Series of knife attacks underscores mental health shortcomings in ‘happy Hong Kong’

After a brutal knife attack killed two women at a mall in Diamond Hill this month, Hong Kong police held a press conference which spelt out the shockingly indiscriminate nature of the assault.

“We found that the arrestee has a history of mental illness… no evidence has shown so far that the two deceased women knew him,” a police officer said. 

The announcement rebutted false media speculation about one of the victims being a former girlfriend of the attacker, but also prompted questions. Are people with mental health disorders dangerous? Was mental illness the sole explanation for the assault?

The alleged attacker in Hollywood Plaza had previously been diagnosed with schizophrenia, according to local media reports. The Hospital Authority (HA) said he had received all necessary assistance from public community support services as per the guidelines, and committed the murders a few days before a scheduled follow-up consultation with a psychiatrist.

More knife assaults and murders were reported in the days after the Diamond Hill tragedy, prompting reporters to ask police the same question each time: had the suspect in question been diagnosed with any mental disorder before?

In internet posts, some Hongkongers have begun satirically calling the city an “International Knife-tropolis” or a “Brave New Hong Kong,” mocking the police for allegedly allocating resources to national security instead of public safety. Amid rising crime rates, police have denied that that this is the case.

Government officials’ reiterations to the public and lawmakers that “there was no sign of inadequacy in the city’s mental health services” have also been increasingly questioned.

HKFP has spoken to a front-line psychiatrist and a psychiatry scholar to delve into the possible root causes of the attacks – and whether they are a symptom of worsening mental health in the city, despite the official launch of a post-Covid “Happy Hong Kong” campaign.

‘The Observatory’

Describing the stabbings in Hollywood Plaza as “an isolated event without any [warning] sign,” Under Secretary for Health Libby Lee told lawmakers on Monday the tragedy was unrelated to a shortage of manpower in mental health services.

Eric Chen, a psychiatry professor at the University of Hong Kong, offered his own understanding of the term “isolated event” to HKFP.

“Let’s say if a tsunami hit us tomorrow – the strongest in the past decade – and there were casualties. While one may call such a natural disaster ‘an isolated event,’ we should also ask: What happened to the Observatory? Why didn’t it give a warning? Was our equipment up to standard, or up to date?”

“If the equipment was not performing as it should, then it was not ‘an isolated event’”.

The Observatory in the metaphor – public counselling services and other treatments offered to people suffering from mental disorders – has always been understaffed, the scholar added.

According to the HA, a psychiatrist in the public hospital system would on average have 761 patients on their books. The total number of psychiatrists has fallen about 300 short of the World Health Organization’s standard, which in Hong Kong’s case recommends 700 psychiatrists.

“It would be a joke to say the incident has no direct connection to a manpower shortage, we were just too used to the lack of manpower sometimes… But now, two people have died – is it really not preventable?” Chen asked.

Quantity over quality

Unlike the stereotype for medical professionals in the private sector, Willy Wong – who had just pulled an all-nighter at work – showed up at a café near his clinic in a T-shirt.

Having worked in the public hospital system for 15 years, the veteran psychiatrist expressed his worries to HKFP on the possible reaction to the stabbings in Hollywood Plaza.

“Every time such incidents happen, everyone would be tense and rushing to react, and every time they urge an increase in manpower to shorten the waiting time for mental health service… But after allocating more resources, [the authority] would expect you to meet certain quantifiable targets,” Wong told HKFP.

Shorter waiting times and more patients receiving treatment are often achieved at the expense of quality of service, he said.

For psychiatrists, the quality of the consultation is directly related to the time invested in each patient and this time cannot possibly afford another cut, both Wong and Chen said.

For Wong, the ideal time for each consultation is around an hour. But he said psychiatrists in public hospitals are currently only given an average of five minutes to talk to a patient – including the time spent writing reports and arranging a follow-up consultation.

“How would anyone be ready to open their heart to a psychiatrist in just five minutes?” Wong asked.

The focus on speed over quality has also affected medical training in the city. As the chair of the HKU psychiatry department, Chen said insufficient consultation time was an obstacle.

“When the entire training environment is forcing the students to see a patient for only a couple of minutes, how do we instil in them the sensitivity to detect subtle clues?” he asked.

The 10 ‘new’ measures

The Health Bureau, while denying the mall attacker lacked medical support and follow-up, said it nonetheless recognised the staff shortage in mental health services.

“That’s why we proposed optimising the ratio of case managers to patients with severe mental illness,” the under secretary told lawmakers on Monday.

Following a meeting with its advisory board on mental health a week after the brutal stabbings, the government proposed 10 “enhanced measures” to support people with mental health needs, including optimising the ratio of a case manager – a psychiatric nurse, an occupational therapist or a social worker – to patients with severe mental disorders to no higher than 1:40.

This would mean they cater to the needs of no more than 40 people at a time.

Expanding the use of psychiatric oral drugs or injections with fewer side effects; shortening the median waiting time for patients; and enhancing communication between the HA and the Social Welfare Department (SWD), were among other proposed measures.

“The measures are too vague,” Chen, who serves on the advisory board on mental health, told HKFP. He said psychiatric drugs with fewer side effects existed 20 years ago, and hospitals were already using them on a daily basis.

“Are we really not using them often enough? Or is [the authority] going to relax the budget limit for medics to use those drugs? To what extent will the relaxation be? All of these issues were not addressed here,” he said.

