China's mental health support in response to COVID-19: progression, challenges and reflection.

The continued spread of the coronavirus disease 2019 (COVID-19) has a serious impact on everyone across the globe, both physically and psychologically. In addition to proactive measures addressing physical survival needs and health protection, China has launched a mental health support system to cope with the widespread psychological stress during the pandemic and its aftermath. In this debate, the authors attempted to depict and reflect upon the overall framework of China's mental health support, with particular reference to the psychological intervention in response to COVID-19 over the last few months. Although a lot of effort has been made to meet the mental health needs, the accessibility, acceptability and effectiveness of the support system still have much room for improvement. Therefore, it is very important to re-think the predicament and challenge on ways of enhancing public mental health emergency responses in China. The concepts of universality, timeliness and scientific rigour were proposed as a possible reform in preparation for large-scale natural or man-made disasters in the coming future.

Consensus statements on the clinical usage and characteristics of aripiprazole for Hong Kong.

Aripiprazole, a dopamine partial agonist, is a second-generation anti-psychotic that is widely used for the treatment of schizophrenia and other psychotic disorders. A group of psychiatric experts in Hong Kong developed a set of consensus statements, aiming to facilitate the understanding of clinical properties and usages of aripiprazole among local physicians. Of note, because aripiprazole long-acting injectable has been available locally not long before the establishment of the consensus panel, which limited the discussion on its use in the local context, the consensus statements were focused primarily on oral aripiprazole. To draft the consensus statements, the panellists discussed the published evidence and their clinical experience regarding aripiprazole in a series of meetings based on several areas. At the final meeting, each drafted statement was voted on anonymously by all panellists based on its practicability of recommendation in Hong Kong. A set of consensus statements on the characteristics and clinical use of aripiprazole was established and accepted by the panel. These statements serve to provide a practical reference for physicians in Hong Kong, and possibly other parts of the Asia-Pacific region, on the use of aripiprazole in people with schizophrenia spectrum disorders and other psychotic problems.

A worldwide survey on training provisions for psychiatric trainees in WPA member associations.

This World Psychiatric Association (WPA) global survey of its WPA member society presidents using an online self-administered 15-item questionnaire successfully recruited 47 WPA member countries or regions (response rate = 39.8%) to provide responses about training provisions of psychiatric education at undergraduate, postgraduate, and post-qualified levels in their respective countries. There were significantly fewer responses from the low and middle income countries (LMIC) than the high income countries (HIC). At undergraduate level, the median duration of psychiatric education during medical school education was 4.0%. However, the current allocated time for psychiatric education was only around one-third to one-half of the time considered as optimal by the member countries or regions (optimal mean = 8.9%; optimal median = 10%). At the postgraduate level, the duration of training varied widely from 12-72 months, with a mean duration of 48 months. In 31% of the respondent countries, psychiatrists only required 36 or fewer months of post-graduate training. The number of months of training required for training a psychiatrist was significantly fewer in the LMIC than HIC. At post-qualified continuing medical education level, all respondents reported providing post-qualified continuing medical education. With the advent of internet technology, many respondents prefer having online training.

Psychiatric education in Greater China.

Multiple surveys have revealed that China has an immense mental health care needs predominantly related to common mental disorders like anxiety and depressive disorders. China has provided different training pathways with an aim of increasing the number of psychiatrists working to address such growing mental health care needs. Although this strategy has successfully doubled the total number of psychiatrists over a couple of years, there remains the problem of harmonising the training standards across different training pathways and across different training units. There is also a pressing need to enhance psychiatric education among other health professionals as it is increasingly recognised that many people with common mental disorders do not have or want to have access to psychiatric care, and need to be taken care of by medical practitioners of other specialties or health professionals. Despite Hong Kong having a different training system from Mainland China, the problems faced with training psychiatrists and other health professionals in Hong Kong are strikingly similar to those encountered by their counterparts in China. Given their different historical origins and subsequent diverse development of training systems, Mainland China and Hong Kong have much to learn from one another.

Brief cognitive-behavioural therapy for patients in the community with schizophrenia: randomised controlled trial in Beijing, China.

