Cognitive-behavioral therapy for patients with somatoform disorders: A pilot preliminary randomized controlled trial.

Background and objective: Cognitive-behavioral therapy (CBT) for somatoform disorders (SFDs) is understudied in China. Western findings may not be applicable to Chinese culture. This preliminary study evaluated the efficacy of CBT for patients in China, relative to treatment-as-usual (TAU). Methods: Seventy patients with SFDs randomly received either combined CBT and TAU (CBT + TAU), or TAU alone between January 2018 to May 2019. The CBT + TAU group received 12 weekly individual 50-minute CBT sessions. Participants were blindly assessed at 4 timepoints (baseline, week 6, end of treatment: week 12; 12 weeks post-treatment: week 24) using the following outcome measures: SQSS (Self-screening Questionnaire for Somatic Symptoms); PHQ-15 (Patient-Health-Questionnaire-15) and the WI (Whiteley Index); GAD-7 (General Anxiety Disorder-7); HAMD-17 (Hamilton Depression Rating Scale-17); Family Burden Interview Schedule (FBIS); Sheehan Disability Scale (SDS); and the Short Form of Quality-of-Life Enjoyment and Satisfaction Questionnaire (Q-LES-Q-SF). The primary endpoint was the difference between the SQSS total score at week 24 and the baseline. A mixed model for repeated measures was used to analyze inter- and intra-group changes from the baseline. Results: At week 24, The least-squares mean (LSM) change of the total score on the SQSS was -18.87 points and -9.69 points, respectively in the CBT + TAU group and in the TAU group (LSM difference, -9.18 points; 95% confidence interval, -15.72 to -2.64; P = 0.0068). At week 24, the LSM changes from baseline in the WI, HAMD, PHQ15, FBIS and SDS total scores were significantly different between the two groups, however, there was no significant difference in the Q-LES-Q-SF. The SQSS of group effect sizes were 0.63 at 24 weeks. The dropout rates of the CBT + TAU and TAU groups were comparable (22.9% and 19.3%). Conclusions: These preliminary findings suggest that CBT may be helpful for improving the symptoms of patients with SFDs in China.

Effectiveness and optimal duration of early intervention treatment in adult-onset psychosis: a randomized clinical trial.

BACKGROUND: Contrasting the well-described effects of early intervention (EI) services for youth-onset psychosis, the potential benefits of the intervention for adult-onset psychosis are uncertain. This paper aims to examine the effectiveness of EI on functioning and symptomatic improvement in adult-onset psychosis, and the optimal duration of the intervention. METHODS: 360 psychosis patients aged 26-55 years were randomized to receive either standard care (SC, n = 120), or case management for two (2-year EI, n = 120) or 4 years (4-year EI, n = 120) in a 4-year rater-masked, parallel-group, superiority, randomized controlled trial of treatment effectiveness (Clinicaltrials.gov: NCT00919620). Primary (i.e. social and occupational functioning) and secondary outcomes (i.e. positive and negative symptoms, and quality of life) were assessed at baseline, 6-month, and yearly for 4 years. RESULTS: Compared with SC, patients with 4-year EI had better Role Functioning Scale (RFS) immediate [interaction estimate = 0.008, 95% confidence interval (CI) = 0.001-0.014, p = 0.02] and extended social network (interaction estimate = 0.011, 95% CI = 0.004-0.018, p = 0.003) scores. Specifically, these improvements were observed in the first 2 years. Compared with the 2-year EI group, the 4-year EI group had better RFS total (p = 0.01), immediate (p = 0.01), and extended social network (p = 0.05) scores at the fourth year. Meanwhile, the 4-year (p = 0.02) and 2-year EI (p = 0.004) group had less severe symptoms than the SC group at the first year. CONCLUSIONS: Specialized EI treatment for psychosis patients aged 26-55 should be provided for at least the initial 2 years of illness. Further treatment up to 4 years confers little benefits in this age range over the course of the study.

IRP commission: sexual minorities and mental health: global perspectives.

