The world is facing multiple interconnected crises, from climate change and economic instability to social inequalities and geopolitical tensions. These crises do not occur in isolation; instead, they interact, reinforce each other, and create unexpected ripple effects – forming what is known as a polycrisis. Traditional ways of analysing problems often fail to grasp these interdependencies, making it difficult to find effective responses. We draw on system archetypes to describe and exemplify three polycrisis patterns. These provide a structured way to analyse how multiple crises unfold and interact, as well as insights into how to navigate such complexity.

The concept of a polycrisis describes the complex interconnections between global issues, which can lead to unexpected emergent behaviours and the possible convergence of undesirable impacts. Understanding these dynamics is crucial for anticipating compounded effects and for identifying leverage points for effective intervention. We propose that system archetypes – generic structures in system dynamics that capture recurring patterns of behaviour – can serve as a useful analytical tool to study polycrises. Specifically, we reinterpret three key system archetypes in this context: Converging Constraints (based on the Limits to Growth system archetype), Deepening Divides (based on Success to the Successful system archetype), and Crisis Deferral (drawing from the Policy Resistance system archetype). These patterns illustrate how resource limitations, structural inequalities, and short-term solutions can sustain or worsen crisis dynamics. Using real-world examples, we show how polycrisis patterns can be employed to map feedback structures between interacting crises and to guide effective interventions. Our work contributes to a more structured and systemic understanding of polycrises, by providing a tool to help researchers and policymakers better anticipate, navigate, and mitigate their effects.

‘Polycrisis patterns reveal how crises like climate change, economic instability, and inequality interact, amplifying their impacts’.

Auditory verbal hallucinations (AVHs) in schizophrenia have been suggested to arise from failure of corollary discharge mechanisms to correctly predict and suppress self-initiated inner speech. However, it is unclear whether such dysfunction is related to motor preparation of inner speech during which sensorimotor predictions are formed. The contingent negative variation (CNV) is a slow-going negative event-related potential that occurs prior to executing an action. A recent meta-analysis has revealed a large effect for CNV blunting in schizophrenia. Given that inner speech, similar to overt speech, has been shown to be preceded by a CNV, the present study tested the notion that AVHs are associated with inner speech-specific motor preparation deficits.

The present study aimed to provide a useful framework for directly testing the long-held idea that AVHs may be related to inner speech-specific CNV blunting in patients with schizophrenia. This may hold promise for a reliable biomarker of AVHs.

Hallucinating (n=52) and non-hallucinating (n=45) patients with schizophrenia, along with matched healthy controls (n=42), participated in a novel electroencephalographic (EEG) paradigm. In the Active condition, they were asked to imagine a single phoneme at a cue moment while, precisely at the same time, being presented with an auditory probe. In the Passive condition, they were asked to passively listen to the auditory probes. The amplitude of the CNV preceding the production of inner speech was examined.

Healthy controls showed a larger CNV amplitude (p = .002, d = .50) in the Active compared to the Passive condition, replicating previous results of a CNV preceding inner speech. However, both patient groups did not show a difference between the two conditions (p > .05). Importantly, a repeated measure ANOVA revealed a significant interaction effect (p = .007, ηp2 = .05). Follow-up contrasts showed that healthy controls exhibited a larger CNV amplitude in the Active condition than both the hallucinating (p = .013, d = .52) and non-hallucinating patients (p < .001, d = .88). No difference was found between the two patient groups (p = .320, d = .20).

The results indicated that motor preparation of inner speech in schizophrenia was disrupted. While the production of inner speech resulted in a larger CNV than passive listening in healthy controls, which was indicative of the involvement of motor planning, patients exhibited markedly blunted motor preparatory activity to inner speech. This may reflect dysfunction in the formation of corollary discharges. Interestingly, the deficits did not differ between hallucinating and non-hallucinating patients. Future work is needed to elucidate the specificity of inner speech-specific motor preparation deficits with AVHs. Overall, this study provides evidence in support of atypical inner speech monitoring in schizophrenia.

