The long road to reintegration

People with mental disorders in Hong Kong face a barrage of hurdles in their recovery process. Psychiatrists and social workers call for more efforts by the government and organizations to help patients reintegrate into society and return to normal life. Xi Tianqi reports from Hong Kong.

For years, Lele, 32, has not eaten at the same table as his father although both live under the same roof. His father can't bear to sit with his son who will, all of a sudden, grab all the food he can lay his hands on.

Lele lives with his parents and two younger sisters in a 470-square-foot (43.7-square-meter) public rental flat in Yau Ma Tei, Yau Tsim Mong district. He has been diagnosed with chronic schizophrenia, and falls under the category of "borderline intellectual functioning", in which a person has below average cognitive ability.

Unlike most people of his age, Lele still needs constant care and attention. Even taking him out on the streets is a challenge as he can't help grabbing things like food from shops without asking. But living with family members can be also a challenge for mentally ill patients like Lele, especially as his parents constantly argue about their son most of the time.

Lele is one of more than 296,900 people in Hong Kong currently seeking treatment for mental illness in public hospitals. The figure is more than 55 percent higher than the 187,000 patients registered in the 2011-12 fiscal year, according to the city's Hospital Authority (HA).

Hong Kong now has about 3,675 available beds for mental disorder patients, with 68 percent of them being occupied in the 2021-22 fiscal year. But this accounts for less than 1 percent of the total number of patients receiving treatment.

According to the HA, among the patients on the recovery list, about 5,600 are included in the special administrative region government's Special Care System, under which patients are assessed on their propensity for violence and criminal violence record, as well as their need for care and follow-up action.

Most mentally ill patients have to stay with their families as the government believes that allowing them to stay in the community will help them to recover faster or "reintegrate" into the society after treatment to alleviate their symptoms.

In early June, a tragic knife attack on two women at a Diamond Hill shopping mall by a man reported to be mentally ill called into question the effectiveness of the principle of allowing patients to remain in the community. The two victims were stabbed to death at Plaza Hollywood in front of terrified passersby. The attack occurred days before the assailant was to have his regular three-monthly appointment with his psychiatrist on June 6.

In response to the incident, the SAR government proposed introducing 10 measures to strengthen support for mental health, including raising the number of case managers and wider use of newer oral drugs or injections, and cutting the waiting time for new cases to be treated. The government is also considering issuing a community treatment order requiring mentally ill patients to receive treatment, counseling or recovery services in the community, and be taken back to hospital if they fail to obey doctors' instructions. The idea of introducing the community treatment order was shelved years ago after research showed there is no evidence it would help reduce the number of mentally sick patients.

Supplementing medical staff

A key link in Hong Kong's supporting system for mental patients is the case management mechanism introduced in 2010, in which case managers are assigned to manage mental health patients, meet patients regularly to help them overcome their frustration in fighting their illness, and arrange meetings with doctors if necessary.

As of the end of March, 430 case managers in the city were handling 18,100 patients, with the ratio of case managers to patients having been lowered from 1:50 to 1:41. The government plans to cut the ratio to 1:40 by the fourth quarter of this year, which means 22 more case managers need to be hired to meet the goal. But the ratio is still lower than those of several developed economies. In the United States, each case manager handles an average of 29 patients while, in the United Kingdom, a case manager handles less than 15 patients.

The dearth of psychiatrists in Hong Kong has strained the support and services for patients with mental disorders. The HA said that last year, it lost 7 percent of its 400 psychiatry specialists responsible for treating patients who make 900,000 medical visits a year to public hospitals.

Apart from the 400 psychiatrists, Hong Kong has another 600 clinical psychologists. The 1,000 psychiatrists and clinical psychologists handle the mental health of the city's 7 million residents. In other words, there is only one psychiatrist for every 7,000 people.

Terry Lum Yat-sang, Henry G Leong professor of social work and social administration at the University of Hong Kong, said it would be difficult to increase the number of psychiatrists and clinical psychologists in the short term.

He suggested that training of social workers should be stepped up to provide psychological services to patients with mild or moderate symptoms. At the same time, the government can strengthen mental health services at the primary care level. Family doctors and the government's local district health centers can also play a role in triaging mild to moderate mentally troubled patients, such as those suffering from depression and anxiety. This would allow specialists to focus on severe cases, Lum said.

His proposals are in line with the government's remedies following the Diamond Hill attack, including launching a pilot program to provide mental health evaluation for the public to try to identify people in the high-risk category and take follow-up action.

Lam Ching-choi, a specialist in pediatrics and a member of the Executive Council, agreed, saying that mild depression is the most common problem involving mental health, with some patients suffering from chronic diseases much likely to be mildly depressed. He believes that trained social workers and nurses can make initial referrals, with the help of many standardized assessment tools for mental health conditions.

