Imagine you’re stressed and anxious to the point of needing help. Maybe it’s depression—job burnout, divorce, or even the death of a loved one. And now, the next step is to consult with a psychiatrist and discuss medication, along with therapy. It’s nothing abnormal.
But now, imagine you’re in Hong Kong—where, turns out, you’re competing with 20,000 others just for an appointment with one practicing psychiatrist. The latest data from the Hong Kong College of Psychiatrists shows that there are only 345 working psychiatrists as of June this year. Hong Kong has a population of just over 7 million—and it’s only getting bigger.
Dr. Roger Ng Man-kin, the co-vice president of the College, said the target is for one psychiatrist to serve a population of 10,000. But that number is still overwhelming—it’s the bare minimum acceptable standard for a developed country. “There’s a stigma about psychiatry,” Ng said, explaining why the field is so short on qualified doctors. “There’s been a lack of medical manpower for the past 10 years.”Enjoying this article? Click here to subscribe for full access. Just $5 a month.
Dr. Phyllis Chan Kwok-ling, also co-vice president of the Hong Kong College of Psychiatrists, said psychiatrists are disillusioned by their workloads. Even those with high aspirations may end up resigning. It’s not surprising—they see 30 to 40 patients in just one visit to a hospital’s outpatient department. Meanwhile, patients wait three to four years just for one of these crammed appointments. Chan said that while in the U.K. a patient sees a psychiatrist for 20 minutes each session, on average, a patient in Hong Kong sees a psychiatrist for six minutes.
And the city desperately needs the manpower in psychiatry. The Hong Kong Mental Morbidity Survey shows that one in six of the city’s residents has a common mental disorder, like anxiety or depression, either now or will in his or her lifetime. The survey, released in 2014, was the last major territory-wide assessment of Hong Kong’s mental health.
The Mental Health Association of Hong Kong (MHA), a large NGO funded mostly by the government, found that in one survey it carried out in 2014, a dramatic 50 percent of respondents felt they had poor mental health. Twenty-five percent reported levels of stress and anxiety—250 times the global average—and 60 percent reported job stress. And in a survey of students that same year, also carried out by the MHA, 10 percent polled had thought about suicide at least once.
These numbers are likely lower than the reality—in Hong Kong, the tendency is for mental illness to go underreported for fear of shame, embarrassment, and stigmatization.
“People just don’t know what mental illness is about,” said Chu Shung-man, the director of policy, research, and training at the Equal Opportunity Commission (EOC), the city’s equality watchdog. “We have to educate the public that it’s not associated with violence, and that it’s not untreatable. It’s a long journey ahead.”
Psychologists might not be coming to the rescue anytime soon, either. Their numbers are also small—there are only 443 clinical psychologists registered with the Hong Kong Psychological Society as of June this year. And this qualifying body has recently drawn criticism for allegedly stemming the flow of psychologists in the city.
The Hong Kong Psychological Society is not a legal body, like the Social Workers Registration Board—by which social workers must legally be registered. But public hospitals and NGOs in Hong Kong will only employ those psychologists certified by the Society, despite the fact the organization has no legal grounding. And for Ching Chi-kong, the assistant director of service and education at the MHA, that’s a problem.
“The Society is very self-protective, and it’s hard to register as a recognized member unless you are trained at Chinese University of Hong Kong or the University of Hong Kong [the city’s well-established universities],” said Ching. “Even if you have a doctoral degree in clinical psychology and a license from the U.S., you might still not get into their circle.”
Alliant International University (AIU) is one example. Its California School of Professional Psychology in Hong Kong offers students a four-year doctoral degree and a clinical internship. Meanwhile, in Hong Kong, the same degree is two years and the internship only requires half the time. But the Society has been non-responsive to some alumni’s applications to join, said Dr. Tien Liang, the program director.
“The alumni who have talked to me report extensive delays in responding to applicants—these delays were up to years,” Liang said.
The president of the Society, Dr. Ephraem Tsui Pui-wang, said he does not recollect any applications from these AIU alumni. “If they have the components or qualities to meet the standards needed today, they may seek recognition,” he said.
