Performance of the 6-item Kessler scale for measuring serious mental illness in Hong Kong.

BACKGROUND: The 6-item Kessler scale (K6) promises to be a valuable epidemiological tool for assessing serious mental illness (SMI) in communities with limited resources for psychiatric research and treatment. Its performance in Chinese community has not been studied with reference to clinically assessed SMI. METHOD: From a representative telephone-based population survey (n = 3014) that administered the K6, 153 participants were readministered the K6 and, on the same day, interviewed face-to-face by clinicians using the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorder, Fourth Edition, Axis I Disorder. Predictive indicators such as McNemar χ(2), area under receiver operating characteristic curve and stratum-specific likelihood ratios were used to investigate the concordance between the K6 and clinical status of SMI, individual-level predicted probabilities of having SMI, and the weighted prevalence of SMI in the community. RESULT: The K6 exhibited high internal consistency and test-retest reliability. Factor analysis revealed 2 correlating components composed of depression and anxiety. Matching of K6 caseness and SMI status showed that at the cutoff of 12/13, the area under receiver operating characteristic curve was moderate (0.69). The K6 had high specificity and was a stronger screen-out than screen-in tool for SMI. The weighted prevalence estimate of SMI in Hong Kong was 6.5%. A person scoring 13 or above on the K6 has a probability of at least 22.2% of having SMI. CONCLUSION: The Chinese K6 is reliable and generates the likelihood of SMI with substantial concordance with face-to-face clinical interviews in Hong Kong. It is a valuable tool for screening SMI, behavioral risk factor surveillance, and community epidemiological surveys.

A general population study of the Chinese Whiteley-7 index in Hong Kong.

OBJECTIVE: To examine the psychometric properties of the Chinese seven-item Whiteley Index (WI-7) in the general population of Hong Kong. METHODS: A random community-based telephone survey of 3014 respondents aged 15-65 was conducted using a fully structured questionnaire that included the WI-7, 15-item Patient Health Questionnaire (PHQ-15), Sheehan Disability Scale (SDS), and items about the frequency of health service use, perceived helpfulness of doctors, level of satisfaction with doctors, and sociodemographic variables. A sub-sample of 199 respondents was re-interviewed to assess test-retest reliability. RESULTS: The WI-7 exhibited satisfactory internal consistency (Cronbach's α=0.73) and stable one-month test-retest reliability. The most commonly endorsed item was "worrying a lot about one's health" (55.7%), followed by "worrying about getting the disease oneself if it is brought to his/her attention" (48.7%) and "bothered by many different pains and aches" (33.9%). Age, gender, and monthly family income significantly predicted WI-7 score. Confirmatory factor analysis revealed that a 2-factor structure was superior to a 1-factor structure in fitting the data. WI-7 total score was positively associated with PHQ-15 somatic distress, SDS impairment, number of healthcare visits, lower levels of perceived helpfulness of doctors and of satisfaction with doctors. CONCLUSION: The Chinese WI-7 exhibits satisfactory reliability and internal validity in a general population. It is a promising tool for the empirical examination of health anxiety which is a common experience with a mostly typical epidemiological profile among Chinese people in Hong Kong.

Premarital mental disorders and physical violence in marriage: cross-national study of married couples.

BACKGROUND: Mental disorders may increase the risk of physical violence among married couples. AIMS: To estimate associations between premarital mental disorders and marital violence in a cross-national sample of married couples. METHOD: A total of 1821 married couples (3642 individuals) from 11 countries were interviewed as part of the World Health Organization's World Mental Health Survey Initiative. Sixteen mental disorders with onset prior to marriage were examined as predictors of marital violence reported by either spouse. RESULTS: Any physical violence was reported by one or both spouses in 20% of couples, and was associated with husbands' externalising disorders (OR = 1.7, 95% CI 1.2-2.3). Overall, the population attributable risk for marital violence related to premarital mental disorders was estimated to be 17.2%. CONCLUSIONS: Husbands' externalising disorders had a modest but consistent association with marital violence across diverse countries. This finding has implications for the development of targeted interventions to reduce risk of marital violence.

Psychometric properties of the Chinese 15-item patient health questionnaire in the general population of Hong Kong.

