Case report: Therapeutic potential of Flourishing-Life-Of-Wish Virtual Reality Therapy on Relaxation (FLOW-VRT-Relaxation)-a novel personalized relaxation in palliative care.

In view of the global aging population and growing need of palliative care, innovative intervention for effective symptom management is of urgent need. Flourishing-Life-Of-Wish Virtual Reality Therapy (FLOW-VRT) is a brief, structured, manualized, and personalized psychological intervention with theoretical foundations based on stress coping theory, self-determination theory, flow theory, and attention restoration theory. With a specific focus on relaxation, FLOW-VRT-Relaxation intends to facilitate adaptive end-of-life coping through delivering personalized relaxation. This paper reports a case study of the application of FLOW-VRT-Relaxation, and discusses its therapeutic potential as a cost-effective method for reducing palliative symptoms by addressing patient's unmet needs. The case study is a 51-year-old Chinese female, diagnosed with advanced cervix cancer, and presented with unmet psychological (i.e., unfulfilled wishes) and physical needs (i.e., pain and fatigue) before FLOW-VRT-Relaxation. To address her unmet needs, FLOW-VRT-Relaxation was delivered by a registered clinical psychologist specialized in palliative care. Need assessment was first conducted, followed by a 10-min VR travel of Japan as her own choice. Relaxation was verbally coached during VR. Right after VR, consolidation with psychological components including psychoeducation, cognitive and emotional processing, and reminiscence intervention were delivered. The patient showed improvement in physical and psychological symptoms, lower sense of loneliness and engulfment, as well as enhanced peace after FLOW-VRT-Relaxation. The current findings provide encouraging initial support for the feasibility, acceptability, and therapeutic potential of using FLOW-VRT-Relaxation as a cost-effective, scalable and personalized VR relaxation for patients under palliative care. It is hoped that with its optimal use, FLOW-VRT-Relaxation can serve as an alternative therapeutic tool that effectively improves the end-on-life care.

Effects of dietary and physical activity interventions on generic and cancer-specific health-related quality of life, anxiety, and depression in colorectal cancer survivors: a randomized controlled trial.

PURPOSE: To assess the effects of dietary and physical activity (PA) interventions on generic and cancer-specific quality of life (QoL), anxiety, and depression levels among adult Chinese colorectal cancer (CRC) survivors. METHODS: Two-hundred twenty-three adult CRC survivors within 1 year of completion of primary cancer treatment were randomized to receive dietary, PA or combined intervention, or usual care for a 12 monthduration, under a 2 (diet vs usual care) × 2 (PA vs usual care) factorial design. Generic and cancer-specific QoL was assessed using a Chinese version 12-Item Short Form Health Survey (SF-12) and the Functional Assessment of Cancer Therapy-Colorectal (FACT-C) scale, respectively. Anxiety and depression was assessed using the Hospital Anxiety and Depression Scale at baseline, 6, 12, 18, and 24 months. Linear mixed models were used for examining the intervention effects. RESULTS: Participants receiving dietary intervention experienced a significant improvement in the generic measure of QoL (SF-6D utility scores, mean difference 0.042, 95%CI 0.03 to 0.081) at 12 months, the cancer-specific QoL scores (mean difference 3.09, 95%CI 0.13 to 6.04), and levels of depression (P = 0.015) at both 12 and 24 months follow-up. Participants receiving PA intervention only demonstrated a significant improvement in SF-6D utility index (mean difference 0.039, 95%CI 0.002 to 0.077) and physical functioning (mean difference 2.85, 95%CI 1.00 to 4.70) at 6 months. CONCLUSIONS: Dietary intervention improved the generic and cancer-specific QoL and depression in CRC survivors. TRIAL REGISTRATION: The study was prospectively registered on 17 October 2012 at ClinicalTrials.gov (NCT01708824). IMPLICATIONS FOR CANCER SURVIVORS: CRC survivors can benefit from dietary interventions in alleviating depression and improving overall health-related QoL.