BackgroundBrief cognitive-behavioural therapy (CBT) is an emerging treatment for schizophrenia in community settings; however, further trials are needed, especially in non-Western countries.AimsTo test the effects of brief CBT for Chinese patients with schizophrenia in the community (trial registration: ChiCTR-TRC-13003709).MethodA total of 220 patients with schizophrenia from four districts of Beijing were randomly assigned to either brief CBT plus treatment as usual (TAU) or TAU alone. Patients were assessed at baseline, post-treatment and at 6- and 12-month follow-ups by raters masked to group allocation.ResultsAt the post-treatment assessment and the 12-month follow-up, patients who received brief CBT showed greater improvement in overall symptoms, general psychopathology, insight and social functioning. In total, 37.3% of those in the brief CBT plus TAU group experienced a clinically significant response, compared with only 19.1% of those in the TAU alone group (P = 0.003).ConclusionsBrief CBT has a positive effect on Chinese patients with schizophrenia in the community.

A pilot controlled trial of a combination of dense cranial electroacupuncture stimulation and body acupuncture for post-stroke depression.

BACKGROUND: Our previous studies have demonstrated the treatment benefits of dense cranial electroacupuncture stimulation (DCEAS), a novel brain stimulation therapy in patients with major depression, postpartum depression and obsessive-compulsive disorder. The purpose of the present study was to further evaluate the effectiveness of DCEAS combined with body acupuncture and selective serotonin reuptake inhibitors (SSRIs) in patients with post-stroke depression (PSD). METHODS: In a single-blind, randomized controlled trial, 43 patients with PSD were randomly assigned to 12 sessions of DCEAS plus SSRI plus body electroacupuncture (n = 23), or sham (non-invasive cranial electroacupuncture, n-CEA) plus SSRI plus body electroacupuncture (n = 20) for 3 sessions per week over 4 weeks. Treatment outcomes were measured using the 17-item Hamilton Depression Rating Scale (HAMD-17), the Clinical Global Impression - Severity scale (CGI-S) and Barthel Index (BI), a measure used to evaluate movement ability associated with daily self-caring activity. RESULTS: DCEAS produced a significantly greater reduction of both HAMD-17 and CGI-S as early as week 1 and CGI-S at endpoint compared to n-CEA, but subjects of n-CEA group exhibited a significantly greater improvement on BI at week 4 than DCEAS. Incidence of adverse events was not different in the two groups. CONCLUSIONS: These results indicate that DCEAS could be effective in reducing stroke patients' depressive symptoms. Superficial electrical stimulation in n-CEA group may be beneficial in improving movement disability of stroke patients. A combination of DCEAS and body acupuncture can be considered a treatment option for neuropsychiatric sequelae of stroke. TRIAL REGISTRATION: http://www.clinicaltrials.gov, NCT01174394.

Families and family therapy in Hong Kong.

Family therapy views humans not as separate entities, but as embedded in a network of relationships, highlighting the reciprocal influences of one's behaviours on one another. This article gives an overview of family demographics and the implementation of family therapy in Hong Kong. We start with a review of the family demographics in Hong Kong and brief notes on families in mainland China. Demographics show that the landscape has changed markedly in the past decade, with more cross-border marriages, an increased divorce rate, and an ageing overall population - all of which could mean that there is increasing demand for professional family therapy interventions. However, only a limited number of professionals are practising the systems-based approach in Hong Kong. Some possible reasons as to why family therapy is not well disseminated and practised are discussed. These reasons include a lack of mental health policy to support family therapy, a lack of systematic family therapy training, and a shortage of skilled professionals. Furthermore, challenges in applying the western model in Chinese culture are also outlined. We conclude that more future research is warranted to investigate how family therapy can be adapted for Chinese families.

Prevalence and predictors of post-traumatic stress disorder in patients with cured coronavirus disease 2019 (COVID-19) one month post-discharge.

Background: Coronavirus disease 2019 (COVID-19) can place an immense psychological strain on the infected patient. The psychological distress can linger after the initial recovery from the infection. Objective: This study aimed to evaluate the prevalence and predictors of provisional post-traumatic stress disorder (PTSD) in patients with cured COVID-2019. Methods: The baseline survey was conducted from 10 to 25 February 2020 in patients with COVID-19 in a designated hospital. Demographic and clinical characteristics were acquired, and depression and anxiety levels were assessed, using the 9-item Patient Health Questionnaire and 7-item Generalized Anxiety Disorder scale, respectively. A follow-up survey was conducted 1 month post-discharge. PTSD symptoms were measured by the Impact of Event Scale-6 (IES-6) and patients' perception of supportive care during hospitalization was investigated using a self-developed questionnaire. Results: In total, 114 patients completed both the baseline and follow-up surveys. Of these, 41 (36.0%) met the cut-off score for provisional PTSD diagnosis according to the IES-6. Female gender [odds ratio (OR) = 4.69, 95% confidence interval (CI) 1.54-14.37], educational level of high school or below (OR = 15.49, 95% CI 1.13-212.71), higher anxiety levels (OR = 1.34, 95% CI 1.12-1.61) and lower perceptions of emotional support during hospitalization (OR = 0.41, 95% CI 0.17-0.96) predicted a higher risk for provisional PTSD. Conclusions: PTSD is commonly seen in patients with COVID-19 1 month post-discharge. Female patients, and patients with lower educational levels, higher anxiety levels and lower perceptions of emotional support during hospitalization may be more likely to develop PTSD in the near future. Enhancing emotional support during hospitalization could help to prevent PTSD in patients with COVID-19.