OBJECTIVE: The objective was to examine the reliability and validity of the Chinese 15-item Patient Health Questionnaire (PHQ-15) in the general population of Hong Kong. METHODS: A random community-based sample of 3014 respondents aged 15-65 was interviewed through telephone using a structured Chinese-language questionnaire that included the PHQ-15, Sheehan Disability Scale, questions about health service use and sociodemographic variables. A random subsample of 200 respondents was reinterviewed for assessing test-retest reliability. RESULTS: The PHQ-15 exhibited satisfactory internal consistency (Cronbach's α=0.79) and stable 1-month test-retest reliability. Being female, younger age, lower education and lower income levels were associated with higher scores. "Bothered a lot" somatic symptoms were less common than in clinical studies, but their general profile was comparable to those found in Western community studies. Pains in the limbs, trouble sleeping and feeling tired (11.2%-16.9%) were the most common, whereas fainting spells and sexual problems (0.6%-0.7%) were the least so. Using principal component analysis, we extracted four clinically meaningful factors that explained 49.7% of the variance. These factors might be termed "cardiopulmonary," "gastrointestinal," "pain" and "neurological." Somatic symptom severity was positively associated with functional impairment and health service use. CONCLUSION: The Chinese PHQ-15 exhibits satisfactory reliability and preliminary evidence of validity in a general population. Revealing a typical profile of somatic symptom severity, it is a promising tool for the empirical examination of somatization in Chinese people.

Psychiatric epidemiological surveys in China 1960-2010: how real is the increase of mental disorders?

PURPOSE OF REVIEW: Community psychiatric epidemiological surveys over the last five decades have revealed a dramatic increase in the prevalence of mental disorders in China. This article summarizes the main surveys and attempts to interpret the increase of prevalence from a methodological perspective. RECENT FINDINGS: Regional and national surveys conducted in China during 1960-1990 focused on severe mental disorders and revealed very low and stable rates of disorders. By contrast, those performed in the last decade, whether psychiatrists or lay interviewers were used, have shown much higher and more 'reliable' rates comparable to those found in high-income countries. This is especially so for depression and anxiety disorders. SUMMARY: Given the sociopolitical turmoil that had previously plagued people in China, the dramatic rise in prevalence estimates of mental disorders in recent years cannot be simply interpreted as a substantive deterioration of mental health following rapid social change. Global and local factors that shape research methodology aimed at showing that mental disorders are common may play an important role in the dramatic increase. Future research in China should move beyond descriptive epidemiology. It should also address policy relevant issues in view of the limited resources available for mental health interventions.

A community study of generalized anxiety disorder with vs. without health anxiety in Hong Kong.

BACKGROUND: Although generalized anxiety disorder (GAD) is characterized by multiple worries, anxiety about one's health is absent in the DSM-IV description of the illness. METHOD: A random community-based telephone survey (N = 2005) that covered DSM-IV symptoms of GAD, two core symptoms of major depression, Rome-III criteria of Irritable Bowel Syndrome (IBS), Sheehan Disability Scale (SDS), and help-seeking behavior was conducted. RESULTS: The 1-year prevalence of 3-month GAD was 5.4%. Among affected individuals, 78.9% reported worry about personal health while 21.1% did not. The former subgroup was significantly older, had higher mean numbers of associated anxiety symptoms and worries, more likely to have worry about finances and sought professional help than the latter subgroup. The two subgroups had similar sex distribution, core depressive symptoms, IBS, distress and SDS impairment profiles. CONCLUSION: Health anxiety is common in GAD. Some but not all illness severity indicators differed between GAD with and without health anxiety.

Community-based co-morbidity of depression and chronic physical illnesses in Hong Kong.

OBJECTIVE: To examine the co-morbidity of depression and chronic physical illnesses in a representative sample of Hong Kong Chinese. METHODS: Five thousand and four participants aged 18-65 years completed a structured telephone interview on major depressive episode (MDE) and eight chronic physical illnesses. RESULTS: 21.5% (N = 1078) of respondents had any physical illness in the previous 1 year. Twelve-month MDE was found in 15% (N = 162) of these physically ill respondents and was significantly associated with physical illnesses (OR: 2.56, 95% CI: 2.07-3.16, p < 0.001). Number of co-morbid physical illnesses had an incremental association with the risk of MDE. CONCLUSION: Co-morbidity of depression and chronic physical illnesses is common in Hong Kong as in Western countries. This speaks to the need for evidence-based practice that encompasses models of integrated care in Hong Kong.

Perceived barriers to mental health treatment in metropolitan China.

