Rethinking risk: Mental health and resilience of migrant workers and migrant domestic workers in Singapore

Over the past 5 years, there has been growing attention to the health and well-being of international migrant workers (MWs) in Singapore, particularly low- to semi-skilled MWs and migrant domestic workers (MDWs). To promote well-being, the government has introduced several initiatives, including mandatory rest days and improved living facilities.^1,2 Non-profit groups, such as HealthServe, have also established peer support networks and a counselling hotline.^3,4

Despite these efforts, ongoing monitoring and programme development have been constrained by limited evidence. Globally, research on MWs is challenging due to difficulties accessing this population along with language, cultural and literacy barriers. In Singapore, very few studies have documented the prevalence, risk factors and protective factors related to mental health among MWs and MDWs.

To address this gap, Koh et al. present the largest mental health study of MWs in Singapore to date in this issue of Annals.⁵ The authors conducted a cross-sectional survey of 1465 MWs and 1462 MDWs, capturing symptoms of depression and anxiety through the widely-used Patient Health Questionnaire-9 (PHQ-9) and Generalized Anxiety Disorder-7 (GAD-7), alongside sociodemographic factors, stress, sleep, social support and resilience.

As the primary finding, the authors reported that MWs and MDWs had lower prevalence of mental health symptoms compared to the host population in Singapore. In their sample, 0.8% of MWs and 4% of MDWs met criteria for moderate-to-severe depression symptoms, while 1% of MWs and 4% of MDWs had moderate-to-severe anxiety symptoms. In contrast, a recent study of the Singapore population reported that 9% had moderate-to-severe depression symptoms, while 7% had moderate-to-severe anxiety symptoms.⁶

The finding that MWs have fewer mental health symptoms is counterintuitive. It challenges a commonly held belief that MWs face greater risk due to economic and social disadvantages. Rather than heightened vulnerability, these results suggest psychological resilience within the population.

Although counterintuitive, the findings align with the well-documented “healthy migrant effect”. This is a global phenomenon describing how international MWs tend to have better health outcomes than the host population across disease categories.⁷ While the mechanisms for this effect remain speculative, this could be because migrant populations are younger or that self-selection results in healthier individuals opting to migrate.⁸ Researchers have also proposed protective mechanisms such as having strong communal ties or a reliance on religion and spirituality.⁹

The authors note that while Koh et al. reported lower rates of mental health symptoms than the Singapore population, earlier studies found more modest differences.^10,11 For example, in a survey conducted among 1011 MWs by this editorial’s authors,¹¹ rates of severe or extremely severe depression, anxiety and stress were comparable to the general Singapore population. However, these studies were conducted during the height of the COVID-19 pandemic. Koh et al. reasonably speculate that the post-pandemic easing of restrictions and well-being initiatives may have alleviated mental distress.

As a further departure from the literature, prior studies outside Singapore suggest that the “healthy migrant effect” diminishes over time, with migrants’ health converging toward or falling below host populations after 5 to 15 years.¹² In contrast, Koh et al. found that longer employment duration was associated with a lower likelihood of depressive symptoms. This discrepancy may reflect several factors such as Singapore’s compact geography, which may foster a sense of community that protects against psychological distress. It may also reflect the stability that comes with having a steady income over time.

More generally, the factors contributing to an individual’s mental health are complex and multifactorial. For example, Koh et al. observed differing rates of depression and anxiety between MDWs and MWs, and across nationalities, age and education levels. This may suggest both distinct stressors (e.g. job demands, pay structure) and coping strategies across subgroups. Accordingly, more studies are needed to draw stronger conclusions about the mechanisms of the “healthy migrant effect” in Singapore and whether mechanisms differ across migrant subpopulations.

At this juncture, concerned readers may reasonably wonder whether Koh et al.’s study has accurately captured mental health symptoms among MWs and MDWs. It is conceivable that symptoms were underreported due to underlying stigma or fear of repercussions. Cross-culturally, Asian respondents also tend to express psychological distress through somatic symptoms (e.g. stomachaches), which are not well-captured by Western-developed questionnaires such as the PHQ-9 or GAD-7.¹³ These considerations underscore the need for caution when interpreting the study and a need to triangulate with other data sources—for example, by tracking general practitioner visits for somatic complaints.

How might Koh et al.’s results inform policy and practice? First, regardless of the prevalence rate, there needs to be continued investment in migrant mental health. Both the process of migration and financial insecurities remain significant stressors that can place an MW at risk for poorer mental health. In psychiatry, the “diathesis-stress model” describes how situational stressors combine with pre-existing vulnerabilities to accrue risk.¹⁴ Applied to MWs, it is plausible that while many adapt successfully to migration-related stressors, those with pre-existing vulnerabilities may face an elevated risk of developing mental health conditions.

Second, both prior research and the study by Koh et al. observed differences in rates of depression and anxiety among subpopulations. This suggests that risk may differ across subpopulations, and that policies should be tailored to the specific needs of each subpopulation. For example, while current policies mainly target MWs, it is MDWs who face higher rates of depression and anxiety.⁵ These higher rates may be linked to the live-in and highly variable nature of MDWs’ work, increasing the risk of isolation and overwork. Tighter policies regulating job scopes could be implemented to reduce burden—for example, by limiting the number of family members an MDW cares for.

Third, Koh et al. identified several factors associated with poorer mental health including long working hours, high stress, poor sleep and limited social support. Potential measures to target these risk factors may include: nationwide education on psychological resilience and sleep hygiene for MWs and community-building interventions. Further, unlike countries such as Hong Kong and Taiwan with universal health systems independent of employers,^15,16 healthcare access for MWs and MDWs remains largely employer-dependent in Singapore. To promote help-seeking, it may be timely to review mental healthcare access across employers.

Finally, Koh et al.’s study highlights several areas that warrant further research. Future studies can employ longitudinal designs to understand mechanisms underlying the “healthy migrant effect”, and to monitor trajectories of mental health over time—particularly rates of depression and anxiety. Qualitative and quantitative studies are also needed to evaluate the impact of well-being policies and interventions (e.g. mandatory rest days, working hour limits) across MW and MDW subpopulations.

In conclusion, Koh et al.’s cross-sectional study represents a significant advancement in understanding depression and anxiety among MWs and MDWs in Singapore. The findings provide crucial evidence in a post-pandemic context, and point to opportunities for policy refinement and further research.

REFERENCES

1. Ministry of Manpower, Singapore. All migrant domestic workers to have one rest day a month that cannot be compensated away. 10 July 2022. https://www.mom.gov.sg/newsroom/press-releases/2022/1007-mandatory-rest-days-for-mdws. Accessed 26 February 2026.
2. Ministry of Manpower, Singapore. Dormitory transition scheme. https://www.mom.gov.sg/passes-and-permits/work-permit-for-foreign-worker/housing/requirements-for-dormitory-operators/dormitory-transition-scheme. Accessed 26 February 2026.
3. HealthServe trains 1,300 migrant workers to support peers in mental health. https://healthserve.org.sg/healthserve-trains-1300-migrant-workers-to-support-peers-in-mental-health/. Accessed 26 February 2026.
4. HealthServe Launches First 24-hour Crisis Helpline for Migrant Workers in Singapore. https://healthserve.org.sg/healthserve-launches-first-24-hour-crisis-helpline-for-migrant-workers-in-singapore/. Accessed 26 February 2026.
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