Sexual orientation is a key determinant of the identity of human beings. It has also been seen as a social determinant of health. People whose sexual orientation is non-heterosexual or sexual minorities or sexually diverse are included in the broad umbrella term LGBT (Lesbian, Gay, Bisexual, and Transgender) which is a commonly used acronym in activism, social policy, and subsequently cultural literature. For this reason, this Commission focuses primarily on sexual orientation i.e. lesbian, gay and bisexual (LGB) groups. We have used terms non-heterosexual, sexual minorities or sexual variation interchangeably. We have not considered asexual individuals as research in the field is too limited. We are cognisant of the fact that topics relating to mental health and sexual orientation discussed in this Commission will intersect with other issues of personal, cultural and social identity, and will thus be relevant to individuals including many transgender individuals. The inclusion of mental health issues relevant to gender-diverse individuals as well as gender identity is important and deserves its own separate detailed discussion. The exact number of sexually diverse individuals in a population is often difficult to estimate but is likely to be somewhere around 5% of the population. Rates of various psychiatry disorders and suicidal ideation and acts of suicide in LGB populations are higher than general population and these have been attributed to minority stress hypothesis. Elimination of inequality in law can lead to reduction in psychiatric morbidity in these groups. However, these are all diverse groups but even within each group there is diversity and each individual has a distinct and unique experiences, upbringing, responses to their own sexual orientation, and generating varying responses from families, peers and friends as well as communities (including healthcare professionals). The mental healthcare needs of sexual minority individuals vary and these variations must be taken into account in design, development and delivery of healthcare and policies. Improving access to services will help engagement and outcomes and also reduce stigma. The commission recommends that there is no role for so-called conversion therapies and other recommendations are made for clinicians, researchers and policymakers.

Adjunctive berberine reduces antipsychotic-associated weight gain and metabolic syndrome in patients with schizophrenia: a randomized controlled trial.

AIM: The aim of this study was to evaluate the efficacy and safety of berberine as an adjuvant in treating antipsychotic-associated weight gain and metabolic syndrome. METHODS: One hundred thirteen participants with schizophrenia spectrum disorders who had developed metabolic syndrome were recruited. They were randomly assigned to berberine (600 mg/d, n = 58) or placebo (n = 55) groups for 12 weeks. The primary outcome was the change from baseline to week 12 in net weight. Secondary outcomes included body mass index, waist circumference, serum glucose and lipid profiles, and the severity of psychotic symptoms. RESULTS: Compared with the placebo group, the berberine group showed a significantly greater reduction in weight gain at 9 weeks (mean difference [MD], -0.75; 95% CI, -1.42 to -0.07 [P = 0.031, d = 0.41]) and 12 weeks (MD, -1.08; 95% CI, -1.76 to -0.40 [P = 0.002, d = 0.59]). Patients who received berberine also showed statistically significant improvements in end point in body mass index (MD, -0.41; 95% CI, -0.65 to -0.17 [P = 0.001, d = 0.64]), total cholesterol (MD, -0.58; 95% CI, -0.74 to -0.41 [P < 0.001, d = 1.31]), low-density lipoprotein (MD, -0.52; 95% CI, -0.68 to -0.35 [P < 0.001, d = 1.19]), and glycated hemoglobin (MD, -0.09; 95% CI, -0.18 to 0 [P = 0.05, d = 0.37]). Berberine was well tolerated without serious adverse events and aggravation of psychotic symptoms compared with placebo. CONCLUSION: The findings suggest that berberine is effective in attenuating antipsychotic-associated weight gain and metabolic syndrome.

Elucidating the relationship between internalized stigma, cognitive insight, illness severity, and functioning in patients with schizophrenia using a path analysis approach.

BACKGROUND: There is a paucity of studies examining the interrelationship between internalized stigma, cognitive insight, illness severity, and functioning. AIMS: This study examined the dynamics of the relationship between these factors using a path modelling approach. METHODS: Two hundred and seven patients with schizophrenia spectrum disorders were recruited in this cross-sectional study. Patients were assessed on internalized stigma, cognitive insight (including its two domains, self-reflectiveness and self-certainty), illness severity and functioning. Path analysis was used to test the hypothesized model for the interrelationship between the variables. RESULTS: A direct positive association was observed between self-certainty and internalized stigma. This was also observed via the paths running through illness severity and functioning. Self-reflectiveness was only associated with self-certainty in the model. The residual variance of internalized stigma in the path model was relatively high. CONCLUSION: Our findings highlight that self-certainty is associated with internalized stigma along with illness severity and functioning in individuals with schizophrenia. Therefore, interventions on reduction of internalized stigma may benefit from a multipronged approach targeting self-certainty, illness severity and functioning. The relatively high residual variance of internalized stigma in the model highlights the need for further research to provide better understanding on the mechanisms underlying internalized stigma.

