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EDITORIAL: THE STATE OF PSYCHIATRY IN HONG KONG: A BIRD'S EYE VIEW

GABOR S. UNGVARI & HELEN F.K. CHIU

It took little more than a hundred years for Hong Kong to transform itself from a chain of small fishing villages into one of the leading financial centers in the world, with all the trappings of a sophisticated urbane environment. Yet, behind the westernized facade, traditional Chinese habits, values and principles, mostly Confucian, and a strong sense of national pride remain influential. Despite its phenomenal economic success, relative political stability, and a highly efficient civil service, the development of psychiatric services in Hong Kong lagged far behind the western world in the first hundred years of its existence (Lo, 1982). In the past two decades, however, there have been significant advancements in psychiatric practice and mental health policy. On the whole, Hong Kong psychiatry has been fashioned close to the British model in terms of its legal framework, guiding theoretical principles, diagnosis and management of psychiatric disorders and types of service delivery. These aspects of mental health have not changed since 1997, when Hong Kong became a Special Administrative Region of China. The recent development of psychiatry is reflected by administrative-organizational changes, which, in turn, have further sped up the development of the profession. Representing the whole psychiatric community, the Hong Kong College of Psychiatrists, which was established in 1990, organizes postgraduate education, training and examinations. Other important activities of the College are to provide professional input into governmental decision making and to voice opinions on psychiatric matters in the media and inform the general public. The Coordinating Committee in Psychiatry, which is comprised of all Chiefs of Services, also provides input for the planning and decision making of the Hospital Authority, the government-funded main public health provider, on all important psychiatric matters. Lack of space permits us to focus on only a few major issues in outlining the present state of affairs in Hong Kong psychiatry. We will try to describe these issues, as much as possible, in their historical contexts to make the reader appreciate how fast Hong Kong psychiatry has recently been catching up despite its very late start.

PSYCHIATRIC SERVICES ­ TOWARD COMMUNITY CARE

Unbelievable as it may sound, Hong Kong had neither a mental health service nor a qualified psychiatrist until 1948. Custodial care was provided mainly on a temporary basis as patients

International Journal of Social Psychiatry. Copyright & 2004 Sage Publications (London, Thousand Oaks and New Delhi) www.sagepublications.com Vol 50(1): 5­9. DOI: 10.1177/0020764004040951

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were regularly sent to Canton for further treatment (Lo, 1982). The first purpose-built psychiatric institution with 1200 beds opened in 1961 and the second with nearly 2000 beds in 1980, at a time when such establishments were busily dismantled in the developed world. The first general hospital psychiatric unit started functioning in 1971 (Lo, 1982). Over the past decade these mental institutions have been drastically `downsized' and transformed into modern psychiatric hospitals while a string of general hospital psychiatric units have been opened. The total number of psychiatric beds reached a peak of 5068 in 1998, but decreased to 4858 by March 2003 (personal communication, Hospital Authority, April 2003). The current ratio is about 0.7 beds/1000 persons. Since the early 1990s, child and adolescent, learning disability, psychogeriatric, rehabilitation and consultation-liaison psychiatric teams have been funded, and now cover the whole territory. Apart from a few, small-scale, pioneering efforts, community psychiatry has also taken off in earnest over the past decade. After the establishment of the first outpatient clinic in 1961, a further 18 opened by 2003, with attendance rising to 511,000 by 2002 (personal communication, Hospital Authority, 2003). The first day hospital was also established in 1961. By 2003 there were 12 day hospitals with 719 places, and further expansion is planned (personal communication, Hospital Authority, April 2003). Each of Hong Kong's seven catchment areas now has its own community psychiatric team, which is organized, like the whole psychiatric service, along the lines of multidisciplinary teamwork. Currently there are five child­adolescent services that, in addition to inpatient units, run outpatient clinics and day hospitals, which is a huge step away from the situation in 1991, when the first child­adolescent team was established. Psychogeriatric services also began in 1991 and have grown rapidly to seven teams. Currently, a comprehensive range of services, including inpatient, outpatient, daypatient and outreach services, are provided for the elderly. Major programs on dementia care and elderly suicide prevention have been established in the last few years. One example is a specially designed dementia center, the Jockey Club Centre for Positive Ageing, which combines clinical services, training and research. Elderly suicide is a major issue in Hong Kong as the elderly suicide rate is about three times higher than that of the general population. In 2002, a major initiative on elderly suicide prevention began to provide fast-track psychiatric outpatient services and home visits for the elderly at risk of suicide, as well as training for general practitioners (GPs) and frontline mental health professionals in the detection and management of depression. From its inception in 1967, when the first halfway house opened, community-based residential rehabilitation has mainly been the task of non-governmental organizations (NGO) in collaboration with the Department of Social Welfare and aided by the psychiatric services. Residential facilities with various degrees of supervision include long-stay care homes, halfway houses, group homes and public housing units that cater for patients with different levels of disability. The fast expanding community facilities can barely keep up with the demand. For instance, in March 2003 there were 1349 and 980 places in halfway houses and longstay care homes, respectively, which is about 1000 places short for both types of setting (personal communication, Hospital Authority, April 2003). Sheltered workshops and supported employment provide vocational training and rehabilitation. Day activity centers and social clubs that engage altogether 1200 patients (personal communication, Hospital Authority, April 2003) are also available to improve social adjustment and organize meaningful leisure activities.

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However, preliminary results of locally conducted research suggest an important caveat. A review of the seven local studies on community services concluded that their effectiveness in Hong Kong had not been unequivocally proven (Chan et al., 2001) and moving to the community did not necessarily increase the objective (Mak & Gow, 1991) or subjective (Chan et al., 2003) aspects of quality of life for Chinese patients with chronic psychosis. Patient advocates, who are independent from treating staff, are available in each hospital, but grassroots patient groups are just beginning to emerge, and their influence on mental health matters is marginal. Robust growth is expected in this area in the near future.

