Healing the mind

Neville Sarony June 15, 2023 10:59

The tragic deaths of three small girls set against their mother’s apparent history of mental illness and the two women randomly stabbed to death by an alleged schizophrenic, focuses attention on the impoverished state of mental health facilities in Hong Kong.

The Advisory Committee on Mental Health has declared that it will review the S.A.R’s health in this field. Given the outstanding mental health practitioners on its Board and a highly respected Chairman, one can only conclude that its deliberations are not being listened to by government.

According to Professor Eric Chen, chair of Psychiatry at Hong Kong University and Professor Linda Lam, chair of Clinical Psychiatry at the Chinese University, Hong Kong is woefully underprovided in terms of psychiatric health.

The international norm requires one psychiatrist for every 10,000 members of the community. Hong Kong has only a total of 7.55 per 100,000, and the OECD average is 18 to 100,000.

Hong Kong has long had a working ethic of long hours and intense commitment.

But long before work begins, children are exposed to an almost frantic intensity of study, including massive amounts of out-of-school tutoring. The concept of the tiger Mum is an unshakeably Hong Kong phenomenon.

Hong Kong’s suicide rate for children up to the age of 15 in 2021 was 1.7 deaths per 100,000.

The pressure on pupils and students carries through into the workplace.

According to the Jockey Club Centre for Research and Prevention, for people between ages 15 to 24 there have been between 900 to 1,000 deaths by suicide every year over the last decade.

Unquestionably, the restrictions imposed during the Covid-19 pandemic effected disastrous damage on the mental health of the community.

Though this was a universal phenomenon, the battery-hen-size living accommodation in Hong Kong, cooping people together and depriving them of normal socialising, only served to intensify the stresses.

Nor can the cultural dimension be ignored.

For many older generation folk, the idea of mental health is an alien concept. Either one is normal or possessed of devils or ghosts.

Though it may well be correct that some vocal members of the community do present as though driven by devils, there is no political exorcism available to address their problems.

The stark reality is that whereas most societies are wrestling with the existential problems of mental health, Hong Kong has a generational post-traumatic stress disorder that its public health system is just not geared to address.

To put it in fair context, the worldwide field of mental health is a history of trial and error with the errors far exceeding the evolution of adequate remedies.

Medical science has barely scratched the surface of that complex of brain cells, metabolisms and chemical of emotions that contribute to mental balance.

Just one medium of therapy illustrates the vacillation amongst mental health specialists, that of electro-convulsive therapy (ECT).

As a form of treatment, ECT has undergone phases of acceptance and rejection.

It is equally correct, historically, that by far the most common treatment for mental health problems is drug therapy.

It only needs to be posited that the human body is an amalgam of different natural chemicals to appreciate that administering an artificially manufactured chemical will alter the natural balance of the body’s endogenous elements.

But even though the artificial drugs may alleviate the symptoms, they also create the risk of the body generating a dependence on alien substances.

As with any aspect of health, accurate diagnosis is critical to any management of a problem. In psychiatry, the major diagnostic route is by evaluation of both perceived and objective behaviour.

Of one thing we may be certain, this process of diagnosing the nature of mental illness is not a task for Artificial Intelligence.

The skills of the psychiatric examiner lie not only in the knowledge acquired through academic studies but call on the ability to read and interpret nuances of thought and expression in the patient, skills which require first-hand experience garnered through the doctor-patient relationship.

The diagnostician’s first task is to identify the nature of the problem. To illustrate how difficult a task this is, we need only ponder on the many years that the international psychiatric community took to agree on the signs and symptoms that comprise the criteria for a particular condition.

The standard reference book in psychiatry is the Diagnostic and Statistical Manual of Mental Illness (DSM 5).

To upgrade DSM 4 to DSM 5 took the psychiatric world 7 years to reach a consensus on the criteria for the various mental disorders.

Psychiatric evaluation is, necessarily, a personal examination in the course of which, amongst other things, the doctor has to tease out the inner thought processes of the patient.

As anyone who has experience of mental health provision in Hong Kong’s public sector knows, on average such an examination translates to approximately a 15 to 20 minute session for each patient.

Also bearing in mind that many patients have a built-in denial of any form of mental disorder, such a limited allotment of time cannot begin to be sufficient to establish a reliable diagnosis or, indeed, the essential confidential relationship.

This inadequacy is compounded by the brevity of follow-up examinations, most especially where the optimal treatment is sessions of psychotherapy, all too often with different clinicians.

At best, this regime results in prescription of drugs to alleviate the symptoms; the prospects of actually treating the underlying causes are illusory.

The problem, put crudely, is kicked down the road.

In turn, this creates an ever-increasing population of drug dependent people with psychiatric disorders, swelling the demand for treatment from a group of specialist clinicians already stressed beyond their ability to cope.

Minimally, the ratio of psychiatrists to members of the community has to be boosted dramatically.

By almost any standard you care to choose, Hong Kong is a wealthy community. It is well overdue for investment in the infrastructure of mental health instead of absurd phantasy islands, bridges to nowhere and vanity projects that leave only a grim legacy of failed leadership.

What does it say of the mental health of an administration that fails to get its priorities right?

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Neville Sarony

King's Counsel