Singapore is a small island located between the Malaysian peninsula and Indonesian archipelago, with a population of about 5.1 million. Its ethnic composition is Chinese (74.1%), Malay (13.4%), Indian (9.2%) and other ethnicities (3.3%).
Transformation of the mental healthcare panorama
The Singapore healthcare system provides services for both the public and the private sector. There are about 150 psychiatrists serving in mental healthcare. The island-wide network of 18 government polyclinics provides 20% of primary healthcare services, while private general practitioners (GPs) provide the remaining 80%. Conversely, government restructured hospitals provide about 80% of tertiary care in Singapore, with the remaining shared among private hospitals. Realising the need for emphasis on good mental health, the Ministry of Health of Singapore implemented the National Mental Health Blueprint in 2007, focusing on four specific areas:
• mental health education and promotion
• integrated mental healthcare through community-based programmes
• nurturing mental health professionals
• developing mental health research.
Psychiatry in Singapore has come a long way since its humble beginnings when the first 30-bed mental hospital was set up by the British colonial government in 1841. It was renamed Woodbridge Hospital in 1951, before being reorganised as the Institute of Mental Health in 1993. With 2400 beds, it is the largest tertiary mental institution in the nation. There are also in-patient psychiatric services in general hospitals, although their profile of psychiatric patients differs from that in the Institute of Mental Health, which has a greater proportion of patients who are severely psychotic or aggressive.
The aims of deinstitutionalising psychiatric patients and supporting them in the community have led to the establishment of several government-driven community psychiatric services. These include: adult community mental health teams (CHMTs), which provide multidisciplinary support for patients to stay in the community as long as possible; Response, Early Intervention and Assessment in Community Mental Health (REACH), which provides front-line emotional support to students in the community; and the Aged Psychiatry Community Assessment and Treatment Service (APCATS), which provides assessment and treatment for housebound or frail elderly people with mental illness. This is complemented by family service centres (FSCs) located in the community, staffed by social workers and counsellors providing counselling and financial advice.
General practitioners in Singapore are consulted much less on mental health issues compared with their counterparts in the UK, USA and Australia (Chong 2012). Therefore, there have been several efforts to engage GPs through the GP Partnership Programme. Under this, hospitals refer patients with mild or stable psychiatric problems to GPs for management, with close support from psychiatrists. The 1-year Graduate Diploma in Mental Health was launched in 2011 to provide GPs with adequate training and encourage them to manage psychiatric patients.
Singapore embraces a firm biopsychosocial slant in the training and practice of psychiatry, with a strong focus on the ‘science of the mind–brain interaction’. Training in psychiatry begins in the undergraduate years, which not only provides medical students with a good foundation in psychiatry necessary for primary care practice, but also intrigues them with the many facets of the specialty so as to attract good candidates to consider traineeship in the future.
With the transition in 2010 from the old Basic and Advanced Specialty Training of 6 years duration (which was modelled on the UK system) to the new Accreditation Council for Graduate Medical Education (ACGME) accredited residency system of 5 years duration, postgraduate psychiatry training is entering a new phase, which has its challenges. Application for specialty traineeship is made at the start of the final year of medical school and many students may not exactly have a fair understanding of what they really want. Thus, the need for a dynamic and impressive psychiatry rotation during the medical school years is necessary to attract potential candidates early.
Although the training follows the American model, most trainees still take the Membership examinations of the Royal College of Psychiatrists (MRCPsych) or the local Master of Medicine (Psychiatry) examination run by the National University of Singapore. The need to streamline the curriculum while ensuring adequate exposure to core psychiatry, related medical specialties, psychotherapy and research, and empowering trainees with leadership skills and competencies to rise to the challenges of the new mental health era is all the more pressing.
The Royal College of Psychiatrists and Singapore
After Singapore gained independence in 1965, most psychiatrists were trained in the UK and acquired the MRCPsych qualification. However, between 1983 and 2007, the majority were trained locally and sat the local examination. Since 2008, the Royal College of Psychiatrists has recognised the local training in Singapore and trainees have the opportunity to sit the MRCPsych. There has been a steady growth in the number of Members of the Royal College of Psychiatrists in Singapore. These individuals are familiar with the National Institute for Health and Care Excellence (NICE) guidelines as part of their examination preparation. British psychiatry remains influential and continues to have a positive influence in Singapore.
The future of psychiatry in Singapore
In the midst of this evolution, Singapore’s psychiatrists need to assume several roles: leaders overseeing the integration of psychiatry and other services, partners with policy makers to drive initiatives, educators of the public and of colleagues from other medical disciplines, not forgetting their primary responsibility as healers of the mind and soul. Indeed, it will be an exciting time ahead for psychiatry in Singapore!