The newly established care teams in Hong Kong's 18 districts could also help, and can be trained to provide community-based care and support for the mentally ill, Lum said. Patients with mild symptoms or who are in a stable condition can be triaged to community-based family doctors and private clinics for treatment, allowing public medical systems to focus on severe cases, thus alleviating their manpower shortages, he said.

According to the HA, there have been 51,271 new bookings at its psychiatry specialist outpatient clinics in the past 12 months. The average waiting time for urgent cases, which account for up to 5 percent of the new cases, is one week, while the waiting time for semi-urgent cases is 3.6 weeks. For stable cases, the waiting time can be as long as 93 weeks, or about two years.

The long wait could be attributed to the rising attrition rate among psychiatrists, as well as the growing number of patients.

Mong Kok-based psychiatrist Au Yeung Kwok-leung said that for new cases, doctors usually have to spend longer on diagnosis during the initial consultation. However, for follow-up visits, doctors may only have one or two minutes to check on a patient.

According to the psychiatrist, some patients transferred from public hospitals to private clinics claimed that doctors only asked about their recent condition and then prescribed medication without further examination.

Lum noted that despite the government's efforts to issue new initiatives to support the integration of mentally ill patients into the community, it's still a challenge for patients with mental disorders and their families in view of the deficiencies in supporting policies without additional resources and manpower.

Creating supportive environment

A social worker surnamed Chan, who has been working on psychiatric rehabilitation cases for years, said living with family members may also exacerbate the condition of patients with mental illness because of the tense family atmosphere.

In Lele's case, he said social workers had conducted face-to-face interviews with all his family members when providing him with support. During these interviews, social workers would express appreciation for the efforts of family members in taking care of patients, and encourage them to reveal their difficulties. For instance, Lele's mother, who is the primary caregiver and didn't have time for her own life, was encouraged to rebuild her social circle and participate in social activities.

Florence Fong Meng-soi, deputy director and senior lecturer at the Asia Pacific Institute of Ageing Studies of Lingnan University, said the key factors in helping mental disorder patients to recover in the community are comprehensive community support, public education, and timely follow-up on individual cases.

She said family members play a vital role in supporting a patient's recovery by encouraging them and reminding them to take medication on time after being discharged from hospital.

Wong Yan-lung, chairman of the Advisory Committee on Mental Health, said only an extreme minority of patients with mental illnesses are violence-prone, and may injure others due to relapse, and that symptoms of mental disorders can be effectively managed through treatment and intervention.

He stressed that attributing such tragic incidents to mental disorders will only keep the community further away from the truth. Such a mindset will not help resolve the problem, but aggravate the stigmatization against persons with mental health issues, and deter those in need from seeking assistance.

"By raising awareness of and reducing the stigma of mental illness, the community can create a more supportive environment for those recovering from the disease, leading to a better quality of life for patients and their families," Fong said. Besides the various challenges that patients face during treatment, it can be difficult for individuals recovering from mental illness to return to the workforce and reintegrate into society, she said. Even if employers are willing to hire those who are recovering, they still have to navigate workplace relationships and interactions with colleagues, she added.

Thomas Chu Sai-ming, CEO (social enterprises) at the New Life Psychiatric Rehabilitation Association, said individuals in psychiatric recovery may face difficulties in finding jobs due to a lack of up-to-date skills or communication ability, low self-confidence, and concerns about discrimination. Side effects, such as hand tremors from medication, also deter some from seeking jobs.

Chu said the association will match those recovering from mental disorders with diverse job options by reviewing their backgrounds, skills, interest and willingness to work. The positions being offered by the association include baristas, cleaners, receptionists and cashiers.

Chu said social workers and case workers will continue to support patients to help them adapt to their work and integrate into society. "If individuals who are recovering experience a relapse or other conditions, employers may worry about whether they can make appropriate contingency arrangements," he said.

Chan suggests that more temporary accommodation services, such as mobile cabin hospitals with case managers, be introduced to provide support for mental patients when halfway houses, which provide accommodation, care and recovery-oriented services for those who are recovering, are insufficient.

Overall, social rehabilitation organizations, such as Chu's, provide vital support for individuals in psychiatric recovery, helping them to overcome the challenges they face in reintegrating into society and increasing their chances of a successful and fulfilling life.

Lele and his family members are still trying to help him convalesce at home. With Chan's help, Lele's relationship with his father has improved after the father was asked to stand in for Lele's overstrained mother when she asked to take several days off from her caring responsibilities.

Any missing link in Lele's family could worsen his situation, and the community is one big family. Only when the members of the public do their part can mentally ill patients get sustained support and recover faster.