Course, risk factors, and adverse outcomes of disordered eating in pregnancy.

OBJECTIVE: Although eating disorders in pregnancy have been studied extensively, little research attention has been given to disordered eating. The objectives of the present study were to determine the prevalence and levels of disordered eating in the perinatal period, and to identify risk factors and adverse outcomes of disordered eating during pregnancy. METHOD: A prospective longitudinal design with a quantitative approach was adopted. A consecutive sample of 1,470 Chinese pregnant women from hospitals in Hong Kong was assessed using standardized instruments at five time points from the first trimester to 6 months postpartum. RESULTS: The levels of disordered eating changed significantly across trimesters. Higher levels of disordered eating in pregnancy were significantly associated with higher levels of disordered eating at 6 weeks and 6 months postpartum, greater anxiety and depressive symptoms, lower 1-min Apgar scores, and abnormal birth weight. DISCUSSION: The present study pointed to the need for more research and clinical attention to antenatal disordered eating given that it is associated with anxiety, depression, postpartum disordered eating and obstetric outcomes.

Dietary and Physical Activity Interventions for Colorectal Cancer Survivors: A Randomized Controlled Trial.

There has been evidence on the protective effects of diets high in fiber and low in red and processed meat (RPM), and physical activity (PA) against colorectal cancer (CRC) development, but that against CRC recurrence has been limited. This study evaluated the efficacy of a behavioral program comprising dietary and PA interventions in improving Chinese CRC survivors' lifestyle. A 2 × 2 factorial randomized controlled trial of 223 CRC patients (82 females, mean age 65), randomly assigned to receive dietary, PA or both interventions, or usual care for 12 months, and assessed every 6 months for 24 months. Primary outcomes included two dietary and two PA targets. Secondary outcomes included changes in dietary consumptions and PA levels. Dietary interventions significantly increased the odds of achieving the targets of consuming less RPM at all time-points (OR 3.22-4.57, all p < 0.01) and refined grain (RG) at months 6 (OR 3.13, p = 0.002) and 24 (OR 2.19, p = 0.039), and reduced RPM (2.49-3.48 servings/week, all p < 0.01) and RG (0.31-0.5 servings/day, all p < 0.01) consumptions. Patients receiving PA interventions potentially spent more time on moderate-to-vigorous PA. This study demonstrated the efficacy of a behavioral program in improving dietary habits of Chinese CRC survivors.

Validity of the Cantonese Chinese Montreal Cognitive Assessment in Southern Chinese.

AIM: The objective of the present study was to investigate the reliability and the validity of the Cantonese Chinese Montreal Cognitive Assessment (MoCA) as a brief screening tool of amnestic mild cognitive impairment (aMCI) and Alzheimer's disease (AD) in Southern Chinese older adults. METHODS: Cognitively normal, aMCI and AD Cantonese-speaking Chinese older adults were recruited from a memory clinic and the community. The English MoCA was translated into Cantonese Chinese and then back-translated. We then evaluated the content validity, reliability, sensitivity and specificity of the Chinese Cantonese MoCA. RESULTS: We recruited 115 cognitively normal controls, 87 aMCI and 64 AD patients. Only education was positively correlated with the Cantonese MoCA score (r = 0.46, P < 0.001). The Chinese Cantonese MoCA had a high internal consistency with a Cronbach's alpha of 0.85. In the test-retest reliability assessment, the intraclass correlation coefficient (ICC) was 0.95 (P < 0.001). The ICC for the interrater reliability was 0.96 (P < 0.001). Receiving operating characteristic curve analyses showed an area under the curve of 0.85 and 0.99 for aMCI and AD, respectively (both P < 0.001). The optimal cut-off score for detection of aMCI was 22/23, which yielded a sensitivity and specificity of 78% and 73%, respectively. The optimal cut-off score for detection of AD was 19/20, which gave sensitivity and specificity of 94% and 92%, respectively. CONCLUSION: The Cantonese Chinese MoCA is a consistent and reliable instrument. In terms of its validity, the MoCA is better in the detection of AD than aMCI in Cantonese-speaking Chinese persons. It is only fair for the screening of aMCI.

