Analyses | Medicine and healthcare | 2017-07-07

Mental health care services for Hong Kong youth

From 2013 to 2016, 71 Hong Kong students chose to take their own lives.[1] After a series of suicides took place in early 2016, the Government set up the Committee on the Prevention of Student Suicides (CPSS), which submitted its final report in November 2016.[2] While the Education Bureau (EDB) is still considering the CPSS report’s recommendations, a survey conducted by the community organisation Caritas and the City University of Hong Kong found that 40% of Form 1 students continue to be at risk of committing suicide from emotional distress brought on by changes in study environments and social circles.[3]

The CPSS has argued that in order to address the multifactorial causes of student suicides, gaps in the mental health system need to be filled. The objective of this article will be to assess how recommendations made by the Review Committee on Mental Health (the Review Committee) to improve mental health services can be implemented by making reference to deputations from stakeholders along with examples from the United Kingdom.

The Food and Health Bureau (FHB) noted that up to half of mental disorders[4] in adults originate before the age of 14.[5] According to Hospital Authority (HA) data, the caseload of the child and adolescent psychiatric teams of the HA rose from 18,900 in 2011-12 to 28,800 in 2015-16, an increase of more than 50%. In 2016, 12,589 mental health patients below the age of 18 received treatment in public hospitals, an increase of 5.8% from 11,900 in 2015.[6] As Figure 1 shows, the number of patients under the age of 18 with attention deficit and hyperactivity disorders, autism spectrum disorders, and other disorders has increased from 2011-12 to 2015-16.[7]

How long do young people have to wait to access HA psychiatric services?

Manpower is an area of concern for mental health professionals catering to young people. According to Dr. Phyllis Chan Kwok-ling, spokesperson for the Hong Kong College of Psychiatrists, only about 20 psychiatrists in Hong Kong’s public hospitals are working in the child and adolescent team.[8] The Secretary for Food and Health has stated that there were 356 psychiatric doctors and 2,473 psychiatric nurses under the HA as at March 31, 2017. The number of psychiatric nurses working for the 24 Integrated Community Centres for Mental Wellness (ICCMWs) in the year of 2016/17 was 43.[9] No data was provided on the number of child and adolescent psychiatrists or child and adolescent psychiatric nurses.

Given the rise in the caseload of the child and adolescent teams, a low number of child and adolescent psychiatrists could be problematic because young patients require specific skills and timing to provide treatment. The Association of Hong Kong Nursing Staff has called on the Government to increase psychiatric ward resources to ensure that there is sufficient manpower for patients.[10]

Young patients face long wait times when they seek psychiatric help. In 2015 the median waiting time of new cases at child and adolescent psychiatric specialist outpatient clinics (SOPCs)[11] was 58 weeks, while the waiting time for psychiatric SOPCs, which do not specifically cater to any age group, was 10 weeks.[12] The median waiting time for child and adolescent SOPCs in 2015 was 24 weeks longer than the waiting time in 2013, while the median waiting time for regular SOPCs increased by two weeks. The cost of seeking private treatment is reportedly HK$3,000 per monthly consultation, which means that many families have no choice but to wait for psychiatric treatment in child and adolescent SOPCs.[13]

Since it normally takes two to three hours per session for psychiatrists in public hospitals to see new cases, the shortage of child and adolescent psychiatrists has contributed to the long waiting times. Dr. Phyllis Chan Kwok-ling asserted that children who do not receive timely treatment for mental illness may give up on school, and their behaviour may deteriorate.[14]

Does the Government provide school-based mental health services for young people? What are the existing problems with these services?

The Government has introduced a variety of school-based services to improve students’ mental health and wellbeing. In 1995, the Department of Health set up the Student Health Service to provide health assessment services in primary schools. Students with suspected mental health problems are provided counselling and may be referred to clinical psychiatrists. Meanwhile, in 2001, the HA began providing the Early Assessment Service for Young People with Early Psychosis (E.A.S.Y.) for early identification and prompt treatment of early psychosis.[15] It should be noted that the E.A.S.Y. programme is not available to young people under the age of 15, so it is not accessible to younger students.

