Hong Kong: The city that can't sleep

Up to 2.8 million people in Hong Kong suffer from some kind of insomnia. Anna Cummins takes a look at this exhausting problem and considers if our work-obsessed culture is slowly pushing us all towards a mental health crisis

How did you sleep last night? Perhaps you struggled to get to sleep, woke up several times throughout the night, or woke up far too early. If you often find yourself counting sheep for hours or raiding the fridge at 4am, then you could well be amongst the 40 percent of Hongkongers who now suffer from some degree of insomnia. 

The effects of this misery-inducing condition extend much further than a feeling of tiredness: insomnia has been shown to result in decreased cognitive functioning and is also associated with a poorer quality of life and weakened immune system. Insomniacs are far more likely to suffer from long-term health problems, and the condition is very often an indicator of mood disorders such as anxiety and depression. Treatment can be difficult; commonly used sleep medications (such as benzodiazepine) can be addictive, and most alternative therapies such as hypnosis or herbal treatments lack evidence for their efficacy. 

So, why do so many people in Hong Kong struggle with sleep? Around 50 percent of insomniacs in Hong Kong – that’s about 1.4 million people – have ‘primary’ insomnia, meaning there are no underlying physical or psychological conditions causing their sleepless nights. For these people, insomnia is arguably a symptom of the hectic lifestyle that Hong Kong entails. Dr Ricci Chang is a psychiatrist, who has treated insomnia both in the UK and in Hong Kong. “In Hong Kong, the most common problem is stress; work stress and city life,” he says. 

Chang has no doubt about the condition of our city’s psychological wellbeing. “In general, the mental health of people in Hong Kong is declining,” he says. “There are a lot of financial issues such as high rent, and the work culture, too. In Hong Kong, people work from 9am until 9pm, whereas in the UK, tomorrow is another day and they’ll leave it. The bosses are more demanding in Hong Kong, the working atmosphere is more stressful. It’s a crowded place and there is a lack of relaxing activities. We rely on more materialistic entertainment; we have less contact with nature. I think these things make people in Hong Kong more unhealthy, psychologically.”

The worrying prevalence of insomnia in our city may be an indicator of something even more serious. Dr Esther Lau is a researcher of the neuropsychology of sleep at The University of Hong Kong. She highlights that ‘recently, more and more research says sleep disturbances can affect your future functioning and predict other psychological problems. That means if you don’t sleep well now, your mood is predicted to be worse off just a few years later’.

 Dr KF Chung, a researcher of sleep and mood disorders at HKU, believes that the root causes of primary insomnia are hard to pin-down. “Stress may be a factor, but it is multi-factorial,” he says. “[Insomnia] can be caused by other things, like genetic factors, upbringing or personality. You can’t say that only stress is an explanation. The environment and crowded living situation in Hong Kong is definitely a factor, but we haven’t looked specifically at how important these factors are.”

Chung points out that many sufferers don’t really understand the cause of their own condition, and are misunderstood by others. “Some feel very frustrated that other people misunderstand their problems,” he continues, “because when you tell your friends that you have insomnia, their first reaction is that ‘I can’t believe you have it – you have no stress, no problem with work or money’.” 

Polina Shubkina is someone who might fit into that category – she has suffered from insomnia for almost her whole life, and has never really understood why; ‘one day I might figure it out!’ she says. The 24-year-old artist moved to Hong Kong from Europe in 2010. “My insomnia has got a bit worse since I got to Hong Kong,” Shubkina admits. “My lifestyle here is a lot less passive, I work a lot more. Also in Hong Kong what I experience is a lack of nice community; I am very close with people who I work with, but I am used to having more people in my life. Friends-wise, it’s very hard to build relationships here.”

Shubkina often struggles to fall asleep before 6am. “It’s exhausting. I know that I want to sleep but I just can’t,” she says. “I get a kind of experience, like dreaming while still awake – I might be in the bathroom getting some water and I will see some random movements, because my mind is switching off. Sometimes it’s really scary.” The experience can be frustrating. “I just feel exhausted. Sometimes it gets to the level where I’m like… ‘I can’t handle this any more’. But usually I’m just there like a zombie.”

Shubkina has recently documented her nocturnal experiences in a candid series of photographs called, unsurprisingly, Insomnia. “I don’t consider my art as therapy,” she says. “Actually, at the beginning I had a tiny feeling that if I made a project about it, it would go away. But in the end I couldn’t sleep because I had to shoot… well, it was a good idea to do a project because I was wasting so much time anyway!”

While Shubkina is very open to discussing her condition, for many in Hong Kong, it is not so easy. Insomnia itself is not a disease, but it is often symptomatic of deeper mental health issues. Around 50 percent of insomnia cases are ‘secondary’, meaning the symptoms are linked to factors such as substance abuse, side-effects of medication or, commonly, mood disorders including depression, bipolar disorder and anxiety. The Chinese culture has a longstanding stigma regarding mental illness, which proves an obstacle to those who worry about being sent to see a psychiatrist to deal with their problem. 