See also: Hong Kong proposes ‘enhanced measures’ to improve mental health support following mall stabbings

In addition, while the government had suggested shortening the median waiting time for urgent cases from two weeks to one week, and for semi-urgent cases from eight weeks to four, the actual waiting time already met those targets, according to the HA’s website.

To put it in a nutshell, the 10 proposed measures – including setting up a service hotline, better communication and enhancing training – were either measures that were already in effect or goals that were set in the past but had not yet been achieved.

“And they never address the root of the problem – lack of manpower,” Chen said.

Both Chen and Wong said the government should consider enhancing the public-private partnership in psychiatric services – which was newly introduced last year – to lighten the burden of psychiatrists in public hospitals.

However, such cooperation would eventually imply spending more to subsidise the service provided by private clinics, the professor added.

The administrative workload might also increase if hospital doctors had to select patients suitable for transfer to private clinics. “It would be difficult if no extra resources were allocated to them,” Chen said.

The Hospital Authority said the public-private partnership programme was only extended to psychiatric services last year, and medical staff were still in the process of identifying suitable patients to be transferred.

It said it would monitor the programme closely and maintain communication with the advisory body and others involved.

The pandemic

Psychiatrists’ groups and health authorities say the crime rate for people with mental illness is lower than that of the general population. But stigmatisation of people with mental needs is still widespread in Hong Kong, on the internet and elsewhere.

Wong said some of his patients were troubled by news of the Diamond Hill attack. “When they read the news, they became more aware of their emotional problems, and more afraid of losing control too,” he said, adding that mocking and misconceptions might keep people from getting the help they need.

The Covid pandemic also hit mental health services, with hospitals accepting fewer psychiatric non-emergency cases. Some patients also stopped making recommended follow-up visits to doctors.

After three years of isolation, Hong Kong is desperate to get back to normal. However, despite the celebration of the city’s return from “chaos” to prosperity, or the government’s “Happy Hong Kong” campaign, certain groups in society – including those struggling with their mental health – may be left behind.

While some patients simply became lost to follow-ups during Covid-19, the condition of others such as students with special education needs worsened irreversibly, Wong said.

“Even though our daily lives and society are gradually returning to normal, can the life of some of these patients return to normal? I really doubt it… first we need to make even more efforts to resume giving them the care we did previously,” he said.

Is Hong Kong happy?

The pandemic not only affected the accessibility of mental health services, but hit the city economically, socially and emotionally.

In May, the University of Hong Kong released a study indicating that a quarter of young Hong Kong people were thought to have suffered from mental health issues, with depression the most prevalent disorder. 

Former justice secretary Wong Yan-lung, who also chairs the official advisory body on mental health, said in the press conference releasing the study that mental health was a wide-ranging subject linked to economics and other factors. “It’s not just an emotional thing to keep yourself happy.”

“But of course it’s not as simple as just, you know, putting up some campaign… [there is] a lot more to be done,” the senior barrister added, responding to HKFP’s questions about his views on the “Happy Hong Kong” campaign.

Willy Wong said while some people were more vulnerable to stress, the environment of Hong Kong – its housing problem, overcrowding, the economy and long working hours – could also trigger psychiatric issues.

“When the space for someone has shrunk, it’s easier to be in a bad temper, hence conflicts with others might surge.”

Over the past decade Hong Kong has seen a worrying trend on the mental health of its population in various research and surveys, ranking 83rd out of 137 in the United Nations World Happiness Report in 2022.

The “Hong Kong Mental Health Index Survey” released annually by multiple rehabilitation and public institutions revealed that the average score of the mental health index for Hong Kong people had been below the passing grade for five consecutive years since 2018.

Does the recent series of assaults suggest deeper concerns about life in Hong Kong?

“I think it all comes down to our attitudes towards life, and the values Hong Kong as a city has been promoting,” Chen said, trying to explain the city’s unique melancholy atmosphere compared to other parts of the world hit by Covid-19 and social unrest.

The scholar – who led the HKU study on young people’s mental health – cited the academic pressure on Hong Kong students.

“Everyone knows that the students are so stressed they feel like nothing matters anymore if they fail an examination. These are the values Hong Kong society has been upholding – that economic success is the only thing that matters,” Chen said.

Amid a continuing exodus from Hong Kong, more and people discussing emigration plans on internet forums said they were motivated not only by political changes but by the prospect of a potentially happier lifestyle aboard.

Some people interviewed by HKFP for another feature said they would rather raise children outside Hong Kong to secure a happier education for them.

See also: Mother’s Day: ‘Why would anyone want a kid?’ – How Hong Kong’s fertility rate sank to the world’s lowest

In this context, boosting psychiatric support might be deemed by some as treating the symptoms instead of the root cause.

Chen agreed that psychiatric medics were, to some extent, putting out fires in a perpetually combustible environment. However, even though they could not do much about that environment, they could still support individual patients.

“Of course you would ask: if the happiness index of Hong Kong were higher, wouldn’t [the number of people with mental illness] become lesser? I believe it would, but it would require our entire society to work on it,” Chen said.

Looking at the bigger picture, some of the problems may be beyond the ambit of government policies, but were still capable of being tackled – such as the choice of words used to refer to people receiving mental health treatment, to pressures put on students or employees.

Chen said he had little hope that policies and other support for patients would be enhanced in ways he had suggested.

“However, even though I do not hold high hopes for it, we should still try our very best – to set clear targets, and to make every effort to achieve them. That way, we can look the people of Hong Kong in the face.”

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