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Although there is an increasing interest in making mental health services (MHS) accessible to youths, there is limited ground-up involvement of youths while designing MHS in Asian settings.

This qualitative study sought to understand what youths considered as important elements of youth centric MHS and how these could be designed to improve access by youths in Singapore.

We conducted seven focus group discussions, and four semi-structured interviews with 50 multiracial youths aged 15-35 years in Singapore - a high-income Southeast Asian country. Purposive sampling allowed adequate representation of age, gender, and race (mainly Chinese, Malay, and Indian) groups. Participants reflected on the features of an ideal MHS for youths and how these could improve youths’ attitude and access to services. Participants also shared their preferences and additional opinions for culturally tailored and age appropriate MHS. Framework analysis using the ‘Conceptual Framework of Access to Healthcare’ (Levesque et al. Int J Equity Health 2013, 12:18) was used to code transcripts and identify the key themes (Ritchie & Spencer. In Analyzing qualitative data, 1994).

The average age of the participants was 24 years. About one third of the participants had accessed MHS in the past. Three key themes were identified – making facilities ‘approachable’, ‘available and appropriate’ and ‘affordable’. (i) Making facilities approachable related to having non-stigmatizing, non-threatening and welcoming aesthetics, organizational culture, and personnel. The participants also recommended a range of professional services, digital tools, and online features to enhance the approachability of MHS designed for youths. (ii) Flexible operating hours, easy appointment management, accessible location, and easy availability to youths with unique needs (e.g., employed youths) or socio-cultural backgrounds were necessary for making facilities available and accessible to youths. (iii) While sharing challenges of family involvement in the help-seeking process, most of the participants, particularly those in the lower ages, talked about tailoring MHS to the ability of youths to pay for the services. Preferences such as having cheaper services for teenagers and initial contacts, offering more non-medical but trained professionals, and considering shorter in-person counselling sessions, followed by free online options were brought up by the participants.

The study provided insights into multiple aspects of MHS and how these could be designed to cater to the needs of youths in Singapore from their perspective. MHS that incorporate non-stigmatizing, flexible, non-threatening and affordable design approaches could improve help-seeking and early interventions in youths.

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1 in 8 people worldwide live with a mental illness (MI). This is expected to rise with increasing societal pressures. Despite the availability of evidence-based treatments, MIs remain undertreated. In Singapore, efforts such as the ‘It’s OK to Reach Out’ campaign was launched to encourage help-seeking. Help-seeking behavior is complex; determined by an interplay of factors including perceptions towards help sources. As seeking ineffective sources contributes to unmet needs, understanding beliefs towards various sources of help is vital.

The study aims to examine perceived helpfulness of various sources of help for 5 mental illnesses and changes in perceptions towards them over time.

The Mind Matters 2023 (M2) is an ongoing nationwide survey of mental health literacy among Singapore residents aged 18-65 years. Analysis is based on a preliminary sample (N=2500). Interviewers read a vignette depicting 1 of 5 randomly assigned MIs- depression (DP), schizophrenia (SZ), obsessive-compulsive disorder (OCD), alcohol abuse (AA) or dementia (DT). Respondents were asked to rate whether 10 Professional/Informal sources and 12 Actions were ‘helpful, ‘harmful’ or ‘neither’ for the person in the vignette. Frequencies of helpful ratings were compared with the first Mind Matters study (M1) conducted in 2015 (N=3006).

In M2, seeing a psychiatrist, psychologist and counsellor were rated helpful most frequently (79%-96%) while seeking traditional medicine and religious advisors were rated the least (12%-60%) across the vignettes, except for DT where doctor and close family (81%-85%) replaced psychologist and counsellor (66%-70%). Compared to M1, phone counselling saw an increase in helpfulness rating across all vignettes (p<.05) except AA. For Actions, reading about how others dealt with similar problems was rated helpful most frequently (76%-89%) while dealing with problems on one’s own was rated the least across all vignettes (3%-11%) in M2. Compared to M1, being more social saw an increase in helpfulness (p<.001) rating for DP but a decrease for AA (p<.001). Admission to an institution was associated with a decrease in helpfulness rating for DP (p=.006) and OCD (p=.04) but increase for AA (p=.03).

