10-year outcome study of an early intervention program for psychosis compared with standard care service.

BACKGROUND: Despite evidence on the short-term benefits of early intervention (EI) service for psychosis, long-term outcome studies are limited by inconsistent results. This study examined the 10-year outcomes of patients with first-episode psychosis who received 2-year territory-wide EI service compared to those who received standard care (SC) in Hong Kong using an historical control design. METHOD: Consecutive patients who received the EI service between 1 July 2001 and 30 June 2002, and with diagnosis of schizophrenia-spectrum disorders, were identified and matched with patients who received SC first presented to the public psychiatric service from 1 July 2000 to 30 June 2001. In total, 148 matched pairs of patients were identified. Cross-sectional information on symptomatology and functioning was obtained through semi-structured interview; longitudinal information on hospitalization, functioning, suicide attempts, mortality and relapse over 10 years was obtained from clinical database. There were 70.3% (N = 104) of SC and 74.3% (N = 110) of EI patients interviewed. RESULTS: Results suggested that EI patients had reduced suicide rate (χ2 (1) = 4.35, p = 0.037), fewer number [odds ratio (OR) 1.56, χ2 = 15.64, p < 0.0001] and shorter duration of hospitalization (OR 1.29, χ2 = 4.06, p = 0.04), longer employment periods (OR -0.28, χ2 = 14.64, p < 0.0001) and fewer suicide attempts (χ2 = 11.47, df = 1, p = 0.001) over 10 years. At 10 years, no difference was found in psychotic symptoms, symptomatic remission and functional recovery. CONCLUSIONS: The short-term benefits of the EI service on number of hospitalizations and employment was sustained after service termination, but the differences narrowed down. This suggests the need to evaluate the optimal duration of the EI service.

Use of electroacupuncture to accelerate the antidepressant action of selective serotonin reuptake inhibitors: a single-blind, randomised, controlled study.

1. Patients treated with dense cranial electroacupuncture stimulation (DCEAS) had a significantly greater reduction in the 17-item Hamilton Rating Scale for Depression scores and clinically significant response to treatment than those having sham acupuncture (19.4% vs.8.8%). 2. Neither sham acupuncture nor DCEAS had effects on the platelet serotonin system. 3. In the early phase of selective serotonin reuptake inhibitor treatment for depressed patients, DCEAS could be used as an additional therapy. 4. Neurobiological mechanisms responsible for DCEAS effects warrant further investigation using neuroimaging.

Introducing family medicine in a pluralistic health care system: how patients and doctors see it.

BACKGROUND: The health care systems in many countries are focused on specialist care. In those countries that have recently changed to a primary care-based system, some doctors and patients were dissatisfied with the change. OBJECTIVE: To explore the opinions of the general public and the doctors on the change to a family medicine (FM)-based health care system. METHODS: Qualitative study with focus groups of doctors working in different practice settings. Quantitative study with questionnaires sent to all doctors registered in Hong Kong and a telephone survey targeting the general public aged ≥18. RESULTS: Doctors in the focus groups generally supported a FM-based health care system. They were concerned that there were not enough family doctors for such a system and the patients' current free choice of any doctor for primary care would impede its success. Thousand six hundred and forty-seven adults took part in the telephone survey (response rate 67.6%) and 2310 doctors (22.8%) responded to the questionnaire. Nearly 95% of the general public respondents agreed to the FM system though only 66.3% of them had ever heard of the term family doctor. About 65% of the doctors supported this system but only 33% agreed that the system would work. The specialist-doctors were less supportive of mandatory referral than the non-specialists, while the public was equally divided on this issue. CONCLUSIONS: The public accepts the FM-based system but needs education on the benefits of primary health care. Direct access to the specialist would be the greatest barrier. Government involvements are essential for the reform.

Family medicine training in Hong Kong: similarities and differences between family and non-family doctors.