Antecedentes: El COVID-19 ha supuesto una inmensa carga psicológica para el paciente infectado. El malestar psicológico puede persistir aún después de la recuperación inicial de la infección.Objetivos: Este estudio tuvo como objetivo evaluar la prevalencia y los factores predictores del trastorno de estrés postraumático (TEPT) provisional en pacientes recuperados de COVID-2019.Métodos: El cuestionario inicial se realizó en pacientes con el COVID-19 desde el 10 de febrero del 2020 hasta el 25 de febrero del 2020 en un hospital designado. Se consideraron las variables demográficas y clínicas, además, se evaluaron los niveles de depresión y ansiedad mediante el cuestionario de salud del paciente de 9 elementos y el cuestionario del trastorno de ansiedad generalizada de 7 elementos, respectivamente. Un cuestionario de seguimiento fue realizado un mes después del alta. Los síntomas de TEPT fueron medidos por el Cuestionario de Eventos de Impacto 6 (IES-6 por sus siglas en ingles) y el nivel de percepción de los pacientes sobre el cuidado de soporte durante la hospitalización fue investigado utilizando un cuestionario auto-administrado.Resultados: Ciento catorce pacientes completaron tanto el cuestionario inicial como el de seguimiento. Cuarenta y un (36.0%) pacientes cumplieron con el punto de corte para el diagnóstico provisional de TEPT según el IES-6. El sexo femenino (OR = 4.69, 95% CI: 1.54-14.37), un nivel de educación secundaria o inferior (OR = 15.49, 95% CI: 1.13-212.71), niveles elevados de ansiedad (OR = 1.34, 95% CI: 1.12-1.61) y una menor percepción de soporte emocional durante la hospitalización (OR = 0.41, 95% CI: 0.17-0.96) fueron factores predictores de riesgo elevado para el desarrollo provisional de TEPT.Conclusiones: El TEPT es observado con frecuencia en pacientes con COVID-19 un mes después del alta. Las pacientes de sexo femenino, los pacientes con un nivel de educación bajo, los pacientes con un nivel elevado de ansiedad y una menor percepción de apoyo emocional durante la hospitalización podrían tener mayor probabilidad de desarrollar TEPT en el futuro cercano. El reforzamiento del apoyo emocional durante la hospitalización podría ayudar a prevenir el TEPT en pacientes con COVID-19.

Psychometric property study of the posttraumatic stress disorder checklist for DSM-5 (PCL-5) in Chinese healthcare workers during the outbreak of corona virus disease 2019.

BACKGROUND: Previous studies about the reliability and validity of the updated PCL version for the fifth edition of the Diagnostic and Statistical Manual for Mental Disorders (PCL-5) have only been evaluated in certain samples of the population, which lacks in the sample of Healthcare Workers. Our study focused on the factor structure, reliability and validity of the PCL-5 among Chinese Healthcare Workers during the Outbreak of Corona Virus Disease 2019. METHODS: We conducted an online survey of frontline healthcare workers using the PCL-5 for PTSD. Total of 212 frontline healthcare providers were included in this study. RESULTS: The findings showed that PCL-5 is a reliable instrument in our sample. The total and subscale scores showed good internal consistency. The convergent and discriminant validity of the PCL-5 were also well demonstrated. Our result showed a better fit with the seven-factor hybrid model compared with other models and supported that the PCL-5 Chinese version can be used as a reliable screening tool to conduct psychological screening for Chinese healthcare workers. LIMITATION: We could not examine other aspects of reliability and validity like test-retest reliability or criterion validity. We didn't use the gold-standard structured interview for PTSD in our study. Besides, most of our samples were young people who had access to the internet. Not all professional levels and seniorities were presented because our sample had a lower mean income and educational level. CONCLUSION: Our study shows that the Chinese PCL-5 has good validity and reliability in frontline healthcare workers during the outbreak.