OBJECTIVES: This community-based study examined perceived barriers to the initiation of mental health treatment among individuals with anxiety, mood, and alcohol use disorders. METHODS: Face-to-face interviews were conducted with 5,201 respondents in Beijing and Shanghai using the World Mental Health Composite International Diagnostic Interview. Perceived barriers to initiating treatment from various health practitioners were examined among 211 individuals who met criteria for 12-month DSM-IV disorders and did not receive treatment. RESULTS: Most respondents (92%) with DSM-IV disorders perceived a low need for treatment. Among respondents who perceived a need, 47% reported structural barriers and 83% reported attitudinal barriers. Respondents who had severe mental disorders and perceived a need reported more structural barriers (72%) than attitudinal barriers (65%). Lack of knowledge about service availability was the most common structural barrier. CONCLUSIONS: Future studies should examine the reasons for perceived low need for treatment and other treatment barriers among people with mental disorders.

Childhood adversities and adult psychopathology in the WHO World Mental Health Surveys.

BACKGROUND: Although significant associations of childhood adversities with adult mental disorders are widely documented, most studies focus on single childhood adversities predicting single disorders. AIMS: To examine joint associations of 12 childhood adversities with first onset of 20 DSM-IV disorders in World Mental Health (WMH) Surveys in 21 countries. METHOD: Nationally or regionally representative surveys of 51 945 adults assessed childhood adversities and lifetime DSM-IV disorders with the WHO Composite International Diagnostic Interview (CIDI). RESULTS: Childhood adversities were highly prevalent and interrelated. Childhood adversities associated with maladaptive family functioning (e.g. parental mental illness, child abuse, neglect) were the strongest predictors of disorders. Co-occurring childhood adversities associated with maladaptive family functioning had significant subadditive predictive associations and little specificity across disorders. Childhood adversities account for 29.8% of all disorders across countries. CONCLUSIONS: Childhood adversities have strong associations with all classes of disorders at all life-course stages in all groups of WMH countries. Long-term associations imply the existence of as-yet undetermined mediators.

Childhood adversities as risk factors for onset and persistence of suicidal behaviour.

BACKGROUND: Suicide is a leading cause of death worldwide, but the precise effect of childhood adversities as risk factors for the onset and persistence of suicidal behaviour (suicide ideation, plans and attempts) are not well understood. AIMS: To examine the associations between childhood adversities as risk factors for the onset and persistence of suicidal behaviour across 21 countries worldwide. METHOD: Respondents from nationally representative samples (n = 55 299) were interviewed regarding childhood adversities that occurred before the age of 18 years and lifetime suicidal behaviour. RESULTS: Childhood adversities were associated with an increased risk of suicide attempt and ideation in both bivariate and multivariate models (odds ratio range 1.2-5.7). The risk increased with the number of adversities experienced, but at a decreasing rate. Sexual and physical abuse were consistently the strongest risk factors for both the onset and persistence of suicidal behaviour, especially during adolescence. Associations remained similar after additional adjustment for respondents' lifetime mental disorder status. CONCLUSIONS: Childhood adversities (especially intrusive or aggressive adversities) are powerful predictors of the onset and persistence of suicidal behaviours.

A population-based study on the prevalence and correlates of drinking and driving in Hong Kong.

To examine the prevalence and correlates of drinking and driving in Hong Kong, an anonymous, random telephone survey was conducted on 9860 Chinese adults (18-70 years of age) from April to June 2006. Trained interviewers administered a structured interview consisting of questions on socio-demographic information, drinking pattern, drink-driving, and motor vehicle accidents. The census age-standardized past-year prevalence of driving within 2h of drinking was 5.2% among males and 0.8% among females. The prevalence across age showed an inverted U-shaped trend for males peaking at 8.2% between 41 and 45 years. For females the prevalence was fairly stable between the ages of 20 and 55. The past-year prevalence of alcohol-related motor vehicle accidents was 0.1%, with the majority being in the 26-30 age group. For males who drank, the prevalence of drinking and driving was 5.0% among those without problem drinking, 14.8% among binge drinkers, 37.1% among alcohol abusers and 22.4% among the alcohol dependent. For females who drank, the corresponding figures were all lower at 1.2%, 6.9%, 12.1% and 12.5%, respectively. Higher socio-economic status, weekly drinking, binge drinking and alcohol abuse were independently associated with higher likelihood of drinking and driving in both genders. Among drinking drivers, having a job that required drinking was the only predictor of having had a motor vehicle accident. The elevated prevalence of drinking and driving among alcohol abusers, binge drinkers and the alcohol dependent may portend higher population-level rates of alcohol-related motor accidents in the future since the prevalence of problem drinking has previously been noted to be increasing rapidly in Hong Kong.

Concordance between telephone survey classification and face-to-face interview diagnosis of one-year major depressive episode in Hong Kong.

