This article summarises the development of mental health legislation in Singapore in three distinctive periods: pre-1965; 1965–2007 and 2007 onwards. It highlights the origin of mental health legislation and the relationship between mental health services and legislation in Singapore. The Mental Health (Care and Treatment) Act 2008 and Mental Capacity Act 2008 are described in detail.

Worldwide, the number of individuals with dementia is growing in an epidemic manner, with an estimated 35.6 million people affected in 2010 (Prince et al., 2013). With the population aging in Asia, dementia care will become a major public health challenge in this region in the coming decades. Over half of the patients with dementia in the world will live in Asia by 2030. In China alone, a recent review of dementia studies showed that there were 9.2 million dementia patients in 2010 (Chan et al., 2013). These figures are staggering. In many Asian countries, dementia is regarded as a shameful illness, and the local terms for dementia are derogatory. Dementia carries a stigma that may lead to patients’ reluctance in seeking treatment and delay in diagnosis. In addition, local names for dementia frequently conjure up pictures of severe stage of dementia, and may lead to therapeutic nihilism, discouraging mental health professionals from working with elderly patients with dementia. As Asia faces the challenges of a rapidly aging population and provisions of care for growing number of dementia patients, change in local names for dementia has become an issue of attention.

Background: This study examined the use of low doses of antipsychotic medications (300 mg/day CPZeq or less) in older Asian patients with schizophrenia and its demographic and clinical correlates.

Methods: Information on hospitalized patients with schizophrenia, aged 55 years or older, was extracted from the database of the Research on Asian Psychotropic Prescription Patterns (REAP) study (2001–2009). Data on 1,452 patients in eight Asian countries and territories including China, Hong Kong, Japan, Korea, Singapore, Taiwan, India, and Malaysia were analyzed. Sociodemographic and clinical characteristics and antipsychotic prescriptions were recorded using a standardized protocol and data collection procedure.

Results: The prescription frequency for low doses of antipsychotic medications was 40.9% in the pooled sample. Multiple logistic regression analysis of the whole sample showed that patients on low doses of antipsychotic medications were more likely to be female, have an older age, a shorter length of illness, and less positive symptoms. Of patients in the six countries and territories that participated in all the surveys between 2001 and 2009, those in Japan were less likely to receive low doses of antipsychotics.

Conclusion: Low doses of antipsychotic medications were only applied in less than half of older Asian patients with schizophrenia.

The report World Population Ageing 1950–2050 (United Nations, 2002) estimated that in 2005 there were 37.3 million elderly people (i.e. aged 65 years or more) in South-East Asia (a region incorporating Brunei, Cambodia, Indonesia, Laos, Malaysia, Myanmar, the Philippines, Singapore, Thailand and Vietnam). There are only a few epidemiological studies on mental disorders among elderly people in this region and the published data are mainly from Singapore, Malaysia and Thailand. Using Singapore's prevalence rate of 3% for dementia and 5.7% for depression, the numbers of elderly people with dementia in this region would be 1.2 million and with depression 2.12 million (Kua, 1992; Kua & Ko, 1995). However, even in Singapore, we have identified only 10% of all potential cases of dementia and depression — meaning that the large majority of elderly people with mental disorders are not detected, although they may be known, for other reasons, to the health services.

Background: The relationship between depressive symptoms and health service use among older people is not well understood. In this study we examined the two-way relationships between depressive symptoms and hospitalization and/or physician visits by older adults.

Methods: In a one-year follow-up study of 973 community-dwelling older adults in the Singapore Longitudinal Aging Studies (SLAS), depressive symptoms (15-item Geriatric Depression Scale score ≥5) were assessed at baseline and one year later. Information on self-reported physician visits and hospitalization were collected bimonthly over one year.

Results: When demographic characteristics, medical comorbidities, functional status and other covariates were controlled for, baseline depressive symptoms were associated with increased episodes of subsequent physician visits during the one-year follow-up (RR,1.34; 95% CI, 1.05–1.70), but not with subsequent hospitalization(s) during the same period. Conversely, participants with five or more physician visits (versus less than 5) over one year were more likely to be depressed at one year (OR, 10.2; 95% CI, 3.36–31.1); hospitalization during this period was also significantly associated with depressive symptoms at one year (OR = 6.43, 95% CI, 2.48–16.6).

