Psychiatrist Singapore

Psychiatrist Singapore: Treats Depression, ADHD, Anxiety Disorders, Insomnia


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Insomnia – FAQs

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What are the main causes for the low quantity/quality sleep in Singapore? Do some of the factors include the use of technology and psychological problems?
This may differ in different age group.

In teens and youth, it is a natural phenomenon that they tend to sleep later, ie. past midnight. However, they are still expected to wake up early for school resulting in inadequate amount of sleep. They also tend to be on their computers and mobile devices late into the night, further affecting sleep.

For adults in Singapore, it is not uncommon to have less than 7 hours of sleep due to work commitment.

For insomnia, where sleep disturbances are more severe and have disrupted daily functioning, there are usually other psychological or medical issues affecting the sleep 90% of the time. These may be depressive disorders, anxiety disorders or physical pain affecting sleep.

Ironically, in many cases I have treated, the poor sleep is perpetuated by anxiety after the sufferers read on the internet and social media about the consequences of poor sleep, whereas in the past they may have just ignored it and recovered spontaneously.

Has there been an increase in the number of sleep deprivation/insomniac cases? Please provide some statistics to back this up.

There are no studies with regards to an increase in prevalence or cases. However, according to market research, people are spending more for sleeping aids and sleep medications.

In my clinic, there is a general trend for many to become more worried about sleeplessness and to come forward for treatment. This may in fact be due to social media propagation about the consequences of insomnia.

(People in Singapore have so far spent S$1.3 million on sleep aids in 2016 – up from S$1 million in 2011 – according to data from market research firm Euromonitor. These aids include prescribed Western medication, herbal remedies and melatonin products, among others.

What are some of the consequences of low quality/quantity of sleep?

Most of the time, a few days of poor sleep is not related to any long term problems and it is best that individuals leave it be and not be anxious about it to avoid perpetuating the sleep difficulties. Chronic poor sleep and sleep deprivation is associated with physical consequences like obesity in adults and children, diabetes and impaired glucose tolerance, cardiovascular disease and hypertension (high blood pressure). Risks of psychological conditions are increased like Anxiety Disorders, and Depressed mood. Many turn to alcohol use and this may lead to abuse and addiction issues.

Case Studies

Case 1
Mr X is a 23 year old man in University. He keeps awake until 2am to study everyday prior to his exams. After his exams, he realized he could not fall asleep when he tries to sleep at 12am and would watch YouTube or surf the web on his mobile phone in bed. Eventually, he would stay up until 5am in the morning.

Mr X was educated about sleep hygiene (keeping to regular sleep hours and not using devices too late and in bed) and given short term sleeping pills to help a proper sleep cycle. He recovered after two weeks.

Case 2
Mrs G is a middle age lady who has been stressed up with her business. She stayed up at night worrying in bed. As her sleep deteriorated, she read about the consequences of poor sleep on the internet. She became even more anxious and her sleep further worsened. After two months, she started feeling depressed over the situation, lost interest in the things around her, had no energy and felt that life was meaningless.

She was diagnosed with a Depressive Episode with Anxious Distress secondary to her Insomnia. She was treated with an antidepressant and short term sleeping pills. Her mood and sleep recovered in two months and eventually went off all medications following after another half a year.

Depression: Burden of Disease

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Excerpts from a recent interview:

1) It has been projected that depression will be the 2nd leading cause of disease by 2020. Why are we seeing this increase in cases of depression worldwide?

It has been postulated that modernisation is correlated with an increase in the prevalence of depression. This may be related to modern diet and a lack of activity, resulting in obesity and more health problems like diabetes. Chronic health issues are factors in precipitating depression. The decrease in exposure to sunlight as we tend to stay indoors more and decrease in sleeping hours can lead to circadian dysregulation resulting in depression. The ready availability and willingness of people to take illicit drugs and abuse alcohol may also increase the rates of depression. From a social perspective, urbanisation and having to live in crowded quarters, a decrease in faith towards religion and an emphasis on individualism and social isolation can all contribute to this trend of depression

2) In Singapore, are there any groups of people who are more at risk of having depression? (in terms of age/race/gender/socioeconomic background etc)

Generally, women are more at risk of have depression. This may really be related to women being more in touch with their emotions and being more likely to present with depression whilst men turn to alcohol and substance abuse. Teens and the elderly are also more at risk of developing depression.

