Abnormal cognitive effort allocation and its association with amotivation in first-episode psychosis.

BACKGROUND: Abnormal effort-based decision-making represents a potential mechanism underlying motivational deficits (amotivation) in psychotic disorders. Previous research identified effort allocation impairment in chronic schizophrenia and focused mostly on physical effort modality. No study has investigated cognitive effort allocation in first-episode psychosis (FEP). METHOD: Cognitive effort allocation was examined in 40 FEP patients and 44 demographically-matched healthy controls, using Cognitive Effort-Discounting (COGED) paradigm which quantified participants' willingness to expend cognitive effort in terms of explicit, continuous discounting of monetary rewards based on parametrically-varied cognitive demands (levels N of N-back task). Relationship between reward-discounting and amotivation was investigated. Group differences in reward-magnitude and effort-cost sensitivity, and differential associations of these sensitivity indices with amotivation were explored. RESULTS: Patients displayed significantly greater reward-discounting than controls. In particular, such discounting was most pronounced in patients with high levels of amotivation even when N-back performance and reward base amount were taken into consideration. Moreover, patients exhibited reduced reward-benefit sensitivity and effort-cost sensitivity relative to controls, and that decreased sensitivity to reward-benefit but not effort-cost was correlated with diminished motivation. Reward-discounting and sensitivity indices were generally unrelated to other symptom dimensions, antipsychotic dose and cognitive deficits. CONCLUSION: This study provides the first evidence of cognitive effort-based decision-making impairment in FEP, and indicates that decreased effort expenditure is associated with amotivation. Our findings further suggest that abnormal effort allocation and amotivation might primarily be related to blunted reward valuation. Prospective research is required to clarify the utility of effort-based measures in predicting amotivation and functional outcome in FEP.

Pulmonary Embolism as a Cause of Death in Psychiatric Inpatients: a Case Series.

We report four cases of fatal pulmonary embolism confirmed by autopsy among inpatients in a Hong Kong psychiatric hospital from 2010 to 2014. None of the four patients had a medical or premorbid condition associated with vascular thromboembolism or causing prolonged immobilisation. Only two patients were taking long-term antipsychotic medication, but all were physically restrained shortly before the event.

New Service Model for Common Mental Disorders in Hong Kong: a Retrospective Outcome Study.

OBJECTIVE: To review the first 8-month outcome of the Common Mental Disorder Clinic model in Hong Kong in terms of patient exit status and improvement in depressive and anxiety symptoms. METHODS: During the first appointment, patients were interviewed by a multidisciplinary team comprising a psychiatrist, a psychiatric nurse, and an occupational therapist. A multidisciplinary case conference was conducted to discuss clinical observations, diagnosis, issues of concern, and the optimal individualised treatment plan. Low-intensity interventions by nurses and/or occupational therapists were provided, as were optional, time-limited, protocol-based interventions by clinical psychologists for those with mild to moderate depressive and anxiety symptoms. Pharmacological intervention may be used when indicated. Upon completion of the treatment plan, patients were reassessed by the treating psychiatrist. Discharge options included discharge without psychiatric follow-up, step-up to psychiatric outpatient clinics, and step-down services. The self-administered Patient Health Questionnaire-9 (PHQ-9) and Generalised Anxiety Disorder 7-item scale (GAD-7) were used to assess the past 2 weeks' depressive and anxiety symptoms, respectively, at baseline and at each session. RESULTS: From July 2015 to February 2016, 1325 Chinese patients received the new service. Of them, 170 men and 363 women (mean age, 52.6 years) completed the treatment plan. After treatment, their mean PHQ-9 score decreased from 11.06 to 7.55 (p < 0.001), and the mean GAD-7 score decreased from 9.94 to 6.54 (p < 0.001). After treatment, 42.4% and 48.2% of the patients were within the normal range of PHQ-9 and GAD-7 scores, respectively, compared with 16.9% and 20.8% before treatment. The mean time to implementation of the individualised treatment plan was 82.33 days. Of the patients, 54.4% were discharged without any need for medical or psychiatric follow-up; 28% were stepped up to psychiatric outpatient clinics; and 17.3% were stepped down. The predictors of exit status were whether psychiatric medication was prescribed during initial intake (p = 0.011), whether psychiatric medication was prescribed at last follow-up (p < 0.001), the service period (p = 0.010), and the GAD-7 final score (p = 0.005). CONCLUSIONS: The first 8-month outcome of the new service model was encouraging, with shortened waiting time, reduced severity of symptoms, and better exit status (high recovery and step-down rates).

Outcome of a Knowledge Contact-based Anti-stigma Programme in Adolescents and Adults in the Chinese Population.

A lack of knowledge about mental health and stigma of the mentally ill are barriers to the treatment of mental disorders. To reduce these barriers, anti-stigma campaigns using a knowledge contact approach were launched to raise public mental health knowledge by education and to reduce stigma by encouraging contact with individuals with mental disorders. The current study attempted to investigate the outcome of a knowledge contact-based programme in adolescents and adults in the Hong Kong Chinese population. Matched background individuals served as controls. Results from the 149 adolescents and 98 adults who participated in our programme showed that they had superior mental health literacy to the control group. Although both adolescents and adults showed a positive outcome on most measures of stigma, the former showed positive outcome on more measures of stigma than the latter. Our results support the initiative of using a knowledge contact-based anti-stigma campaign in Chinese societies. The results of this study provide preliminary data that will help inform and guide future research and development of effective mental health awareness programmes specific to people of various age-groups in the Chinese community.

Direct trocar insertion technique: an alternative for creation of pneumoperitoneum.

OBJECTIVES: The direct trocar insertion technique (DTI) for the creation of pneumoperitoneum has been described as an alternative to open and Veress needle (VN) techniques. This study assesses the safety and feasibility of direct trocar insertion without a pre-existing pneumoperitoneum in patients undergoing elective laparoscopic procedures. METHODS: From November 2001 to February 2006, we retrospectively studied 196 (146 women and 50 men) consecutive patients. A single consultant laparoscopic surgeon performed all operations. The mean patient age was 57 years (range, 22 to 81). The procedures included 186 laparoscopic cholecystectomies, 3 laparoscopic appendectomies, 1 laparoscopic Nissen, 5 laparoscopic groin hernia repairs, and 1 conversion to open surgery. RESULTS: Creation of pneumoperitoneum with DTI was feasible in 99.5% of patients. No major complications were associated with the technique. Immediate minor postoperative complications included 1 (0.5%) wound infection and 3 (1.5%) hematomas. At mean follow-up of 23 months, 4 (2%) umbilical wound stitch granulomas and 1 (0.5%) incisional hernia from the umbilical port site were observed. CONCLUSION: This study shows that that when performed by an experienced laparoscopic surgeon the direct trocar insertion technique is a safe and effective alternative for creation of pneumoperitoneum.