Conclusion: Depressive symptoms and health service use have reciprocal relationships. Health service use for non-mental illnesses may be optimized by efforts at post-hospitalization interventions to recognize and treat depression in older persons.

Sir: The editorial by George Christodoulou et al (2008) on ‘Psychiatry for the person’ and the response by Jeremy Holmes (2008) have been read with avid interest on this side of the globe. Listening to previous presentations on this topic at Asian meetings of the World Psychiatric Association (WPA), we were often left with a sinking feeling that they resonate well with our work but could be better. For the Institutional Programme on Psychiatry for the Person (IPPP) to succeed, there should be more participation from developing countries. The marketplace of ideas should not be confined to academics in Europe and North America and ignoring the rich experience of clinicians in Chennai, Singapore or Batu Pahat.

Objective: This cross-sectional study examined the clinical significance and impact of subsyndromal depression in a sample of elderly people living in the community in Singapore.

Method: Data were analyzed from a population survey (the Singapore National Mental Health Survey of the Elderly). A total of 1092 respondents from a nationally representative multi-ethnic (Chinese, Malay and Indian) stratified random sample of older adults aged 60 and above were examined for depression using the Geriatric Mental State Examination (GMS). Diagnostic confidence levels of 3–5 indicated a DSM-IV diagnosis of syndromal depression, and 1–2 indicated subsyndromal depression. Other variables included sociodemographic characteristics, psychiatric and medical comorbidities, MMSE, health awareness, health and functional status.

Results: Subjects with subsyndromal depression were more likely to have poor socioeconomic status, cognitive impairment, anxiety, and measures of poor mental, physical and functional status compared with non-depressed subjects, and were similar to or worse than syndromal cases. In multivariate analyses that controlled for age, gender, ethnicity, education and several other sociodemographic factors, both subsyndromal and syndromal depression were significantly associated with higher numbers of medical comorbidities, diagnoses of comorbid dementia and anxiety, lower MMSE scores, self-reported mental health problem, functional disability and poor health status.

Conclusion: In this Asian population, subsydromal depression had the same clinical significance and health impact as syndromal depression, similar to findings in the West.

Background: We evaluated the combined and differential effects of physical, social and productive activities on cognitive decline and whether they were modified by the presence of the APOE-ε4 allele.

Methods: In a prospective cohort study of 1635 community-dwelling Chinese older adults aged 55 or older participating in the ongoing Singapore Longitudinal Aging Study, physical, social and productive leisure activities were assessed at baseline, and cognitive decline (at least one point drop) in MMSE scores between baseline and follow-up after one year.

Results: Cognitive decline was observed in 30% of the respondents. Controlling for age, gender, education and other risk factors, odds ratios (ORs) were significantly reduced in those with medium (OR: 0.60, 95% CI: 0.45–0.79) and high activity levels (OR: 0.62, 95% CI: 0.46–0.84). A stronger association was shown for productive activity (OR = 0.36), than for physical (OR = 0.78) and social activities (OR = 0.85). These associations showed statistically significant interactions with APOE genotype, being more pronounced in those with the APOE-ε4 allele.

Conclusion: Increased leisure activity, especially productive activities more than physical or social activities, was associated with a lowered risk of cognitive decline. APOE-ε4 genotype individuals appeared to be more vulnerable to the effects of low and high levels of leisure activities.

Background: Few studies have investigated the association of psychiatric morbidity with acute hospitalization risk in elderly people.

Method: We examined this association using population-based data for 1092 older adults aged ≥60 years in Singapore, including subjects who reported at least one acute hospitalization from any medical condition(s) in the 12 months prior to interview (N = 136). Psychiatric morbid/comorbid disorders were diagnosed using the Geriatric Mental State examination.

Results: In a multivariate analysis, comorbid psychiatric disorders were inde-pendently associated with hospitalization [adjusted odds ratio 2.76, 95% confidence interval 1.20–6.33], after controlling for age, ethnicity, employment status, number of medical comorbidities, number of activities of daily living limitations, hearing and visual impairment, SF-12 Physical and Mental Component Summary scores, social, productive, fitness and health activities, and regular visits to health-care providers. Neither dementia diagnosis nor cognitive impairment measured by the Mini-mental State Examination was associated with increased hospitalization risk.

Conclusion: Psychiatric morbidity in old age was significantly associated with increased hospitalization risk. This finding underlines the importance of treating psychiatric illness to reduce the risk of acute hospitalization in elderly patients.