3) Why is depression a form of disability? How does it manifest as one?

Depression can be debilitating. Even in mild form of depression, the patients can have difficulties concentrating, making decisions, feel lethargic and experience a slowing in their thinking processes, making everyday activities and work hard to accomplish. In severe forms, they may be incapacitated and housebound, losing all energy to go out and having no confidence to face the world.

4) Other than the fear of stigma, what are the difficulties that your patients face when they seek treatment for depression?

The understanding of depression is poor. Many still do not see it as a multi-factorial medical condition and think that there is a root cause that they can get rid of. Sufferers often think that they can snap themselves out of depression just by being positive. Often even when they want to seek treatment, they may meet resistance from family members who urge them not not to have treatment but instead advise them to do the impossible by snapping themselves out of depression. Many also view treatment with suspicion and think of antidepressants as dangerous drugs. They believe erroneously that medication will numb the mind, cause addictions and dependency and cause long time physical problems. For therapy, they assume that it is something didactic and are not willing or motivated to put the hard work and hours necessary to improve.

5) Can patients get an MC (medical leave) when they have depression? If so, are there any criteria they have to meet?

Yes, they can get MC. As long as they are having clinical depression and this is affecting their work or social life, MCs may be warranted. In Singapore, the problem is that even when MCs are offered, patients often decline as they cannot afford to rest from work.

6) Can depression be treated or can it only be suppressed with medicine?

They can be treated effectively with antidepressants and many will recover. Conversely, if depression is not treated, it can become long term and chronic. That is when a person will have to take long term medications and be reliant on treatment.

Four Differences Between Depression and Burnout

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Many a times, clinical depression can be triggered by stresses at work. It is no wonder then that people often wonder what the differences between depression and burnout from work are.

1. Depression, A Diagnosis. Burnout, A Description

The biggest difference is that clinical depression or major depressive disorder is a formal psychiatric diagnosis whilst burnout is a description of one’s feelings towards work. To be diagnosed with clinical depression, the sufferer has to have several symptoms of depression and for a duration of at least 2 weeks. You can read this page to find out more about clinical depression.

“Burnout” was coined in the 70s by psychologist, Herbert Freudenberger. To date there is no scientific definition for burnout. It is  general description of  loss of interest and motivation towards work, following a long period of excessive stress. The sufferer complains of tiredness and lethargy. He or she may feel unappreciated and may be cynical about work and colleagues.

2. Pervasiveness

If an individual is just burnt out from work and has not developed clinical depression, the difficult mood and lack of motivation is generally limited to work and work related events. He will feel fine when he is at home, or when he is doing his hobbies. A tell tale sign that this is just burnout and not depression is if the individual feels alright during weekends and starts to worry and brood about work on Sunday night. In depression, not only will the individual have a sense of negativity towards work, the negativity spreads to many other areas of life as well.

3. Severity of Symptoms

Compared to just burnout where physical exhaustion, feeling low about work and poor work performance are typical symptoms, the symptoms of clinical depression can be a lot more serious and include:

i) Hopelessness and Despair
ii) Low Self Esteem and Loss of Confidence
iii) Suicidal Thoughts and Suicidal Attempts

4. Treatment Recommendations

For purely individuals with burnout, removing the source of stress will lead to rapid improvement of symptoms. Quitting or changing one’s job will help to rid one of the feelings of burnout. However, in clinical depression, the sufferer will persist in feeling negative about his new circumstances or new job. In fact, losing one’s job may aggravate the depression! As such, allowing the depressed individual to have some rest from work and to only make a decision AFTER the depression has been adequately treated is important.

When Burnout is Depression and Vice Versa….

The relationship between burnout and depression is a complex one with numerous overlap in symptoms and a bi-directional influence. It is easy to see why a burnout individual who is unhappy at work is at risk of developing depression. Clinical depression can bring about a loss of motivation and lethargy which can worsen work burnout as well. When this happens, the sufferer becomes trapped in a negative vicious cycle.

Regardless of the terminology, there are solutions and treatment for both work burnout and clinical depression. Identifying and delineating the two with careful assessment and investigations will help the clinician / psychiatrist provide the best and optimum treatment for the patient.

