Apart from having to see the psychiatrist for five minutes every month, his personal freedom was constrained and it affected his mental health too.

“A young man once bumped into me on the street and I fell to the ground,” recalled Ha, now 58. “He didn’t say anything and left. Aware of my conditional discharge status, I could only swallow what I felt at that moment.”

Another time, a man told him off despite having accidentally stepped on Ha’s foot.

“I did nothing,” he said. “What if he resorted to violence and people pointed the finger at me because I had mental illnesses? The medical officer might say I had a relapse.”

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About 1,300 people with mental illnesses in Hong Kong live with the same conditional discharge status hanging over their heads.

According to the Mental Health Ordinance, patients who have been detained and have “a medical history of criminal violence or a disposition to commit such violence” may be subject to specific conditions when discharged from hospital.

They may be required to live in a specific place, go for consultations at a hospital or clinic, take prescribed medicine and be supervised by the director of social welfare.

They face being readmitted if they fail to comply with the conditions or if the hospital thinks “it is necessary in the interests of the patient’s health or safety, or for the protection of other persons”.

While mental health experts considered the mechanism useful, social workers and legal scholars said it was a flawed system in which patients could be mistreated.

‘Easy to be trapped, hard to escape’

In early June, the government’s Advisory Committee on Mental Health proposed 10 measures to improve the city’s public mental health services.

They included a review of the conditional discharge system and exploring introducing community treatment orders for patients.

The committee is expected to meet this week to get an update from the Hospital Authority, which has conducted a review of the conditional discharge mechanism.

Experts hoped the review would set clearer thresholds for giving patients a conditional discharge and also indicate a time limit.

The committee acted after two women were killed in a frenzied stabbing incident at a shopping mall in Diamond Hill in June. The suspect, a 39-year-old man, was reported to be a schizophrenia patient who received treatment at a public outpatient clinic.

Currently, patients may ask the Mental Health Review Tribunal to review their conditional discharge status, but cannot file an appeal within 12 months of the last request. The status can also be lifted if their attending doctor considers it appropriate and has the approval of the hospital’s head.

The Hospital Authority, which oversees Hong Kong’s public health institutions, said it did not have statistics for the number of appeals.

Many patients do not know they have the right to appeal.

Ha said he had regular follow-up sessions with his doctor and social workers for four years before he learned about the tribunal.

“Before 2015, I felt like I was screaming in a dark room and no one heard me,” he said.

He appealed four times between 2015 and 2019 for his conditional discharge to be revoked but was unsuccessful.

In its 2019 decision, tribunal member Dr Mary Lee Wing-ming supported revoking Ha’s conditions.

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She pointed to his medical records which mentioned that he “fought with three strangers three times under psychotic influence” before being admitted to hospital the first time, but no details or evidence were provided.

Ha insisted the fights never happened and there was also no police record of them.

The tribunal report quoted Lee as saying: “Without solid supporting evidence that he had assaulted others, and in line with the fair principle of ‘presumed innocent until proven guilty beyond reasonable doubt’, classifying him as having a history of violence is not justified.”

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Noting that there was no indication that Ha would cause immediate or serious harm to himself or others, she said retaining the conditions would be “detrimental to his mental well-being”.

But other tribunal members objected and Ha’s appeal was rejected, saying he was likely to skip medical treatment if his status was revoked.

Then, in 2020, the hospital called and told him his conditional discharge status had been lifted, but gave him no further explanation.

It marked a turning point for him.

“I simply hope to live normally. I wish that I can find someone to love,” he said. “I have also made it my life’s mission to help the community of patients with conditional discharges.”

‘Stressed and anxious all the time’

Social worker Chow Cheung-shun of the Concord Mutual-Aid Club Alliance, a group that supports mental illness patients, said a number had told him they were not briefed clearly on what the conditional discharge meant and were not told they could appeal.

“Nurses would tell them if they signed some documents, they could be discharged, but they did not know the conditional discharge would have such a huge impact on their lives,” he said.

Chow said doctors could impose a conditional discharge order merely after being told that a patient had suicidal or violent tendencies, without proof.

With strict rules and the threat of being readmitted hanging over them, patients lived with apprehension and were also wary about what they told their doctors and social workers, whose reports could affect the result of their appeals.

