A stepped care approach to mental health in Singapore: challenges and opportunities

Abstract

The Stepped Care Model (SCM) has emerged as an effective approach to delivering mental health services, organizing care in a hierarchical manner from low- to high-intensity interventions. Singapore’s adaptation, the Tiered Care Model, aligns with the SCM principles and addresses the nation’s unique mental health challenges. This paper explores Singapore’s implementation of the Tiered Care Model, emphasizing how it addresses mental health needs through a patient-centered, community-based approach. The model leverages four levels of care—ranging from mental well-being promotion to high-intensity specialist interventions—ensuring individuals receive the right level of support. A key pillar of the Tiered Care Model is collaboration with community partners, which is vital for the success of the lower tiers focused on prevention, early intervention, and moderate-intensity support. Building trust with community partners is essential and requires strong governance, clear guidelines, capability building, and technological integration. In addition, the model faces challenges, including the complexity of mental health disorders, fragmentation in care delivery, and the need for adaptive, data-driven approaches. Effective care coordination and digital solutions are necessary to streamline referrals, track outcomes, and ensure continuity of care. As Singapore continues to refine its Tiered Care Model, collaboration and trust among stakeholders will be critical to establishing a resilient mental health ecosystem, enabling individuals to access timely and appropriate support.

Background

Mental health plays a critical role in individual well-being and societal productivity, yet mental healthcare systems worldwide continue to face significant challenges in providing timely, accessible, and effective services [1, 2]. Despite growing awareness and increasing demand for mental health support, service delivery often remains fragmented, hindered by enduring stigma, and constrained by manpower and financial resources [3, 4]. In many countries, mental health services suffer from underfunding, poor insurance coverage, and uneven quality of care [5, 6]. Patel and colleagues argue that mental health systems worldwide remain misaligned with the actual needs of populations, particularly due to an over-reliance on diagnosis-based and specialist-driven care, with underutilization of non-specialist and community-based resources [7]. The World Health Organization (WHO) has similarly emphasized the urgent need for integrated service delivery, early intervention, and reduced stigma surrounding mental health issues [8].

In its most recent Guidance on Mental Health Policy, the WHO calls on countries to adopt a strategic approach to mental health reform [9]. It outlines five key policy areas: strengthening leadership and governance, developing community-based services, cultivating a diverse and multidisciplinary mental health workforce, providing rights-based and person-centered care, and expanding the sector’s role in addressing social determinants of mental health. Similarly, Patel and colleagues advocate for a shift in mental healthcare toward upstream, preventive approaches. They have proposed the use of a staging model that recognizes the progressive nature of mental illness, enabling the delivery of a broader spectrum of interventions as early as possible in the course of the condition [7].

The Stepped Care Model (SCM) offers a promising framework to address many of these needs and challenges. The SCM organizes mental health services in a hierarchical manner—services are graduated from low-intensity interventions, such as self-help and group therapy, to high-intensity treatments, including specialized or multidisciplinary interventions [10, 11]. The SCM maximizes the effectiveness and efficiency of mental health services by systematically providing treatment on an “as needed” basis [10]. This approach enables individuals to receive the least intensive intervention necessary to address their concerns while also retaining the flexibility to “step-up” the level of care and treatment based on clinical response, symptom severity, and changes in risk or need [12].

The SCM offers several potential advantages. Studies have shown that the SCM enhances cost-effectiveness by allocating resources efficiently—reserving intensive, high-cost interventions for individuals who truly need them while providing low-intensity options for those with mild or moderate conditions [13–15]. Secondly, the model improves access to care by offering a broad spectrum of interventions, making mental health support more accessible and scalable [11, 16, 17]. Moreover, it promotes personalized care through a tailored approach, ensuring that patients receive treatment aligned with their specific needs, preferences, and severity of symptoms. Lastly, the SCM’s flexibility allows for dynamic adjustments to care plans based on real-time monitoring and patient feedback, thereby contributing to better clinical outcomes and higher patient satisfaction [12].

A common critique of the SCM is the absence of a standardized operational definition, which has led to variation in how the model is implemented across settings and studies [18]. This inconsistency makes it difficult to compare outcomes and evaluate the model’s overall effectiveness [11]. However, such variability may be a strength rather than a limitation, as it reflects the model’s ability to adapt to differing local contexts, resources, and needs. To address this tension between consistency and flexibility, Mughal and colleagues proposed a set of core guiding principles that define the essential features of SCM while allowing room for local adaptation [19]. These principles include providing a continuum of services at varying intensities, supporting informed client choice, using outcome measurement tools to guide care, ensuring integration across services, and designing systems that are responsive to community needs.