The findings suggest recognition that MIs would be helped by professionals and self-reliance is ineffective to address these problems. Increased perceived helpfulness of telephone counselling was promising as studies have shown high client satisfaction coupled with its potential in reducing some barriers to care. Differences in directional changes in helpfulness rating for institutional care and socialising for DP and AA may represent understanding of the importance of behavioral activation and stimulus control for these MIs respectively. Literacy regarding help-seeking sources has improved in Singapore over the last 8 years which may translate into increments in seeking appropriate care.

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Stigma towards mental disorders has been shown to be a major obstacle to recovery and quality of life among people with psychiatric disorders. Despite significant advances in the treatment of mental disorders, stigma remains concerning to patients, caregivers, and healthcare professionals. Singapore is a city state in South-East Asia with a multi-ethnic population. A nation-wide campaign launched in 2018, Beyond the Label, focusing on addressing stigma and promoting social inclusion for persons with mental health conditions.

The aims of the current study were to (i) establish the dimensions of stigma and examine its correlates in the general population of Singapore using a vignette approach, and (ii) examine whether there was any change in stigma levels from 2016 to 2023.

Data for the current study comes from an ongoing nation-wide, cross-sectional study of mental health literacy conducted in Singapore since September 2022. The study population comprises Singapore Residents aged 18–65 years who are currently living in Singapore. Respondents were randomly assigned and presented a vignette describing one of seven specific disorders: alcohol abuse, dementia, depression, depression with suicidality, gambling disorder, obsessive-compulsive disorder, and schizophrenia. Stigma was assessed using Personal and Perceived scales of the Depression Stigma Scale (DSS) (Griffiths et al. Br J Psychiatry; 2004 185 342-349), and the Social Distance scale (SDS) (Link et al. Am J Public Health 1999; 89 1328–1333).

2500 respondents who completed the survey were included in the current analysis. The mean age of the respondents was 42.8 years. A three-factor model comprising ‘weak-not-sick’, ‘dangerous/undesirable’, and ‘social distance’ provided acceptable fit. Multivariable linear regression analyses revealed that younger age, female gender, students, and dementia vignette were significantly associated with lower weak-not-sick scores while Malay and Indian ethnicity, lower education, and alcohol abuse and gambling disorder vignette were significantly associated with higher weak-not-sick scores. Those of Malay and Indian ethnicities and those with a family member or close friend who had problems similar to the person in the vignette were significantly associated with lower social distance scores.

A significant decrease (p<0.001) in all three factor scores was observed from 2016 to 2023 (Table 1).Table 1.

Mean stigma scores over time

Our study found a significant decrease in stigma from 2016 to 2023 in the Singapore population which indicates the positive impact of anti-stigma initiatives in Singapore. Interventions must be co-developed with males, older adults, and those with a lower education to further reduce stigma in this multi-ethnic population.

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There is compelling evidence for gradient effects of household income on school readiness. Potential mechanisms are described, yet the growth curve trajectory of maternal mental health in a child's early life has not been thoroughly investigated. We aimed to examine the relationships between household incomes, maternal mental health trajectories from antenatal to the postnatal period, and school readiness.

Prospective data from 505 mother–child dyads in a birth cohort in Singapore were used, including household income, repeated measures of maternal mental health from pregnancy to 2-years postpartum, and a range of child behavioural, socio-emotional and cognitive outcomes from 2 to 6 years of age. Antenatal mental health and its trajectory were tested as mediators in the latent growth curve models.

