What's New

Jurong Ageing Study (JAS)

To promote mental well-being and prevent depression and dementia among the elderly community living in Singapore, a community-based psychosocial intervention programme has been initiated at TaRA@JP in March 2013. For more information click here.



Research Papers

Intergenerational transmission of parenting styles in elderly Chinese living in Singapore

Lim, H. A., Mahendran, R., Lei, F., Kayanoth, R. K., Wong, J. C. M., & Kua, E. H. (2014). Intergenerational transmission of parenting styles in elderly Chinese living in Singapore. Annals, Academy of Medicine, Singapore, 43, S17–18. Poster presentation at the Academic Psychiatry Conference 2014 in Singapore, Singapore. Best Poster Competition Finalist.

Introduction: Parenting styles (PS) have both positive and adverse downstream effects in children and their progeny. The challenge is in measuring these styles: they are dynamic, unique, not immutable, and are influenced not only by the socio-cultural environment, but also by one’s own parents. A review of the published literature has not surfaced any study simultaneously examining how parents were parented, how satisfied they were with their own parenting, and how this affected their own PS. This study thus first developed and examined the psychometric properties of the Personal and Parents’ Parenting Style Scale (PaPPS), and second, explored the mechanisms of transmission between parental PS and personal PS in an Asian context. It was hypothesized that (1) (the perceptions of) personal PS would be positively correlated with (the perceptions of) parents’ PS, and that, in line with Western studies, this would differ across (2) genders, and be mediated by their (3) satisfaction with their parents’ parenting, and (4) educational attainment.

Methods: The PaPPS, developed in accordance with the Delphi method, allows researchers to examine the relationship between parents’ child-rearing strategies and how they were parented as children. It consists of 12 items that simultaneously asks participants how frequently (on a five-point Likert-type scale) an agent (i.e., their mother, father, or themselves) engaged in specific behavior to them/their children (if any), and two additional items that asks participants how satisfied they were with their parents’ parenting. 294 Chinese participants from Singapore (67.4 ± 5.9 years; 76% women; 7.0 ± 3.5 years of formal schooling), with no adverse cognitive impairments (MMSE-S score > 22), completed the PaPPS and a sociodemographic questionnaire as part of a larger ongoing survey of the Singapore elderly in Jurong.

Results: PaPPS analyses suggested an internally-reliable three-factor model (Positive-Authoritative [PA], Authoritarian [AN], and Permissive [PE] PS) each for all three agents (father, mother, and personal). There seemed to be a distinct intergenerational transmission of parenting styles (parental parenting styles influenced individual parenting styles; ps <.001), although the patterns of influence differed by gender, with men adopting their parents’ preferred parenting style (ps < .01) but not women. Both men and women seemed to be satisfied if their parents were PA (ps < .01), or their parent of the opposite gender was more PE (ps < .01). Women were also highly dissatisfied if their mothers were AN (p < .001) and men felt that their fathers’ were more frequently AN with them (p = .034). For men, positive-authoritative mothering seemed to be strongly predictive of more years of formal schooling (rho = .28, p = .032); however, this was not true for women. Across genders, neither parental satisfaction nor years of formal education were found to mediate the intergenerational transmission of parenting styles in Chinese Singaporeans.

Discussion: This study is the first to show the intergenerational transmission of parenting in an Asian population of immigrants and children of immigrants from China living in Singapore, as well as the preliminary utility of the PaPPS. Unexpectedly, parental satisfaction and years of parenting did not seem to mediate the transmission; there may perhaps be key cultural differences that require further exploration between both Asian and Western cultures.


Personal and parents’ parenting styles and depression and anxiety: the mediating role of psychological resilience among community-dwelling elderly in China

Zhong, X., Wu, D., Nie, X., Xia, J., Li, M., Lei, F. … Kua, E. H. Personal and parents’ parenting styles and depression and anxiety: the mediating role of psychological resilience among community-dwelling elderly in China

Introduction: Parenting styles have often been associated with downstream psychiatric sequelae, such as anxiety and depression; however, much of research has previously focused only on the negative consequences of improper parenting as a mechanism of transmission. Few have considered the potential positive effects of parenting in buffering individuals from such sequelae. In this cross-sectional study, we sought to investigate the role of psychological resilience as a mediator between parenting styles and subsequent anxious and depressive symptomatology in a sample of community-dwelling elderly in China.