“In Hong Kong, one in six or seven people suffer from mood disorders,” says Dr Chang. “This number is not much higher than other countries, but perhaps because of the Chinese culture, or the stigma of seeing a psychiatrist, only 25 percent of those people seek help.”

Dr Bonnie Siu, a psychiatrist at the Institute of Mental Health, Castle Peak Hospital, agrees.
“In Hong Kong there is a lot of stigmatisation about mental illness,” she says. “Chinese people are afraid of having a label. Their family members may also be afraid of this. So on top of the stigma adhered to the patients, we have what we call ‘stigma by association’. It’s a prominent problem in the Chinese population that they have a lot of wrong concepts about mental illness.” 

Yet, there are claims that the medical system doesn’t adequately provide for people  with insomnia. Dr Chung feels that many GPs in Hong Kong are not sufficiently trained in basic psychiatry.  “If you go to a doctor, most of them will tell you to relax, and that’s it!” he says. “Many doctors, if not trained, think psychiatric problems are things that are easily reversible… they think that you are responsible for it. That’s one extreme. The other extreme is to prescribe you with hypnotics right away.” Shubkina has experienced this problem first hand. “It’s hard to find a good therapist here,” she says. “Some of them are not helpful at all. They just say ‘you need to be less nervous’ and it’s like… ‘Okay, thanks’.” 

As someone who treats long-term insomniacs, Chang is worried about the common use of hypnotic drugs in Hong Kong. “The medical council guidelines say that these should be prescribed for the shortest duration [necessary], but I see people who have been addicted to sleeping pills for years.” This trend is particularly worrying as, according to Chang, long-term use of these drugs is associated with cognitive impairment and poorer memory, as well as the early onset of dementia.  

So, why are people struggling to get adequate treatment for insomnia in Hong Kong? “In government clinics, I think time is a limitation,” says Chang. “It’s like going to McDonald’s! You only have five or six minutes for an appointment.  There may not be time to review the underlying problem. We have a fast-food culture way of dealing with insomnia – hypnotics are being prescribed and we are not being regulated enough by good pharmacists.”

Perhaps the most worrying aspect of all these sleepless nights is that it’s not just adults, stressed out by rent and jobs, who are suffering. Many of the experts agree that Hong Kong’s children are also suffering from stress-related insomnia. “Our new generations, they are overprotected by parents, and their ability to cope with stress and daily problems becomes diminished,” says Siu. “If they are faced with stress, it can cause some anxiety problems – this is quite a general phenomenon in Hong Kong.”

“I can see a lot of children not sleeping well,” agrees Chang. “They have more vivid dreams, meaning they aren’t in deep sleep, and have difficulty initiating sleep. That’s a reflection of their psychological health. They are being brought up in a more protective environment, but they have more stresses. I can foresee our new generation having more emotional problems.” 

 Ironically, the stresses of schoolwork on children may ultimately decrease their performance at school. Dr Lau’s own research has found a lack of sleep directly affects learning and academic performance in adolescents. “In a study of adolescents in high school, the average sleep duration in Hong Kong was far less than other countries,” she points out. “We have a problem.”

But will we ever really overhaul the prevailing attitudes in our work-obsessed city? “Some people treat short sleep as something great and they brag about it,” says Lau. “It’s a sign of hard work, being conscientious – people in Hong Kong are proud of having very little sleep and still performing. It’s totally problematic.” 

If Hong Kong is really a ticking time-bomb of over-medicated office workers and fatigued adolescents, we urgently need to start getting some more sleep. Luckily, there is hope. For those with primary insomnia, it’s shown that over 50 percent of cases can be cured by simple ‘sleep hygiene’ – the things your mum always told you to do. “We ask patients to get up and go to bed at a regular time, have comfortable bed sheets and pillows, have a comfortable temperature in the room as well as avoiding caffeine,” explains Siu. “We ask them to listen to soft music, do relaxation exercises, have a warm bath before sleep and also have a cup of warm milk.”

Siu continues, “even though it seems like common sense, I find that in this busy city, some people do not take sleep hygiene very seriously. Many people have an idea that they need to sleep until the afternoon to compensate for the previous night’s poor sleep. It’s very common to have such wrong concepts!”

For those who find sleep hygiene isn’t enough, sessions of cognitive behavioural therapy – available via GPs – can also cure a very high percentage of cases within weeks, without any need for medication. So it’s vitally important that more insomnia sufferers in Hong Kong feel able to seek the help that is available. As Chang puts it, “sleep is like a light on the dashboard on your car. If you have insomnia, it’s a signal that the stress level is too high or that you may be suffering from emotional problems – something is going wrong.”

For more info on dealing with insomnia and how to treat it, see bit.ly/InsomniaTOHK.