Household income was a robust predictor of antenatal maternal mental health and all child outcomes. Between children from the bottom and top household income quartiles, four dimensions of school readiness skills differed by a range of 0.52 (95% Cl: 0.23, 0.67) to 1.21 s.d. (95% CI: 1.02, 1.40). Thirty-eight percent of pregnant mothers in this cohort were found to have perinatal depressive and anxiety symptoms in the subclinical and clinical ranges. Poorer school readiness skills were found in children of these mothers when compared to those of mothers with little or no symptoms. After adjustment of unmeasured confounding on the indirect effect, antenatal maternal mental health provided a robust mediating path between household income and multiple school readiness outcomes (χ2 126.05, df 63, p < 0.001; RMSEA = 0.031, CFI = 0.980, SRMR = 0.034).

Pregnant mothers with mental health symptoms, particularly those from economically-challenged households, are potential targets for intervention to level the playing field of their children.

Studies have shown that mental health problems during pregnancy have adverse effects on fetal growth. The impact of depressive and anxiety symptoms during pregnancy on the fetus have not yet been examined in Singapore.

To examine the association between mental health problems during the second trimester of pregnancy on the quality of the pregnancy, reflected by birth weight and birth length of the newborn.

This study aims to understand the importance of mental health during pregnancy on the development of the child in an Asian population.

Preliminary data of a prospective cohort study of pregnant women (GUSTO), were followed from pregnancy onwards. At 26 weeks of the pregnancy, the Edinburgh Postnatal Depression Scale (EPDS), the Beck Depression Inventory (BDI) and the State Trait Anxiety Inventory (STAI) were administered. Data on birth parameters were collected from medical records.

Linear regression analyses of preliminary data show negative correlations between depressive symptoms measured with EPDS (n = 1025, P = 0.54), BDI (n = 1012, P = 0.001), and anxiety symptoms measured with STAI (n = 1023, P = 0.002) and birth length (corrected for gestational age and gender). No associations were found for birth weight.

There is an association between depressive and anxiety symptoms reported at the end of the second trimester of the pregnancy and birth length, but not birth weight, of the newborn. As it is known that fetal length increases mainly in the second trimester, it suggests that stress of the mother influences the development of the fetus during this trimester.

Mental health stigma is a multidimensional concept that encompasses many different themes and definitions. Public stigma is defined as the degree to which the general public holds negative views and discriminates against a specific group.

To understand the context and correlates of stigma in multi-ethnic Singapore.

The current study aimed to (i) explore the factor structure of the Depression Stigma Scale and the Social Distance Scale using an exploratory structural equation modelling approach and (ii) examine the correlates of the identified dimensions of stigma in the general population of Singapore.

Data for the current study came from a larger nation-wide cross-sectional study of mental health literacy conducted in Singapore. All respondents were administered the Personal and Perceived scales of the Depression Stigma Scale and the Social Distance scale to measure personal stigma and social distance respectively.

The findings from the factor analysis revealed that personal stigma formed two distinct dimensions comprising “Weak-not-Sick” and “Dangerous/Unpredictable” components while social distance stigma items loaded strongly into a single factor. Those of Malay and Indian ethnicity, lower education, lower income status and those who were administered the depression and alcohol abuse vignette were significantly associated with higher weak-not-sick scores. Those of Indian ethnicity, 6 years of education and below, lower income status and those who were administered the alcohol abuse vignette were significantly associated with higher dangerous/unpredictable scores.

There is a need for well-planned and culturally relevant anti-stigma campaigns in this population.

The authors have not supplied their declaration of competing interest.

Various socio-demographic variables have been shown to influence attitudes towards seeking professional psychological help (ATSPPH), while negative ATSPPH can act as a barrier to mental healthcare, resulting in under-utilization of psychological services.

To explore the factor structure of the ATSPPH scale and determine whether any significant socio-demographic differences exist in relation to ATSPPH among a nationally representative sample.