Also beginning in 2001, the Government has implemented the policy of “one school social worker per secondary school” through 34 non-governmental organisations (NGOs).[16] Teachers may consult social workers in cases where students are suspected of having mental illness, and social workers may refer these students to psychiatrists for diagnosis or medication. The policy of one social worker per school does not apply to primary schools, although the Government has stated that primary schools have access to other mental health resources such as the Student Guidance Service Grant under the Comprehensive Student Guidance Service.[17] Deputations to the Panel on Health Services and the Panel on Education of the Legislative Council observed that there is also a manpower shortage of guidance staff in schools such as social workers and educational psychologists (EPs).

More recently, the FHB, in collaboration with the HA, the EDB and the Social Welfare Department (SWD) launched the Student Mental Health Support Scheme in 2016, which is a “school-based communication platform involving healthcare, education and social care professionals…. to coordinate and provide support for children with mental health needs in the school setting”.[18] Psychiatric nurses “regularly visit” participating schools and collaborate with teachers, social workers and EPs to conduct deliberations on specific cases. It is not clear how frequently these visits occur, however, and psychiatric nurses are not available to provide treatment in participating schools on a full-time basis. Nine schools participated in the first phase of the Scheme, which was expanded to eight more schools in April 2017.

To improve teacher training in student mental health, the FHB has arranged for the Hong Kong College of Psychiatrists to provide training for teachers participating in the Scheme. The EDB will launch “gatekeeper training” for teachers, including elementary training for teachers at large and in-depth training for designated teachers, in September 2017.[19]

Are there any community-based services for mental health that cater to youth? What are the existing problems that may impede the delivery of these services?

The SWD has set up ICCMWs to provide one-stop, district-based community psychiatric rehabilitation and mental health services since 2010.[20] Yet service users must be aged 15 or above, which means that many young people cannot receive assistance at ICCMWs. Moreover, young people and adults tend to suffer from different mental health disorders; for example, youth tend to be more susceptible to autism spectrum disorders and attention deficit and hyperactivity disorders.[21]

Additional community support services are provided by Integrated Family Services Centres (IFSCs), Integrated Services Centres (ISCs) and Integrated Children and Youth Services Centres (ICYSCs), which are supported by the SWD and NGOs.[22] However, like ICCMWs, IFSCs and ISCs are not necessarily “youth-friendly,”[23] which means that they may not appeal to young people with mental health needs. In other words, the services provided at IFSCs and ISCs are not tailored for young people and youth issues. As for ICYSCs, while targeted at youth, they do not provide specialist services, and complicated cases may need to be referred to child and adolescent psychiatric SOPCs.

The Bauhinia Foundation Research Centre has advocated for the Government to adopt a community-based approach by involving welfare organisations and family doctors in providing support services and establishing a checklist of “one-stop occupational health support services” to ensure that needy people can get early intervention services.[24] A “one-stop mental health support services” checklist for young people may similarly help reduce wait times for young people waiting to receive psychiatric care. Family doctors could potentially play an expanded role in treating young people with mental problems as well.

According to Professor Samuel Wong from the Chinese University of Hong Kong (CUHK), physical health problems can affect mental health, and mental health problems increase the risk of premature mortality from diseases such as cardiovascular disease.[25] Moreover, multi-morbidity[26] is commonly encountered by primary care physicians. Thus, the World Health Organization has advocated for the integration of mental health into primary care, because providing preventive interventions in the primary care setting may improve early detection and treatment of mental health problems, especially for people with multiple chronic conditions.[27] Patients who suffer from medically unexplained symptoms may also suffer from mental health problems, which makes primary care the ideal setting to treat these issues. Finally, since patients often have continuing relationships with their primary care providers, they may be more willing to disclose their mental health issues to these providers.