OBJECTIVE: To study the local medical profession's opinions on the training requirements for the specialty of family medicine. This was to serve as a reference for future planning of the health care system. DESIGN: Cross-sectional study. PARTICIPANTS AND SETTING: All registered doctors in Hong Kong. MAIN OUTCOME MEASURES: Doctors' ratings on the importance of vocational training, professional assessment, job nature, and experience to become suitably qualified as a family doctor, and their opinions on the length of necessary vocational training. RESULTS: A total of 2310 doctors (23% of doctors in the local register) responded. Professional assessment was mostly agreed as a qualification, followed by vocational training, clinical experience, and job nature. Over 70% agreed on a training period of 4 years or less. Non-family doctors were more likely to opt for professional assessment as the qualification and also opt for a longer training period. CONCLUSION: Vocational training was considered important as a qualification for the specialty of family medicine. The length of training was mostly agreed to be 4 years or less, not the 6 years currently required by the Hong Kong Academy of Medicine. The vocational training programme for family medicine might require re-examination.

Health and society in China: public health education for the community, 1912--1937.

The paper studies the public health education activities of the American medical missionaries, the Rockefeller Foundation, the Nationalist government, and the Mass Education Movement in China during 1912--1937. It argues that the mission-oriented policies of the medical missionaries as well as the 'technique' approaches of the Rockefeller Foundation which were adopted by the majority of the health officials of the Nationalist government were inappropriate in an agrarian country like China. The Mass Education Movement, by combining health education with the improvement of the living conditions of the people as a whole, proved to be quite successful although it too failed to utilize the traditional medical system in public health activities.

A survey of antipsychotic treatment for schizophrenia in Hong Kong.

OBJECTIVE: To obtain information on prescription pattern of antipsychotic drugs for schizophrenic in-patients treated in public hospitals in Hong Kong. Four main areas of antipsychotic treatment are reported in this paper: (1) doses of antipsychotic drugs, (2) the practice of giving multiple antipsychotic agents simultaneously, (3) use of antipsychotics in divided daily doses and (4) co-administration of antipsychotic and antiparkinson drugs. METHODS: A cross-sectional survey of prescriptions of antipsychotic medication for a representative sample of 957 schizophrenic in-patients was conducted on a randomly chosen census day. Questionnaire items included basic demographic and clinical data, as well as inventory for all medications received by patients on census day. RESULTS: The mean antipsychotic dose was 854 +/- 759 (median: 600; range) 0-4450) mg CPZeq. Over two-third of the patients were given more than drug concurrently while less than 20% received the medication in multiple divided doses. Antiparkinson drugs were prescribed with antipsychotic medication in 69.61%, of the subjects. There were few differences between acute and chronic patients with respect to their respective prescription patterns. CONCLUSIONS: Antipsychotic treatment of schizophrenic inpatients in Hong Kong is largely in accord with international standards. Problematic areas identified for closer scrutiny include the concurrent use of more than one antipsychotic drug for both acute and chronic patients, and the higher than recommended doses for antipsychotic drugs and frequent use of antiparkinson medication for chronic patients. Dissemination of these results, accompanied by continuing medical education about psychopharmacology, are planned to further improve the quality of treatment for schizophrenic patients.

Community psychiatry in Hong Kong.

Community psychiatry is well developed in many western countries. However, this psychiatric subspecialty has only recently been officially recognized and established in Hong Kong. This article describes the development and current scope of services. It illustrates how local psychiatrists have met the challenge of adopting a western service model to suit the local Chinese population, with its different socio-cultural value system.

Relationship of cognitions and symptoms of agoraphobia in Hong Kong Chinese: a combined quantitative and qualitative study.

OBJECTIVES: The aim of this study was to explore and describe the subjective experiences of agoraphobia in Hong Kong Chinese. METHOD: This was a cross-sectional descriptive study, using a combined qualitative-quantitative approach. In the qualitative part, two focus groups were held with nine participants suffering from DSM-IV panic disorder with agoraphobia, followed up in a regional hospital in Hong Kong. The audiotaped MATERIAL: was transcribed and analysed into four main categories and 13 subcategories based on a grounded theory approach. One subcategory ('Fear of making others worried and being a burden to others') was identified as a novel, culture-specific concept in agoraphobia that was not reported in Western literature. In the quantitative part, this subcategory was redefined and measured by a two-item, self-rated questionnaire survey in another 35 participants suffering from DSM-IV defined panic disorder with agoraphobia. RESULTS: Qualitative data showed that the clinical manifestations of agoraphobia were specifically related to the underlying corresponding catastrophic cognitions. An individual's agoraphobic cognitions and symptoms were highly related to the identity of the surrounding people during panic attacks in agoraphobic situations, which reflected the characteristic structure of the Chinese interpersonal network. Participants preferred reliance on self to cope with the anxiety first, then turned to their family members for help due to higher interpersonal trust. Participants also expressed fear of affecting others due to their illness. A new sub-theme of agoraphobia ('Fear of making others worried and being a burden to others') was extracted from the qualitative data. Its validity was confirmed by the quantitative description of this new theme using a self-rated questionnaire as a methodological triangulation. CONCLUSIONS: The central theme to emerge from the qualitative data was that agoraphobia is a clinical condition that has a close relationship to Chinese cultural factors. 'Fear of making others worried and being a burden to others' is a new concept in agoraphobia worthy of further study.