“As a result, they are very stressed and anxious all the time,” Chow said.

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Agreeing that the grounds for imposing the order were unclear, assistant professor of law Daisy Cheung Tin-muk, from the University of Hong Kong (HKU) said: “As long as in the medical records someone has mentioned that the patient has been involved in violent events, including anonymous accounts, it is sufficient for the order to be imposed.”

A specialist in mental health law and deputy director of HKU’s Centre for Medical Ethics and Law, Cheung said the mechanism failed to safeguard patients’ rights as it was easy to be subjected to it, but difficult to break free.

She said in other countries, measures similar to the conditional discharge usually came with an expiry date and to extend the order, evidence had to be provided.

The opinions of social workers should also be considered when imposing the order, instead of being determined solely by the doctor, she added.

There was also no obligation on the tribunal to review patients’ cases from time to time, she said, and current laws did not give doctors an explicit right to remove the order.

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She also said overseas studies had shown that conditional discharge had low efficacy in preventing readmission to hospital.

In deciding whether to keep the mechanism, she said the government should consider ways to improve its effectiveness, including by making clear the specific criteria for patients to be subjected to conditional discharge.

On whether the government should expand the conditional discharge regime to those who go to hospital voluntarily, she said she was worried that it would deter people from seeking medical help as they might be afraid of the harsh conditions.

Psychiatric nurse Amy Chan* said she followed up with more than 30 patients recovering from severe mental illnesses and most of them had been given conditional discharges.

In her four years as a case manager, she had not encountered a single patient who succeeded in getting the conditional discharge lifted.

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Given the patients’ backgrounds, she said, not many doctors would be willing to take the risk of removing the restrictions.

But she also questioned retaining them permanently, asking: “Is it fair for someone to bear this for the rest of their lives?”

‘A necessary tool’ but can be improved

Defending the current regime, Samson Tse Shu-ki, professor of mental health at HKU, said that conditional discharge was a “necessary tool”, especially for people with severe psychiatric illnesses.

A member of the Advisory Committee on Mental Health, he said the mechanism was “robust”, but there could be improvements.

One area worth looking into, he said, was whether patients lived in a suitable environment after leaving hospital.

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“If a patient does not have to stay in hospital and can receive treatment in another setting, is there enough support in that environment?” he said.

Some may benefit from staying in halfway houses, but he said Hong Kong did not have enough places for recovering mental patients to reintegrate into the community.

According to Social Welfare Department data, there were 1,594 places at halfway houses in 2021-22, with an average waiting time of 4.2 months.

Tse said the city needed to strengthen the support for recovering patients, and hoped that counsellors could be included in the standard manpower establishment of public bodies and non-governmental organisations.

He said recovery was not only about medicines or injections, and counselling could help rebuild patients’ confidence and ability in regaining their lives and learning to get along with others.

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“It’s not only about relationships among friends but also families and spouses,” he said. “Professional counselling could provide advice on matters closely related to daily life.”

Patricia Ann Ho, a principal lecturer at HKU’s department of law, who specialises in civil interests and judicial reviews on public policies, agreed that the conditional discharge could be beneficial to patients and the public, but felt there was “procedural injustice” in the current situation.

She said there was only limited protection for patients’ rights and in reviewing the mechanism, the government should ensure that social workers or lawyers could offer representations on behalf of patients to help discuss with the hospital the best arrangements.

“There is an imbalance of interests if we simply rely on doctors and nurses, who may look at the cases from their perspective,” she said.

“As conditional discharge affects patients’ personal freedom to a large extent, there is a greater need to balance the interests. As they may become very vulnerable, they need appropriate representation.”

Psychiatrist David Tsang Fan-Kwong agreed that the conditional discharge regime was necessary but said there was insufficient manpower and support for this group of patients.

“For example, for those with higher risks, visits can be arranged once every two weeks instead of every two months,” he said.

He added that if the government decided to expand the eligibility of conditional discharge, it should make sure it was flexible enough for different patients and would not be abused.

He felt that resources or changes for mental health-related measures were “squeezed out bit by bit like toothpaste” by the government every time mental illness patients were linked to violent incidents.

What Hong Kong needed, he said, was a well-thought-out road map for its mental health policies.

* Name changed at interviewee’s request.