Summary

Over the past several years, mental health of the population has seemed to be going downhill. The hidden psychiatric morbidity or psychopathology becomes more prominent and more people are suffering from mood disorders. Even young people are not exempted. Health status indicators such as sleeping or eating habits have shown unfavourable trends. None of the social indicators such as feeling of optimism, cry for help and aggression support a notion of better mental health. In fact not only suicide rates are startling, but there are also more children or families taking their own lives. Mounting level of stress appears to be the culprit. Family physicians can help by active listening, providing support, instilling hope or a sense of humour, and teaching a repertoire of coping and problem-solving skills. Stress inoculation training may also be useful.

摘要

過去數年，香港人口的精神健康有下滑的跡象。 潛伏的精神及心理問題日趨明顯，更多人口患上情緒病，甚至年青一輩亦不能倖免。健康狀況指標如睡眠 及飲食習慣均顯示不理想的趨勢，同時社會指標如滿足感，求助及暴力傾向等，也說明精神健康水平降 低。實際上，自殺率上升不單令人震驚，當中還包括了更多的兒童及家庭集體的自殺。越趨沉重的壓力似 乎是主因。家庭醫生可以籍細心聆聽、給予支持、灌輸希望或幽默感、以及教授各種面對和解 問題的技巧，來幫助這類病人。壓力預防訓練亦可能有效。

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Stress as a contemporary phenomenon

In modern life, stress is a single variable that is assumed to be able to account for much of variance related to trends of ill-health. No doubt stressful life is a problem for civilised living.¹ Like Japan, Hong Kong had by 1990 become one of the most stressful Asian countries.² Shortly later, an independent study by ARISE³ in 1994 suggested that Hong Kong was regarded by workers themselves, among 16 countries in the world, including the United States, Canada, the United Kingdom and France, to be the most stressful place to work in. This observation was confirmed by the epidemiological data from a territory-wide survey by stratified sampling in 1995.⁴

Unfortunately, the work-hard, play-hard lifestyles of Hong Kong men so familiar to all of us are now taking their toll after long years of dogged toiling and in effect beginning to cost them their health. This attribution was used in a survey by the Department of Health⁵ to explain why men in Hong Kong die on average 5 years before women. Apart from longer working hours which is now the order of the day, the higher rates of drinking and smoking as ways of maladaptive coping and a "men don't cry" mentality anchored in the traditional culture might have diverted men from paying due concern to their health. The alternative explanation is that men are usually escapists and they all like to bury their heads in the sand, until it is too late for intervention.

In all events, stress does find its way into every aspect of daily life, and it does comes in all shapes and forms. Even young age confers no immunity, as it now comes to surface that the figures about emotional problems among students in Hong Kong are in fact very perturbing. When 3,764 students were surveyed by the Department of Community and Family Medicine of the Chinese University in March 2001, 42.4% of senior secondary, 29.5% of junior secondary and 18% of primary students admitted having experienced stress. A significant number (8-15% in primary to senior secondary classes) of students even claimed health and emotional problems had affected their social life.

Psychological ill-health

As with other aspects of health, the state of affairs might be reflected in the factual materials from the other polarity, that is, psychological ill-health. "Ill-health", like "wellness", is largely a subjective self-assessment. Although subjective assessment does not necessarily agree well with medically determined status, self-assessment of overall health provides a good indicator of actual health status and of use of health-related services. Recent findings, for instance, reveal that the better the self-rated health, the fewer are the number of health problems, ambulatory and medical care visits, and number of days hospitalised in the previous year. Using the General Health Questionnaire which is often used in epidemiological surveys to identify those who have a high or low probability of presenting a mental disorder,^6,7 the psychological ill-health of the local population was estimated in the early 1990s to be 26.3%.⁸ It was revealed in that study that whereas the youngest respondents complained of emotional disturbance, the older ones more readily emphasised their cognitive failure. The oldest respondent in contrast denoted a feeling of worthlessness and not doing well while under similar stressful situation. The younger respondents were aware of their stress responses while those in the oldest age-group tended to react negatively with a sense of helplessness.