How does the “three-tier stepped care model” for mental health care aim to help youth?

On April 18, 2017, the Review Committee released its Mental Health Review Report (the Report).[28] This Review Committee was originally set up in May 2013. In the Report, the Review Committee put forward 40 recommendations to improve Hong Kong’s mental health services along with a proposal to set up a standing Advisory Committee on Mental Health (the Advisory Committee) to monitor the implementation of these recommendations. Several of these recommendations were aimed at young people as well as their families.

To improve existing services for youth, the Report recommended strengthening the “three-tier stepped care model” for youth mental health care and facilitating more multidisciplinary collaboration in the delivery of child and adolescent psychiatric services. The stepped care model already exists in Hong Kong but the Report has recommended that coordination and collaboration in the three tiers should be improved to enhance delivery of services.

In the three-tier model, Tier 1 refers to prevention, early intervention and maintenance strategies, handling of mild mental health issues, and referral of complicated cases to specialist services. Tier 1 professionals may include social workers, teachers, and primary care doctors not necessarily trained as mental health specialists. Tier 2 professionals should serve as a bridge between Tier 1 and Tier 3 in order to “provide more structured and targeted assessment and intervention for relatively complex cases identified by Tier 1”. Tier 2 intervention can take the form of medical treatment, social care and educational support. Tier 3 refers to specialist intervention for youth with moderate to severe health difficulties, usually in the form of crisis resolution, in-patient and day care services.

What are some of the gaps in the three-tier stepped care model in Hong Kong?

According to the Report, there is little communication between professionals across the three tiers and across sectors within each tier. Due to “the variations in perspectives and skills among professionals within each tier,” the priorities of the three tiers are often not in sync. This means that the mental health needs of young people are not always matched with an appropriate level of care, especially as children mature from pre-schoolers into adolescents and young adults. Thus, it is important to bolster communication and collaboration between families, schools, healthcare, social care professionals and communities at large throughout all stages of a young person’s life.

In Tier 1, for example, insufficient knowledge on mental health among service providers may have contributed to the societal stigmatisation surrounding mental health disorders. Meanwhile, Tier 2 is reportedly “the weakest link among the three tiers due to inadequate coordination,” which means that students are often turning to Tier 3 services for less serious cases. This may have contributed to long waiting times for patients of child and adolescent psychiatric SOPCs. To bridge the gaps in the stepped care model, the Report suggested that enhanced mental health training for professionals in all three tiers should be provided. Tier 3 specialists could provide support and advice for Tier 2 multi-disciplinary professionals so that they do not feel compelled to seek unnecessary help from Tier 3 support.

As youth spend most of their time at school, the Report suggested that school-based platforms should be established bringing together teachers, social workers, and healthcare professionals such as psychiatrists or hospital nurses to improve coordination. The Student Mental Health Support Scheme aspires to create such a platform. Although it is still too early to assess the Scheme’s effectiveness, the Report did mention that an ideal school-based platform should involve parents in discussions, while a school coordinator could be assigned to liaise appropriate services across sectors based on student needs.

How can mental health services be made more “youth-friendly”?

Youth engagement of mental health services is reportedly the poorest among all age groups based on data from the Hong Kong Mental Morbidity Survey from 2010 to 2014.[29] The Review Committee affirmed that conventional platforms such as ICCMWs are not catered for youth needs, and therefore a youth-friendly platform needs to be set up to encourage youth to seek help.[30] This platform could be set up with support from a team of mental health professionals to enhance youth mental health services for mood disorders, anxiety disorders, substance abuse, and other common mental health problems. Ideally, the platform would allow young people to feel comfortable visiting the platform without committing to a formal consultation. There should also be physical space for a range of leisure activities and social gatherings in addition to medical and psychological counselling.