Study protocol for "Moving Bright, Eating Smart"- A phase 2 clinical trial on the acceptability and feasibility of a diet and physical activity intervention to prevent recurrence in colorectal cancer survivors.

BACKGROUND: Colorectal cancer is the second most common cancer and cancer-killer in Hong Kong with an alarming increasing incidence in recent years. The latest World Cancer Research Fund report concluded that foods low in fibre, and high in red and processed meat cause colorectal cancer whereas physical activity protects against colon cancer. Yet, the influence of these lifestyle factors on cancer outcome is largely unknown even though cancer survivors are eager for lifestyle modifications. Observational studies suggested that low intake of a Western-pattern diet and high physical activity level reduced colorectal cancer mortality. The Theory of Planned Behaviour and the Health Action Process Approach have guided the design of intervention models targeting a wide range of health-related behaviours. METHODS/DESIGN: We aim to demonstrate the feasibility of two behavioural interventions intended to improve colorectal cancer outcome and which are designed to increase physical activity level and reduce consumption of a Western-pattern diet. This three year study will be a multicentre, randomised controlled trial in a 2x2 factorial design comparing the "Moving Bright, Eating Smart" (physical activity and diet) programme against usual care. Subjects will be recruited over a 12-month period, undertake intervention for 12 months and followed up for a further 12 months. Baseline, interim and three post-intervention assessments will be conducted.Two hundred and twenty-two colorectal cancer patients who completed curative treatment without evidence of recurrence will be recruited into the study. Primary outcome measure will be whether physical activity and dietary targets are met at the end of the 12-month intervention. Secondary outcome measures include the magnitude and mechanism of behavioural change, the degree and determinants of compliance, and the additional health benefits and side effects of the intervention. DISCUSSION: The results of this study will establish the feasibility of targeting the two behaviours (diet and physical activity) and demonstrate the magnitude of behaviour change. The information will facilitate the design of a further larger phase III randomised controlled trial with colorectal cancer outcome as the study endpoint to determine whether this intervention model would reduce colorectal cancer recurrence and mortality. TRIAL REGISTRATION: ClinicalTrials.gov No: NCT01708824.

Culturally sensitive, preventive antenatal group cognitive-behavioural therapy for Chinese women with depression.

Postnatal depression (PND) affects 10-15% of postnatal women worldwide, yet it is poorly recognized and managed. Among the psychological interventions, which are used to manage PND, cognitive-behavioural therapy was found to be effective and promising. In the past decade, research efforts have focused on developing effective antenatal interventions to prevent PND. Strong antenatal predictors such as antenatal depressive symptoms have been identified for targeted early intervention or prevention to help reduce the risk of developing depression after childbirth. However, the findings regarding effectiveness of antenatal preventive interventions have been inconsistent. Based on the reports of previous studies, a brief group antenatal intervention using cognitive-behavioural approach is necessary, particularly one with sensitivity for Chinese woman. This paper reports the details of a nurse-led cognitive-behavioural programme developed and tested in, and for use with a sample of Hong Kong pregnant women. The trial run showed that the programme was feasible to be implemented and well received by the participants.

Physical activity for cancer survivors: meta-analysis of randomised controlled trials.