UPDATE: Dr. Tsui, in a follow-up email to The Diplomat, clarifies that HKPS has received applications from AIU alumni. His comment above should be understood to mean that he does not recall an application for AIU’s entire clinical psychology training program to be recognized by HKPS. According to HKPS’s investigation, Dr. Tsui says, “the AIU Hong Kong program is not accredited by the American Psychological Association.”
Dr. Tsui adds, “We have always welcomed properly trained clinical psychologists from abroad, I being one of them, and no less than 12 percent of our DCP members are trained in USA, Canada, U.K., and Australia.”
As for the small number of clinical psychologists associated with the Society, he said that “there is no way we can produce a mass quantity of clinical psychologists.” For one, Tsui said, training is long and intensive for clinical psychology—and, the other problem, he said, is that “training is subsidized by the government. The number of places is limited by government funding.”
But whether the Society is too self-protective or not, perhaps one of the largest hurdles to accessing care for mental health in Hong Kong is insurance. “There’s no insurance plan I can think of that covers mental health,” said the College of Psychiatrists’ Dr. Ng. And if a patient wants to see a public psychologist subsidized by the government’s Hospital Authority, the wait is three to six months, Ching of MHA said. The interval between appointments is four to eight weeks, or even longer, depending on the severity of the patient’s problems.
“Patients can choose to see a private psychologist, but the consultation fee is expensive for the general public. They can charge their clients HKD$1200 to HKD$2000 [roughly $155 to $260 in U.S. dollars] for an hour’s consultation,” said Ching. “I can’t give a reason as to why insurance doesn’t cover this. It may be the result of stigmatization that mental health patients have a high risk of self-harm and suicide.”
In Hong Kong, there’s an old saying that one should only buy insurance when he or she is healthy—and it’s for good reason. An insurer is allowed to drop the insured at any time if there’s medical proof he or she is too high risk. Insurers see any mental health problems, no matter how common, as high risk. The law allowing this is part of the Disability Discrimination Ordinance, which clearly spells out a provision for insurance exemption based on risk factors.
Many of those with mental health illnesses, the MHA has found, are willing to pay higher insurance premiums, but this isn’t a choice when they’re dropped from their policies altogether.
“The general direction the EOC wants to go in is for the industry to provide coverage for every individual,” said Chu. “But the industry says that mental illness may cause people to have more physical illnesses, and there’s more risk. I’m not saying this is right.”
The EOC can take on complaints from those who are dropped by their insurers on a case-by-case basis and launch an investigation, but Chu said he couldn’t answer the question of whether this is effective. The EOC has long been derided in Hong Kong as toothless: it last made the news in April for winning a case against a bar hosting ladies’ night, on the grounds it was discriminatory towards men.
So, what options are left? There’s a network of outpatient clinics run by social workers, but the caseload is astronomical; they’re understaffed, and struggling to find facility space so frantically the social workers mostly counsel patients at fast-food chains. The College of Psychiatry demands the Hospital Authority take mental illnesses more seriously and put aside a special budget for mental health services. The MHA wants a legally recognized body for the registration of psychologists and asks for the EOC to push far harder on changing Hong Kong’s discriminatory insurance legislation.
No matter how quickly the Hospital Authority or the EOC acts, for some, still, there are no options.
At the Lok Sum House in Sha Tin, patients with moderate intellectual disabilities are taken care of until they die. Tucked away in a quiet, leafy housing estate, Lok Sum House is a public medical hostel, where insurance isn’t needed. The majority of patients, unable to function on their own, are 50 and older. Some have been there since the 1970s. The waiting list to get a bed at Lok Sum House is 12 to 13 years—when most of the current residents will die. Until then, the caretakers of their intellectually disabled children will have to struggle with long wait times for specialized mental health professionals over years and years.
Many of these parents are coping with the needs of grown children and have little help from the Hospital Authority. The parents and children will age together during the long wait, and some parents, inevitably, will hope their adult children, with nowhere to go and so few doctors to offer help, will die before they do.
Justin Heifetz is a freelance journalist based in Hong Kong. He has previously written for the Columbia Journalism Review, HK Magazine, The Bangkok Post, The Myanmar Times, and The Phnom Penh Post.