WHO: No health without mental health!
Mental illness is worsening due to a combination of school pressure, job insecurity, social disorder, political bullying, elderly isolation, and the pandemic terror of contagion. The city’s public health services are overstretched, and only the most severe cases are receiving prompt treatment. Wang Yuke reports from Hong Kong.
The World Health Organization (WHO) has embraced a more holistic definition of human well-being beyond disease afflictions that require sick leave, hospitalization, surgery, or medication. Given the social and emotional impacts of an individual within the family unit, workplace, and community, the WHO has declared that there is “no health, without mental health”.
While mental illness remains mostly unrecognized, and largely untreated, the whole world has endured a year of relentless COVID-19 virus siege. We agonize under an ominous shadow of anxiety — fraying family, work, and social relationships.
The World Economic Forum, framing mental health from an economic viewpoint, warned in pre-COVID 2019 that the global mental health crisis could cost, directly and indirectly, up to $16 trillion between 2010 and 2030. One in four people are affected by mental health problems at least once in their life. Almost two-thirds of such cases never seek professional help.
Hong Kong was ranked the fifth most stressed population on Earth in a 2018 survey of 23 economies by Cigna, a health service company.
A study initiated by the Mental Health Month Organising Committee and conducted by the Chinese University of Hong Kong revealed the deteriorating state of our mental health. The average score of the 1,009 residents surveyed in 2019 was 44.6 points — the worst in eight years — significantly below the 52-point pass mark.
A study by the University of Hong Kong, released in August 2020, found 74 percent of Hong Kong residents showed moderate-to-high depressive symptoms, with over 40 percent showing post-traumatic stress disorder triggered by the months-long social unrest and the lingering pandemic.
The pandemic’s consequences of job loss, social disconnection, and bereavement make things worse, says Patrick Corrigan, professor of psychology at the Illinois Institute of Technology. Corrigan is the principal investigator for the National Consortium for Stigma and Empowerment. “Talking to loved ones is the prime antidote to stress, but the pandemic makes it impossible.”
The caseload of children and adolescents aged below 18 handled by the Hospital Authority’s psychiatric teams rose from 18,900 in 2011-12 to 364,00 in 2018-19, representing an increase of nearly 93 percent in seven years. This is an alarming trend that needs an urgent response.
The growing awareness of mental well-being enables early detection of youth’s mental issues, and this probably leads to the escalating register of cases, says Chen Juan, professor of applied social sciences at the Polytechnic University of Hong Kong. However, she notes, the increase in cases may also be a sign that children and adolescents are more susceptible to mental illnesses.
The strain on students to perform well at school is extreme, observes Hector Tsang, head of the Department of Rehabilitation Sciences at PolyU. Only 18 percent of graduates can secure a seat at local universities. “The stiff competition amplifies stress, anxiety, and depression,” says Tsang, who studies mental illness stigma and vocational rehabilitation for the mentally ill.
The destructive impact of social media dependency can’t be ignored in youth mental disorders. There is a correlation between the long time spent on social media and feeling excluded, depressed, and lonely, says Steven Taylor, professor and clinical psychologist at the University of British Columbia.
“When they rely on the approval of peers on social media, that can be a problem.” Peer-comparison on social media can be toxic, warns Taylor. The constant exposure to polished photos and airbrushed make-believe fun can fuel insecurity, damage self-esteem, and trigger inadequacy about life.
“There is also ‘response anxiety’ and ‘fear of missing out’ for youth in social media... and cyberbullying can cause deep-reaching trauma,” says Chan Kai-tai, clinical associate professor of psychiatry at HKU. Chan specializes in youth mental health and anti-stigmatization.
Social media magnifies divisive opinions toward more polarized views, omitting balanced perspectives, says PolyU’s Chen. This can provoke hatred, offensive insults, and cyberbullying, which can inflict lasting emotional scars, cautions Chen.
While women are more vulnerable to mental health illness, men are more likely to kill themselves when experiencing it. Studies show that more women have been treated for mental health problems than men, says Tsang of PolyU. “The social expectation for men to be strong physically, and mentally, may inhibit them from reporting mental symptoms. They resort to alcohol and drugs to mask their issues, which can escalate to mental illness.”
In Hong Kong, men have registered a significantly higher suicide rate than women since 1981. In 2019, the numbers were 18.9 percent for men and 8 percent for women, according to the Hong Kong Jockey Club Centre for Suicide Research and Prevention.
For men, the fear of being fired if they disclose mental problems adds more stress, says Taylor. “It dissuades them from seeking help, leaving them isolated, with no one to talk to, out of shame.” Bottling up feelings aggravates mental stress, leading to potentially irreversible consequences.
The Global and Community Mental Health Research Group of the University of Macau probed the barriers among Chinese adults to seek help for mental illness. The 2020 findings listed these prime inhibitors: self-reliance; alternative treatment; low perceived need of help; distrust in treatment and psychology professionals; affordability; negative attitude; and self-denial.