Since its inception, the SCM has been successfully implemented across several countries, including France, Germany, the USA, Australia, and Canada, demonstrating its global appeal and effectiveness in addressing mental health needs [11, 20–22]. Indeed, the model’s advantages—improved patient outcomes, cost-effectiveness, and its ability to adapt to the evolving needs of patients—make it a compelling approach to mental healthcare. However, most of the evidence and literature surrounding SCMs originate from Western countries; little has been done in Asian countries [11]. For instance, based on a 2022 review, Japan’s mental health system is still largely characterized by a hospital-centric approach, though there have been ongoing reforms toward community-based care such as home-visit nursing, Assertive Community Treatment, and community outreach by Mental Health and Welfare Centers [23]. In Korea, a recent qualitative research study outlined the possible development of an integrated community-based mental health care model [24]. These examples highlight a growing interest in adapting community-based mental health approaches in Asia, yet a contextually adapted stepped care model has yet to be fully realized in the region.

In this article, we provide a descriptive overview of how Singapore has drawn on the principles of the SCM to develop its own Tiered Care Model and examine how this framework is being operationalized to meet the country’s mental health needs. Our aim is twofold: first, to introduce the structure and components of the Tiered Care Model within the broader context of Singapore’s mental health system; and second, to discuss the challenges in implementing a SCM system, including engaging with community stakeholders and the use of technology in integrating healthcare. In doing so, we hope to highlight the potential of the SCM in improving access to services and ensuring that individuals receive the care they need in a timely and efficient manner.

Adapting the Stepped Care Model in Singapore: the Tiered Care Model

The 2019 Global Burden of Disease Study identified mental disorders as the fourth leading contributor to disease burden in Singapore, accounting for 8.3% of the total disease burden [25]. More recent data from the National Population Health Survey 2022 highlighted a rise in the prevalence of poor mental health from 13.4% in 2020 to 17% in 2022. Among the population subgroups in the survey, young adults aged 18–29 years reported the highest prevalence, with 25.3% reporting poor mental health [26].

Singapore faces unique challenges in mental healthcare delivery, shaped by its multicultural population, fast-paced urban environment, and evolving societal attitudes toward mental health. In recent years, mental health has gained prominence in national policy, driven by rising mental health concerns and a growing recognition of the importance of mental well-being. The Singapore Ministry of Health, Institute of Mental Health, and various community partners have implemented a range of mental health initiatives, including the National Mental Health Blueprint (2007-to date) and the subsequent Community Mental Health Masterplan (2012-to date), aimed at providing comprehensive, accessible, and community-based mental health services [27, 28].

The demand for mental healthcare services in Singapore has been rising, particularly in the wake of the COVID-19 pandemic. However, the current workforce capacity may be inadequate to meet the increasing need for specialist care. In Singapore, the ratios of psychiatrists and psychologists to the population are 4.6 and 9.7 per 100,000, respectively, significantly lower than the average ratio among Organization for Economic Co-operation and Development (OECD) countries [29, 30]. To maintain timely access and long-term sustainability of mental health services, it is essential to deliver care in the most appropriate setting. In response, Singapore has examined and adapted international stepped care models to form its own Tiered Care Model.

Singapore’s Tiered Care Model draws on stepped care principles to organize mental health care services into four care levels based on the severity of mental health needs and intensity of interventions required [31] (Fig. 1). Standardized detection, assessment, and referral protocols enable appropriate right-siting of individuals. The following sections describe each tier in detail, outlining the target population, core services, and intended outcomes.

Fig. 1.

The Singapore’s Tiered Care Model. Note: IMH, Institute of Mental Health; ASCAT, Assessment and Shared Care Team; COMIT, Community Intervention Team; CREST, Community Resource, Engagement and Support Team

Tier 1: promoting mental well-being and resilience

Tier 1 aims to enhance mental well-being and resilience among the general population, with a strong focus on mental health promotion, prevention, and stigma reduction. Indeed, stigma continues to be one of the most significant barriers to mental health help-seeking globally and in Singapore. Cultural beliefs, fear of discrimination, and concerns about employment and social relationships often deter individuals from accessing mental health services early. This delay in help-seeking can lead to worsening symptoms, reduced recovery potential, and increased health and societal costs. The WHO underscores the importance of tackling stigma through national strategies that prioritize public awareness, mental health education, and the promotion of recovery-oriented practices [8]. Singapore has taken important steps with campaigns like “Beyond the Label” and “It’s OKAY to Reach Out,” but more can be done to embed anti-stigma practices across systems [32, 33]. Other aspects of Tier 1 services include community support groups and digital self-help platforms, such as Mindline that provide accessible mental health resources and tools for emotional well-being [34]. Within schools, Mental Health Education lessons and Social and Emotional Development programs are implemented to nurture resilience from an early age [35]. These public education campaigns and school-based programs are fully funded by the government through the respective Ministries. These nationwide initiatives are freely accessible and are a key investment in population-level mental health.

