of my patients. It seemed a reasonable and sensible thing to do. After all, being shunted from one clinic to another (at times in different locations) for different conditions is an inconvenient and confusing experience. It can potentially lead to duplicated investigations, conflicting medical advice, and possibly an increased likelihood of medical errors.

But the reality was that I did not feel particularly confident treating him. I have become so specialised (and further subspecialised within psychiatry) that I have forgotten how to treat common medical conditions, let alone keep up with the latest treatments.

Advances in medical knowledge and technology have increased life expectancy for most in the general population. But people with serious mental illnesses like schizophrenia, bipolar disorder and major depression are exceptions. They die 15 to 20 years earlier than the rest of the population, mostly (and tragically) from preventable health conditions.

These mental illnesses, however, are not rare. The Singapore Mental Health Study has established that 1.2 per cent of the adult population have bipolar disorder in their lifetime, while 5.8 per cent have major depression. the adult population have bipolar disorder in their lifetime, while 5.8 per cent have major depression.

Lower life expectancy

Those who are mentally ill die much earlier from treatable medical illnesses because they are less likely to avail themselves of public health screening programmes.

They may also have greater difficulty interpreting and understanding physical signs and symptoms, as well as caring for themselves.

More fundamentally, however, they are victims of a failed system. They are also far less likely to have health insurance have poorer access to health care, and are more likely to receive poorer care.

Studies in the United States showed that people who are mentally ill and with ischaemic heart disease (blockage of blood vessels) were less likely to have the necessary surgical procedures, while people with mental illness and diabetes were less likely to be hospitalised for diabetic complications.

This could be partly due to "diagnostic overshadowing". This happens when health-care providers incorrectly perceive physical complaints as psychosomatic in nature or attribute them to the mental illness.

At the core of this may be what Dr Jerome Groopman - a Harvard professor of medicine who made a study of the erroneous thinking of doctors - called "attribution error".

This occurs when a doctor does not think beyond a negative stereotype. In other words, it is a form of stigmatisation.

The consequence is that many patients who are mentally ill rely solely on the mental health sector, and it becomes the only point of contact with the health-care system. But mental health-care providers often fail to provide the standard of medical care needed for general health problems.

Striving towards parity

Mental health does not receive the same attention as physical health. In a recent report, the United Nations Committee on Economic, Social and Cultural Rights recognised that people with mental health problems have "significantly poorer health conditions" than others.

The Royal College of Psychiatrists in Britain was asked by the British government to produce a report meant to be a call for action to achieve parity between mental and physical health.

The report, which was released in March, was titled Whole- Person Care: From Rhetoric To Reality.

It defined parity as "valuing mental health equally with physical health".

The report highlighted the wide gap between physical and mental health care, including preventable premature deaths, lower treatment rates for mental health conditions and the under-funding of mental health care relative to the scale and impact of mental health problems.

It also emphasises the strong relationship between mental health and physical health.

Poor mental health is associated with a greater risk of physical health problems, and vice versa. This was also revealed in the Singapore Mental Health Study.

More than half of those with a history of mental illness had at least one or more chronic medical conditions.

The way ahead

The implementation of the National Mental Health Blueprint and Policy in 2007 has had a positive impact, but much still needs to be done to ameliorate disparities which require commitment at multiple levels. These include governmental funding and policies aimed at those on the front line of health care.

There is also much that Singapore can learn from the British report. Among the recommendations are the inclusion of the mental health dimension in public health programmes traditionally regarded as purely physical health concerns, such as smoking and obesity.

There should also be zero tolerance for stigmatisation and discrimination, with a system that takes "a whole-person, integrated approach to health care".

On that last point, health-care workers need to start with themselves and rethink their attitudes and roles, and be committed to helping people with mental health problems.

Psychiatrists need to abandon that somewhat blinkered perception of their roles as being confined to treating only the psychiatric symptoms while leaving the physical health aspects to their medical colleagues.

Parcelling out a patient's problems to multiple health providers can result in no one being in charge. And psychiatrists need to take charge - not necessarily to treat these medical conditions themselves - but to ensure that the tasks of detection and management of these medical conditions are clearly defined, delegated, and carried out.

"For too long," commented Professor Lindsey Davies, president of the Faculty of Public Health, the standard-setting body for public health specialists in Britain, "mental health has not had equal status with physical health among doctors."

Consequently, the physical health of people who are mentally ill has been given short shrift. She urged that individuals should be treated "holistically" - taking in all aspects of their physical, social and mental health. "There's some way to go before we in the public health profession are fully playing our part in achieving this," Prof Davies concluded.

And so it is for all health-care workers in Singapore.


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