Method: 439 Chinese community elderly, aged between 60 and 91 completed the Personal and Parents’ Parenting Style Scale (PaPPS), Connor-Davidson Resilience Scale (CD-RISC), Zung Self-Rating Depression Scale (SDS) and Zung Self-Rating Anxiety Scale (SAS).
Results: Psychological resilience was found to be negatively correlated with depression and anxiety (rs = -.23 to -.31, ps < .01). Positive parenting style was significantly positively correlated with psychological resilience (r = .36, p < .01). Authoritative parenting style was positively correlated with psychological resilience (r = .25, p < .01) and negatively correlated with depression (r = -.10, p < .05). Authoritarian parenting style was negatively correlated with psychological resilience (r = -.17, p < .01), but positively correlated with depression and anxiety (rs = .20 to .30, ps < .01). While the authoritarian parenting style had a direct effect on depression and anxiety, positive parenting style, authoritative parenting style and authoritarian parenting style exerted its indirect effect on depression and anxiety through resilience.

Discussion: Psychological resilience functioned as a partial mediator between positive and authoritative parenting style and both depressive and anxious symptomatology, and completely mediated the association between authoritarian parenting style and both depressive and anxious symptomatology. Psychological resilience is therefore key in examining the relationship between parenting styles and downstream psychiatric sequelae.


Marital Status and Cognitive Impairment among Community-Dwelling Chinese Older Adults: The Role of Gender and Social Engagement

Feng, L., Ng, X.-T., Yap, P., Li, J., Lee, T.-S., Håkansson, K., … Ng, T.-P. (2014). Marital Status and Cognitive Impairment among Community-Dwelling Chinese Older Adults: The Role of Gender and Social Engagement. Dementia and Geriatric Cognitive Disorders EXTRA4(3), 375–384. doi:10.1159/000358584


Aims: To examine the association between marital status and cognitive impairment among community-dwelling Chinese older adults.

Methods: We analyzed data from 2,498 Chinese aged 55 and older from the Singapore Longitudinal Aging Study cohort. Cognitive impairment was defined as a Mini-Mental State Examination total score of 23 or below. Odds ratios of associations were reported and adjusted for potential confounders in logistic regression models.

Results: The prevalence of cognitive impairment was 12.2% (n = 306). Being single was associated with about 2.5 times increased odds of cognitive impairment compared to being married (adjusted OR = 2.53, 95% CI: 1.41-4.55). The association between marital status and cognitive impairment was much stronger in men compared to that in women, and was indeed statistically significant only for men. Among the single and widowed persons social engagement was associated with a lower risk of cognitive impairment. Compared with subjects in the lowest tertile of social engagement scores, the odds of having cognitive impairment was lowered by 50% for subjects in the second and the third tertile.
Conclusion: Being single or widowed was associated with higher odds of cognitive impairment compared to being married in a cohort of older Chinese men but not women.


Taowu, Hantu and Lear:  Age-Old / Old Age, Singapore Prepares for the Future

Michael M.J. Fischer
Professor of Anthropology at Harvard and MIT

Singapore, like Japan, is a rapidly aging population, a hotly debated policy issue for city-planners, health care, and religious-or-community organizations. Aging is a dynamic space between thickened Mystic Writing Pads of the psyche, and dynamic forms of Archive Fever.  Archive fever expands the psychic mystic writing pad to histories and historical memories in their multiplicities. Also to neurology and biology, the dynamics of matter, something insisted upon by both Freud and Derrida, an intermingling, non-possibility of separation between nature and culture.   Hauntology is the interzone, third space, or shared interworkings of biology, psyche, text, and technological supplements, none of them entirely stable. In science fiction, the forensic ability to decipher more and more of varied pasts through reading the mutations and accretions of DNA, the scars and diseases of tissues, chemical signatures and decay, and other processes of aging provides a kind of template for literacies of the future, not just of death to come, but of worlds opening up to discovery, to new regenerative medical possibilities, to new forms of aesthetics, and new complications of ethical civic responsibilities. We speak thus in languages our parental generations never could, and through fogs of pollution and epidemic disease mechanisms they were not subject to.  Ghosts and revenants, uncanny doublings, that puzzle identity, change and persistence.