Tier 2: early intervention and low-intensity support

Tier 2 offers low-intensity services to individuals with mild mental health concerns. It involves primary and community intervention, focusing on early detection and prevention of symptom escalation. In Singapore, Social Service Agencies operate community mental health teams like Community Resource Engagement and Support Teams (CREST) and Community Intervention Teams (COMIT), both of which play a significant role in Tier 2 services [36]. CREST functions as a mental health first-stop touchpoint, aiming to identify individuals at risk early, offer psychosocial support, and improve mental health literacy through community engagement. These teams also work closely with community partners to raise public awareness and reduce stigma around mental health conditions. COMIT is a Tier 3 service and complements CREST by delivering more structured support through clinical assessment, psychotherapy, and psychosocial interventions, including cognitive behavioural therapy and psychoeducation for both individuals and their caregivers. Both CREST and COMIT are fully subsidized by the government through the Agency for Integrated Care, ensuring they remain accessible and free for clients.

Tier 3: moderate-intensity support and psychotherapy

Tier 3 provides secondary care to individuals experiencing moderate mental health conditions, offering assessments, psychotherapy, and coordinated care. The Mental Health General Practitioner (GP) Partnership and Primary Care Network-Mental Health train GPs to diagnose and manage mental health conditions within the community. Additionally, multidisciplinary teams comprising doctors, nurses, psychologists, and medical social workers also collaborate to provide holistic and continuity of care to clients within the community. While consultations with GPs, polyclinic doctors, and psychiatrists involve out-of-pocket payments, these services can be subsidized or paid for under Singapore’s national healthcare financing schemes, including MediSave, MediShield Life, and the Community Health Assist Scheme [37]. This co-payment model ensures that medical care remains affordable while enabling service users to access the appropriate level of clinical care.

Tier 4: high-intensity specialist care

Tier 4 delivers high-intensity tertiary and quaternary care for individuals with severe and complex mental health conditions. The Institute of Mental Health (IMH) is Singapore’s only tertiary psychiatric hospital and provides comprehensive inpatient and outpatient psychiatric services, crisis intervention, rehabilitation, and community outreach. Additionally, all public hospitals offer psychiatric services, and crisis support has been reinforced through helplines, mobile crisis teams, and expanded psychiatric services at Alexandra Hospital. This tier ensures individuals in acute distress receive immediate, specialized support. This integrated and patient-centered approach aims to ensure mental healthcare is delivered effectively and efficiently, supporting individuals across the care continuum and addressing Singapore’s evolving mental health needs.

Lastly, Peer Support Specialists—individuals with lived experience of mental health challenges—are a powerful resource in reducing stigma and improving system trust. The WHO (2021) and the Guidance on Mental Health Policy and Strategic Action Plans (2025) emphasize the inclusion of people with lived experience as essential to creating rights-based, person-centered services [8, 9]. In Singapore, certified Peer Support Specialists work across hospitals, community mental health teams, and social service agencies. They offer authentic empathy, normalize help-seeking, and foster hope for recovery. Integrating Peer Support Specialists in all tiers of the Tiered Care Model not only humanizes care, but also builds trust, encourages early intervention, and complements the work of healthcare professionals.

All in all, the Tiered Care Model has become the cornerstone of Singapore’s mental health strategy, focusing on providing the care needed to support individuals across the mental health continuum. It involves key stakeholders from the government ministries and agencies (e.g., Ministry of Health, Agency for Integrated Care), public healthcare institutions (e.g., Institute of Mental Health, restructured hospitals), community-based organizations and social service agencies (e.g., CREST and COMIT), educational institutions, and people with lived experiences. Each of these stakeholders contributes to a coordinated, person-centered, and right-sited mental health ecosystem aligned with the principles of stepped care.

Working with community partners

Singapore’s Tiered Care Model emphasizes a shift from an acute-centric, institutionalized approach to an integrated community-involved model of mental healthcare. This transition underscores the importance of strong partnerships with community organizations, which are integral to the success of Tiers 1 and 2. These partnerships enable the delivery of accessible, effective, and coordinated mental health services within the community. Additionally, community partners play a crucial role in early intervention, mental health promotion, and creating seamless care pathways.

