Hong Kong J Psychiatry 2002;12(3):2-4

CURRENT ISSUE

YM Ip

Dr YM Ip, JP, FRCPsych; FHKCPsych; FHKAM(Psychiatry); Chairman of Public Awareness Subcommittee, Hong Kong College of Psychiatrists, Hong Kong; Chairman of Subcommittee on Public Education on Rehabilitation, Rehabilitation Advisory Committee, Hong Kong.

Address for correspondence: Dr YM Ip, 208 Melbourne Plaza, 33 Queen’s Road Central, Hong Kong

E-mail: ymip@hotmail.com

Submitted: 15 February 2002; Accepted: 08 May 2002

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Introduction

Experiencing a mental disorder is often a painful journey, yet only a minority of people with mental disorder seek proper treatment, largely due to myths and misunderstanding, stigma, and discrimination. Stigma stems from ignorance and fear while discrimination arises from hostility to those who are different.

The only cure is enlightenment of the population through promotion of understanding of mental health through educa- tion and timely management of mental disorders. Mental health promotion (aiming to enhance positive mental health and to reduce the burden of mental health problems and dis- orders) is an important step to improving quality of life for those we care about.

History of Mental Health Promotion in Hong Kong

As with the advent of any service industry, the history of mental health promotion in Hong Kong has gone through a process of change from a general need to specifics of know- ledge and application.

Mental Health Promotion 20 Years Ago

Up to 20 years ago, psychiatric resources were limited and mainly targeted towards treatment, while proactive mental health promotion was scarce, apart from some sporadic responses reacting to psychiatric issues that caused public concern.

At the time, stigma and discrimination prevailed and ignorance among the population led to negative attitudes, not only towards mental disorders but also towards the psychiatric system. As psychiatric information for the public was mainly procured from the mass media in an emotive and skewed fashion, mental disorder was viewed as another name for insanity.

Psychiatrists were sometimes wrongly perceived as either “doctors evil” or omnipotent, being capable of controlling people’s mind through special techniques such as hypnosis. Treatments were considered inhumane and institutional- isation was the destiny for patients with mental disorders. Castle Peak Hospital was often misrepresented as a punish- ment for those who acted unreasonably.

As a result, people tended to hide their mental problems, delay or reject treatment, and even distrust the psychiatric system. Psychiatrists at the time saw the need for public education but were often put off by the tight rules against self-advertising set by the medical council in their book Professional discipline. In addition, progress was hampered by the lack of epidemiological research data in Hong Kong and there was no agreed Chinese terminology for most mental disorders. Certainly more needed to be done for the promotion of positive mental health.

Mental Health Promotion in the late 1980s

Approximately 15 years ago, mental health promotion was still at an embryonic stage, but its growth was enhanced by changes occurring at that time. More qualified psychiatrists became available. The Medical and Health Department was restructured to become the Hospital Authority and the Department of Health, each striving for value. Mental health services gradually moved away from institutions to a community care approach with integration into general hos- pitals. The increased respect for human rights led the public to demand more transparency about treatment procedures, indirectly improving their trust in the psychiatric system.

On the other hand, environmental factors such as the political changes, the emigration flux demanding extra adjustments, and volatile economic changes all created stress and social unrest, taxing people’s mental health and engendering a need for mental health awareness.

Between 1984 and 1986, the Chinese University of Hong Kong conducted the first large-scale community survey in Shatin to screen for psychiatric disturbance in the general population. This not only provided epidemiological data but also alerted psychiatrists to the need to address the issue.

Responding to the call for mental health promotion as an important means of primary prevention, psychiatrists saw where their responsibilities lay and were prepared to meet this need.

At first, mental health promotion occurred in a scattered and disorganised manner. Psychiatrists appeared in the mass media responding to issues that caused public concern, talked to the public, and held seminars for primary care workers and concerned parties. Non-governmental or- ganisations (NGOs), especially the New Life Psychiatric Rehabilitation Association and Mental Health Association, also began actively to take part in promoting mental health. The emphasis then was mainly on the understanding of mental disorders, treatment options, and working against stigma and discrimination, while enhancing acceptance of people with a mental disorder. The ‘mental hotline’ had been running for years, although it was underused. Little work was done on the importance of positive mental health, apart from mentioning it in discussions about stress management.

There was still a long way to go to the factual under- standing of mental health and disorders. Stigma and dis- crimination were still conspicuous, as evidenced by the attitude of local residents in Richland Gardens in Kowloon Bay who protested against the opening of a sheltered workshop in their vicinity, even abusing patients and staff at the facility. Something needed to be done.

Mental Health Promotion in the 1990s

Mental health promotion developed into a more mature form only during the past 10 years. This has been made possible by government policies and more refined mental health research and services, as well as the community’s awareness of the issue.

The Green Paper on Rehabilitation was published for public consultation in March 1992, and was later consolidated as the White Paper, titled Equal opportunities and full participation: a better tomorrow for all in May 1995. The aim was to promote and provide comprehensive and effective measures to meet the goals for mental health promotion. A full chapter was dedicated to public education and information, including mental health. The Mental Health Ordinance was also reviewed.

More research materials were becoming available, providing better information about the mental health problems in Hong Kong, while follow-up research could then show trends.

Formation of the Hong Kong College of Psychiatrists in 1990 helped to promote the psychiatric development in Hong Kong. A Public Awareness Subcommittee was also set up in 1999 to promote mental health. Psychiatric terminology in Chinese gradually converged to more communicable terms. Enhancement of human rights (with sanctions against discrimination according to the Disability Discrimination Bill) as well as patients’ rights led indirectly to the better acceptance of psychiatric treatment.

