Compulsory psychiatric treatment and care plan can help neglected psychiatric patients reintegrate into society and gain acceptance: An open proposal to the Singapore Government led by His Excellency, President Tony Tan, the Honourable Prime Minister Lee Hsien Loong and his ministers

"The task of caring for the mentally ill is extremely challenging, more so when there is widespread prejudice against mental illness. Very few people will understand how arduous the journey is until they are in the same predicament themselves."
- Raymond Anthony Fernando-

Your Excellency, President Dr Tony Tan, Prime Minister Lee Hsien Long & ministers,

I’d like to present the above proposal and hope that the Singapore Government will lend support and assistance to what I am suggesting.  If the Government intends to engage Singaporeans to improve the quality of life in Singapore, then it must also make the effort to reply or at least acknowledge suggestions or letters that are painstakingly put forward. I have not seen this happening.

Introduction

In a Straits Times (ST) report on Wednesday, August 15, 2012, a 76-year-old man was found dead in his Bedok Reservoir Road flat which was filled with trash. The Singapore Civil Defence Force (SCDF) took an hour to reach his dead body amid mounds of junk. The SCDF was called in after a foul smell was detected coming from the owner’s flat.

A neighbour who only wanted to be known as Madam Kwan told the ST that the man used to be a business owner who moved in about 25 years ago with his wife and daughter.  The wife and daughter moved out 10 years ago and the hoarding habit appeared to have started about the same period.

Addiction specialist Dr Munidasa Winslow, a well known psychiatrist who used to work at the Institute of Mental Health (IMH) mentioned that hoarding could be due to a mental illness, personality disorder or compulsive behaviour.

Follow-up ST report on hoarding

In a follow-up story on Friday, August 17, 2012, the Straits Times ran a report- “Hoarding – common problems in small rental flats”.

Members of Parliament interviewed told ST that although the hoarding problem is not widespread, it is hard to eradicate.

Dr Lee Cheng, Chief of the Department Of Community Psychiatry at IMH believes that such behaviour could be due to mental illnesses such as Obsessive Compulsive Disorder (OCD), Schizophrenia and Dementia.  Dr Lee opinions that hoarders he has come across tend to be isolated and have a low socio-economic status.  

Dr Carol Tan-Goh, a specialist in geriatric medicine at Raffles Hospital feels that it is crucial to address the hoarding problem as the people around the hoarder suffers, resulting in children moving out of the house and relationships with neighbours deteriorating.

“Pressing” issues

M. Lukshumayeh’s letter on Tuesday “Did this fall through the cracks?” to the 15^th August report was spot on when he observed that the HDB, town council, Singapore Power and related grassroots agencies failed to act decisively to the plight of the 76-year-old man who died in a trash-filled flat.

It is also very sad that neighbours who knew of the man’s strange behaviour did not feel it necessary to help.  If everyone adopts a “this is not my job” or “this is none of my business” attitude, then more lives will be lost, and in such a tragic manner too.  Perhaps it is fear. Fear due to lack of understanding of mental illness.

In another report published in The New Paper on Friday 24^th August 2012 - “They wait 3 hours to nab vandal”, a lady living in Hougang Avenue 9, believed to be in her mid-50s and of unsound mind was arrested by police after she had placed urine and faeces at the door of one of her neighbours.  

All these bizarre behaviour will only further stigmatize the mentally ill and alienate them from society because they will be viewed as trouble makers who have no economic value.  We must correct this or we will create enclaves in our society. Enclaves that will seen the mentally ill and their caregivers shunned and discriminated against- all their lives.

Members of Parliament, be they from the ruling party or opposition must take a vested interest in the welfare of their residents because every Singaporean has a stake in this country, and that includes those who are marginalized.   After all, aren’t MPs elected to serve all Singaporeans?

The Prime Minister has repeatedly assured all Singaporeans that every Singaporean matters and that no one will be left behind.  But from the many reports that I read about the neglect of the mentally ill, I am inclined to think otherwise.

Another one bites the dusk

At the market place at Block 628 Ang Mo Kio Avenue 5, which is about 400 metres from where live, I have witnessed an elderly Chinese lady, probably past 60 years old who uses her bare hands to “sweep” the floor near the bus stop. The irony of it all is that this is taking place just opposite the Yio Chu Kang Community Club.  Don’t get me wrong I am not trying to politicize this situation, but merely pointing out that if everyone adopts a “couldn’t-care-less attitude”, how can we ever become a cohesive society as one Singapore, One People, One nation. While the lady in question does not disturb anyone, her actions are not only harmful to her health, but to her overall mental state as well.