ADHD Medications Cheatsheet

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The use of medications revolutionised the treatment of ADHD /ADD. Today, international consensus often recommends medication as the first line of treatment for ADHD / ADD in patients above the age of 6 years of age. This is a introduction to ADHD medications or a ADHD Medications Cheatsheet for your quick reference. You can also visit the following pages for more details on ADHD:

i)  Symptoms of ADHD /ADD
ii) CDC (USA) Guidelines and Recommendations

Medications for ADHD / ADD can be categorised as:

1) Stimulants
2) Non-stimulants
3) Antidepressants
4) Medical Food / Supplements

1) Stimulants

Stimulant medications have the best evidence in the treatment of ADHD for children and Adult ADD. As such it is often recommended as the medication of choice to start for both child and adult patients with ADHD. In Singapore, only methylphenidate based medications are available. They may come in short acting forms (lasting 3-4 hours) and long acting forms (lasting 8-10 hours).Common brand names: Ritalin, Concerta

Advantages:

  1. Most likely to be effective
  2. works almost immediately
  3. can be taken only when necessary

Disadvantages:

  1. Can be potentially abused
  2. effects does not last the whole day

Common side effects: Headache, insomnia, poor appetite

2) Non stimulants

Atomoxetine is a selective noradrenaline reuptake inhibitor indicated for the treatment of ADHD /ADD. Unlike stimulants which has immediate effects, the benefits of atomoxetine is gradual and subtle, and its effect is only apparent usually after two weeks. For it to be effective, Atomoxetine has to be taken daily.Common brand names: Strattera

Advantages

  1. No abuse potential
  2. if effective, will last 24/7
  3. may be effective for concomitant depression

Disadvantages:

  1. Has to be taken daily
  2. only works after two to four weeks
  3. probably less likely to be effective than stimulants

Common side effects: Nausea, headache, insomnia

3) Antidepressants

Bupropion, an antidepressant, used in the treatment of depression and smoking cessation has been shown in some studies to help with the symptoms in ADHD / ADD. However, comparatively, the evidence for Bupropion is not as robust as stimulants and atomoxetine. As such, guidelines often recommends antidepressants as the third line of treatment, after stimulants and atomoxetine.

Advantages:

  1. No abuse potential
  2. if effective, will last 24/7
  3. effective for concomitant depression

Disadvantages:

  1. Has to be taken daily
  2. only works after two to four weeks
  3. probably less likely to be effective than stimulants and atomoxetine

Common side effects: Headache, insomnia, anxiety

4) Supplements

There has recently been some research which suggests a decrease level of Omega-3 fatty acids (fish oils) may be associated with ADHD and taking Omega-3 supplements can help in controlling ADHD symptoms. Parents who may not be ready to medicate their children can consider this option as Omega-3 is a natural supplement. A recent product Lipirinen which contains phosphatidylserine-omega 3, EPA enriched, has shown effectiveness in studies, improving symptoms. Omega-3 can be used to supplement current treatment with other medications as well.

Advantages:

  1. Natural product,
  2. no abuse potential,
  3. if effective, will last 24/7

Disadvantages:

  1. Has to be taken daily
  2. only works after at least four weeks
  3. probably less likely to be effective than stimulants, atomoxetine and antidepressants

Common side effects: no significant side effects

Pharmacogenomics – Tailoring Medicine

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Pharmacogenomics can be understood as the science of how genes interact with medication in a person’s body to affect its response. We know that every individual is different and would respond differently when given the same medication. Some may need a higher dose. Some may need medication of a different mechanism. In the past, we are not able to determine who will need what and medication treatment is often a one size fit all or even carpet bombing approach. The lack of predictability to side effects, and effective doses often leave doctors blind sided and frustrated.

Today, we know that our genes play a big part in how our body interacts with drugs. A major system is the cytochrome P-450 (CYP) family of enzymes which metabolizes drugs in the liver. To put it simply, the presence of genetic differences (what we call allelic variants / polymorphisms ) in the CYP enzymes result in three main phenotypes (observable characteristics), i. e. poor metabolizers (PMs), normal metabolizers (NMs), and extensive metabolizers (EMs). This results in some people having more side effects with certain medications and can account for some of the reasons why some people need higher or lower doses of medication.