Various international psychiatric promotions occurred which helped the psychiatric voice to be heard in Hong Kong. These included Mental Health Week/Month organised by the World Federation on Mental Health since 1993 and World Health Day on 7 April 2001, which was dedicated to Mental Health by the World health Organisation.

The Current Situation

In Hong Kong, an intersectoral and multi-level approach is taken in promoting mental health, mostly in a coordinated manner, although there are also other individual efforts. While the Department of Health is responsible for public education on health, including mental health, other govern- ment agencies and statutory bodies such as the Hospital Authority, as well as NGOs and community bodies also take an active part in mental health promotion.

Since 1997, the government has spent HK$8 million on mental health promotion and acceptance of people with mental illness. The Subcommittee for Public Education on Rehabilitation, part of the Rehabilitation Advisory Commit- tee, has taken steps to advise, coordinate, and monitor the effectiveness of the programmes and activities organised by government departments and NGOs. Publicity programmes include TV shows, announcements of public interests radio programmes, seminars, workshops, exhibitions, carnivals, and integrated activities with patients with mental disorders. A case in point is the large-scale annual publicity programme, Mental Health Month, which has been organised since 1995 (previously the Mental Health Week in 1993 and 1994) to promote mental health and public acceptance of persons with mental illness, with the participation of 85 organisations and thousands of people.

In the community, promotion by various health profession- als also occurs in a scattered fashion and via the mass media, the most powerful tool for disseminating information to the public.

Newspaper reports , especially in the tabloids, were still mainly concerned about the negative aspects of patients’ violent, suicidal, or abnormal behaviour. Emotive reporting coupled with some expert opinions often engendered fear and negativity. It was in the health columns that positive and proper dissemination of psychiatric issues was made possible. Psychiatrists, psychologists, and other health professionals are now more willing to submit special or serial articles to promote mental health.

The materials in magazines tended to be relatively posi- tive, and books related to mental health were more original. Television documentary and drama series promoting mental health became more frequent. Movies that were both negative and positive were made, providing a more balanced view than before. Radio programmes were either reactive to topical issues or proactive series.

However, despite these efforts, the public still had mis- conceptions and unclear psychiatric knowledge, for example mental disorder or psychosis; psychotropic medication or recreational drugs; psychiatrist or psychologist; and so on. Stigma, although less than before, is still present, while discrimination has become less visible.

It is good to see that the public attitude towards mentally ill people has significantly improved in the past 8 years. For example, serial surveys on Public attitudes towards disabled people in Hong Kong commissioned by the Health and Welfare Bureau found that significantly more respondents in 2002 felt that mentally ill people “can communicate with others” or “can live a normal life” than in 1994 (82.3% vs 75.3% and 76.5% vs 68.7%, respectively, p < 0.01). This is a better situation, but it is still far from satisfactory.

The Way Forward

Although a lot has been done, more has yet to be conceived and implemented. Mental health promotion should enter a stage of refinement and affirmation, utilizing the inter- sectoral and multi-level approach to effect the goal of mental health for all and by all.

In order to be effective, the government should act as the ultimate steward of mental health promotion and needs to set policies within the context of the general health system, finance arrangements that will protect and improve the mental health of the population, take on the role of planner, advisor, coordinator, and monitor of the activities, and enlist the participation of various government sectors, as well as NGOs and community bodies.

In addition, the government should finance relevant research in Hong Kong so as to provide accurate and usable epidemiological information about mental health and mental disorder in the population. Such audited material will allow better planning and implementation of programmes. There should be systematic training on mental health promotion to staff in mental health-related fields. A team of professionals should be empowered to promote mental health both proactively and reactively. Publication of educational materials should be formulated and produced to help those working in the field.

The importance of mental health promotion must also reach the policy makers so that a vision may be formed, timely policy adopted, and funding approved. There should be closer collaboration with district organisations such as the District Committee for running public awareness pro- grammes. In schools, education programmes should include life-skills teaching as well as emotional, relationship, and stress management skills.

General public health education programmes run by the Department of Health should increase the proportion of information about mental health. User groups (for patients and their families) and the private sector (business sector, employers) should be encouraged and facilitated to take a more active part in mental health promotion. There should also be good networking with professional associations (universities and colleges) and international agencies (WHO, World Federation on Mental Health) to share experiences and concert the efforts. On-going mental health education programmes should be encouraged and implemented regu- larly and serially.

For the media, factual rather than emotive reporting should be encouraged. Planned programmes should appear on television and radio and in newspapers and magazines, covering both general mental health issues and specific areas (including child development, childhood problems, adolescent lifestyle, family influences, life events, old age, dementia, female psychiatric morbidity, mental health and work, quality of life, depression, early psychosis, etc). If funding is available, advertising (albeit expensive) is a good way to increase awareness and neutralise misconceptions. Place- ment of mental health messages in the entertainment media (‘edutainment’) could be done by collaboration with the entertainment business, a cheap and powerful tool. An account of mental health promotion programmes should be reviewed regularly so that reassessment and improvement may be made with relevance to the prevailing needs of the community.

Much is yet to be done in order that mental health can be effectively promoted, myths be dispelled, facts be used, ac- ceptance be enhanced and quality of life be improved, so that a better tomorrow could be created for our next generation to live in Hong Kong. Everybody’s partnership in making this happen is most valued. Prevention is always better than cure. The less the promotion, the more will be the cost.