MENTAL HEALTH ISSUES: OUR STATUS QUO
There has been a lot of traction around mental health and mental illness recently with the rising rates of mental illness and mental health issues around the world and in Singapore. The World Health Organization (WHO) has released a special initiative[1] and report[2], which stated that depression and anxiety increased by 25 percent in the COVID-19 pandemic’s first year. This means that those living with a mental disorder now amount to 1 billion people worldwide. Aggravating the issue, a WHO spokesperson mentioned, “What’s more, mental health services have been severely disrupted in recent years, and the treatment gap for mental health conditions has widened”[3] in a global situation where 1 in 8 of us live with a mental health condition.
In Singapore, an Institute of Mental Health (IMH) study points to likely increase in mental health issues in Singapore amid COVID-19[4]. According to the Singapore Youth Epidemiology and Resilience Study involving 3,336 young people aged 11 to 18 here, about 1 in 3 of these young people in Singapore has mental health symptoms[5]. In our generally youth-centric and -biased world where youth is given an unjust prime, we need to pay attention to our Singapore’s ageing population, where depression strikes about six percent of the elderly population aged 65 and above[6], with a prevalence of other mental health issues. There is, of course, the broad middle of the demographic age group, in a time where Singapore’s old-age dependency ratio has increased from 13.5 percent to 23.4 percent[7].
Of course, we need to correct the growing metaphor of the Silver Tsunami that suggests how an ageing population looms to impede the potential, well-being and even growth of our whole society. In Malay, we call our elderly ‘warga emas’ or the golden members of our society, indicating how valuable this population is. Instead of the Silver Tsunami, we could speak of metaphors such as ‘Hujan Emas di Singapura’ or the Golden Rain in Singapore – conveying the potential wisdom, love and compassion that our more elderly population brings.
There is the broad middle, who are often positioned as the ones on whom the young and old are dependent upon. World Economics reported Singapore’s age dependency ratio for the dependent population as 64.6 percent in 2019[8]. This is higher than the global average of 40.1 percent. A higher ratio indicates more financial stress on working people and possible political instability. This indication of stress and instability, which could contribute to mental health issues, is often cited as rooted in the structural and systemic issues and our political economy.
FROM INDIVIDUALISING MENTAL ILLNESS TO STRUCTURES AND SYSTEMS
Much has been written about the fact that structures contribute to mental health issues. It is rather prevalent in the global dominant discourse that it is imperative for us to have concerted efforts in “tackling social inequalities to reduce mental health problems”[9]. This is alongside WHO galvanising the world towards “promoting mental health and well-being to reduce inequality and achieve universal health coverage”[10], and other reports stating unequivocally that some groups of people have far poorer mental health than others, often reflecting social disadvantage[11].
Actors in Singapore are also knee-deep into the structural and systemic issues. The discourse that we should not individualise mental illness, disorders or mental health issues has started to gain more traction. CNA reported that there are calls for a societal movement to move away from individualised mental illness or problems removed from the systems and structures they are embedded in towards structural-historical trauma. The movement calls for focus on the social determinants of mental health[12]; while a number of academic publications have indicated a link between inequality and mental health[13]. Even in the realm of genetic research, where there had been a tendency to debate about nature versus nurture, and the perils of genetic determinism, the growing field of epigenetics emphasises the importance of both nature and nurture affecting mental health. Epigenetics studies are the link between genes and environment through epigenetic mechanisms, which determines that individual’s vulnerability to psychiatric syndromes over a lifetime[14], leading to more plausibilities of multidisciplinary and interdisciplinary research, both addressing upstream and downstream research into the epigenetic basis of mental illness.
Non-governmental organisations and other civil society bodies such as AMP Singapore, as well as social service agencies such as family service centres, have also chimed in to the concerted efforts. During the AMP 4th National Convention in 2022, its Youth Panel had discussed, diagnosed, and co-created solutions to address this concern. I had also published an article on the social determinants of health rooted in the political economy, and contextualised it to both Singapore and the Malay/Muslim community[15].