Two parts follow: Part One — Psyche and Archive: Fear beyond Reason — is composed of three interrelated scenes: the beginnings of Asia’s first 10 year longitudinal study on whether activity interventions can cut the rates of depression and slow the processes of dementia; a novelistic account of the dangers and benefits of cathartic group therapy; and Qing Ming rites that serve also to stimulate thoughts on unsettled political histories.   Part Two — II.  Aesthetics and Civic Responsibilities: Passages and Student Plays— explores how creative writers and college students might engage with senior populations in anticipation of urban life to come.   I conclude with a brief reflection through the ancient Chinese figure of taowu, the tomb guardian, combinatory of animal parts, that sees into the future as into the past, the Malayan figure of haunting ghosts (hantu), and Singapore’s Lear

I.  Psyche and Archive: Fear beyond Reason
It was part of a ten week pilot experimental program to prevent or moderate depression and dementia among seniors run by the Department of Psychological Medicine of the National University Hospital of Singapore, under the direction of psychiatrist Prof. Kua Ee Heok.  On the sixth floor of a new high rise mall in a set of rooms provided by the owner of the mall, a program co-sponsored by the Presbyterian Community Services and Kua’s Gerontological Research Program at NUHS, the program held a feedback conference for participants, volunteers and funders; and kicked off the first longitudinal study in Asia to track the mental health of 600 seniors over ten years, seeking to cut rates of depression by 50% and delay the onset or progress of dementia.  Singapore reports about 28,000 people with dementia, and predicts this will be 80,000 by 2030.  Suicide rates for 65 and older run around 24 per hundred thousand (27.6 in 2007) compared with 14 in the U.S., and 8-12 per thousand in the general Singapore population. In a rapidly ageing society, depression and dementia affecting quality of life, life expectancy and health care costs has become a widely discussed and debated public policy issue, especially with the increase of seniors living alone, and debates about what sorts of housing can be provided.

The three month pilot study was conducted with 108 people with some mild symptoms of depression or memory problems, identified by nurses who knocked on every door in the surrounding area to identify all elderly people, and invite them for physical, psychological, and social screening.  A second batch of 100 began in October 2013.  The full cohort to be followed for ten years will be 600. The activity interventions, each interesting in its own localized, even personalized, modes of cognitive-affective unfoldings, of the pilot program included yoga; mindfulness exercises; tai chi; the telling of personal histories; and art therapy with music, attuned, it is said, to the hippocampus (“sea horse”) where new visual, spatial and autobiographical memory is said to be formed and perhaps renewed.

The pilot program was run on a shoe string, with volunteers.  Therapists are expensive, Kua points out.  Virtue forged from necessity, Kua now carefully promotes preventive medicine by the community for the community, part of what he called a new eco- or ecological medicine, paying attention for instance to the effects of the annual haze from fires in Indonesia that affect the elderly disproportionately, and has become an international bone of contention among Indonesia, Singapore and Malay. Already other members of Parliament have asked about starting similar programs in their constituencies.  Suicide rates for people aged over 65 in Singapore, he said, have been brought down from 62 per 100,000 in 1995 (the second highest in the world) to 24 per 100,000, still very high.  His goal is bringing down the depression rate by half and defining a new paradigm for ageing well. 
*                      *                      *
Drawing on his experience earlier as CEO of the Institute of Mental Health/ Woodbridge Hospital, as well as interviewing 612 elderly people in Singapore’s Chinatown in 1987 as part of a WHO research team for the global study of dementia, Kua wrote Listening to Letter from America, a novella about a novice psychiatrist who reluctantly takes up an assignment at the IMH Day Care Center, but comes to be so emotionally involved, it changes his life.  Listening to Letter from America, is of course the famous weekly 15 minute radio program of Alistair Cooke on BBC Radio 4, that ran from 1946 to 2004, when Cooke retired at age 95 (dying a month later, the longest running radio progam on BBC).  The show serves as memory triggers for two of the characters for events in their own lives in Singapore or Malaya at the times described by Alistair Cooke (1940s occupation, 1950s communist uprising, 1960s race riots), and as a role model that an octogenerian can still be a public figure influencing others.  The characters in the novel come to ask if they can tell their stories on a radio program.