BACKGROUND: Community-based telephone surveys of depression have generated reliable findings but their concordance with standardized clinical diagnostic interviews is uncommonly examined, especially in non-western populations. METHOD: 106 consenting participants from a previous telephone-based population survey of major depressive episode (MDE) using a structured questionnaire were re-assessed face-to-face by clinical interviewers using the Structured Clinical Interview for DSM-IV Axis I Disorder (SCID-I). Receiver operating characteristic and other predictive indicators were used to investigate the concordance between the telephone survey instrument and SCID interview. RESULT: The telephone survey instrument adequately classified MDE when the DSM-IV symptom number standard was fulfilled at moderate to severe levels of distress and impairment. It performed best when the cut-off was set at a severe level of distress or impairment in any one of four domains of functioning (AUC=0.76). Feeling useless, fatigue, loss of motivation and difficulty in concentration were the most prominent items for increasing the certainty of SCID-MDE diagnosis. CONCLUSION: Classification of MDE by telephone-based structured interview of MDE exhibited generally good agreement with face-to-face clinical interview diagnosis in the Chinese population of Hong Kong. Further research on the telephone-based methodology should address inter-rater reliability, specificity of diagnosis, and variability of concordance across different mental disorder diagnoses and criteria of clinically significant impairment.

Individual and societal impact on earnings associated with serious mental illness in metropolitan China.

To evaluate individual-level and societal-level losses of income associated with serious mental illness in metropolitan China, a multi-stage probability survey was administered to adults aged 18-70 years in Beijing and Shanghai. We used data to estimate individual-level expected earnings from a model that included information about the respondents' education level, marital status, age, and gender. Expected earnings were compared to observed earnings among respondents with mental illness and serious disability. The result shows that the 12-month prevalence of such serious mental illness was 0.6%. Its impact on earnings was significant in the total sample and was higher for males (76% of gender-specific expected salary was lost) than for females (32%). When projected to societal level, the annual impact was estimated to be 466 million Renminbi (RMB 8.27=USD 1), less than 0.2% of the gross domestic product (GDP) of the two cities. Serious mental illness was associated with a substantial decrease in individual-level earnings, but the burden that resulted from societal-level loss of earnings was not large enough to help drive mental health policy and programs in China.

Evidence for the 2008 economic crisis exacerbating depression in Hong Kong.

BACKGROUND: There is a lack of population-level research on the relationship between economic contraction and specific mental disorders and how individual-level variables may mediate such a relationship. METHODS: Two cross-sectional surveys using identical random sampling and diagnostic methods were conducted among Hong Kong adults in 2007 (January-February) and 2009 (April-May). 3016 and 2011 Chinese speaking adults completed structured interviews based on the criteria of Diagnostic and Statistical Manual of Mental Disorders (4th edition) (DSM-IV). RESULTS: The twelve-month prevalence of DSM-IV major depressive episode (MDE) was significantly higher in 2009 (12.5%) than 2007 (8.5%). A significant increase of prevalence was found in both male and female respondents, those in the highest (55-65 years) age group, having secondary education level, were married/cohabited, divorced/widowed, employed, home-making, and in the lowest and high-middle income groups. Those with large investment loss had a significantly higher prevalence of MDE (20.3%) than those with less or no-investment loss (9.2-13.7%). The symptom pattern and severity of depression in 2007 and 2009 were similar. CONCLUSION: Economic contraction triggered by a global financial crisis was associated with a significant increase in the risk of depression in the Hong Kong population. This increase was not explained primarily by unemployment and had a significant contribution from employed, home-making, high-middle income, and having married people. A holistic perspective that encompasses both ecological and individual levels of analysis is essential for studying the net impact of economic contraction on depression across communities and sociodemographic groups and for health policy planning.

Rapid-cycling bipolar disorder: cross-national community study.

BACKGROUND: The epidemiology of rapid-cycling bipolar disorder in the community is largely unknown. AIMS: To investigate the epidemiological characteristics of rapid-cycling and non-rapid-cycling bipolar disorder in a large cross-national community sample. METHOD: The Composite International Diagnostic Interview (CIDI version 3.0) was used to examine the prevalence, severity, comorbidity, impairment, suicidality, sociodemographics, childhood adversity and treatment of rapid-cycling and non-rapid-cycling bipolar disorder in ten countries (n = 54 257). RESULTS: The 12-month prevalence of rapid-cycling bipolar disorder was 0.3%. Roughly a third and two-fifths of participants with lifetime and 12-month bipolar disorder respectively met criteria for rapid cycling. Compared with the non-rapid-cycling, rapid-cycling bipolar disorder was associated with younger age at onset, higher persistence, more severe depressive symptoms, greater impairment from depressive symptoms, more out-of-role days from mania/hypomania, more anxiety disorders and an increased likelihood of using health services. Associations regarding childhood, family and other sociodemographic correlates were less clear cut. CONCLUSIONS: The community epidemiological profile of rapid-cycling bipolar disorder confirms most but not all current clinically based knowledge about the illness.