A six-month prospective case-controlled study of the effects of the clubhouse rehabilitation model on Chinese patients with chronic schizophrenia.

OBJECTIVE: To investigate the effects of the 'clubhouse' model of rehabilitation on various psychosocial issues for Chinese patients with schizophrenia living in the community. METHODS: A longitudinal, case-controlled and naturalistic design was used. A total of 92 participants were recruited via criteria-guided systematic sampling for a study lasting 6 months. Forty-six participants attending a local clubhouse programme were matched for sex and age with a control group of patients recruited from a regional outpatient clinic who were not attending a clubhouse programme. Case note reviews, standardised assessments of psychotic symptoms, depressive symptoms, quality of life, self-esteem, and locus of control were performed at baseline, 3 and 6 months. RESULTS: Clubhouse participants showed significant improvements in their positive and negative scales, general psychopathology, and total scores after attending the clubhouse for 6 months. The clubhouse participants' employment rate also improved. CONCLUSION: The clubhouse model of rehabilitation may have beneficial effects on various psychiatric symptoms in Chinese patients with schizophrenia living in Hong Kong.

Early intervention for psychosis in Hong Kong--the EASY programme.

AIM: This article aims to describe the Hong Kong experience in developing and implementing an early psychosis programme. METHODS: In 2001, the Early Assessment Service for Young People with Psychosis programme was launched in Hong Kong, providing both educational and service components. Public education includes promotion of timely help-seeking, accessible channels to service and knowledge of psychosis. The 2-year phase-specific intervention includes intensive medical follow-up and individualized psychosocial intervention. The programme has adopted the case-management approach, in which case managers provide protocol-based psychosocial intervention. The programme collaborates with non-governmental organizations and community networks in the provision of rehabilitation service. RESULTS: An average of over 600 young patients enter the programme for intensive treatment each year. Based on preliminary data from a 3-year outcome study, patients in the programme have remarkable reductions in hospital stay accompanied by improvements in vocational functioning. CONCLUSIONS: The results suggested that the programme improved patients' outcome. Additional costs such as extra medical staff and medications may be offset by the shortened hospital stay. Further directions in early intervention are also discussed.

Detection of non-adherent behaviour in early psychosis.

OBJECTIVE: Adherence to antipsychotic treatment is an important aspect of the long-term management of schizophrenia. The evaluation of adherence is often difficult in the clinical setting. This study compared patient self-reporting and clinician judgment of adherence behaviour in patients with early and chronic schizophrenia. METHOD: Clinician-rated questionnaires and parallel patient self-rated questionnaires were administered to 229 patients with early schizophrenia (illness duration < 5 years) and 255 patients with chronic schizophrenia. Items in the questionnaires addressed two forms of adherence behaviour (forgetting to take medication and deciding to stop medication) as well as attitudes toward medication. RESULTS: Significant non-adherent behaviour was reported by patients, particularly in the early schizophrenia group. Non-adherent behaviour was related to feelings of embarrassment about taking medication. Both non-adherence and embarrassment were under-recognized by clinicians. Starting from a prior probability of 0.24, knowledge of the patients' attitudes increased the posterior probability to 0.33, whereas clinicians' detection of non-adherence (deciding to stop medication) improved the posterior probability to 0.65. When both clinicians' evaluations and patients' attitudes were known, the posterior probability improved to 0.68. CONCLUSION: Non-adherence is a widespread phenomenon in early schizophrenia. Increasing clinicians' sensitivity to patients' feelings of embarrassment may be an important factor in the detection of non-adherence. When taking a base rate of non-adherence into consideration, clinicians' evaluations appeared to be more effective in detecting non-adherence than simple information obtained from patients on their attitudes toward medication. Pragmatic real-life estimation of non-adherence has important implications for the possibility of intervention.