OBJECTIVE: To systematically evaluate the effects of physical activity in adult patients after completion of main treatment related to cancer. DESIGN: Meta-analysis of randomised controlled trials with data extraction and quality assessment performed independently by two researchers. DATA SOURCES: Pubmed, CINAHL, and Google Scholar from the earliest possible year to September 2011. References from meta-analyses and reviews. STUDY SELECTION: Randomised controlled trials that assessed the effects of physical activity in adults who had completed their main cancer treatment, except hormonal treatment. RESULTS: There were 34 randomised controlled trials, of which 22 (65%) focused on patients with breast cancer, and 48 outcomes in our meta-analysis. Twenty two studies assessed aerobic exercise, and four also included resistance or strength training. The median duration of physical activity was 13 weeks (range 3-60 weeks). Most control groups were considered sedentary or were assigned no exercise. Based on studies on patients with breast cancer, physical activity was associated with improvements in insulin-like growth factor-I, bench press, leg press, fatigue, depression, and quality of life. When we combined studies on different types of cancer, we found significant improvements in body mass index (BMI), body weight, peak oxygen consumption, peak power output, distance walked in six minutes, right handgrip strength, and quality of life. Sources of study heterogeneity included age, study quality, study size, and type and duration of physical activity. Publication bias did not alter our conclusions. CONCLUSIONS: Physical activity has positive effects on physiology, body composition, physical functions, psychological outcomes, and quality of life in patients after treatment for breast cancer. When patients with cancer other than breast cancer were also included, physical activity was associated with reduced BMI and body weight, increased peak oxygen consumption and peak power output, and improved quality of life.

Psychometric evaluation of the Hospital Anxiety and Depression Scale in a large community sample of adolescents in Hong Kong.

PURPOSE: The Hospital Anxiety and Depression Scale (HADS) is widely used in adult populations; however, its usefulness with adolescents has been explored less. This study sought to evaluate the reliability, validity, and factor structure of the Chinese version of HADS in a community sample of adolescents residing in Hong Kong. METHODS: A prospective cohort of 5,857 students recruited from 17 secondary schools completed the HADS. Internal consistency and concurrent validity were examined. Confirmatory factor analysis was applied to test the relative fits of six factor structures of the HADS. The best fitting model was further cross-validated by male, female, split-half samples, and age subgroups. RESULTS: The HADS possessed adequate internal consistency, especially for the anxiety subscale. Significant concurrent intercorrelations with self-reported suicidal thoughts and the Youth Self Report Anxious/Depressed subscale were discovered and found to be stronger for females. The cross-validation supported a two-factor model, where anxiety item 7, "I can sit at ease and feel relaxed", was placed in the depression subscale. CONCLUSIONS: The HADS showed satisfactory psychometric properties as a screening instrument in assessing anxious and depressive states as two correlated but distinct factors in adolescents. Study implications and recommendations for future research were discussed.

A culturally sensitive study of premenstrual and menstrual symptoms among Chinese women.

This is a two-part study of perimenstrual symptomatology in Chinese women. We developed and validated the Chinese Questionnaire of Perimenstrual Symptoms (CQ-PERI-MS), which was adapted from the Moos Menstrual Distress Questionnaire, and used this instrument to assess the prevalence and nature of perimenstrual symptoms among Chinese women in Hong Kong. The initial CQ-PERI-MS was first administered to a sample of 538 menstruating Chinese women in Hong Kong together with measures of anxiety, depression and neuroticism. Psychometric analyses rendered a 32-item CQ-PERI-MS which demonstrated good reliability, convergent and discriminant validity, and factorial validity. Four factors were yielded, namely, Dysphoria, Somatic distress, Cognitive problems and Arousal. The CQ-PERI-MS was then administered to a separate sample of 339 menstruating Chinese women in Hong Kong for further examination of validity as well as pattern of perimenstrual symptoms. It was found that perimenstrual symptoms were common, with 18.6% and 34.2% of the participants reporting 10 or more premenstrual and menstrual symptoms, respectively. Both premenstrual and menstrual distress were characterised by a combination of emotional and somatic symptoms. Contrary to previous preconceptions, perimenstrual symptoms are commonly experienced by Chinese women, with both overlapping and distinct features when compared with patterns in the West.

Prevalence, course, and risk factors for antenatal anxiety and depression.