Data was extracted from a population-based, cross-sectional survey conducted between March 2014 and March 2015 among Singapore Residents aged 18-65 years (n = 3006). Respondents completed the 10-item ATSPPH scale and also provided socio-demographic information. Exploratory factor analysis (EFA) was performed to establish the factor structure of the ATSPPH scale. Multivariable linear regression analyses were conducted to examine socio-demographic factors associated with ATSPPH.

EFA revealed that the ATSPPH scale formed three distinct dimensions comprising “Openness to seeking professional help”, “Value in seeking professional help” and “Preference to cope on your own”. Higher “Openness to seeking professional help” scores were significantly associated with 18-34-year-olds and unmarried respondents, whilst Malay ethnicity and lower education were significantly associated with lower openness scores. Malays, Indians and lower education were significantly associated with lower “Value in seeking professional help” scores, whereas higher “Preference to cope on your own” scores were significantly associated with lower education.

Population subgroups including those with lower educational levels and different ethnic groups have more negative ATSPPH. Tailored, culturally appropriate educational interventions which reduce negative ATSPPH are needed, which effectively target these populations.

The authors have not supplied their declaration of competing interest.

Given the emphasis on inclusion of well-being interventions in the treatment and rehabilitation of individuals with mental disorders, it is important to understand the level and determinants of positive mental health (PMH) among them.

To conduct a cross-sectional study among patients with schizophrenia, depression and anxiety spectrum disorders to estimate PMH.

(i) To estimate the level of PMH among patients with mental disorders and compare these with the established general population estimates; (ii) to identify socio-demographic and clinical determinants of PMH.

Following ethics approval, 353 patients aged 21-65 years, receiving treatment at a psychiatric hospital in Singapore for schizophrenia, depression or anxiety spectrum disorders were included. Patients provided socio-demographic information and completed the multidimensional PMH instrument that provides total and domain-specific scores ranging from 1 to 6; higher scores indicate better PMH. Functioning was assessed with the Global Assessment of Functioning (GAF) scale and clinical data were obtained from administrative databases.

Sample comprised 142, 139 and 72 patients with schizophrenia, depression and anxiety spectrum disorders respectively, with a mean age of 39.2 years. Mean total PMH scores among them were 4.2, 3.7 and 3.8 respectively which were significantly lower than the general population mean of 4.5 (P < 0.001). Patients of Chinese ethnicity, with lower education, depression or anxiety, and lower GAF scores were more likely to have lower PMH.

This study identified patient subgroups that are likely to have poorer PMH. Interventions facilitating PMH among these patient groups would be beneficial and are needed.

The authors have not supplied their declaration of competing interest.

Though sleep disturbances are common among psychiatric patients, some patients may trivialize their problem and not discuss it with their doctors. This study thus aimed to assess patient profile that is associated with help seeking for sleep problems among psychiatric patients.

Outpatients from a tertiary psychiatric hospital were recruited for this study (n = 400). The pittsburgh sleep quality index was administered to identify cases of probable insomnia, and daytime impairment due to sleep disturbances was recorded. Participants were asked if they have ever consulted a doctor or any health professionals for their sleep problems. Sociodemographic information was recorded and clinical profile was obtained from the patient's medical records. Multivariate logistic regression was used to examine correlates of help-seeking behaviour among patients with probable insomnia.

275 cases of probable insomnia were identified. Among this group of patients, 38.9% had never sought help for their sleep problems. Participants who were single were less likely to seek help as compared to those who were widowed/separated/divorced (OR= 0.319, P = 0.023). Having a comorbid psychiatric condition was independently associated with increased odds of help seeking (OR= 1.952, P = 0.027). Participants who perceived greater daytime impairment due to sleep problems were more likely to seek help (OR= 1.465, P = 0.007).

The majority of psychiatry patients with sleep problems sought professional help, though there remained a substantial group that did not do so. There is a need to educate and create awareness of potential sleep problems among psychiatric patients, and to inform them of the availability of treatment.

The authors have not supplied their declaration of competing interest.