The COVID-19 Mental Wellness Taskforce report[16] by the Ministry of Health and the Institute of Mental Health in October 2020, shows that the government is committed to both raising awareness of elderly and youth mental health challenges[17]. These efforts received both positive and negative reception. While Forbes cited Singapore as an “international model for mental health”[18], local observers such as former Nominated Member of Parliament, Ms Anthea Ong, said that while she was initially encouraged by the news of the mental health taskforce, her “optimism has slowly faded” reasoning that “because of the transient nature of a task force, no one ministry owns it and it’s not the highest priority for the people involved since they also have their main jobs”[19]. As such, more can be done in our whole-of-society approach.
STRUCTURES, OBJECTIVE FICTIONS AND POSITIVE INDIVIDUALISM
While we have focused on structures such as the impact of systemic inequality on mental health, what is seldom talked about is that structures do not exist in isolation. Similar to how individuals do not exist in a vacuum, structures are also not self-generating. Usually, when I try to convey that it would be better to not place the entire fault on an individual, I use the analogy of a flower. If the flower wilts, we do not blame the flower. We look at the conditions around the flower that sustain, nourish or impede its growth and well-being. We consider the soil, the sunlight, the minerals, and so on, and even whether someone has plucked it out of its home, or violently crushed it. But perhaps, this is not entirely true.
Unlike the flower, we have a consciousness that can impact the world through our agency. We are that someone who can act to uproot the flower, or tenderly care for it. The flower, although interconnected to everything just like how we are, do not have that same potential in agency as we humans are capable of. However, our individual agency is within a set of constraints, as well as empowerments, rooted in our positions in the overall structure. Some of us might have more socio-economic advantage to convert to either services, goods or other deeds that can benefit others in distress, who are socio-economically weaker than us. Just as inequality contributes to the risk factor of an individual developing mental health issues, we might assume that it also contributes to both the quality and the quantity of someone making an impact.
However, we should not confuse ourselves by disempowering those who we might think have less resources and advantages, from making an impact, and disqualifying them from a whole-of-society’s approach towards alleviating mental health issues. There is wisdom in understanding that we should not undermine the efforts of any one individual in contributing to improving our mental health, and relieving mental or emotional distress with compassion.
While the thought of structures can be overpowering and disempowering, we need to strengthen our positive individualism. The Islamic traditions of the Malay-Indonesian world emphasises this trait of positive individualism that is captured by the great works of Taj-us Salatin, a form of advice for kings. I also have written about this positive individualism and Islamic humanism in an article during the height of the pandemic[20].
However, while we all have a part to play, it is of course the elites in our society, our leaders, who have a responsibility, with their positive individualism, and the resources and advantages they have, to create the stories that move us. These stories have power, and we humans are, by both nature and nurture, storytellers. This is what sets us apart from other living beings.
Johnston, A., et. al. call some of these powerful reality shaping stories objective fictions[21] especially in our political economy, where the lines between the common-sense understandings of fact, fiction and truth are blurred and interconnected – much like ideologies and utopianisms. Ideologies are stories that maintain the status quo, whereas utopians are stories that seek to replace the status quo with another reality. Stories have power, especially so, when told by the powerful, well-resourced and influential – namely, the elites and leaders in a given society. In our political economy, the source of these stories that might be negative for us is not clear, as they are self-generating by and within the political economy itself, and not clearly imposed by a higher authority. For example, in the historical political economy of the Malays before colonial capitalism, it is clear that certain unjust stories to justify oppression and exploitation came from Malay Sultans and their feudal class, who justify their adverse actions through magico-religious stories and myths to bolster their divine right to rule as God’s shadows on earth, no matter how unjust their actions may be. In our current political economy however, if stories are oppressive, there is no centre or clear source. These self-generating stories with no clear source or centre within the system are our objective fictions from which we must awaken.
This has changed further with social media and the rise of influencers to challenge the centres of storytelling. But there is a need to look beyond the dominant stories, and to look at the alternative or even marginalised stories. One objective fiction, and a powerful story, that we tell ourselves as I mentioned earlier is the narrative of a looming silver tsunami as the dominant narrative. The alternative narrative I suggested was the Hujan Emas or the Golden Rain; seeing our elderly as our warga emas or our golden members of society, where they are treasured, honoured, seen as extremely valuable, and priceless even, empowered and empowering, as opposed to being a burden that will overpower us like a tsunami arriving to crush us, deplete our resources and disempower us.