OBJECTIVE: To estimate the prevalence and course of antenatal anxiety and depression across different stages of pregnancy, risk factors at each stage, and the relationship between antenatal anxiety and depression and postpartum depression. METHODS: A consecutive sample of 357 pregnant women in an antenatal clinic in a regional hospital was assessed longitudinally at four stages of pregnancy: first trimester, second trimester, third trimester, and 6 weeks postpartum. The antenatal questionnaire assessed anxiety and depression (using the Hospital Anxiety and Depression Scale) and demographic and psychosocial risk factors. The postpartum questionnaire assessed postpartum depression with the Edinburgh Postnatal Depression Scale. RESULTS: More than one half (54%) and more than one third (37.1%) of the women had antenatal anxiety and depressive symptoms, respectively, in at least one antenatal assessment. Anxiety was more prevalent than depression at all stages. A mixed-effects model showed that both conditions had a nonlinear changing course (P<.05 for both), with both being more prevalent and severe in the first and third trimesters. Risk factors were slightly different at different stages. Both antenatal anxiety (adjusted odds ratio [OR] 2.66, P=.004 in the first trimester; adjusted OR 3.65, P<.001 in the second trimester; adjusted OR 3.84, P<.001 in the third trimester) and depression (adjusted OR 4.16, P<.001 in the first trimester; adjusted OR 3.35, P=.001 in the second trimester; adjusted OR 2.67, P=.009 in the third trimester) increased the risk of postpartum depression. CONCLUSION: Antenatal anxiety and depression are prevalent and serious problems with changing courses. Continuous assessment over the course of pregnancy is warranted. Identifying and treating these problems is important in preventing postpartum depression. LEVEL OF EVIDENCE: II.

Disorientation and reconstruction:the meaning searching pathways of patients with colorectal cancer.

This study examines psychosocial difficulties faced by Chinese patients with colorectal cancer, and attempts to identify factors that contribute to the meaning searching process that in turn brings about growth and transformation. Twenty-six patients with colorectal cancer were interviewed. Data were analyzed using the constant comparative method. Two domains of psychosocial disorientation states were identified, namely, cognitive disorientation and emotional disorientation. Factors that facilitate meaning searching were identified and categorized into personal factors and external factors. The areas of growth and transformation through meaning searching were presented with narratives. Findings from the present study not only shed light on psychosocial hindrances among colorectal cancer patients but also have the potential to inform the design of intervention strategies to bring about meaning-orientated transformation through cancer experiences.

Stress and psychological distress among SARS survivors 1 year after the outbreak.

OBJECTIVE: Our study examined the stress level and psychological distress of severe acute respiratory syndrome (SARS) survivors 1 year after the outbreak. METHOD: During the SARS outbreak in 2003, we used the 10-item Perceived Stress Scale (PSS-10) to assess SARS survivors treated in 2 major hospitals (non-health care workers, n = 49; health care workers, n = 30). We invited SARS survivors from the same hospitals (non-health care workers, n = 63; health care workers, n = 33) to complete the PSS-10 again in 2004. At that time, they were also asked to complete the General Health Questionnaire (GHQ-12) and measures of depression, anxiety, and posttraumatic symptoms. PSS-10 scores were also obtained from matched community control subjects during the outbreak (n = 145) and again in 2004 (n = 112). RESULTS: SARS survivors had higher stress levels during the outbreak, compared with control subjects (PSS-10 scores = 19.8 and 17.9, respectively; P < 0.01), and this persisted 1 year later (PSS-10 scores = 19.9 and 17.3, respectively; P < 0.01) without signs of decrease. In 2004, SARS survivors also showed worrying levels of depression, anxiety, and posttraumatic symptoms. An alarming proportion (64%) scored above the GHQ-12 cut-off that suggests psychiatric morbidity. During the outbreak, health care worker SARS survivors had stress levels similar to those of non-health care workers, but health care workers showed significantly higher stress levels in 2004 (PSS-10 score = 22.8, compared with PSS-10 score = 18.4; P < 0.05) and had higher depression, anxiety, posttraumatic symptoms, and GHQ-12 scores. CONCLUSIONS: One year after the outbreak, SARS survivors still had elevated stress levels and worrying levels of psychological distress. The situation of health care worker SARS survivors is particularly worrying. The long-term psychological implications of infectious diseases should not be ignored. Mental health services could play an important role in rehabilitation.

