Singapore is well-known for its efficient healthcare system. It consistently ranks high in global health indexes, with longer life expectancies and low infant mortality rates to show for it. And it’s the so-called “envy of the West” for its balanced approach to regulation and sustainable financing model. However, Singapore’s healthcare system isn’t perfect. In fact, it fails to address one of the most prevalent medical conditions that plague mankind: mental illness.
According to the second Singapore Mental Health Study (SMHS) initiated in 2016, one in seven Singaporeans experience a mood, anxiety, or alcohol use disorder within their lifetime. More troubling is the fact that after being diagnosed with a mental illness, less than a quarter of Singaporeans seek professional help. Those who do seek treatment do so after a considerable delay. People with obsessive-compulsive disorder, for example, only seek treatment after an average of 11 years. This is the longest treatment delay recorded among all disorders, followed by bipolar disorder and alcohol abuse that have a treatment gap of four years.
While Singapore nationals and permanent residents get universal health coverage, highly subsidized basic care at public hospitals, and a plethora of private healthcare insurances to pad their coverage with, these are more geared toward physical afflictions. When it comes to getting affordable, quality mental healthcare, it’s a different story.
Food or therapy
“I grew up listening to my mom and aunts say ‘it’s cheaper to die than be sick in Singapore.’ I thought that was a joke,” Mel Frisk, an artist and mental health advocate, also known by her social media moniker Ikigaijin, told VICE World News. “I am in the middle of an autism assessment, which I’m trying to afford. In Singapore, it can cost up to SG$2,500 ($1,883).”
“I grew up listening to my mom and aunts say ‘it’s cheaper to die than be sick in Singapore.’ I thought that was a joke.”
Treatments, grants, and subsidies for mental healthcare are available, but they’re limited. For example, the government’s Chronic Disease Management Programme (CDMP) covers schizophrenia, major depression, bipolar disorder, and anxiety. Citizens can use their MediSave accounts — cash set aside for healthcare as part of their national medical savings scheme — to pay for outpatient treatment. But there’s a cap of SG$500 ($377) per year, with each claim subject to a 15 percent co-payment in cash.
Citizens can also withdraw up to SG$150 ($113) per day for psychiatrist in-patient care, capped at SG$5,000 ($3,767) per year, from their MediSave accounts. But the most prevalent disorders in the country — major depressive disorder, alcohol abuse, and obsessive-compulsive disorder, according to the SMHS — are typically only treated with medication and therapy, and not in-patient psychiatric treatment.
“Just because [certain mental illnesses do not require] in-patient [care], doesn’t mean they don’t deserve the time of day. People are trying to find ways ‘in’ to get subsidized and afford care. I don’t know if insurance covers it. And what will admitting [mental illness] do to [an insurance] premium?” said Frisk.
Many Singaporeans choose to stay silent about their mental health condition to stay insured, as some companies have reportedly denied life insurance and other kinds of coverage to those dealing with disorders like depression and anxiety.
There are few options for private health insurance that covers mental health. In fact: AIA’s Beyond Critical Care insurance was the first one to offer it, and it was launched in 2019. In this plan, citizens are only allowed to make one claim for each of the five covered illnesses.
Even with all of these options combined, the subsidies provided wouldn’t even be enough for Frisk’s autism assessment. Not to mention the succeeding consultations, therapies, and treatment options that can cost anywhere from SG$40 ($30) at subsidized rates to SG$3,300 ($2,487) depending on where you go. For many Singaporeans, particularly those from low to middle-income backgrounds, this simply isn’t feasible. But for those suffering from mental illnesses, what other option is there?
“It feels dirty to admit privilege, but I will. It’s something that needs to be discussed: there’s a high price to pay for quality mental healthcare,” Frisk said. “Once in a while, it’s food or therapy.”
“It feels dirty to admit privilege, but I will. It’s something that needs to be discussed: there’s a high price to pay for quality mental healthcare.”
Treated or sedated
“The [therapist] I [used] to go to was SG$235 ($177) for a 50-minute session. I could only go once a month because I couldn’t afford to spend SG$1,000 ($754) a month on therapy. But she was the best therapist I found and I’ve tried many therapists in Singapore,” Aleesha Khan, 23, an aspiring psychologist and founder of mental health organization Self-Ally, said to VICE World News.