A repeat survey of such a wide scale alongside with the by-census three years later gave similar figures.⁹ It would have appeared that by 1997, little has changed over the years in the area of mental health in Hong Kong.

Hidden psychiatric morbidity in the community

In adults, it would be quite appropriate to examine the hidden psychiatric morbidity or psychopathology in the population. Some data in this regard have been available for some time. Back in the 1980's, in a busy family practice in Kowloon, depressive cases constituted 9.25% of 6,000 patients seen over a period of two years.¹⁰ Among 2,093 patients attending a general practice on the Island side, 213 of them representing 10.13% of the patient sample were diagnosed to be depressed.¹¹ These figures appeared to tally with those obtained in other studies on the Chinese communities. The question whether depression is masked in general practice, thus making it less detectable, was raised.¹² There was also a controversy as to whether somatisation is a culture-specific phenomenon to the Chinese¹³ and this has statistical implications as, if this were true, the morbidity of an emotional disorder will be far greater than that calculated solely from the clinically overt cases. The debate seems to be still going on¹⁴ at the present moment.

No longer taken as a banal fact of life, depressive illness has become the focus of attention in the recent years not only because of its colossal economic impact and burden, but also because of its escalating prevalence, it being surmised by the World Health Organisation as one of the foremost killers in this new millennium. It is expected that this illness alone will take the lives of tens of million people in the world each year. The sixty-four million dollar question will be: how many would be killed in Hong Kong, given the enormous level of stress and the devastating aftermath of the regional coupled with local economic meltdown?

More recently, among 1,023 people surveyed in September 2001 by a psychiatric team from the Mood Disorder Centre of Chinese University, one in five people in the population was found to suffer from mood disorders. In real terms, it was estimated that more than 800,000 people aged 15 and above were suffering from mood disorder in different degrees of severity. The survey also indicated that people of working age were most likely to be victims to mood disorder, with nearly 68% of sufferers aged between 25 and 54. It was speculated that the prevalence of mood disorder among people of working age was a strong indicator linking their mental condition to their financial situation. Another investigation group from the same psychiatric department also revealed that more than one in seven mothers-to-be suffer clinically significant depression during pregnancy, an apparently benign condition. This would imply that out of about 50,000 babies born each year in Hong Kong, about 7,500 pregnant women will in different measures be affected by antenatal depression. This study of 959 mothers-to-be was launched in 1997. It was disquieting to note that 15% turned out to be afflicted with severe antenatal depression and 10% severe postnatal depression. The group predicted that babies born to women who experienced depression during pregnancy are 2.2 times more likely to need some form of medical care later on in life.

Health status indicators

To take the step further, one could be more informed about the status of psychological health by amassing pertinent information from different health status indicators.^15-17 Some earlier studies on sleep disturbance already suggested that sleep difficulty is a very frequent complaint in general practice. In the first study,^18,19 sleep difficulty was admitted by 7.89% of 1,636 patients in 13.14% of their consultations, while in the second study,²⁰ insomnia, irrespective of their chief complaint on presentation, was present in 13.61% of 1,786 patients during their 746 out of 16,667 attendances. It was suggested that sleep disorders are simply one of the many faces of stress in general practice²¹ and are envisaged to contribute substantially to the reason of visit by a significant number of chronic attenders. Sleep debt is now acknowledged as a health risk and this phenomenon has been brought into public light by the press. This happens even to a significant and ever-increasing proportion of local schoolchildren.

Likewise, encounter with a chronically tired patient has been a daily event in general practice²² and tiredness or lassitude is in fact among the commonest presenting symptoms in the surgery. Traffic accidents caused by worn-out drivers after a hectic day or sleep loss for nights are well recognised. Similarly, it is often observed that a chronically fatigued person is prone to exhibit rage reaction ensuing in a skirmish or even a fray, when frustrated or just mildly provoked. Lack of a feeling of recuperation certainly compromises a good sense of well-being and sets the stage for a displeasing experience soon to be felt.