Like the Jurong Aging Study, the novella is built around weekly group therapy meetings.  The characters – a Eurasian alcoholic former stevedore, a Malay former sergeant in the Malay Regiment and Force 136, a severely depressed and withdrawn Chinese man, an Chinese man recovering from stroke, a Chinese woman piano teacher, a Tamil woman former rubber tapper – have representative living arrangements, some living with a son or daughter and conflicts with the son-in-law or daughter-in-law, and hailing from various places.  As the group therapy meetings progress, talk evolves from superficial chatter about the poor food at the Center and the lack of dignity with which older people are treated, a felt injustice for once productive lives contributing to the building of the nation, towards increasingly experientially formative, emotionally riveting, moments during the Japanese occupation (taken from Kua’s earlier interviewing): horrendous witnessing of massacres, beheadings, traumatized relatives who committed suicide or withdrew into mental illness, and survival stories of guilt and shame.  The climax comes at the end of one of their radio sessions when they receive an emergency call that the depressed man, Seng Huat, is on his apartment’s fifteenth floor ledge about to commit suicide. He is pulled back, and eventually is able to tell his story of deep shame and guilt about having survived the killing of his father and two brothers, of not having been able to help, of hiding under water in a ditch saving his life but feeling dead to life. 

He has never talked about it, and the group therapy session almost killed him:

“I not told anyone.  Shameful.  Coward.  Not about son or
daughter-in-law.  Can’t blame them if I sad and want to die. 
You not know . . . whenever you all talk about war, I become
fearful and want to get out.  Very painful memory. That’s why
I try to avoid Day Center – but deep inside I know all of you
good to me and want to help me. . . . This morning during
radio talk, same feeling of fear and sadness came over me” (231).

In turn, two of the others tell stories they have not dared reveal so far, using one another’s examples to over-come their deep ‘fears beyond reason’.

In the short final, epilogue-like, chapter 6, the doctor finds Ali, the Malay former sergeant visiting Pasir Panjang Hill (now Kent Ridge Park) for the first time since the Japanese overran his unit there.  Only a small unassuming historical plaque marks the history. 

It is a place Prof Kua, the author, has taken me and like Ali pointed out the features of the site.  It now overlooks “the industrial island of Pulau Bukum with its gigantic oil refineries and iridescent lights” (242), and in another direction one can see the white buildings of the new Alexandra Hospital, replacing the old one which Ali’s unit was to protect.  The doctor, the novella concludes, considers “writing a book [about the group’s] experiences during the war but his wife discourages him, ‘Don't waste your time. Nobody will buy your book.  A best-seller is always a book about ghosts or sex!’” (247).  Ghosts and sex indeed.  Stife and love.  Deeply affecting and haunting.


NUS Students Experience  - Telomere MCI Study
As part of our graduation research project, a group of us from NUS High School joined TaRA's clinical research study on elderly healthcare. Also known as the Training and Research Academy, TaRA was our chosen platform to learn and implement research skills. Throughout the month of June, we went down to TaRA at Jurong Point, where we got to interact with the retired nurses running the study.


Our learning process at TaRA consisted of various different areas, and each session allowed us to experience a different aspect of it. For instance, we accompanied the nurses for home visits, where we encouraged more elderly to participate in the study. While these home visits were pretty tiring, it was a fulfilling and interesting experience. We were also given the opportunity to observe and help interview these participants. There were also 'intervention sessions' where various activities were conducted to help improve the mental states of the elderly. In a short month at TaRA, not only were we able to gain valuable experience, and learn the basics of clinical research, it was also an extremely wonderful educational opportunity.


