What you need to know
What has Taiwan learned about its mental health system after the murder of a four-year-old last year?
On the morning of March 28, 2016, "Little Light Bulb (小燈泡)" was riding her bicycle just meters ahead of her mother on a Taipei street when she was suddenly grabbed and decapitated with a cleaver.
News of the attack on the four-year-old, known to the nation as "Little Light Bulb," spread like wildfire across Taiwan. As is often the case with a high-profile violent crime in Taiwan, there were immediate calls for the perpetrator to be executed. In the immediate aftermath of the attack, wild mob hysteria was tempered by more sober voices, including, almost unfathomably, the girl’s bereaving mother, who pointed towards the likelihood that the killer had mental health problems.
Wang Ching-yu (王景玉), 33 at the time, was charged with the murder and his case is moving through Taiwan’s criminal courts. Prosecutors have sought the death penalty while defense lawyers argue he is criminally insane; in dispute is his psychiatric state at the time of the killing.
Wang’s lawyer, Leon Huang (黃致豪), believes the accused suffers from schizophrenia and had fully developed delusional symptoms when he killed the four-year-old. Over at least four years prior to the attack, Wang had drifted in and out of a "world" in which he is the reincarnation of a Yiao (堯) dynasty emperor, Huang told The News Lens in Taipei. In that world, Wang could justify taking a little girl’s life.
“He can pardon himself in his own kingdom; he is the emperor,” Huang says. “He has written 29 journals of this stuff.”
Wang is understood to have sought psychiatric treatment in 2014. But the fact Wang’s symptoms were able to develop to the extent that they did, Huang believes, shows that Taiwan’s mental health care system has serious gaps in it, as well as a broader misunderstanding about mental illness across society.
Taiwan may have other “ticking time bombs" like Wang, Huang cautions.
Shen Lih-jong (諶立中) is the director of the Ministry of Health and Welfare’s Department of Mental and Oral Health. For the past 16 months, he has overseen the department's five divisions which are focused on: oral health; domestic and sexual violence; drug and alcohol abuse; mental illness; mental health awareness and suicide prevention.
In an interview at his Taipei office, the former clinical psychiatrist is outspoken about the chronic underfunding of mental health care in Taiwan, which limits his department’s ability to serve the community, but he pushes back on the notion that psychiatric patients pose a great danger to society. He believes psychosis plays a much lower role as a proportion of criminal behavior than what has been reflected in the media frenzy following high-profile violent crimes, like the murder of Little Light Bulb.
“It is only because they have psychosis, they are in the news,” Shen says.
The truth, he says, is that psychiatric patients hurt themselves much more frequently than they hurt others; the rate of suicide among people with psychosis is as much as 20-times higher than the general public.
Still, Shen acknowledges that Taiwan’s mental health system has not been given enough attention from senior officials and government ministers, and that the potential is high for people, like Wang, to deteriorate without a health professional being aware of the situation.
“As the director of this department, in charge of the policy for mental health for the whole of Taiwan, I face the problem of not enough budget,” he says. “From the first day I came here, I tried to argue for more budget.”
The Taiwan government spends about 1.4 percent of its entire budget on mental health care, but 97 percent of that is related to clinical visits and medication subsidies, via the country’s universal health care system.
“I think the [spending on] medication in Taiwan is enough,” Shen says.
The key gap, he believes, is in early stage prevention and awareness, as well ongoing case management to support patients – that includes community visits and follow up calls.
“Now, the manpower is very low. Every case manager has to take care of about 300 to 350 cases. In the West, it may be 20 to 25,” Shen says. “The frequency of consultancy is not enough.”
This, Shen says, has led to patients having low compliance in continuing their treatment and taking medication.
“As I remember, the drop-out rate is higher than 50 percent. That means that the patient sees a psychiatrist but they don’t continue to take their medication or follow-up regularly.”
According to official statistics, the number of people in Taiwan with affective psychoses, which includes major depressive and bipolar disorders, increased from 199,000 in 2006 to 249,000 in 2014, a 25 percent increase. During the same period, the number of patients with schizophrenia increased 12 percent to 249,000. In that time, public spending on mental health – almost all via the national health insurance scheme – increased by more than 30 percent, but from a very low base, Shen says.
He suggests the reticence on the part of the government to allocate more resources to his department reflects a broad public misunderstanding of the nature and extent of mental health problems in Taiwan.
“The stigma issue is a big issue in Taiwan,” he says. “I think the stigma issue is much, much bigger than the harm caused by psychiatric patients.”
While the situation in Taiwan today is “much improved” compared to earlier in his career, there is still reluctance to seek help, Shen says.
“If people have relatives with psychosis they don’t like going to hospitals; they like to pray to some god or take some traditional medicine, even today,” he says.
He says that 20 years ago, by the time he would see a patient with psychosis their condition would typically have developed for at least one year. “In that year, their family, their relatives did a lot of effort to bring the patient to visit every place, except the hospital.”
Gradually, the time between the onset of a psychiatric condition and when a patient starts to receive treatment has decreased. “It is getting shorter, that means there is something is changing in society,” Shen says.
And he says there has been a big improvement in attitudes towards people with depression in Taiwan.
“People accept it much better than psychosis, but still they have some hesitancy in talking with others about depression, anxiety," he says. “No one would dare say to their boss, ‘I feel depressed today, can I get the day off?’ It is not possible in Taiwan. You can only say, you have a stomachache, a headache, some physical problem."
Into the community
Broadly, Shen points to a slow improvement in how Taiwan delivers mental health care over the past 30 years. Initially, policymakers concentrated on building the capacity to care for patients in public institutions.
“At the beginning, we all focused on the manpower, how many psychiatric beds we had,” Shen says.
However, as Taiwan built up its institutions, many people in the sector, like Shen, trained overseas and observed that the structure of treatment in the West was concurrently progressing towards a greater focus on working in the community, rather than institutions. Subsequently, in the past 20 years, the country has been trying to move to a more community-level system, with a focus on awareness, prevention and early stage care.
But as policymakers work to shift mental health services from the institutions to the community, they still meet “a lot” of resistance, Shen says.
“The people still do not accept the psychiatric patients. Though it is much improved from before, we are still in the process. That is the real situation," he says. “If we want to have a mental health center in the community – like a halfway house – neighbors will have a lot of anger over that. Not only because it may decrease the value of their house, but because they fear those patients might harm them.”
If health care professionals cannot work with the community to help patients earlier, people like Wang may continue to slip through the cracks.
In her inauguration speech in May last year, when the murder of Little Light Bulb was still fresh in the minds of many Taiwanese, President Tsai Ing-wen (蔡英文) acknowledged the country’s social safety net was “full of holes.”
“Over the past few years, several incidents of violent crime affecting the safety of children and youth have shaken our entire society,” Tsai said. “We must do everything we can to prevent the repeated occurrences of tragedy by swiftly mending holes in areas such as public safety, education, mental health and social work.”
The new administration would address those issues with the "utmost seriousness and readiness to act," she said.
Shen, however, has seen little change.
While perhaps not agreeing with Huang’s “ticking time bomb” warning, Shen suggests it may take another incident of a similar magnitude to the horrific death of Little Light Bulb before the government takes notice and gives his department the resources it needs.
“I have to wait for some big problem to happen,” he says.
Editor: Oliva Yang