In Singapore, mental health services in primary and community care settings comprise a robust network of GPs and community mental health teams such as CREST and COMIT teams. In addition, school counsellors play an important role in supporting students’ mental and emotional well-being while collaborating closely with the REACH (Response, Early Intervention, and Assessment in Community Mental Health) teams led by public healthcare institutions [38].

Given the diversity and sheer number of community partners working within a SCM of healthcare, it can be a challenge to build trust and foster collaboration. In this section, we highlight strategies to engage meaningfully with community partners.

Effective governance

Strong governance plays a crucial role in building relationships with community partners and the overall success of a SCM. Governing bodies establish the framework for coordination and oversight across all levels of care, and this ensures consistency in service delivery and aligns all stakeholders with national mental health strategies. Additionally, governing bodies should facilitate communication between different tiers of care. For instance, in Singapore, the Interagency Taskforce on Mental Health and Well-being was established in July 2021 to oversee and coordinate multi-agency efforts to address mental health challenges [39]. Between May and August 2022, the Taskforce conducted a public consultation, gathering feedback from over 950 respondents, including members of the public and stakeholders. The feedback obtained ultimately informed the development of the National Mental Health and Well-Being Strategy. In the long run, community partners and stakeholders should feel that their concerns are being heard and that they can rely on governing bodies for information and assistance when required.

The Agency for Care Effectiveness plays a key role in the development of cost-effective, evidence-based guidelines for mental health interventions in Singapore [40]. The Agency systematically evaluates clinical and economic evidence to inform best practices, helping to align treatment decisions with patient needs and resource constraints. In the context of the Tiered Care Model, the Agency for Care Effectiveness can possibly support the creation of clinical pathways that balance access, effectiveness, and value, ensuring that each tier of care delivers high-quality, consistent outcomes.

Establishing clear guidelines

Clear guidelines and frameworks are needed to guide community partners and improve consistency in service delivery. These guidelines provide community partners with a comprehensive understanding of their roles within the larger mental health ecosystem, enabling them to tailor their services effectively and cohesively. The National Mental Health Competency Training Framework in Singapore aims to do that. The framework was developed by a workgroup comprising representatives from various ministries (including the Ministry of Health, Ministry of Education, Ministry of Social and Family Development), statutory boards (such as the Agency for Integrated Care and Health Promotion Board) and Singapore’s tertiary mental health hospital, the Institute of Mental Health. It outlines the requisite skills and competencies for practitioners at each tier of the Tiered Care Model. This clarity ensures that community partners can design services with a clear focus and structure, aligning their efforts with national mental health objectives.

For example, under Tier 1 of the framework, practitioners are expected to understand mental well-being, promote mental health, and apply Psychological First Aid techniques effectively. Expected skills would include being able to identify individuals in distress, teach self-help techniques, and being able to communicate empathetically. This structured approach ensures that community partners have a clear understanding of their roles and responsibilities within the Tiered Care Model.

Additionally, Singapore is developing a comprehensive Practice Guide to standardize triaging, referral, and care coordination processes across providers in different tiers. This guide will streamline workflows, promote consistent care delivery, and ensure clients receive appropriate support based on their needs.

Building capabilities through training and support

Continued training, support, and the development of communities of practice are essential in building trust with community partners. Equipping them with necessary information, skills, and resources fosters mutual respect and shared goals, while involving them in training design and decision-making empowers them and cultivates a sense of ownership. Within Singapore, primary healthcare providers in polyclinics are supported by psychiatrists through a shared care model, and the Mental Health General Practitioner Partnership programs equip GPs to manage mental health conditions. Additionally, communities of practice among healthcare providers and partners can facilitate sharing best practices, promote continuous learning, and provide a platform for collaborative problem-solving, creating a network dedicated to improving mental health services and outcomes.

Using technology for care coordination

Effective collaboration and trust-building among community partners also requires strong connectivity and communication across tiers. With the diversity of community partners and healthcare providers, it can be challenging to coordinate different systems and infrastructure. Technology will likely be crucial in the future in enabling collaboration within a SCM. Singapore has developed several digital mental health platforms to improve access and support. MindSG, curated by the Health Promotion Board with whole-of-government input, offers mental health resources, self-assessments, and service navigation, reaching over 1.4 million users [41]. Mindline, an anonymous platform launched by Ministry of Health Office for Healthcare Transformation (MOHT), supports stress management through AI tools and self-assessments, with strong uptake among working adults and youths [34, 42]. Let’s Talk, co-created with young people, is a digital peer support forum that lowers help-seeking barriers and offers expert-backed guidance. To ensure the quality and safety of such tools, the National Mental Health Office will introduce a Technological Evaluation Framework to assess digital mental health solutions for effectiveness, safety, and alignment with care protocols under Healthier SG, Singapore’s prevention health initiative [31].