Khan was diagnosed with general anxiety disorder and clinical depression when she was just 14 years old. The therapist she’s referring to was an expat who worked at a private clinic. After being referred to at least five therapists from public institutions, she found that the treatment just wasn’t working for her.
“I found it all very unhelpful. It was like being handed a homework assignment,” Khan said. “I was a teenager. I just wanted someone to talk to.”
“I was a teenager. I just wanted someone to talk to.”
According to Khan, her treatment with government sector therapists “felt mechanical and lacking empathy and connection.” She then turned to private healthcare to seek help, and finally found a therapist she felt comfortable with.
“The reason I felt safe and comfortable is because, firstly, she was an amazing therapist. She took the time to understand everything. But she was also very culturally informed and culturally sensitive. So when I was talking about my culture, she understood it,” Khan said.
Khan comes from a Pakistani-Iranian family. She was born and raised in Singapore, is relatively light-skinned, and well-spoken, but felt like an “other” growing up. Because of this, finding a therapist that she could connect with was extra challenging.
“Majority of therapists are Chinese in Singapore, because that’s the majority race. It’s very difficult to converse with them because, as minorities, a huge part of our experience is being mistreated by Chinese people. A huge part of my experience with mental health is, on a daily basis, seeing and experiencing racism. How do you sit in a room with a Chinese person and tell them that unless they’re willing to hear it?” Khan said.
In Khan’s experience, there aren’t enough people of color in mental healthcare. She likes her therapist, but is still frustrated with the fact that it was a white woman she was pouring her grief to. But at least with private healthcare, Khan had the option of choosing her therapist instead of relying on referrals from polyclinics.
“There’s definitely going to be therapists at these government hospitals who are amazing and actually helping people, but there should be more options. There are people like me who go and have seen four or five therapists and didn’t like any of them. It’s not because we’re being picky, it’s because we want someone who we can actually connect with,” she said.
Finding the right therapist is extremely important in treating mental disorders. Based on Khan’s and Frisk’s experiences, the road to healing is an iterative process. And like Frisk said, there’s a fine line between treatment and sedation. “So are we just being sedated, or are we being treated?”
‘Normal’ or other
In Singapore, there’s a stigma against mental illness. A 2018 survey conducted by the Institute of Mental Health (IMH) found that more than five in 10 Singaporeans are unwilling to live with, live nearby, or work with a person with a mental health condition. Six in 10 also believe that mental health conditions are a result of a lack of self-discipline and willpower. This lack of understanding puts a double burden on those with mental illness.
“It’s just a difficult process to go through and explain to people. [I remember] printing out research at 14 trying to explain to my parents that it’s actually real and I’m not just being ‘overly sensitive’ and stuff,” Khan said.
Outside the healthcare system, this stigma is reflected in other social structures. Both Khan and Frisk struggled to keep up at school and work.
“I got retained because I got pulled back a year as a result of my depression, because I was struggling with school. One of the vice principals said to me that ‘depression doesn’t affect your grades, so this is on you,’” Khan recalled.
Meanwhile, Frisk wishes companies would be more flexible with their working conditions and understanding of the needs of those with mental illness.
“The thing about mental health is that it makes it hard to work. Even if you’re good at something that pays you well, you can’t keep up because the structures have not changed enough to hold you,” she said.
“The thing about mental health is that it makes it hard to work. Even if you’re good at something that pays you well, you can’t keep up because the structures have not changed enough to hold you.”
For Khan and Frisk, change is an uphill battle.
“It’s like, a lot of people are stuck in these binary ways of seeing life. So when you present them with a new way of thought, there’s a cognitive dissonance. It would take so much mental effort and consciousness to unlearn something and relearn something else. The easy approach is just to push back,” Khan said.
But both agree that Singapore has been making progress in the right direction. Just last year, the government decriminalized suicide. It also acknowledged that asking job applicants to declare their mental health conditions is discriminatory, and stopped the practice. While these are definitely wins for mental health advocates in the country, Singapore’s mental healthcare still has a long way to go.