Using clinical depression as an example, there may be individuals who have major gene-drug interaction. An increase in the metabolism due to the genotype (genes) may decrease the patient’s exposure to the medication, necessitating a higher dose. An inadequate dose may result in treatment failure or mimic treatment resistance. Conversely an decrease in metabolism may increase exposure to medication resulting in more side effects like diarrhoea or nausea.

pharmacogenomics kitNow that pharmacogenomic testing is available, we can now piece in this missing part of the jigsaw. Testing for certain polymorphisms / genetic differences before prescribing certain drugs can help avoid adverse drug effects and improve efficacy.

Psychiatrist vs Psychologist

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In Singapore, many people do not know the differences between psychiatrist vs psychologist. What do Singapore psychiatrist do? How are they different from psychologist? Even healthcare professionals sometimes get confused between psychiatrist and psychologist. Let me start by explaining what Psychiatry is as that was where it all started from……

What is Psychiatry? A Historical Perspective.

Psychiatrist vs Psychologist Pic

Sigmund Freud, Father of Psychiatry

Psychiatry is a medical specialisation focusing on mental illnesses and disorders. Before Psychiatry, mental disorders were thought of as demonic possessions or character flaws. Sufferers were often locked up and kept away from society. In the 20th century, psychological treatments were discovered for these illnesses. In the early 1800s, mood disorders started to be recognised as a psychiatric disorder. Doctors and scientist started to classify these disorders and to study them scientifically. In the 1880s, Sigmund Freud, started his career as a neurologist. He went on to help patients who suffered from hysteria with hypnosis but quickly abandoned hypnosis as a clinical technique, both because of its inconsistency and ineffectiveness and because patients were able to retrieve crucial memories and process them while conscious.  This lead to him devising the technique of psychoanalysis or talk therapy. Subsequently the discipline of psychiatry branched into psychology when non-medically trained individuals became proficient in these talk therapy to become experts in their own rights. These experts came to be known as psychologists and they help further evolve talk therapy to its current modern versions like Cognitive Behavioural Therapy.

Following talk therapy, the first medication for psychiatric disorders were discovered in the 1950s. First tranquilisers were discovered and were found to in fact help with the symptoms of Schizophrenia like delusions and hallucinations. Subsequently sleeping aids and antidepressants were discovered bringing about relief to hundreds of millions of sufferers.

Who are Psychiatrists? The Practice of Modern Psychiatry.

Today, Psychiatrists are medical doctors who are trained and specialises in the field of psychiatry and psychology. As medical doctors, we are trained to identify and diagnose psychiatric and mental disorders. At times, there may be need for physical examinations, blood tests, brain imaging and pharmacogenomic testing to exclude other physical conditions or to help with further treatment. We can then prescribed the necessary treatment for our patients and these can be therapy, medications and even simple lifestyle changes.

When it comes to talk therapy, the role of psychiatrists, psychologists and counsellors often overlap. Depending on his training, the psychiatrist may decide to perform the talk therapy with the patients himself. Often, he will work with the psychologist or counsellor in his team to implement the therapy.

Psychiatrist vs Psychologist. Who to see?

This is where it may sometimes get confusing. If you suspect you or your loved one has a psychiatric illness or condition, it will be best for you to seek help from a medical doctor. A good staring point may be your family physician or a psychiatrist. Many a times, medical conditions (eg. Hyperthyroidism) can masquerade as low mood, anxiety or poor sleep. You should see someone medically trained to make sure that the psychiatric condition is not due to a medical or physical problem.

For this reason, in most Singapore public hospitals, you will need to consult a psychiatrist before you can be referred to a psychologist or a counsellor for therapy. The psychiatrist plays the role of a case manager, is responsible for making the diagnosis and to decide on the treatment plans for you. Only a medically trained doctor can order blood tests, brain imaging or prescribe medications. He will bear the medical and legal responsibility of your well being.

However, if you are looking for help to talk about difficult issues in your life, or a specific problem, like relationship issues with your partner, and you are sure you are not looking into a medical model of treatment, a counsellor or a psychologist can be a good starting point. In particular, clinical psychologists are trained to provide therapy to help with emotional and psychological issues.

For the best outcomes in treatment, a multi-pronged biological-psychological and social approach is recommended. Hence, when considering private care treatment, it is important to remember that a psychiatrist is in the unique position to provide and recommend holistic and comprehensive care:

  • Exclude other medical problems
  • Diagnose your condition
  • Prescribe the appropriate medication /  biological therapy
  • Address psychological issues and perform or refer you for further psychological therapy
  • Advise on lifestyle changes
  • Address social issues