Preventive Psychiatry in Late Life: Studies on Depression and Dementia from the Singapore Gerontology Research Programme

Ee Heok Kua, M.B.B.S., M.D., F.R.C. Psych.,
Mahendran Rathi, M.B.B.S., M.Med. (Psych.), D.P.M.,
Lei Feng, M.D., Ph.D., Xianfeng Tian, B.D.S., M.Sc.,
Tze Pin Ng, M.B.B.S., Ph.D.

This overview summarizes the research results on depression and dementia in ethnic Chinese elderly conducted by the Gerontology Research Programme of the Yong Loo Lin School of Medicine, National University of Singapore. Health policies are dependent on information of evidence-based studies and it is of utmost importance to encourage research on preventive psychiatry. Interventional strategies in psycho-social therapy, diet and stability of chronic illnesses like diabetes mellitus and hypertension, are critical in lowering the rates of depression and dementia in late life. The challenge is how to translate research results into public policies. Preventive psychiatry is not just an endeavor from the government but should also from the private sector and non-governmental organizations (NGOs). If measures are taken collectively, it is plausible that the quiet epidemic of elderly depression and dementia this century can be averted.


Click here for more information.


Academic psychiatry across the Pacific: Challenges and opportunities for the Pacific-Rim College of Psychiatrists

Ee Heok Kua MBBS, MD, FRCPsych

Asia_Pacific Psychiatry 5 (2013) 51–53

There is cautious optimism that the economic growth around the Pacific-Rim, will stir opportunities to redress the mental health resource deficiencies and inequity of access to services. Many psychiatric services are without psychiatrists and the primary care doctor or nurse is the key mental health professional. One of the challenges is a paucity of training opportunities and a dearth of trainers. Primary care psychiatry training should be the focus of educational programs. Collaboration in research has been gathering momentum in recent years. The Research in East Asia of Psychotropic Prescription (REAP) includes a consortium of eight countries in Asia. More recently, there have been workshops organized for leadership training of young psychiatrists. The Pacific-Rim College of Psychiatrists and Asia-Pacific Psychiatry journal can be a platform for education and research. The myriad cultures and wide expertise across the Pacific-Rim will make collaboration more exciting and challenging.


Dementia in Chinese populations: Current data and future research

Lei Feng MD PhD, Helen Chiu MD FRCPsych, Mian-Yoon Chong MD FRCPsych, Xin Yu4 MD PhD & Ee-Heok Kua1 MD FRCPsych

Asia-Pacific Psychiatry 3 (2011) 109–114

This review summarizes the literature on the prevalence and incidence rates of dementia in Chinese populations, including survey results outside mainland China. We identified 15 prevalence studies and five incidence studies. The studies consistently reported sharply increased prevalence and incidence rates of dementia with increasing age. As estimated, there are at least 6,464,040 dementia patients in mainland China alone and we expect the number to rise in the coming decades. It is clear that dementia will be a new epidemic of the 21st century without major public health policies and preventive measures that target at the disease. We urge more research and hope that we will be able to prevent dementia or at least delay the onset in the near future with evidence-based measures.


The many faces of geriatric depression

Kua Ee Heok and Roger Ho

Current Opinion in Psychiatry 2008, 21:540–545


Recent studies on five aspects of geriatric depression, namely subsyndromal depression, risk factors and association with chronic pain, cardiovascular disease and cognitive impairment, are reviewed.
Subsyndromal depression in the elderly population is not uncommon in East Asia; the prevalence is about 8–9%. Risk factors of geriatric depression include poor health, brain injury, low folate and vitamin B12 and raised plasma homocysteine levels. Depressed elderly with chronic pain are prone to suicidal ideation. Depression is a risk factor for cardiovascular diseases and mortality in coronary heart disease. The growing interest in research on geriatric depression could focus on early diagnosis to help doctors treat depression better at primary care level.