Our stories and emancipation from adverse objective fictions about this shape the structures and systems, as well as the direction of our individualism – towards positive humanism rooted in universal, life-giving, enriching and compassionate values, or towards a kind of individualism that sees life as a zero-sum game, with envy, self-centredness, greed, extreme selfishness and stinginess towards our others, and ourselves.
We have to move away from just looking at all these structures and systems as being apart and independent from the stories we tell ourselves as individuals, as families, as communities and as a society. Structures and systems, objective fictions and stories, and positive individualism are a trio that exist in mutual interdependence and relate to each other in a feedback loop. We have to ask ourselves: What are the conditions that we are in if we are flowers (the earth, the sunlight, the air and the nutrients that feed us)? This is a diagnosis of the reality of the structures we are in. We have to remind ourselves and be awakened from our slumber that we are not flowers that have no agency to act on the world, for even flowers act on the world to give oxygen and to nourish living beings with food and other gifts, by nurturing our being. This is our realisation of our power to think, feel, act and behave aligned with positive individualism.
Lastly, once we understand the power that we have as individuals to contribute to the world based on universal human values, with humanism and in respect of the dignity of not only humankind but other living beings and the world, we have to listen to the stories that we tell ourselves and each other. And we have to shape better stories that can then shape the reality we are in, such that it nourishes our well-being, the well-being of living beings and our planet’s well-being.
FROM SURVIVING TO THRIVING FOR BOTH THE INDIVIDUAL AND THE COLLECTIVE
As a final note, there is a need to move away from the idea that mental health and well-being is the absence of mental illness or mental disorder. That is merely surviving mentally and emotionally. Organisational psychologist Professor Adam Grant wrote that the state of languishing is the “middle child of mental health” and “the void between depression and flourishing – the absence of well-being”[22]. I suspect that many of us were, are or will be languishing, and this is a problem because it might impede positive individualism where we can empathise, engage in reflexivity, and then practise compassion both for ourselves and others. This then will impact the stories that we, as a society, tell ourselves, if the majority of us are either languishing, or trying to mentally and emotionally survive. As a result, the systemic and structural inequalities and inequities and other social determinants of health might either continue or worsen, which could lead to either a perpetuation of the status quo of mental health issues and languishing, or the situation worsening.
All three factors, structures and systems, objective fictions, and positive individualism are interconnected, and one key of unlocking the power of a whole-of-society approach to enact improvements in our mental health and well-being is by moving from seeing survival as the goal and towards thriving as both a value and a goal. We all would want to thrive as both individuals as a united and diverse people, and we should not be afraid of positive power as individuals and peoples to shape the stories that in turn influence the structures and systems we are in. This is not power over, but power with others in order to have power to change things for the better, for other people and the world, and for our mental health and well-being. ⬛
1 World Health Organization. Special initiative for mental health (2019–2023). 2019, May 2. Available at: https://www.who.int/publications-detail-redirect/special-initiative-for-mental-health-(2019-2023)
2 World Health Organization. World Mental Health Report: Transforming Mental Health for All. 2022, June 16. Available at: https://www.who.int/publications-detail-redirect/9789240049338
3 Schwaller, F. Global mental health issues on the rise. Deutsche Welle. 2022, October 10. Available at: https://www.dw.com/en/mental-health-issues-like-depression-and-anxiety-on-the-rise-globally/a-63371304
4 Goh, T. IMH study points to likely increase in mental health issues in S’pore amid Covid-19. The Straits Times. 2021, August 24. Available at: https://www.straitstimes.com/singapore/health/imh-study-points-to-likely-increase-in-mental-health-issues-in-spore-amid-covid-19