Homocysteine level in schizophrenia patients.

OBJECTIVE: Elevated serum levels of homocysteine have been shown to be associated with schizophrenia in some studies, but the evidence is still limited and mixed. The aim of the present study was therefore to evaluate the serum homocysteine level in Chinese in schizophrenia patients and assess its association with clinical phenotypes of the disease. METHOD: A total of 250 inpatients and 250 healthy controls were identified at Kowloon Hospital and the Red Cross Blood Donation Centre, respectively. Each subject was evaluated with a structured diagnostic interview. Demographic data were collected and blood was analysed for homocysteine level. The Positive and Negative Syndrome Scale was used to grade clinical symptoms of schizophrenia. Confounding factors affecting homocysteine levels were controlled by strict exclusion criteria or statistical methods. RESULTS: Serum homocysteine level was elevated in Chinese schizophrenia patients. Both male (mean, 12.26 micromol L(-1); control, 11.40 micromol L(-1), p = 0.026) and female (mean, 9.61 micromol L(-1); control, 8.33 micromol L(-1), p < 0.001) patients had a higher serum homocysteine level than the healthy controls, and these differences persisted after controlling for age. There was no significant association between serum homocysteine level and duration of illness, clinical symptoms or age of onset of schizophrenia. CONCLUSION: The serum homocysteine levels were elevated in both male and female Chinese schizophrenia patients. The levels were not apparently related to other clinical parameters.

What does recovery from schizophrenia mean? Perceptions of long-term patients.

BACKGROUND: The study investigated the meaning of recovery to eight people with chronic schizophrenia. METHOD: A qualitative methodology was used based on a 3-hour focus group. The material was transcribed and analysed into 18 subcategories and 4 categories; namely recovery as a multi-dimensional construct, the relationship of medication to recovery, a sense of hopelessness and helplessness about recovery, factors that promoted recovery. DISCUSSION: Respondents believed that full recovery could not be said to have been achieved until they stopped medication and had a steady job. The support and care of family and friends were also vital, although sometimes problematic. Independent living has a different meaning in Chinese culture. CONCLUSIONS: Further research directions are suggested as well as ways to change attitudes to the inclusion of medication in recovery.

Long-term effects of discontinuation from antipsychotic maintenance following first-episode schizophrenia and related disorders: a 10 year follow-up of a randomised, double-blind trial.

BACKGROUND: The long-term consequences of discontinuing antipsychotic medication after successful treatment of first-episode psychosis are not well studied. We assess the relation between early maintenance therapy decisions in first-episode psychosis and the subsequent clinical outcome at 10 years. METHODS: This is a 10 year follow-up study, spanning Sept 5, 2003, to Dec 30, 2014, of a randomised, double-blind trial in seven centres in Hong Kong in which 178 patients with first-episode psychosis with full positive symptom resolution after at least 1 year of antipsychotic treatment were given maintenance treatment (n=89; oral quetiapine 400 mg daily) or early treatment discontinuation (n=89; placebo) for 12 months. After the trial, patients received naturalistic treatment. Overall this cohort of patients will have received about 3 years of treatment before entering the follow-up phase of the study: about 2 years of maintenance treatment before study entry and 1 year of treatment in the trial. The primary outcome of this follow-up was the proportion of patients in each group (including those for whom direct follow-up was not available) with good or poor long-term clinical outcomes at 10 years, with poor outcome defined as a composite of persistent psychotic symptoms, a requirement for clozapine treatment, or death by suicide. The randomised trial was registered with ClinicalTrials.gov, number NCT00334035, and the follow-up study was registered with ClinicalTrials.gov, number NCT01926340. FINDINGS: Poor 10 year clinical outcome occurred in 35 (39%) of 89 patients in the discontinuation group and 19 (21%) of 89 patients in the maintenance treatment group (risk ratio 1·84, 95% CI 1·15-2·96; p=0·012). Suicide was the only serious adverse event that occurred in the follow-up phase (four [4%] patients in the early discontinuation group vs two [2%] in the maintenance group). INTERPRETATION: In patients with first-episode psychosis with a full initial response to treatment, medication continuation for at least the first 3 years after starting treatment decreases the risk of relapse and poor long-term clinical outcome. FUNDING: Food and Health Bureau, Research Grants Council of Hong Kong, and AstraZeneca.