Depression in Chinese elderly populations

Lena L. Lim1MA, Weining Chang PhD, Xin Yu3MD, Helen Chiu4 MD, Mian-Yoon Chong MD PhD & Ee-Heok Kua1MD

Asia-Pacific Psychiatry 3 (2011) 46–53


There is a scarcity of systematic reports on the prevalence of depression in Chinese elderly populations. The available reports used a variety of diagnostic and screening instruments to identify elderly depression. Furthermore, samples were drawn from different elderly populations. In spite of these difficulties, the reports are consistent in terms of the prevalence rates of severe depression which is lower than those reported in Western studies; though the prevalence rates of depressive symptoms approach those of most Western countries. However, the Chinese elderly showed a particular sensitivity to social factors either as vulnerability or protection factors for depression. There is a consistent social dimension in depressive complaints by Chinese elderly; hence the need to construct specific culturally sensitive instruments and to establish within ethnic group norms and diagnostic criteria for elderly depression. Current intervention efforts to prevent and ameliorate depression in the community-dwelling elderly will be discussed.


Psychological therapy with Chinese patients

Lei Feng MD PhD, Yuping Cao MD PhD, Yalin Zhang MD PhD, Sin-Tho Wee BSocSc & Ee-Heok Kua MD FRCPsych

Asia-Pacific Psychiatry 3 (2011) 167–172

There is a growing interest about psychological therapy and training in Asian countries. However, there is a paucity of information on how psychological therapy is practiced in Asia. In this article, we discussed 3 methods of psychological therapy in the management of anxiety and depression in Chinese patients – mindfulness meditation, Chinese Taoist cognitive psychotherapy (CTCP) and brief integrative psychological therapy (BIPT). The CTCP for generalized anxiety disorders was a multi-site randomized study conducted in China. It was found that CTCP reduced symptoms more slowly than anxiolytics but the effect of CTCP was still significant at 6-month follow-up. The mindfulness meditation study examined the outcome of a community training program on the management of mild anxiety. We found that overall mental well-being and anxiety symptoms were significantly improved during the period of the training course. The BIPT project was a naturalistic study of elderly people with depression at an outpatient psychiatric clinic. Results from this study indicated that BIPT was as effective although the onset of recovery was slower compared with BIPT combined with an antidepressant. In the 3 methods discussed, cultural issues are explored with affirmation of cultural values and reinforcement of culturally sanctioned coping pattern. Brief therapy and integration are the psychotherapeutic zeitgeist of the 21st century in Asia and we hope that there will be more studies on psychological therapy from different Asian countries in the future.


Suicidal and help-seeking behavior in Xiamen, south China

Cheng Wen MMed, Wen-Qiang Wang MMed, Li-Jun Ding MPH, Lei Feng PhD,
John Chee-Meng Wong MMed MSc & Ee-Heok Kua MD FRCPsych

Asia-Pacific Psychiatry ISSN 1758-5864

Introduction: The aim of this study is to examine the association between suicidal behaviour and mental health status of south Chinese people, and explore the mediating effect of help-seeking behaviours. Methods: The study participants were 10,757 persons aged 18 years and older from the mental health survey of Xiamen city. Data on suicidal behaviour and help-seeking behaviour were collected by trained psychiatric nurses through face-to-face interviews. Mental health status was assessed using the 12-item General Health Questionnaire (GHQ-12). Multiple logistic regression and general linear model were used in statistical analysis. Results: In the entire study sample, 236 study participants reported suicide ideation (2.19%, 95% CI: 1.92–2.47%), and 59 reported at least one suicide attempt (0.55%, 95% CI: 0.41–0.69%). Individuals with suicide attempt and suicide ideation had higher GHQ scores than those without suicidal behaviour. The majority of study participants with suicide ideation or suicide attempt did not seek any help (77.5% and 79.7%, respectively). Among participants with suicidal behaviour, seeking help from mental health professional was associated with a better mental health status (OR = 4.04, 95%CI: 1.17–10.16). Discussion: Only a small proportion of individuals with suicide behaviour in south China had ever sought help. Seeking help was associated with a better mental health status.