2 years ago, I saw this elderly lady and alerted MCYS. After the second call, I managed to persuade MCYS staff to check on her. One month ago, she has returned, “sweeping” the floor at the bus stop with her worn out hands as everyone looks on.  I have not seen her since, but I wonder where else she has gone to. 

Isn’t that lady someone’s mother, daughter or sister who needs love, understanding and most of all, support?

These are reported cases, but what about those that go unreported?  It is never easy taking care of a loved one stricken with mental illness, and that could be one reason why some family members choose to abandon them. This is why it is crucial for a good supporting system for caregivers to be put in place.  We don’t have that here in Singapore, despite my relentless pursuits to secure this.

Laws need to change

Currently, the Institute of Mental Health is not empowered to bring in any person who is mentally ill to seek compulsory treatment if the person is not registered with the hospital. This must change if we want to reclaim and save lives.

Let us take a look at how two western countries have put in place a good mental health care system, which Singapore can adopt with modifications and a light handed approach, given our own unique ethnic and religious backgrounds.

(a) Finland’s model of mandatory psychiatric treatment

In Finland, the process of compulsory detention is initiated by a referral for observation (known as MI), which can be written by any physician if they consider it likely that the criteria for involuntary admission are fulfilled.  In the hospital, the patient is then examined by a second doctor who must be a psychiatrist. At this stage the patient can be admitted on a voluntary basis, or indeed not at all, if the psychiatrist does not consider the criteria for detention to be fulfilled. If compulsory admission is recommended by the psychiatrist, a written statement or an MII describing the patient’s condition, detention criteria, as well as the patient’s own views, has to be produced on the fourth day after initial admission at the latest. A third recommendation - MIII, the final decision, is then required by the psychiatrist in charge at the hospital to which the patient is admitted. This completes the procedure; the detention is then valid for 3 months.

Finland takes a medical approach to compulsory detentions of psychiatric patients, emphasizing the need for treatment in the best interest of the patient. The decision for compulsory admission is based on the assessment of medical professionals only.

(b) U.K’s model of mandatory psychiatric treatment

In the U.K, the Government has made it compulsory for the mentally ill who do not take their medications and pose a danger to themselves as well as those in the community to be re-admitted into a hospital.   Patients who are discharged after treatment could be given a compulsory care and treatment order specifying where they live and a care plan.  Under this care-in-the-community programme, social and healthcare workers have a duty to ensure that the care plans stipulated are carried out.

Perhaps it is time to review our laws with regards to treatment of the mentally ill. Needless to say, such treatment orders and care plan need only be imposed on patients who are in dire need of treatment or whose family members have either abandoned them or are unable to take care of them. Of course, helping to secure jobs for these patients which will give them a sense of worthiness will also help a great deal in their recovery.


Such treatment orders can also see a reduction in the number of cases in the forensic ward of the Institute of Mental Health (IMH). This will then simultaneously see a reduced workload for the police, IMH and the courts. However, these proposed treatment orders should not be use against Government critics or for political reasons.

Resources & objectives

To tie-in with this proposed programme, more beds need to be secured and specialist crisis teams need to be created with the ultimate goal of improving access to care.  I hope the Ministry of Health & the newly set up ministries can lend support in these areas.

Conclusion

The objective of this whole programme that can be “tailored” to suit our own local needs is to ensure that people who are in dire need of psychiatric treatment can be given proper medical care which will enable them to lead a normal life.  I do not advocate detention, but rather mandatory treatment for those who are in dire need of psychiatric care. 

Once these patients are on the road to recovery, a support system for both the patients and their caregivers must be incorporated. Ultimately, if the mentally ill are given proper treatment, they will not cause disruption to the lives of those who live with them and those around them.

This will then pave the way for society to slowly, but surely accept that mental patients are also human and can with support and care, go on to lead perfectly normal lives. We will then see fewer enclaves in our society and indeed become the best home to live, work and play in. Thank you.

Sincerely,

Raymond Anthony Fernando

Advocate for the mentally ill
P.S: I am very passionate about mental illness because I have seen suffering right before my very own eyes (my wife has battled schizophrenia for 40 years) and my Catholic faith teaches me to show compassion, love and care for the less fortunate in our society.

Reply from Ministry of Health today, 29th August 2012, after this proposal was also routed to the Health Minister Gan Kim Yong:

Dear Mr Fernando ,

We refer to your email to the Minister for Health. 

Thank you for sharing your suggestions on the programme for Mental Health patients for our consideration.

We will monitor and study into this matter, and keep your suggestion in mind during our reviews.

Your constructive ideas will be useful in fine tuning our policies.

Best Regards.

Yours sincerely,
Aven Khoo
for Quality Service Manager
Ministry of Health, Singapore