Today it is increasingly recognised that eating disorders are a growing problem in any cosmopolitan city such as Hong Kong. Here, people may gormandise, especially in the evening, partly to allay anxiety built up over a hectic day, which is part and parcel of Chinese philosophy and comes to be the so-called food culture.²³ This might be part of the explanation for the eating behaviour, gluttony or bulimia, of the local people. In one extreme, the issue of obesity which brings about and perpetuates a gamut of diseases is coming into limelight, in view of its prevalence. Not only adults today are generally overweight as a result of more and more Westernised diets, but the proportion of schoolchildren eating junk foods with all the dire consequences, from medical, psychological to social, have also increased alarmingly. In the other extreme, anorexia or bulimia nervosa not only poses a health risk, but also incurs a strain in family relationships. There is clear sign that anorectic disorders, once believed to be non-existent in the Chinese societies, are looming large and fast in Hong Kong.

According to Eating Disorder Centre of the Chinese University, primary school children are increasingly obsessed with their weight, with two in five in higher grades hoping to be slimmer and one in five having dieted. 44% of 617 pupils surveyed aged 9-11 wanted to be slimmer in the belief it could make them more attractive. For whatever reason, adults and children alike are increasingly uncomfortable with their weight and appearance and so readily take this as an admission ticket to the medical consultation room or the fitness club. It makes one wonder why and how the traditional middle-path philosophy of the Chinese has steadily given way to the extremist positions in life, evidenced in the sphere of eating. Eating no longer remains as a means for survival or pleasure, but it now takes on a meaning of coping with stress,²³ exerting self-control, re-aligning with self-esteem or even abusing one's own body.²⁴

Not so long ago, stress was blamed as the culprit of sexual dysfunction by 50% of respondents to a poll conducted by the Centre for Clinical Trials and Epidemiological Research of the Chinese University. 1,571 men and 1,656 women between 18 and 59 were quizzed. 51% of men and 53% of women reported having suffered from at least one sexual problem for three months or more in the past year, believed to be triggered by financial stress and backbreaking lifestyle. Economic worries now emerge as a factor of spoiling the joy of sex.

Social indicators

The mental health status can also be approached by examining social indicators in turn.^23,25,26 After their use for decades, they are supposed to be able to pick up the signals of any tumults arising from the disruptions of health in general and mental health in particular, as social well-being often goes in tandem with psychological well-being. Any unusual alterations in the social indicators will give away the anomaly in the mental health of the community.

It is beyond dispute that for some years tragic suicide incidents, especially pact suicide using charcoal burning, have often hit the headlines. According to a report released on the eve of the World Mental Health Day last year, suicide is a rising health problem in Asia, particularly among young people in China. In Hong Kong, based on the government figures and information from the Coroners' Court, overall suicide rate has increased by 39% from 9.6 to 13.3 per 100,000 people between 1981 and 1999, according to the research by the Department of Statistics and Actuarial Sciences in the University of Hong Kong. While a rise in the general suicide rate was in the past caused by an increasing number of elderly people taking their lives, suicide is now seen to be among the leading causes of deaths among young people. The suicide rate among people aged between 15 and 24 stands at 9 per 100,000. The Social Welfare Department recently provided data which confirmed that the number of suicides had risen tremendously from 2000 to 2001, now well above 900 in number per year. In real numbers, this means that the suicide toll on an average day could be two to four, yet the phenomenon that pact or family suicides have come in a row through imitation or copycat is a staggering one. Charcoal burning has become a popular means of suicide, having increased by 60 per cent from 154 cases in 2000 to 250 cases in 2001, with more cases being expected this year.

It is striking that suicide is no longer a taboo subject in our society. The Scout Association did a poll in September 2000 and surveyed 940 persons over 16 of age. The finding was that about one in five people in Hong Kong have friends who have tried to commit suicide. When a four-day telephone poll was carried out by a psychiatric team of the Chinese University in September 2001, one of the findings was that 13% of 1,023 people interviewed had thought of suicide over the past three years and 17.6% of them were suffering from mood disorder.

