No health without mental health: united we stand

October 10 marks World Mental Health Day. Mental health is integral to the overall health of every individual in the context of family, workplace and the society at large. In this special issue of the Singapore Medical Journal, we have compiled a collection of articles that focus on different mental disorders across the age span and varied clinical aspects, ranging from diagnosis, cognitive functioning, lived experience of individuals, parental bonding and treatment modalities, including nutritional protocols, neurostimulation interventions and the adoption of technology tools to improve mental health care.

The commentary on stigma and mental health by Subramaniam[1] relates to negative attitudes, beliefs and behaviours directed at individuals with mental disorders. The nature of stigma can be socially driven, self-directed or even institutional in origin, and it is associated with specific impact on individuals. There is a need for ongoing efforts to combat stigma associated with mental disorders, varying from interventional national efforts to legislative changes involving the community, organisations, individuals and healthcare professionals. One important aspect for healthcare professionals to note is diagnostic overshadowing. First used in the context of management of individuals with intellectual disability by Jones et al.,[2] diagnostic overshadowing describes the phenomenon whereby healthcare providers may misattribute symptoms of physical illness to a mental condition, which can delay diagnosis and appropriate treatment of underlying physical conditions. This can serve as a barrier to the provision of better medical care for individuals with mental disorders.

Several studies have focused on younger individuals. Attention deficit hyperactivity disorder (ADHD), a neurodevelopmental condition marked by inattention and hyperactivity, is associated with behavioural issues, interpersonal difficulties, and lower self-esteem and educational attainment, requiring a multi-informant approach in management. Poh et al.[3] sought to compare the use of an objective rating tool, Conners’ Continuous Performance Test II, with other subjective measures by carers, including the ADHD Rating Scale, Child Behaviour Checklist, Clinical Global Assessment Scale and the Clinical Global Impression Scale. Their findings warrant further examination of the inter-relationships between the different assessment tools to enrich the information available for better care of individuals with ADHD. Teo et al.[4] examined anorexia nervosa (AN), a psychiatric condition with potentially severe physical complications arising from malnutrition. They sought to understand the profile of individuals treated with an inpatient nutritional rehabilitation protocol for AN. They found that the majority in their cohort were female, with a median age of 14 years and a median duration of presentation to dietician of 9.5 months. While medical stabilisation of patients with AN can be achieved more quickly through a higher calorie inpatient AN treatment protocol, future studies may want to look at the impact of the AN protocol on other outcome parameters, such as refeeding syndrome, time to remission and functional status over time. Poon and Loh[5] conducted a qualitative study to understand the lived experience of adolescents with depression. The study found that adolescents often attempted to manage depression on their own, and that management of specific psychopathology such as suicidality and anhedonia–avolition symptoms — though more challenging — also provided opportunities for engagement, risk monitoring and building of trust, which can facilitate better long-term management and outcome.

On the family front, Tan et al.[6] examined the associations between facets of parental bonding and health-related quality of life (HRQOL) in a clinical sample of youths. The team hypothesised that high parental care and low parental overprotectiveness are associated with higher levels of HRQOL. They found that individuals reported better mental health functioning when parents showed care during their early years, suggesting that early maternal care has an enduring protective effect on mental health later in life.

Moving to the adult group, Mok et al.[7] emphasised the crucial role that a general practitioner can play in early recognition, treatment and engagement of low-risk individuals with first-episode psychosis, as well as timely referral to specialist treatment units whenever needed. This can go some distance in reducing the duration of untreated psychosis to minimise its impact on clinical outcomes and foster better recovery and quality of life. There is also a need to monitor the individual for response to treatment and treatment emergent adverse effects. Still on psychotic spectrum disorders, Sun et al.[8] examined the relationship between cognitive functioning and treatment response in schizophrenia, ranging from antipsychotic-responsive to clozapine-responsive and clozapine-resistant treatment statuses. The team found that the greater the degree of treatment resistance, the poorer the cognitive functioning, and highlighted that strategies to improve negative and disorganisation symptoms might be useful to improve cognitive functioning and treatment outcomes in schizophrenia.

In terms of treatment modalities, Tan et al.[9] provided a narrative synthesis of transcranial magnetic stimulation (TMS) in the management of treatment-resistant depression, depression with anxiety and schizophrenia with negative symptoms. Advances in neuroimaging technology and methodology allow for elucidation of involved brain regions and circuits within the different psychiatric disorders, which paves the way for more personalised targeting during TMS treatment. More specific and individualised treatment approaches can potentially reduce cognitive and related adverse effects with better overall outcomes in the context of precision psychiatry. In the arena of technology tools, Mahreen et al.[10] performed a comprehensive review of extant reviews (systematic, scoping, narrative, etc.) on the use of mobile health tools in enhancing mental health care. It is heartening to observe that to date, there are over 100 reviews on the use of such mobile technology tools that have shown promise in managing a range of psychiatric conditions, including depression, anxiety, psychotic spectrum disorders and substance use disorders.

World Mental Health Day is a timely reminder that there can be no holistic well-being without addressing the issue of mental health. Concerted efforts are needed for impactful changes. Just as attempts in addressing stigma surrounding mental illness require a whole of society framework, the approaches to tackling challenges in diagnosis and management in psychiatry require a multifaceted paradigm. This includes education, engagement and empowerment of individuals to take care of their mental health, expanding resources and access to available services, and enduring efforts to innovate and improve ways of managing, rehabilitating and supporting individuals with mental illness, so that they can regain normal functioning in their daily lives. We must be united in striving towards these goals. United we stand.