The epidemiological profile of alcohol and other drug use in metropolitan China.

PURPOSE: There is evidence that alcohol, tobacco, and other drug use may be rising in China, but epidemiological studies that examine several drugs simultaneously and the transition from initial try to current use are limited. The present study provides an epidemiological profile of drug use in contemporary metropolitan China. METHODS: A multistage probability sampling method was used to select household-dwelling adults in Beijing and Shanghai. Standard face-to-face interviews with 5,201 participants were completed during 2002-2003. RESULTS: An estimated 70-76% had used any type of drug: alcohol and tobacco were the most commonly used drugs (alcohol, 67%; tobacco, 39%). Regarding extra-medical use of internationally regulated drugs, sedatives and analgesics were most common and illegal drug use was rare. The majority of tobacco users used it recently (82.5%), especially young adults. Male-female differences were observed in lifetime tobacco use, but not for recent use. Concurrent use of alcohol and tobacco was very common. CONCLUSION: Psychoactive drug use is common in metropolitan China. Public health policies and prevention initiatives may be needed to address associated problems that may increase following the country's rapid socioeconomic change.

Prevalence and correlates of depression with atypical symptoms in Hong Kong.

OBJECTIVE: Previous studies of atypical depression have been conducted in Western communities. There has been no community-based epidemiological study of atypical depression that covers the entire spectrum of bipolar disorders. The aim of the present study was to examine the 12 month prevalence of atypical depression and the differences in demographic and clinical profiles between depressed patients with and without atypical symptoms in the Chinese adult population of Hong Kong. METHOD: A random sample of 3016 Chinese adults completed a telephone-based structured interview that examined their 12 month prevalence of major depressive episode. Atypical depression was defined as major depressive episode with hypersomnia and increased weight or appetite. Major depressive episode with and without atypical symptoms were compared on sociodemographic variables, number of depressive and manic/hypomanic symptoms, proportion of having lifetime mania/hypomania, suicidality, family psychiatric history, help-seeking behaviour, level of distress and role impairment. RESULTS: The 12 month prevalence of atypical depression was 1.3%. Compared to non-atypical depression, atypical depression was associated with female gender, soft (subthreshold) bipolar II disorder, family psychiatric history, higher suicidality, more help-seeking from psychiatrists, and more depressive and manic/hypomanic symptoms. There was no difference in levels of distress or impairment. CONCLUSIONS: Although limited by the lack of detailed information on comorbidity, bipolar family history, and age of onset, the findings support the hypothesis that atypical depression among Chinese people in Hong Kong exhibited prevalence and correlates similar to those found in Western epidemiological and clinical studies. Further research is warranted to examine its association with hypomania and how atypical depression may occupy a nosological position between typical unipolar depression and bipolar spectrum disorders.

Impaired role functioning and treatment rates for mental disorders and chronic physical disorders in metropolitan China.

OBJECTIVES: To compare impairments in role functioning and treatment rate of mental disorders and chronic physical disorders in the general population of metropolitan China. METHOD: Face-to-face household interviews of 5201 people aged 18 to 70 years in Beijing and Shanghai were conducted from November 2001 to February 2002, using a multistage household probability sampling method. The World Mental Health version of the Composite International Diagnostic Interview (WMH-CIDI) was used for assessing sociodemographic characteristics, diagnoses, and treatment. The Sheehan Disability Scale (SDS) was used to measure disorder-specific role impairment. RESULTS: Respondents generally attributed greater impairment to mental disorders than to chronic physical disorders, although there were some variations among specific disorders. This general pattern was supported by within-person comparison of impairment associated with a mental disorder versus any chronic physical disorder. Depression, generalized anxiety disorder, and specific phobia were the most impairing mental disorders. Diabetes, headaches, and asthma were the most impairing physical disorders. Comorbid mental and physical disorders were associated with more severe impairment. A much lower percentage of respondents with mental disorders (3.0%) than chronic physical disorders (42.8%) received treatment in the previous 12 months. CONCLUSION: Common mental disorders were associated with greater impairment than chronic physical disorders but were markedly undertreated. They warrant prioritization in the allocation of healthcare resources in China.