Challenges and future directions

While the SCM presents a compelling approach to mental healthcare, several challenges must be addressed to optimize its effectiveness and ensure continuity of care.

A key limitation of the SCM lies in the inherent complexity of mental health disorders, which often involve comorbidities and fluctuating symptom severity [43]. Individuals with severe conditions may initially access lower-tier services, risking delayed escalation and poorer outcomes, while those with milder symptoms may deteriorate over time. To address this, mental health services must be adaptive and responsive, with proactive outcome monitoring through psychometric tools, patient-reported measures, and clinical interviews. Regular assessments are crucial for timely decisions on stepping up or down in care intensity. Future research should explore how digital technologies can support routine and real-time data collection to identify individuals at risk early and enable timely interventions.

Fragmented care remains a key challenge in the SCM, especially during transitions between community, primary, and specialist services [44, 45]. This issue is particularly critical for individuals at risk of self-harm or suicide, who require continuous and coordinated support. To address this, a central case management system will be piloted at the IMH, National University Hospital (NUH), and KK Women’s and Children’s Hospital (KKH), with dedicated case managers tracking patients from first contact—often in the emergency department—through the care pathway and liaising with schools and community providers. Additional measures, such as standardized referral, triage, and care planning protocols, aim to reduce fragmentation. Maehder et al. [21] further recommend strengthening collaboration through local networks, digital tools, structured communication, and addressing interprofessional tensions via joint training and equitable partnerships [21].

While digital tools hold immense promise for enhancing mental health services, the largely unregulated digital landscape—home to over 30,000 mental health applications in Singapore—raises concerns about safety, efficacy, and data privacy. A nationally led oversight framework is needed to evaluate these platforms and guide their integration. Within the SCM, harmonizing existing portals can streamline access, referrals, and care coordination across all tiers. A unified platform could support self-care at lower tiers while enabling seamless referrals and data sharing among clinicians and counsellors. Integration with the National Electronic Health Records would further enhance continuity and right-siting of care.

Working with community partners is a cornerstone of every SCM. Providing clear guidelines and governance, upskilling practitioners, and leveraging technology are some strategies to build trust and foster collaboration with community stakeholders.

Conclusions

Singapore’s Tiered Care Model shows how stepped care principles can be adapted to the local context to improve access to mental health services. Its emphasis on prevention, early intervention, and community-based care aligns with global recommendations from the WHO and reflects a shift toward more person-centered and inclusive mental health systems [8, 9]. Moving forward, the Singapore experience offers valuable insights for countries seeking to develop mental healthcare systems based on stepped care principles. To further strengthen the effectiveness of the SCM, more needs to be done to improve digital tools, strengthen interagency collaboration, and enhance care coordination across service tiers.

Abbreviations

COMIT

Community Intervention Team

CREST

Community Resource, Engagement and Support Team

DMHC

Digital Mental Health Connect

EHR

Electronic Health Record

GP

General Practitioner

HPB

Health Promotion Board

IMH

Institute of Mental Health

MHGPP

Mental Health General Practitioner Partnership

MOH

Ministry of Health

NMHCTF

National Mental Health Competency Training Framework

OECD

Organisation for Economic Co-operation and Development

PCN-MH

Primary Care Network - Mental Health

REACH

Response, Early Intervention and Assessment in Community Mental Health

SCM

Stepped Care Model

WHO

World Health Organization

Daniel Shuen Sheng Fung

is a Singaporean psychiatrist and CEO of the Institute of Mental Health (IMH), Singapore. He has held leadership roles, including President of the International Association for Child and Adolescent Psychiatry and Allied Professions (2018–2022), and President of the College of Psychiatrists in Singapore (2020–2021).

Authors’ contributions

CYSL was responsible for the original drafting of the manuscript and project administration. DFSS contributed to the conceptualization of the study, provided supervision, and was involved in reviewing and editing the manuscript.

Funding

The authors did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. The article processing charges for this manuscript were waived by the journal.

Data availability

No datasets were generated or analysed during the current study.

Declarations

Ethics approval and consent to participate

Not applicable.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.