The Report suggested that a physical setting for a youth-friendly platform could be supplemented with an online component, in a way that could be more appealing and convenient for young people. In March 2017, researchers from CUHK published a study of college students and young workers which found that Internet-based mental health programmes showed potential in improving the mental wellbeing of study subjects.[31] The researchers concluded that “Internet-based mindfulness programmes…can be a highly scalable and convenient way for prevention and promotion of mental health”. Professor Winnie Mak Wing-sze from the Department of Psychology at CUHK stated: “Internet-based interventions are easily accessible and affordable….They can fill the gaps in mental health promotion, prevention of common mental disorders, and early treatment”.[32]

Hong Kong youth are spending more and more time on their mobile devices.[33] If existing programmes can be converted to mobile phone applications, Internet-based programmes could promote mental health and disorder prevention to young people by bolstering delivery of Tier 1, 2 and 3 services under the stepped care model. The NGO Baptist Oi Kwan Social Service has supported the idea of using mobile apps to promote mental wellness among youth.[34] Even though there would be limitations with online-based programmes as compared to physical centres, they may be able to reach out to more individuals over a shorter period of time, which is important considering the long waiting times for child and adolescent psychiatric services and the low youth engagement in mental health services.

How can “early intervention” be used to enhance mental health services for youth?

Some children are more at risk of suffering from mental illness disorders due to biological, psychological, and social factors.[35] For example, children who are exposed to toxins during pregnancy or have a genetic tendency to psychiatric disorder may be more at risk of developing mental health problems. Other children may be at risk due to learning disorders and difficult temperament. Still others could be negatively impacted by family conflicts, academic failures, or discrimination and marginalisation from the community. Early intervention is a strategy whereby these children are identified at a preliminary stage so that they can be provided with services that will prevent their conditions from worsening.

The Review Committee has noted that while some platforms such as the Comprehensive Child Development Service and Maternal and Child Health Centres exist to identify at-risk parents, these parents may not be willing to be referred for treatment or they may not be reached for other reasons. The Report suggested that a framework should be developed to better assess the parenting capacity of at-risk parents, and more effective intervention programmes should be put in place to provide timely intervention for at-risk children. Further steps that can improve early intervention include the promotion of positive parent-child and teacher-student relationships, physical exercise, healthy lifestyles, stress management, and meaningful participation in schools and the community.

What measures are being implemented in the United Kingdom to improve mental health?

Hong Kong is, of course, not the only region in the world that grapples with the issue of insufficient manpower to provide mental health services. Thus, it may be helpful to make reference to efforts made by foreign governments to address the manpower issue. In January 2017, Prime Minister Theresa May of the United Kingdom (UK) announced plans to improve mental health services through the “Five Year Forward View for Mental Health”.[36] The British Government vowed to support schools, colleges and the National Health Service (NHS) to work “more closely together to provide dedicated children and young people’s mental health services.” For example, a programme implemented by the Department of Education, the NHS and clinical commissioning groups that trains teachers to function as a “single point of contact” for mental health services will be extended to 1,200 more schools.

Through these efforts, the British Government hopes to help 70,000 more young people access mental health care by hiring 10,000 more staff to work in NHS mental health services[37] while training 1,700 more therapists and supervisors within the next four years, a goal which will be backed by £1.4 billion in extra funding for mental health. The Government has also set a target of a four-week wait time for young people referred to routine mental health services and a one-week wait time for young people referred to urgent help.

Finally, the British Government aspires to provide “mental health first aid” training for one teacher in every secondary school by 2019, through the community interest organisation Mental Health First Aid England. This training teaches school staff how to spot the early signs of mental illness in young people, helping prevent mental issues from worsening, and guiding young people towards the right support.[38] Beginning from April 2017, Mental Health First Aid England will offer a free one-day course for all secondary school teachers.

Can any lessons be learned from the United Kingdom to improve mental health services in Hong Kong?