THE ADVENT OF PRIMARY CARE PSYCHIATRY

The only comprehensive community survey of mental health problems in Hong Kong called attention to hidden `minor' psychiatric problems that were amplified by the recent economic downturn (Chen et al., 1993). Apart from major depression, lifetime prevalence rates for anxiety and impulse control disorders, alcohol and drug abuse in the community were similar or close to those found in western countries (Chen et al., 1993). In addition, child and elderly abuse have lately become major public health concerns. Primary care psychiatry is slowly emerging in response to recent findings of significant psychiatric morbidity among primary care attendants. A recent study using standardized assessment found that 20% of 1300 adult general practice patients had a diagnosable psychiatric disorder according to DSM-IV criteria (Pang et al., 1997). In sharp contrast, another survey showed that only 1.6% of adult patients in general practices were diagnosed by their GPs as having psychiatric disorders (Lee et al., 1997), which suggests that a sizeable proportion of GPs are not yet sufficiently trained to identify psychiatric problems. In this respect there have been promising developments lately in terms of extending postgraduate psychiatric training and launching a diploma course in psychiatry for GPs. The situation, however, is confounded by the stigma attached to psychiatric illnesses in Chinese societies (Yip, 1997), which prevents people from seeking help for psychological problems despite the considerable attention that the media pay to psychiatric problems in the local community.

MANPOWER ISSUES

The first, and at the time only, qualified psychiatrist to organize and run mental health services, P.M. Yap, was appointed in 1948 when Hong Kong's population was well over 1 million. Even in 1981, Hong Kong's nearly 5 million inhabitants were served by only 55 psychiatrists in public service, of whom only 15 were fully qualified. Currently, there are 152 Fellows of the Hong Kong College of Psychiatrists and 130 junior psychiatrists at different stages of training toward Fellowship. (Fellowship requires six years of postgraduate training and passing three examinations.) For a population of nearly 7 million this is still a woefully inadequate number, even more so when taking into account that 42 of the 152 psychiatrists are in private practice and 11 are working overseas. (There are no separate psychiatric services for the approximately 400,000 expatriates, of which around 200,000 are domestic helpers mainly from Southeast Asia.) There are signs that the manpower shortage may

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improve; over the past few years, 5­7% of fresh graduates have applied for training positions in psychiatry. Also, having recognized the importance of mental health, the Government is willing to spend more on advancing psychiatric services; recently four multidisciplinary early psychosis teams have been established.

ACADEMIC PSYCHIATRY

There are two medical schools in Hong Kong. P.M. Yap, whose name has been associated with the `culture-bound syndrome' (Yap, 1952), was the founding Professor at the first academic department of psychiatry at the University of Hong Kong in 1971. In 1981, a second academic department was founded at the Chinese University of Hong Kong. Psychiatric research has taken off in the past 15 years. Its main areas have been epidemiology in adult and geriatric psychiatry, schizophrenia, rehabilitation, women's mental health, sleep disorders, psychiatric genetics, suicide, transcultural psychiatry and psychopharmacology.

THE FUTURE

We envisage that Hong Kong will become one of the main centers for research and clinical excellence in China while maintaining its close contact with the international psychiatric community. Closer cooperation with major Chinese psychiatric centers and with those in southern China has already begun. Hong Kong psychiatry is bringing its international experience, particularly its traditional ties with British psychiatry, into this partnership.

REFERENCES CHAN, G.W.L., UNGVARI, G.S. & LEUNG, J.P. (2001) Residential services for psychiatric patients. Hong Kong Journal of Psychiatry, 11, 13­17. CHAN, G.W.L., UNGVARI, G.S., SHEK, D. & LEUNG, J.P. (2003) Hospital and community-based care for patients with schizophrenia in Hong Kong: quality of life and its correlates. Social Psychiatry Psychiatric Epidemiology, 38, 196­203. CHEN, C.N., WONG, J., LEE, N., CHAN-HO, M.W., LAU, J.T. & FUNG, M. (1993) The Shatin Community Mental Health Survey in Hong Kong. II. Major findings. Archives of General Psychiatry, 50, 125­133. LEE, A., WUN, Y.T. & CHAN, K.K.C. (1997) Changing family medicine/general practice morbidity patterns in Hong Kong adults. Hong Kong Practitioner, 19, 508­517. LO, W.H. (1982) Government mental health service. In Aspect of Mental Health Care: Hong Kong 1981 (ed. T.P. Khoo). Hong Kong: Mental Health Association. MAK, K.Y. & GOW, L. (1991) The living conditions of psychiatric patients discharged from half-way houses in Hong Kong. International Journal of Social Psychiatry, 37, 107­112. PANG, A.H.T., CHAN, D.V.K. & FEBB, W.E. (1997) Validation study of the Chinese version of the Primary Care Evaluation of Mental Disorders (cPRIME-MD). Journal of the American Medical Association (South East Asia), 13, 16­22. YAP, P.M. (1952) The Latah reaction: its pathodynamics and nosological position. Journal of Mental Science, 98, 515­564.

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YIP, K.S. (1997) An overview of the development of psychiatric rehabilitation services in Hong Kong. Hong Kong Journal of Mental Health, 26, 8­27.

Gabor S. Ungvari, Professor, Department of Psychiatry, Chinese University of Hong Kong. Helen F.K. Chiu, Professor and Chair, Department of Psychiatry, Chinese University of Hong Kong. Correspondence to Professor Gabor S. Ungvari, Department of Psychiatry, Shatin Hospital, Shatin, N.T. Hong Kong SAR, China. Email: [email protected]

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