Impact of an integrated care programme on patient-reported outcomes for mild to moderate mental health conditions in Singapore: a pilot study.

1Department of Psychological Medicine, Changi General Hospital, 2Singapore Health Services, 3Department of Psychiatry, Ng Teng Fong General Hospital, 4Centre for Quantitative Medicine, Duke-NUS Medical School, Singapore *These two authors contributed equally as first author in this work. Correspondence: Dr David Choon Liang Teo, Consultant, Department of Psychological Medicine, Changi General Hospital, 2 Simei Street 3, Singapore 529889. david.teo. c.l@singhealth.com. sg INTRODUCTION In recent years, substantial research efforts have focused on reducing the global burden of mental illness. However, translation of research into real-world clinical services has lagged behind. (1) Large gaps in the provision of mental health services persist, even in developed countries. (2-4) Although there has been a burgeoning focus on improving mental health services in Singapore,(5) recent studies have demonstrated a significant treatment gap for mental disorders. (6-8) There is a high prevalence of mental disorders in Singapore. (9,10) However, the 2010 Singapore Mental Health Study found that only 31.7% of individuals with mental disorders had ever sought help, and only 8.4% of those were managed by primary care physicians (PCPs). (8) Many mental disorders can be effectively managed in primary care settings,(11) and the integration of mental health services in community settings has been shown to improve patient outcomes. (12) Community mental health services have well-documented advantages, including better accessibility and acceptability of care, and reduced stigma and social discrimination. (13-15) Therefore, a key thrust of the Community Mental Health Masterplan of 2012 was to strengthen primary care to deliver accessible mental health services in the community. (16) Nevertheless, the follow-up Singapore Mental Health Study in 2016 found that the treatment gap for mental disorders remained high at 78.6%. (7) A local study found that PCPs in Singapore tend to shy away from managing mental conditions because of inadequate support and perceived lack of training. (17) These findings underscore the pressing need to continually enhance primary care mental health services and develop real-world interventions to bridge the treatment gap in Singapore. Integrated care programmes have been developed in many countries worldwide to support the significant demand for mental health services in primary care settings. (18) In these programmes, patients who are within the patient base of primary care service networks receive integrated mental healthcare with input from specialist mental health professionals within the community. PCPs remain the primary treating physicians and work in close collaboration with specialist mental health professionals to support the mental health needs of their patients. To enhance the integration of mental health in primary care in Singapore, Changi General Hospital launched the Health Wellness Programme (HWP), a pilot integrated care programme, in 2013. The HWP is a restructured hospital-led, integrated community mental health programme comprising psychiatrists and therapists (clinical psychologists and counsellors). It provides communitybased specialised psychotherapy services to patients with mild to moderate mental health conditions who are managed by PCPs in the eastern region of Singapore. The HWP employs a shared care model that is characterised by close collaboration between members of the team and PCPs. The PCPs receive specialist psychiatric liaison support for patients whom they refer to the programme for psychotherapy. The therapists in the HWP, in discussion with psychiatrists at weekly case conferences, provide regular feedback to the referring PCPs regarding the progress of patients in therapy. PCPs may, in turn, flag patients who are unstable or unresponsive to first-line treatments to attend consultations with the programme’s psychiatrists. These patients may be given an early appointment to see a psychiatrist at the specialist outpatient clinic in Changi General Hospital for timely escalation of care. This stepped care model provides patients in primary care with timely access to specialised psychotherapy interventions within the community, allowing for more effective integration of mental health services within primary care. By empowering and supporting PCPs in managing mental health conditions in the community, our integrated care programme helps to address two key barriers and challenges to mental healthcare in Singapore, namely the stigma associated with seeking tertiary psychiatric treatment and suboptimal accessibility (in terms of cost, scheduling and transport) of mental health services. (7) The primary aim of this study was to examine the impact of the HWP on mental health-related patient-reported outcomes (PROs) for patients enrolled within the programme. The secondary aim was to describe the demographic and clinical profiles of the study participants.