The Review Committee recommended that all tiers and especially Tier 2 in the stepped care model need to be adequately staffed with trained professionals to shorten waiting times of new cases. While the shortage of child and adolescent psychiatrists is a concern, enhancing the capacity of specialist care alone cannot address the problems arising from increased demand for mental health services. To fully resolve these issues, “capacity and manpower at different tiers of the service delivery model need to be strengthened”.[39]

It may not be possible to emulate the UK’s approach to mental health. However, the Hong Kong Government may consider the feasibility of setting long-term targets in terms of lowering wait times for accessing child and adolescent mental health service needs. The Hong Kong Council of Social Service has urged the Government to set up long-term strategies to meet the demand for psychiatric services among young people.[40] This would help determine whether increases in resources and manpower allocation will be sufficient to meet the increasing demand for mental health services. Similarly, it may be helpful to set a target number of teachers, service staff, or volunteers in each public school who will be trained in the early intervention and identification of mental health problems. Training could be modelled after courses conducted by the Psychology Support Team of the Hong Kong Red Cross.[41] Teachers could also play more of a role in providing simple assessments for young people who may be experiencing difficulties with their mood or emotions, in consultation with families and youths, before referring complicated cases to professionals.

At the same time, the Government could aim to recruit a certain number of new psychiatric nurses and psychiatrists to join the child and adolescent psychiatric SOPCs in the HA.[42] Only two community psychiatric nurses were reportedly added over the past five years.[43] If there are not enough psychiatric nurses or psychiatrists to be recruited from the private sector or elsewhere, then it may be worthwhile to see if training programmes in these areas could possibly be expanded to meet demand. The ultimate goal should be to maximise the number of students with access to quality mental health care across all three tiers.


Carrie Lam Cheng Yuet-ngor has noted during her tenure as Chief Secretary that the Government “attaches great importance to the promotion of mental well-being of our citizens”.[44] With regard to medical services, Lam promised in her manifesto that “greater efforts will be made and resources put in place to promote health education, primary care and community care so as to reduce the need for specialist and hospital services”.[45] Considering the fact that Lam’s manifesto focused on livelihood issues, while offering several proposals targeted at young people, it is expected that Lam may work towards improving the mental wellbeing of youth in Hong Kong while in office.

A collaborative effort among professionals in all tiers of the stepped care model will likely be required to make lasting improvements in the delivery of youth mental health services. Manpower among the third tier is a concern, as the waiting time for child and adolescent psychiatric SOPCs demonstrates, but efforts should also be made to strengthen the capacities of the first and second tiers to ease the burden on specialist services. Schools and NGOs could be provided with additional resources, while setting concrete targets with regard to training and recruitment could improve manpower planning and development.