Whereas suicide is aggression turned inwards, domestic violence, the incidence of which is on the rise, is certainly aggression externalised. If anger is accepted to have plagued our society, it is not surprisingly to note from a survey by the Department of Obstetrics and Gynaecology in the University of Hong Kong between October 2000 and February 2001 that 16.6% of 838 mothers polled had suffered domestic violence. Abuse of women during pregnancy doubled the risk of postnatal depression, an illness that strikes more than one in seven Hong Kong women. Men also fall victim to domestic violence. One study done by the Nursing Department of the same University several months later indicated that nearly 13% of 100 men, including husbands or boyfriends, said that they had been abused - mostly verbal and emotional abuse. About 1% of the men reported having experienced sexual abuse.

The survey by telephone poll of 1,023 people undertaken in last September showed that 25.5 per cent of those trapped with negative equity were suffering from mood disorder, compared to 16.1 per cent of those without such financial problems. This would mean people affected by negative equity have an almost 60 per cent higher risk of developing mood disorder and they are more likely to have symptoms such as insomnia, intense headaches, chest pains, a sense of frailty, feelings of stress, anxiety or depression. 38.5% of those suffering mood disorder had considered suicide over the past three years, compared to 8% of healthy people. It means mood disorder sufferers have a nearly five-fold higher risk of suicidal tendencies than healthy people.

In a similar vein, out of 63,000 hotline calls to Mutual Aid Help-line supported by the Hong Kong Council of Social Services between June and September 2001, many people had had a bad time going through the economic downturn. There was no shortage of tales of tribulations. 3,590 calls were subsequently diverted to suicide prevention services. The percentage of calls expressing suicidal intentions had increased from 15% in 1998 to 20% in 2000.

Optimism as a barometer of mental health

If optimism is at all an indicator of psychological well-being in the community, as asserted by Strassle, McKee & Plant,²⁷ it is obvious that the prevailing sentiment among most people in the street of Hong Kong is anything but optimism. The consensus of the majority of common people is that in the face of the record-high unemployment rate, the local economy has not yet turned the corner. Though most people have put on a strong face, there is reason to believe that they are glum, foreboding the worse to come, as others. Medical evidence abounds that an unrelenting sense of pessimism often spells a subsequent string of ailments by way of compromised immunity or reduced survival rate after acute episodes of life-threatening illnesses, as documented in events such as myocardial infarction.²⁸

Received wisdom has it that humour can add flavour to life. Yet, although a sense of humour has been linked positively with psychological health²⁹ and is truly therapeutic in many illnesses, somatic and psychiatric alike, it itself is a double-edged sword. It appears that in the current state of psychological tension from whatever cause in Hong Kong, one is not normally in the mood for it. Sometimes even a modest dose of ill-timed dry humour is already enough to push the vulnerable one to the brink of aggression.³⁰ Humour, originally a nostrum for many evils including illness, is no longer sufficient to offset the melancholy of the people.

The current status of mental health

With the data now available, it is patent that although mental health of the population has never been an important issue till 1990s, the current state of psychological well-being as the reflection of the quality of life we are enjoying is far from admirable. The heart of the matter seems to be that in the backdrop of transmutation along various lines in the world, politically Hong Kong has gone through a conspicuous metamorphosis, socially she has to bear the brunt of problems stemming from the influx of immigrants, and economically she has never been prepared for setbacks of such dimensions as the legacy of the Asian economic collapse worsened by the fallout of the recent global economic slowdown. Metaphorically, Hong Kong is still in shock and at a loss. Smiling faces are vanishing from the streets and many people are seen to walk with their frowned faces deeply inclined, as if they were absorbed and musing. Yet, the case remains that because of the sweeping effect of global economy, the circumstance is likely to be here to stay. It reminds one of the popular notion of a 'maddening society'.

It would appear that without any timely actions, mental health of the city is merely mirage in the air or chimera in the mind. There is no question that economically it is incumbent upon the Government, alongside with the voluntary or non-government agencies, to sort out the impasse and bring her people out of the wood, but the medical profession definitely has a pivotal role to play in becoming a source of strength to people in their moments of distress and buoying up their spirits. One thing for sure is that it can never be promoted by increased sophistication, however enhanced, of tertiary care, that is, specialist services, as the current impact does not fall squarely upon mental patients alone. This is evidenced by the fact that it is always the man in the street, not necessarily the patient in the specialist clinic alone, who feels the pinch, and those who have committed suicide are often previously deemed normal people with undetectable mental illness. Therefore, something can be done in the primary care or family practice in order to nurture a sense of well-being through holistic care of the needy and secondary prevention of ailments that are brought to its attention. After all, family physicians have always been prepared for the challenge of relieving the pain and comforting the sorrow.