“Stigmatization can hinder mentally distressed people from seeking proper mental health services, and worsen their personal suffering,” says Chan.
“The stigma associated with mental disorders hasn’t got any better over the years,” Corrigan says, noting that even though people are better educated, the social stigma persists.
“People often associate mental illness with violence, as exaggerated by social media, news outlets, and movies,” observes Corrigan. From news of a mass shooting by a mentally sick perpetrator, the public concludes the mentally ill are inherently dangerous.
Barriers for Chinese adults seeking psychiatric help
The stigma regarding mental problems is pronounced among Chinese employers, says Corrigan. Tsang led a cross-cultural study of employers from Chicago, Beijing, and Hong Kong, on hiring people with psychotic disorders. Chinese employers perceived the mentally ill might have a weaker work ethic and be less loyal to the company. Employers in Hong Kong worry about how dangerous they are.
Hong Kong employers are profit-oriented, says Tsang. They stereotype people with mental problems as incompetent and unreliable, which could harm company productivity and performance. That stops them hiring mentally challenged people, explains Tsang.
Another source of crushing stigma in Asia is from within family, adds Corrigan. Ashamed families tend to sweep the dark secret under the carpet, keeping many mental illness sufferers beyond the best window for them to get treatment. They are typically hidden from visitors and neighbors. Nobody talks about them.
Self-stigma is even more debilitating. As a response to their exclusion, people with mental illness are likely to internalize the external stigma and become ashamed of their condition, notes Corrigan. Furthermore, the self-shame and blame can worsen depression, leading to suicidal thoughts.
Our population is aging. “The older you get, the greater your chances of dementia,” says Taylor. The elderly are a vulnerable group in Hong Kong, with depression and dementia being the most common issues plaguing them, notes Tsang.
The government projects the number of elderly will increase from 1.32 million (18.4 percent of the population) in 2019 to 2.52 million (33.3 percent) by 2039. That will add 1.2 million more elderly people in 20 years. Experts project the incidence of dementia to double, with every five-year increase in age after 65.
The elderly aged 65 and above have recorded the highest suicide rate since 1981, a tragic statistic driven by loneliness, abandonment, and surrendering the will to live. Due to lack of knowledge among family members and caregivers, the onset of dementia is dismissed as a “normal” age-related factor, which delays diagnosis and intervention, causing fast deterioration, says Tsang.
Surprisingly, medical staff harbor negative attitudes toward patients with mental illness. The 2015 CUHK study showed that nursing and medical students, nurses and doctors have higher levels of stigma. They are less optimistic about people with psychiatric disorders than the general public.
Studies showed doctors have a tendency to exhibit the greatest, and social workers the least social distance from people with schizophrenia, bipolar disorder, depression, alcohol abuse, and drug dependence.
“On most occasions, when doctors and psychiatrists meet mentally ill patients, they (patients) are in a dire crisis or serious condition, with outrageous behaviors,” explains Tsang.
Repeated exposure to such cases could reinforce a negative attitude to mental illness, notes Tsang. “By comparison, occupational therapists and social workers deal with patients in a more stable condition. That’s why they are less prone to stigmatize.”
The special administrative region government and NGOs provide responsive support for the mentally needy, while countering misconceptions about them. The “Joyful@HK” and the Student Mental Health Support Scheme were launched in 2016, followed by the Dementia Community Support Scheme in 2017.
Under the HA, a Case Management Programme for patients with severe mental illness is available, and enhanced Common Mental Disorder Clinics supported by multi-disciplinary teams are in place. The government has steadily increased budget allocations for the Integrated Community Centres for Mental Wellness.
There are positive signs that the millennial generation is less prejudiced about the normalization of mental problems. They feel the stereotyping and stigma are lame and inhuman, says Corrigan. “Young medical staff, aged 18 to 25 in particular, are more hopeful about mental illness, because they’ve got a chance to see the treatment through to recovery.”
Corrigan welcomes more peer services for mentally ill patients. “Survivors of mental illness can relate to the patients. So, if they can be social workers, they will help the patients quickly engage in rehabilitation and recovery,” he says. “It has already happened in Guangzhou.”
Rehabilitation is crucial for mentally ill patients to reintegrate into society to recover self-esteem and gain social acceptance. Tsang is relieved that Hong Kong rehabilitation services are subsidized by the government, and are easily accessible. However, he says they need to go further.
“They are catering only to severe mental illnesses. The service excludes those with CMD, which are mild, moderate, and stress-induced. These wait at least 18 months for treatment,” says Tsang. Tsang points out that during the 18 months, their symptoms could deteriorate to the point of severity.
The Legislative Council Panel on Health Services proposed in 2020 that the HA implement a triage system for first appointment at specialist psychiatric outpatient clinics, to ensure the more urgent and severe cases receive prompt attention.
Better utilization of mental illness services takes time, from a more supportive community culture, says Chan from HKU. “Apart from anti-stigmatization, social inclusion, and user-friendly access, advocacy for psychiatric patients and their caregivers should be encouraged. It is a never-ending mission.”
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