The 12-month prevalence of psychotic experiences and their association with clinical outcomes in Hong Kong: an epidemiological and a 2-year follow up studies.

BACKGROUND: The relationship between the subtypes of psychotic experiences (PEs) and common mental health symptoms remains unclear. The current study aims to establish the 12-month prevalence of PEs in a representative sample of community-dwelling Chinese population in Hong Kong and explore the relationship of types of PEs and common mental health symptoms. METHOD: This is a population-based two-phase household survey of Chinese population in Hong Kong aged 16-75 (N = 5719) conducted between 2010 and 2013 and a 2-year follow-up study of PEs positive subjects (N = 152). PEs were measured with Psychosis Screening Questionnaire (PSQ) and subjects who endorsed any item on the PSQ without a clinical diagnosis of psychotic disorder were considered as PE-positive. Types of PEs were characterized using a number of PEs (single v. multiple) and latent class analysis. All PE-positive subjects were assessed with common mental health symptoms and suicidal ideations at baseline and 2-year follow-up. PE status was also assessed at 2-year follow-up. RESULTS: The 12-month prevalence of PEs in Hong Kong was 2.7% with 21.1% had multiple PEs. Three latent classes of PEs were identified: hallucination, paranoia and mixed. Multiple PEs and hallucination latent class of PEs were associated with higher levels of common mental health symptoms. PE persistent rate at 2-year follow-up was 15.1%. Multiple PEs was associated with poorer mental health at 2-year follow-up. CONCLUSIONS: Results highlighted the transient and heterogeneous nature of PEs, and that multiple PEs and hallucination subtype of PEs may be specific indices of poorer common mental health.

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.

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.

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.

Predicting first-episode psychosis patients who will never relapse over 10 years.

BACKGROUND: Although relapse in psychosis is common, a small proportion of patients will not relapse in the long term. We examined the proportion and predictors of patients who never relapsed in the 10 years following complete resolution of positive symptoms from their first psychotic episode. METHOD: Patients who previously enrolled in a 12-month randomized controlled trial on medication discontinuation and relapse following first-episode psychosis (FEP) were followed up after 10 years. Relapse of positive symptoms was operationalized as a change from a Clinical Global Impression scale positive score of <3 for at least 3 consecutive months to a score of ⩾3 (mild or more severe). Baseline predictors included basic demographics, premorbid functioning, symptoms, functioning, and neurocognitive functioning. RESULTS: Out of 178 first-episode patients, 37 (21%) never relapsed during the 10-year period. Univariate predictors (p ⩽ 0.1) of patients who never relapsed included a duration of untreated psychosis (DUP) ⩽30 days, diagnosed with non-schizophrenia spectrum disorders, having less severe negative symptoms, and performing better in logical memory immediate recall and verbal fluency tests. A multivariate logistic regression analysis further suggested that the absence of any relapsing episodes was significantly related to better short-term verbal memory, shorter DUP, and non-schizophrenia spectrum disorders. CONCLUSIONS: Treatment delay and neurocognitive function are potentially modifiable predictors of good long-term prognosis in FEP. These predictors are informative as they can be incorporated into an optimum risk prediction model in the future, which would help with clinical decision making regarding maintenance treatment in FEP.

Wellbeing and mental health amongst medical students from Hong Kong.