Immediate and sustained psychological impact of an emerging infectious disease outbreak on health care workers.

OBJECTIVE: To assess the immediate and sustained psychological health of health care workers who were at high risk of exposure during the severe acute respiratory syndrome (SARS) outbreak. METHODS: At the peak of the 2003 SARS outbreak, we assessed health care workers in 2 acute care Hong Kong general hospitals with the Perceived Stress Scale (PSS-10). One year later, we reassessed these health care workers with the PSS-10, the 21-Item Depression and Anxiety Scale (DASS-21), and the Impact of Events Scale-Revised (IES-R). We recruited high-risk health care workers who practised respiratory medicine and compared them with nonrespiratory medicine workers, who formed the low-risk health care worker control group. RESULTS: In 2003, high-risk health care workers had elevated stress levels (PSS-10 score = 17.0) that were not significantly different from levels in low-risk health care worker control subjects (PSS-10 score = 15.9). More high-risk health care workers reported fatigue, poor sleep, worry about health, and fear of social contact, despite their confidence in infection-control measures. By 2004, however, stress levels in the high-risk group were not only higher (PSS-10 score = 18.6) but also significantly higher than scores among low-risk health care worker control subjects (PSS-10 score = 14.8, P < 0.05). In 2004, the perceived stress levels in the high-risk group were associated with higher depression, anxiety, and posttraumatic stress scores (P < 0.001). Posttraumatic stress scores were a partial mediator of the relation between the high risk of exposure to SARS and higher perceived stress. CONCLUSIONS: Health care workers who were at high risk of contracting SARS appear not only to have chronic stress but also higher levels of depression and anxiety. Front-line staff could benefit from stress management as part of preparation for future outbreaks.

Group debriefing for people with chronic diseases during the SARS pandemic: Strength-Focused and Meaning-Oriented Approach for Resilience and Transformation (SMART).

This study presented preliminary results on the efficacy of a novel group debriefing model called Strength-Focused and Meaning-Oriented Approach for Resilience and Transformation (SMART). The SMART debriefing (1) aimed at boosting resilience and catalyzing transformation among persons undergoing stressful events, (2) adopted a growth-oriented and holistic approach of health promotion, and (3) employed methods drawn from various indigenous sources (e.g. Asian philosophies and Traditional Chinese Medicine). Participants (N=51) were people with chronic diseases recruited about 1 month (August 2003) after the Severe Acute Respiratory Syndrome (SARS) outbreak was eventually under control, after causing widespread panic in Hong Kong. After the one-day group debriefing, participants showed significant decrease in depression level, as measured by Brief Symptom Inventory (Derogatis & Melisaratos, 1983, Psychological Medicine, 13(3), 595-605) and changes in cognitive appraisal towards SARS. Such changes were sustained in a 1-month follow-up. Clinical implications and directions for further study were discussed.

Role occupancy, role quality, and psychological distress in Chinese women.

This study explored the associations between role occupancy, role quality, and psychological distress in 897 Chinese women in Hong Kong. Results showed that employed as compared to nonemployed women reported a lower level of psychological distress. Never married as compared to married women, and mothers as compared to childless women, did not differ in their levels of psychological symptoms. Correlation results indicated that a net gain of rewards over concerns about social roles was negatively related to psychological distress. The number of social roles was related to the balance between rewards and concerns between social roles, but had no significant association with mental health status of women. Results of the hierarchical regression analyses showed that good mother role quality and the occupancy of the paid worker role were significant predictors of a low level of psychological distress. Findings based on a subsample of employed mothers failed to support the compensatory and spillover hypotheses. Limitations and implications for future studies were discussed.