What can a family physician do?

As a counsellor, a family physician can help by listening actively and with concern. At least for the loss events, the opportunity to ventilate anxieties, sadness, anger or despair seems to have some benefits.³¹

When a person is ashamed of his or her ability to cope with a problem or feels that the problem is too minor to be so upset about or too personal to divulge, a good and sincere listener can dispel some of these feelings. Being listened to helps a person feel important and deserving of help no matter how trivial the problem may appear. Effective listening demands attention to possible listening barriers and the other factors influencing communication. The failure to listen forms a barrier to all other intervention strategies.³² When they go to see their family doctor, many people primarily want information, advice and reassurance - information about what is wrong with them, what they can do to rid themselves of the problem, or how they may control it, and whether it is controllable.

Apart from advice, information and counselling, most people coping with distressing events or long-term difficulties need emotional and practical support. The support can prevent a depressive mood from developing into a depression of clinical proportion. It is useful for the counsellor to show concern and empathy and that he cares. The aim, as in supportive psychotherapy, is to support the individuals through the crisis without attempting in-depth exploration of their psyche.

Those who have suffered losses, for example, of their job, wealth, esteem, dignity or confidence, should be handled as if they were in grief. For them, the losses are equally traumatic, seemingly irrecoverable and hopelessly private. They need some form of grief counselling.

For those in more serious trouble, crisis intervention is in order. Essentially it is a supportive but intensified counselling that provides distressed individuals with a forum to express feelings about their losses within a non-judgemental environment. It is normally time-limited and issue-orientated or focal in nature and the counsellor responds actively to the crisis-related problems. The counsellor should strive to provide a reorganising influence that can mollify the individual who is feeling overwhelmed. The critical dimension is to assist the person in re-establishing rational problem-solving. It goes without saying that if possible, it is beneficial to help the distraught to develop coping and problem-solving skills which are crucial in raising their feelings of competence and efficacy once again.

Dealing with suicidal persons may be problematic, as they may feel befuddled through disappointment, disillusionment, rejection or abandonment. As a result, they question their worth, feel hopeless and helpless, and try, as a goal of their suicidal behaviour, to jettison their anguish by putting an end to their lives. Challenging tactfully their irrational beliefs may be useful in some cases. Employed judiciously, cognitive restructuring or positive reframing is a powerful weapon.

The caveat is that primary care physicians are typically not orientated towards mental health problems. The skill base of most physicians does not include mental health counselling or special ability to detect mental health problem, particularly suicide, in patients. This means that opportunities for risk reduction or early intervention may be missed,³³ so there is an urgent need to increase the sensitivity of the primary care providers, in particularly the family physicians, to psychological problems.³⁴ This is yet another challenge family physician should rise to.

Conclusion

In conclusion, while there is no panacea for every sort of emotional or psychological problems a patient brings to the surgery, there is always something a family physician can do - cures sometimes but comforts always. A patient in distress does not expect a miracle at all times from a doctor, but he is not asking for too much if he is looking for attention, concern, care and patience which he thinks he deserves. This is well within the reach and ability of a competent family physician and this is where the doctor-patient relationship breeds and thrives.

Key messages

1. Positive mental health implies a sense of psychological well-being, and not just an absence of disease.
2. Mental health of a population can be estimated through the use of appropriate health status indicators and social indicators.
3. There are signs of increased psychiatric morbidity such as mood disorders in both adults and children and postnatal depression in women over the past several years.
4. Some of the mood disorders are attributed to study stress in children and financial stress in adults.
5. Men live shorter than women by an average of 5 years, probably in part due to lifestyle and work stress.
6. Family physicians can help their patients through support therapy, grief counselling, stress management, anticipatory guidance and crisis intervention.
7. Instillation of hope and judicious use of humour are often useful in buoying up the spirit of the distressed.

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References