Abnormal effort-based decision-making represents a potential mechanism underlying motivational deficits (amotivation) in psychotic disorders. Previous research identified effort allocation impairment in chronic schizophrenia and focused mostly on physical effort modality. No study has investigated cognitive effort allocation in first-episode psychosis (FEP).

Cognitive effort allocation was examined in 40 FEP patients and 44 demographically-matched healthy controls, using Cognitive Effort-Discounting (COGED) paradigm which quantified participants’ willingness to expend cognitive effort in terms of explicit, continuous discounting of monetary rewards based on parametrically-varied cognitive demands (levels N of N-back task). Relationship between reward-discounting and amotivation was investigated. Group differences in reward-magnitude and effort-cost sensitivity, and differential associations of these sensitivity indices with amotivation were explored.

Patients displayed significantly greater reward-discounting than controls. In particular, such discounting was most pronounced in patients with high levels of amotivation even when N-back performance and reward base amount were taken into consideration. Moreover, patients exhibited reduced reward-benefit sensitivity and effort-cost sensitivity relative to controls, and that decreased sensitivity to reward-benefit but not effort-cost was correlated with diminished motivation. Reward-discounting and sensitivity indices were generally unrelated to other symptom dimensions, antipsychotic dose and cognitive deficits.

This study provides the first evidence of cognitive effort-based decision-making impairment in FEP, and indicates that decreased effort expenditure is associated with amotivation. Our findings further suggest that abnormal effort allocation and amotivation might primarily be related to blunted reward valuation. Prospective research is required to clarify the utility of effort-based measures in predicting amotivation and functional outcome in FEP.

The second Singapore Mental Health Study (SMHS) – a nationwide, cross-sectional, epidemiological survey - was initiated in 2016 with the intent of tracking the state of mental health of the general population in Singapore. The study employed the same methodology as the first survey initiated in 2010. The SMHS 2016 aimed to (i) establish the 12-month and lifetime prevalence and correlates of major depressive disorder (MDD), dysthymia, bipolar disorder, generalised anxiety disorder (GAD), obsessive compulsive disorder (OCD) and alcohol use disorder (AUD) (which included alcohol abuse and dependence) and (ii) compare the prevalence of these disorders with reference to data from the SMHS 2010.

Door-to-door household surveys were conducted with adult Singapore residents aged 18 years and above from 2016 to 2018 (n = 6126) which yielded a response rate of 69.0%. The subjects were randomly selected using a disproportionate stratified sampling method and assessed using World Health Organization Composite International Diagnostic Interview version 3.0 (WHO-CIDI 3.0). The diagnoses of lifetime and 12-month selected mental disorders including MDD, dysthymia, bipolar disorder, GAD, OCD, and AUD (alcohol abuse and alcohol dependence), were based on the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) criteria.

The lifetime prevalence of at least one mood, anxiety or alcohol use disorder was 13.9% in the adult population. MDD had the highest lifetime prevalence (6.3%) followed by alcohol abuse (4.1%). The 12-month prevalence of any DSM-IV mental disorders was 6.5%. OCD had the highest 12-month prevalence (2.9%) followed by MDD (2.3%). Lifetime and 12-month prevalence of mental disorders assessed in SMHS 2016 (13.8% and 6.4%) was significantly higher than that in SMHS 2010 (12.0% and 4.4%). A significant increase was observed in the prevalence of lifetime GAD (0.9% to 1.6%) and alcohol abuse (3.1% to 4.1%). The 12-month prevalence of GAD (0.8% vs. 0.4%) and OCD (2.9% vs. 1.1%) was significantly higher in SMHS 2016 as compared to SMHS 2010.

The high prevalence of OCD and the increase across the two surveys needs to be tackled at a population level both in terms of creating awareness of the disorder and the need for early treatment. Youth emerge as a vulnerable group who are more likely to be associated with mental disorders and thus targeted interventions in this group with a focus on youth friendly and accessible care centres may lead to earlier detection and treatment of mental disorders.