Medical students are a known high-risk group for mental health issues. This study aimed to survey the psychological well-being of medical students from Hong Kong, a known stressful city. This study is part of a wider effort to compare the psychological well-being of medical students world-wide. We invited medical students from Hong Kong to complete a self-report questionnaire online. The questionnaire included questions on demographics, known mental health issues, sources of psychological stress, and substance use. It also included the cut-annoyed-guilty-eye (CAGE) questionnaire, Short-Form General Health Questionnaire (GHQ-12), and the Oldenburg Burnout Inventory (OLBI). There were 123 responses. Our results suggest high levels of psychological morbidity and distress among medical students in Hong Kong. 87% screened positive for minor psychiatric disorders on the GHQ-12 and 95% met OLBI thresholds for burnout. Female respondents demonstrated significantly higher mean GHQ-12 scores than male. Despite the apparent high prevalence of mental ill-health in this population, only 15% of respondents reported receiving professional help.

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.

Prevalence of anxiety disorders in community dwelling older adults in Hong Kong.

BACKGROUND: Anxiety disorders are prevalent yet under-recognized in late life. We examined the prevalence of anxiety disorders in a representative sample of community dwelling older adults in Hong Kong. METHOD: Data on 1,158 non-demented respondents aged 60-75 years were extracted from the Hong Kong Mental Morbidity survey (HKMMS). Anxiety was assessed with the revised Clinical Interview Schedule (CIS-R). RESULT: One hundred and thirty-seven respondents (11.9%, 95% CI = 10-13.7%) had common mental disorders with a CIS-R score of 12 or above. 8% (95% CI = 6.5-9.6%) had anxiety, 2.2% (95% CI = 1.3-3%) had an anxiety disorder comorbid with depressive disorder, and 1.7% (95% CI = 1-2.5%) had depression. Anxious individuals were more likely to be females (χ 2 = 25.3, p < 0.001), had higher chronic physical burden (t = -9.3, p < 0.001), lower SF-12 physical functioning score (t = 9.2, p < 0.001), and poorer delayed recall (t = 2.3, p = 0.022). The risk of anxiety was higher for females (OR 2.8, 95% C.I. 1.7-4.6, p < 0.001) and those with physical illnesses (OR 1.4, 95% C.I. 1.3-1.6, p < 0.001). The risk of anxiety disorders increased in those with disorders of cardiovascular (OR 1.9, 95% C.I. 1.2-2.9, p = 0.003), musculoskeletal (OR 2.0, 95% C.I. 1.5-2.7, p < 0.001), and genitourinary system (OR 2.0, 95% C.I. 1.3-3.2, p = 0.002). CONCLUSIONS: The prevalence of anxiety disorders in Hong Kong older population was 8%. Female gender and those with poor physical health were at a greater risk of developing anxiety disorders. Our findings also suggested potential risk for early sign of memory impairment in cognitively healthy individuals with anxiety disorders.

Electroacupuncture for tapering off long-term benzodiazepine use: study protocol of randomized controlled trial.

BACKGROUND: Conventional approaches for benzodiazepine tapering have their limitations. Anecdotal studies have shown that acupuncture is a potential treatment for facilitating successful benzodiazepine tapering. As of today, there was no randomized controlled trial examining its efficacy and safety. The purpose of the study is to evaluate the efficacy of using electroacupuncture as an adjunct treatment to gradual tapering of benzodiazepine doses in complete benzodiazepine cessation in long-term benzodiazepine users. METHODS/DESIGN: The study protocol of a randomized, assessor- and subject-blinded, controlled trial is presented. One hundred and forty-four patients with histories of using benzodiazepines in ≥50% of days for more than 3 months will be randomly assigned in a 1:1 ratio to receive either electroacupuncture or placebo electroacupuncture combined with gradual benzodiazepine tapering schedule. Both experimental and placebo treatments will be delivered twice per week for 4 weeks. Major assessments will be conducted at baseline, week 6 and week 16 post-randomization. Primary outcome is the cessation rate of benzodiazepine use. Secondary outcomes include the percentage change in the doses of benzodiazepine usage and the severity of withdrawal symptoms experienced based on the Benzodiazepine Withdrawal Symptom Questionnaire, insomnia as measured by the Insomnia Severity Index, and anxiety and depressive symptoms as evaluated by the Hospital Anxiety and Depression Scale. Adverse events will also be measured at each study visit. DISCUSSION: Results of this study will provide high quality evidence of the efficacy and safety of electroacupuncture as an adjunct treatment for benzodiazepine tapering in long-term users. TRIAL REGISTRATION: ClinicalTrials.gov NCT02475538 .