1 Elizabeth Cheung, After 71 student suicides since 2013, education chief told Hong Kong schools are like a ‘prison’, South China Morning Post, January 7, 2017,
2 Committee on Prevention of Student Suicides: Final Report, Education Bureau, November 2016,
3 Cannix Yau, One in three primary school students in Hong Kong at risk of suicide, South China Morning Post, May 16, 2017,
4 According to the Hong Kong Mental Morbidity Survey in 2013, the most common mental disorders in Hong Kong were mixed anxiety and depressive disorder, generalised anxiety disorder, depressive episode, and other anxiety disorders including panic disorders, phobias and obsessive compulsive disorder.
5 A local study conducted in 2008 by the Chinese University of Hong Kong found that the most common mental disorders among high school adolescents were anxiety disorders, oppositional defiant disorder, Attention Deficit/Hyperactivity Disorder (AD/HD), conduct disorder, depressive disorders, and substance use disorders.
6 Emily Tsang, Study reveals need for psychiatric services in Hong Kong, but also warns against forcing treatment on mentally ill, South China Morning Post, April 19, 2017,
7 Some patients were categorised into more than one disease group each year.
8 Emily Tsang, Hong Kong children wait more than a year for mental health treatment as list increases to 27,000, South China Morning Post, May 25, 2016,
9 LCQ13: Treatment and support for patients with mental illness, The Government of the Hong Kong Special Administrative Region, April 26, 2017,
10 LC Paper No. CB(2)1416/16-17(09), Legislative Council, May 22, 2017,
11 Child and adolescent SOPCs are targeted at patients under the age of 18. SOPCs in general are not targeted at patients of any particular age group.
12 Annex I, Legislative Council, May 25, 2016,
13 Emily Tsang, Charity offers low-income Hong Kong children mental health care as city waiting times hit 3 years, South China Morning Post, May 8, 2017,
14 Emily Tsang, Hong Kong children wait more than a year for mental health treatment as list increases to 27,000, South China Morning Post, May 25, 2016,
15 Service Framework for Community Mental Health Services, Hospital Authority,
16 LC Paper No. CB (4) 800/16-17(01), Legislative Council, January 7, 2017,
17 LC Paper No. CB(4)800/16-17(01), Legislative Council, March 31, 2017,
18 LC Paper No. CB(2)1228/16-17(06), Legislative Council, April 25, 2017,
19 LC Paper No. CB(4)800/16-17(01), Legislative Council, March 31, 2017,
20 Integrated Community Centre for Mental Wellness, Social Welfare Department,
21 Mental Health Review Report, Food and Health Bureau, April 18, 2017,
22 Service Framework for Community Mental Health Services, Hospital Authority,
23 Mental Health Review Report, Food and Health Bureau, April 18, 2017,
24 Workplace flexibility: A win-win situation for employees and employers, Bauhinia Foundation Research Centre, January 24, 2017,
25 Samuel Wong, Mental health problems in primary care, Chinese University of Hong Kong, 2011,
26 This is a medical term that refers to co-occurring diseases in the same person.
27 Donald Li, Modern Primary Care Models- Integration or Collaboration, Hospital Authority, 2014,
28 Mental Health Review Report, Food and Health Bureau, April 18, 2017,
29 Mental Health Review Report, Food and Health Bureau, April 18, 2017,
30 The Report did not clarify whether the “youth-friendly platform” would supplement the school-based platform or how these two platforms would coordinate their work and allocate resources or manpower.
31 Winnie Mak, The Efficacy of Internet-Based Mindfulness Training and Cognitive-Behavioural Training with Telephone Support in the Enhancement of Mental Health among college students and young working adults: randomised controlled trial, Journal of Medical Internet Research, March 22, 2017,
32 Winnie Mak, Stressed Hong Kong workers can find mental well-being with web-based behavioural training, South China Morning Post, June 1, 2017,
33 Ernest Kao, Many young Hongkongers unable to control their smartphone addiction, new survey finds, South China Morning Post, April 3, 2017,
34 LC Paper No. CB(2)1416/16-17(05), Legislative Council, May 22, 2017,
35 Mental Health Review Report, Food and Health Bureau, April 18, 2017,
36 The Government’s response to the Five Year Forward View for Mental Health, Department of Health, January 2017,
37 Michael Savage, Theresa May pledges mental health revolution will reduce detentions, The Guardian, May 7, 2017,
38 Youth MHFA Schools & Colleges, MHFA England,
39 Mental Health Review Report, Food and Health Bureau, April 18, 2017,
40 LC Paper No. CB(2)1475/16-17(03), Legislative Council, May 22, 2017,
41 Psychological support service- volunteering, Hong Kong Red Cross,
42 Since the number of psychiatric nurses in child and adolescent SOPCs has not been made public, it is difficult to say exactly how many new psychiatric staff would be needed to meet current demand for services, but it can be inferred by the long wait times that manpower will need to be bolstered by a significant amount.
43 Elizabeth Cheung, Long waiting times at Hong Kong public hospitals for mentally ill patients, South China Morning Post, February 20, 2017,
44 Carrie Lam, Speech by CS at opening ceremony of Central Rat Race 2015,, October 25, 2015,
45 Carrie Lam, Manifesto of Carrie Lam: Chief Executive Election 2017, February 27, 2017,