By Professor Tommy Koh: Time to put mental health high on list of national priorities

February 29, 2020

I have been thinking and worrying about the mental health of Singaporeans. I am the Rector of a College at NUS. One of my responsibilities is to look after the welfare and well-being of the 600 students who stay at the College. The report of a Visiting Committee, on the College, highlighted the need for the College to pay greater attention to the mental health and pastoral care of our students. In this essay, I wish to make five points.

Mens Sana In Corpore Sano
There is wisdom in the Latin saying, “mens sana in corpore sano”, which means, a healthy mind in a healthy body. The first point I want to make is that mental health and physical health are two sides of the same coin. There is an inextricable link between mind and body.
Let me tell you a story. When I was living in New York, I befriended the distinguished editor of a weekly magazine, Norman Cousins. He fell ill after returning from a work trip to the Soviet Union. His doctors diagnosed his condition as ankylosing spondylitis, a crippling connective tissue disease. He was told that the prognosis was very bad, with a one in 500 chance of recovery.
Norman Cousins was a fighter and he refused to accept the prognosis. He checked himself into a hospital and designed his own recovery programme. It consisted of massive intravenous doses of Vitamin C and laughter induced by watching comical movies and television shows. Miraculously, he recovered. His 1979 book, Anatomy of an Illness as Perceived by a Patient, was a best seller. It also got him an appointment, as an adjunct professor, in the Department of Psychology and Biobehavioral Sciences, of the University of California, at Los Angeles, Medical School. His research interest was the connection between attitude and health.
Like Cousins, I believe that a happy, optimistic and positive attitude helps one cope better with illness than a sad, pessimistic and negative attitude. A positive attitude may even aid recovery. I commend the Readers Digest for publishing a regular column, entitled, Laughter Is The Best Medicine.

Irrational Attitude Towards Mental Illness
My second point is that we need to change our attitude towards mental illness. We have a healthy attitude towards physical illness. A person who is physically ill, evokes our sympathy and support.
In contrast, a person who is mentally ill, evokes fear, suspicion and hostility. We call persons with mental illness by such pejorative terms as “mad” and “crazy”. We should recognise that our attitude towards mental illness is not rational and is not supported by science or the facts.
An example of the discrimination which persons with a mental illness suffer, compared to persons with a physical illness, is the attitude of our insurance companies.
Persons suffering from depression or anxiety have been rejected by our insurance companies, when they apply for medical insurance policies. I call on our regulators to end this discriminatory practice.  I wish to salute the NMP, Anthea Ong and the Straits Times’ Singaporean of the Year 2019, Angie Chew, for their admirable work in championing mental health.

State Of Our Mental Health
My third point is that the statistics on the mental health of Singaporeans probably under-report the incidence of mental illness in Singapore. In a survey carried out by the Institute of Mental Health (IMH) in 2016, 13.9 percent or 1 in 7 persons in the survey, said that they suffered from mental illness. The global average is 20 percent.
Why do I think that there is under-reporting in Singapore? In the same survey, 64 percent of the respondents said that they would feel embarrassed to admit that they had a mental problem.
Nominated MP Anthea Ong has pointed out in her excellent commentary, ”Let’s Talk about the ‘men’ in mental illness” (ST 24/8/2019) that the problem of under-reporting is particularly acute among our men.
The reason is cultural. Our society expects men to be strong and tough. Men fear that to seek help is a sign of weakness and could damage their masculinity and status. Men therefore prefer to suffer in silence. In Singapore, men are 2½ times more likely to commit suicide than women. In 2018, 283 men and 114 women committed suicide.
We should encourage our men to seek help when they are mentally unwell and not to be ashamed of doing so.

Mental Health of Young Singaporeans
My fourth point is that our alarm bells ought to be ringing about the mental health of our students and young Singaporeans. The situation is quite serious.
According to YouGov, one-third of young adults in Singapore have suicidal thoughts. The same percentage of young Singaporeans have indulged in self-harming activities.
According to one study, 18 percent of young Singaporeans suffer from depression. In 2018, 19 young Singaporeans, between the ages of 10 and 19, committed suicide. Suicide is the main cause of death of the millennials in Singapore.
Singapore is a very successful country. Singapore is also a very competitive and success-oriented society. We put enormous pressure on our students to excel in their studies. This generates stress. Some students cope well with the stress. Other students cannot cope with the stress and with the fear of not meeting the high expectations of their parents.
In the 2018 Programme for International Students Assessment (Pisa), carried out by the Organization for Economic Cooperation and Development (OECD), Singapore came in second, after China when it came to students’ performance in math, science and reading.
However, a high percentage of Singapore’s students, 86 percent were worried about getting poor grades, compared to the OECD average of 66 percent. 72 percent of Singapore’s students expressed fear of failure, compared to the OECD average of 56 percent.
The NUS Mind Science Centre, together with the Ministry of Education and the Ministry of Health will be jointly conducting a study on the psychological well-being of our students. We want Singapore to continue to out-perform other countries. However, we don’t want Singaporeans to be a nation of anxious, depressed and neurotic people. We want Singaporeans to be successful, healthy and happy.

Mental Health Of The Elderly
My fifth and last point is that the mental health of the elderly also needs our attention.  In 2019, persons over the age of 65 make p 14.4 percent of our population. The fact that 36 percent of the suicides in Singapore are by persons over the age of 60, should ring an alarm bell.

Why are older Singaporeans killing themselves? Is it due to poverty, ill health, loneliness or for some other reasons?
According to the Singapore Longitudinal Ageing Study (SLAS), carried out by the NUS Medical School, in 2012, one in five elderly persons, over the age of 75, showed signs of depression. Elderly depression was due to limited mobility, senile dementia, loneliness and financial problems.
Prof Chong Siow Ann, of IMH, is the principal investigator of a major study on the well-being of the Singapore elderly. The study will establish the prevalence of dementia and depression among the elderly in Singapore and describe the current healthcare services provided to this population as well as the unmet needs.
In his admirable book, The Colours of Ageing, Professor Kua Ee Heok discussed the work he has done, over the past 30 years, in looking after the mental health of elderly Singaporeans. He described a path-breaking programme, initiated by NUS and involving the People’s Association and the National Parks Board, called the Dementia Prevention Programme.
The programme enlists elderly Singaporean to boost their mental well-being through exercise, gardening, choral singing and group dancing. The results have been encouraging.
The lesson learnt is that preventive medicine is the best medicine. In view of this, I would encourage our educational institutions to offer their students, courses in meditation, yoga and taichi. This will help them to de-stress and to calm their minds.

I shall conclude by recapitulating my five propositions. First, I believe that mind and body are inextricably linked and a healthy mind can affect one’s physical health.
Second, we should give up our irrational and prejudicial attitude towards mental illness.
Third, we should encourage Singaporeans with mental health problems, especially the men, to seek help.
Fourth, the mental health of our students and young adults, manifested by depression, self-harming activities and suicide, has reached an alarming level and requires the joint attention of the Ministries of Education and Health.
Fifth, the mental health of elderly Singaporean also needs attention because of the suicide rate and the rising incidence of dementia.
Finally, speaking as an octogenarian, I want to say that for those lucky enough to live till a ripe old age, growing old is inevitable but good mental ill health is not inevitable. - we need to work hard as individuals and as a society, to maintain that.


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