Legislative provisions related to marriage and divorce of persons with mental health problems: a global review.

Realization of right to marry by a person is an exercise of personal liberty, even if concepts of marriage and expectations from such commitment vary across cultures and societies. Once married, if an individual develops mental illness the legal system often starts to discriminate against the individual. There is no doubt that every individual's right to marry or remain married is regulated by their country's family codes, civil codes, marriage laws, or divorce laws. Historically mental health condition of a spouse or intending spouse has been of interest to lawmakers in a number of ways from facilitating divorce to helping the individual with mental illness. There is no doubt that there are deeply ingrained stereotypes that persons with mental health problems lack capacity to consent and, therefore, cannot enter into a marital contract of their own free will. These assumptions lead to discrimination both in practice and in law. Furthermore, the probability of mental illness being genetically transmitted and passed on to offspring adds yet another dimension of discrimination. Thus, the system may also raise questions about the ability of persons with mental health problems to care, nurture, and support a family and children. Internationally, rights to marry, the right to remain married, and dissolution of marriage have been enshrined in several human rights instruments. Domestic laws were studied in 193 countries to explore whether laws affected the rights of people with mental illness with respect to marriage; it was found that 37% of countries explicitly prohibit marriage by persons with mental health problems. In 11% (21 countries) the presence of mental health problems can render a marriage void or can be considered grounds for nullity of marriage. Thus, in many countries basic human rights related to marriage are being flouted.

Mental illness and the right to vote: a review of legislation across the world.

The right to vote is an important right signifying freedom of thought as well as full citizenship in any setting. Right to vote is enshrined and protected by international human rights treaties. The right of 'everyone' to take part in the political process and elections is based on universal and equal suffrage. Although these International Conventions have been ratified by the large majority of United Nations Member States, their application across the globe is by no means universal. This study sets out to examine the domestic laws of UN Member States in order to explore whether individuals with mental health problems have the right to vote in actuality and, thu,s can participate in political life. Through various searches, electoral laws and Constitutions of 193 Member States of the United Nations were studied. The authors were able to find legislation and/or Constitutional provisions in 167 of the 193 Member States. Twenty-one countries (11%) only placed no restrictions on the right to vote by persons with mental health problems. Over one third of the countries (36%) deny all persons with any mental health problems a right to vote without any qualifier. Some of these discriminatory attitudes are reflected in the multiplicity of terms used to describe persons with mental health problems. Another 21 countries (11%) denied the right to vote to detained persons; of these, nine Member States specifically denied the right to vote to persons who were detained under the mental health law, while the remainder denied the right to vote to all those who were interdicted or judicially interdicted. It would appear that in many countries the denial of voting rights is attributed to a lack of ability to consent by the individuals with mental illness. Further exploration of explanation is required to understand these variations, which exist in spite of international treaties.

Prevalence, psychosocial correlates and service utilization of depressive and anxiety disorders in Hong Kong: the Hong Kong Mental Morbidity Survey (HKMMS).

PURPOSE: Data on mental disorder prevalence and health service utilization required to inform healthcare management and planning are lacking in Hong Kong. The current study determined the prevalence of common mental disorders (CMD), and examined the patterns of mental health service utilization and associated factors. METHODS: We analyzed data from the Hong Kong Mental Morbidity Survey (HKMMS) of 5,719 Chinese adults aged 16-75 years in the general Hong Kong population, using the Chinese Revised Clinical Interview Schedule (CIS-R). RESULTS: The weighted prevalence estimate for any past-week CMD was 13.3 %, with mixed anxiety and depressive disorder being the most frequent diagnoses. CMD was positively associated with female gender, being divorced or separated, alcohol misuse, substance dependence, lack of regular physical exercise, and a family history of mental disorder. Among individuals with CMD, only 26 % had consulted mental health services in the past year; less than 10 % consulted general practitioners or family physicians. Lack of mental health service usage was significantly more likely in men and those with lower educational attainment. CONCLUSIONS: Apart from attention to psychosocial risks, health and lifestyle factors are important considerations for mental health promotion. Service utilization for individuals with CMD in Hong Kong remains suboptimal, and would be enhanced by strengthening community primary care.