5 Ang, Q. About 1 in 3 Young People in Singapore Has Mental Health Symptoms: Study. The Straits Times. 2022, May 20. Available at: https://www.straitstimes.com/singapore/about-1-in-3-youths-in-singapore-has-mental-health-symptoms-study
6 HealthXchange. Elderly Depression: Signs and Causes. Accessed on 2023, March 22 at: https://www.healthxchange.sg/seniors/ageing-concerns/elderly-depression-signs-causes
7 DUKE-NUS Medical School. A ‘silver tsunami’ looms. What can Singapore do about it? (Straits Times Premium). 2021, June 27. Available at: https://www.duke-nus.edu.sg/care/news-events/news/articles/articles/a-%27silver-tsunami%27-looms.-what-can-singapore-do-about-it-(straits-times-premium)
8 The total age dependency ratio is the ratio of young and elderly dependents (who are generally economically inactive, under 15 or over 64 years old), compared to the number of people of working age (15 to 64-year-olds). See: World Economics. Singapore’s Age Dependency Ratio: Total. Accessed on 2023, March 22 at: https://www.worldeconomics.com/Demographics/Age-Dependency-Ratio-Total/Singapore.aspx
9 Mental Health Foundation. Tackling Social Inequalities to Reduce Mental Health Problems. Accessed on 2023, March 22 at: https://www.mentalhealth.org.uk/explore-mental-health/publications/tackling-social-inequalities-reduce-mental-health-problems
10 World Health Organization. Promoting mental health and well-being to reduce inequality and achieve universal health coverage. 2021, October 12. Available at: https://www.afro.who.int/news/promoting-mental-health-and-well-being-reduce-inequality-and-achieve-universal-health-coverage
11 Centre for Mental Health. Mental Health Inequalities: Factsheet. 2020, November 11. Available at: https://www.centreformentalhealth.org.uk/publications/mental-health-inequalities-factsheet
12 Social determinants of health are the non-medical related factors and contributors that influence health, including mental health. See: World Health Organization. Social Determinants of Health. Accessed on 2023, March 22 at: https://www.who.int/health-topics/social-determinants-of-health
13 Subramaniam, M. Swapna, V., and Siow, A. C. Mental health in an unequal world. The Indian Journal of Medical Research, 154, No. 4. October 2021. pp. 545-547. Available at: https://doi.org/10.4103/ijmr.ijmr_2972_21
14 Nestler, E. J., et. al. Epigenetic Basis of Mental Illness. The Neuroscientist: A Review Journal Bringing Neurobiology, Neurology and Psychiatry 22, No. 5. October 2016. pp. 447–463. Available at: https://doi.org/10.1177/1073858415608147
15 Ridzuan, F. NADI KAMPUS: Usah Anggap Penyakit Mental Sebagai Masalah Individu. BERITA Mediacorp. 2022, June 11. Available at: https://berita.mediacorp.sg/nadi-kampus/nadi-kampus-usah-anggap-penyakit-mental-sebagai-masalah-individu-666441
16 Ministry of Health. COVID-19 Mental Wellness Taskforce Report. October 2022. Available at: https://www.moh.gov.sg/resources-statistics/reports/covid-19-mental-wellness-taskforce-report
17 See: Ministry of Health. Raising Awareness of Elderly Mental Health Challenges. 2022, November 7. Available at: https://www.moh.gov.sg/news-highlights/details/raising-awareness-of-elderly-mental-health-challenges
18 Staglin, G. Singapore: An International Model For Mental Health. Forbes. 2021, April 6. Available at: https://www.forbes.com/sites/onemind/2021/04/06/singapore-an-international-model-for-mental-health
19 Lim, S. With Budget 2022, Can We Take Mental Health More Seriously? Rice Media. 2022, March 4. Available at: https://www.ricemedia.co/with-budget-2022-can-we-take-mental-health-more-seriously/
20 Ridzuan, F. KOMENTAR: Setiap Kita Boleh Perkasakan Diri Demi Perpaduan Sosial Pasca Krisis COVID-19. BERITA Mediacorp. 2020, April 19. Available at: https://berita.mediacorp.sg/komentar/komentar-setiap-kita-boleh-perkasakan-diri-demi-perpaduan-sosial-113766
21 See: Johnston, A., et. al. Objective Fictions: Philosophy, Psychoanalysis, Marxism. Edinburgh University Press. 2021
22 Grant, A. Feeling Blah During the Pandemic? It’s Called Languishing. The New York Times. 2021, April 19. Available at: https://www.nytimes.com/2021/04/19/well/mind/covid-mental-health-languishing.html
Faris Ridzuan works as an academic tutor in Asian Studies and is a graduate student in Malay Studies at the National University of Singapore (NUS). He graduated with a first class honours in Sociology with a minor in European Studies from NUS. He is also an IP English and General Paper Teaching and Curriculum Specialist at illum.e. His community and other voluntary works encompass issues such as climate change, interfaith relations, social cohesion, the alleviation of inequality and relative and absolute poverty and others.
