Higher Risk Population #1: Caregivers
The first population I want to zoom in is caregivers of stroke patients. And I want to talk about stroke patients mainly because the ageing population is a big problem. We have a"silver tsunami" currently, whether it is Singapore or Japan, many of the developed countries actually, we are actually facing this problem. Stroke has been ranked the top causes of disability for many years according to WHO. I will introduce you to some terms like incidence and prevalence. Incidence of 9 million means each year we have 9 million patients diagnosed with stroke and 20.7 is the existing patients with stroke. This is a very high disease burden, therefore this is a topic that is worth looking into. So, before we did the study, there have been studies that show there are the reduced quality of life among caregivers, that when the stroke survivor has a high level of disability, the stroke survivors caregiver tends to have a major depressive disorder or anxiety.
From the caregiver's mouth:"Caregivers must realise that you need to save you, first. Or there will be nothing left for anyone else."
Caregiving for Stroke: A very real risk
- Among the general population worldwide, 5% is the prevalence rate for depression, according to the World Health Organisation
- The aggregated prevalence of depressive symptoms (40.2%) in caregivers of stroke survivors is 8 times that of depression
- The prevalence of anxiety in the general population is estimated to be 7.3% (Baxrer AJ et al., 2012)
- The aggregated prevalence of anxiety symptoms (21.4%) in caregivers of stroke survivors is nearly 3 times that
Referring to the data above:
We focus so much on the patient, but the family of the patient, the caregiver of the patient is something that is sometimes forgotten. So, apart from knowing the statistics we want to know which caregivers are at higher risk. We found that if the caregiver is a female caucasian and the stroke survivor is a female, there is actually a risk of major depressive disorder. Whereas some protective factors that prevent the caregiver from having depressive symptoms are spousal relationships with the patient or children of the patient. That means, for example, if you are not a spouse or child, maybe a parent of the patient then you may be at higher risk. Some factors that don't matter are the employment status or age of the caregiver.
Higher Risk Population #2: Heart Transplant Recipients
Another one that I thought was interesting is another study I did which is going to be published this year. We thought this was interesting because of the ageing population which was affecting Singapore and so many parts of the developed world. Heart transplant is a good treatment for patients with end-stage heart failure and why patients have this is mainly because of issues like cardiac failure or heart disease. These have always ranked high as a disease in the WHO. Among death, heart disease is definitely among the top 3.
And according to our data, about 100,000 patients received a heart transplant globally, which is a relatively high number. Again, we found this is a very real risk.
Heart Transplant: A very real risk
Statistics
- Depression among this population was about 5% according to WHO. The aggregated prevalence depression (21.6%) in heart transplant recipient is 4 times that.
- The prevalence of anxiety in the general population is estimated to be 7.3%. The aggregated prevalence of anxiety (11.1%) in heart transplant recipients is 1.5 times that.
- The global prevalence of adjustment disorder is sparse with prevalence <1% among 5 European countries. However, a study in Germany found that the prevalence of adjustment disorder with clinically significant impairment to be approximately 0.9 % and without clinically significant impairment to be 1.4%. The aggregated prevalence of adjustment disorder (11%) in heart transplant recipients is over 8 times that.
- The lifetime prevalence of PTSD is 3.9% in the general population and the aggregated prevalence of PTSD (13.5%) in heart transplant recipients is over 3 times that.
Meta-Regression: Heart Transplant recipients
Depression
Anxiety
Adjustment Disorder
PTSD
Predisposing
NYHA Class III/IV
On steroid treatment
Had Acute rejection of transplant (<3 months)
Female
Singlehood
Number of months since transplant
Singlehood
Singlehood
Protective
Age
Pre-transplant depression of patients
Ejection fraction post-transplant
Age
NIL
NIL
State of Mental Health in Singapore
If we look at some other parts of the world, for example, Southeast Asia, countries may not even understand what mental health is or even have a facility for psychiatric patients. We are quite fortunate to have the Institute of Mental Health. This is actually an interesting article from Channel NewsAsia that I would like to share. It is actually very interesting because of COVID-19 many people speculated that COVID-19 will lead to a mental health pandemic. Some people think there will be a wave of mental illnesses after COVID-19. And this article pointed out some interesting facts. In Singapore, we have about 4.4 psychiatrists and 8.3 psychologists for about every 100k people in Singapore. This is actually lower than the OECD countries but of course, the authors did not compare us to other Southeast Asian countries. So we are actually at a very privileged position but we can do more to match up to those OECD countries and match up with the facilities and manpower of the OECD countries. Also, Singapore's total expenditure on mental health made up only 3 % of MOH's operating expenditure for 2017, according to the latest data shared by parliament in 2019.
Academia into Action/Support
- The high global prevalence of depressive and anxiety symptoms among the high-risk population warrants mental health surveillance for them
- Prompt referrals to mental health professionals and early intervention may reduce the incidence/ severity of mental health issues
- Interventions e.g support group, psychoeducation, counselling, social services and respite facilities should be considered to support caregivers.
