'I am more stressed if my infection affects others': development of a COVID-19-related stress scale in older people and examination of its validity and associations with mental health risks.

BACKGROUND: COVID-19 was a collective traumatic event; however, different individuals may have perceived it differently. AIMS: This study investigated what older people in a collective culture perceived as stressful during COVID-19 and examined how different stressors related to COVID-19 infection and mental health risks. METHOD: Thirty-six participants from diverse backgrounds engaged in a three-round Delphi study to generate items for a COVID-19-related stress scale for older adults (CSS-OA). Subsequently, 4674 people (aged ≥60 years) participated in a cross-sectional telephone survey; interviewers collected their responses to CSS-OA and information about COVID-19 infection, depressive symptoms, anxiety, loneliness and demographics. Exploratory factor analysis and confirmatory factor analysis were conducted on CSS-OA. A multiple indicator multiple cause (MIMIC) model was used to examine associations between CSS-OA and other measures. RESULTS: The Delphi process generated eight items, all secondary or tertiary stressors related to infection. Exploratory factor analysis revealed a three-factor model, and confirmatory factor analysis confirmed an excellent fit (comparative fit index = 0.99, root mean square error of approximation = 0.06). Pre-existing mental health conditions, having family members/friends infected with COVID-19, loneliness, anxiety and depressive symptoms were associated with higher stress. Conversely, self-infection with COVID-19, older age, being female and living alone were negatively associated with some domains of CSS-OA (all P < 0.05). CONCLUSIONS: The Delphi process enhanced our understanding of what older people perceived as stressful, much of which resulted from certain healthcare strategies and reflected cultural influences. These and the MIMIC results highlight the need to balance public health policies with respect to infectious diseases and older people's mental health and quality of life.

Supporting Older Adults' Mental Health Against Suspected Mental Health Problems: The Moderating Role of an Age-Friendly Neighborhood.

This study examined how compensatory and enabling domains of an Age-Friendly City (AFC) moderate the relationship between suspected mental health problems and depressive and anxiety symptoms among older adults. Four thousand six hundred and twenty-five Hong Kong Chinese aged ≥60 years completed a telephone survey between April and July 2022, including PHQ-2 and GAD-2. AFC indices sourced from prior territory-wide study. Linear mixed models showed that enabling AFC domains, namely, social participation, respect and social inclusion, and civic participation and employment, alleviated the effects of suspected mental health problems on respondents' depressive and anxiety symptoms (b = -0.40 to -0.56). Three-way interaction models revealed that the protective effects of all compensatory and enabling AFCC domains (b = -1.23 to -6.18), except civic participation and employment, were stronger in old-old (70-79 years) and oldest-old (≥80 years) than young-old (60-69 years). AFCC-based interventions should focus on compensatory and enabling domains to support older adults' mental health.

Hybrid-delivered community psychoeducation for people aged 50 and older: A mixed-method evaluation and lesson learned.

Introduction: Hybrid training mode comprising in-person and teleconferencing sessions is effective and sustainable, yet no standardized principles guide its development for older people. This study aimed to develop a set of principles for hybrid-mode psychoeducation for older people from the experiences of middle-aged and older people in two folds: (1) examining the effects of hybrid-mode community psychoeducation and (2) identifying features that could enhance participants' experience. Methods: We delivered 12-hour Older Person Mental Health First Aid and 3-hour late-life depression training to adults aged 50 and older in in-person and hybrid modes. Hybrid group participants received technology-related support, including in-advance training and on-site support. All participants completed assessments on depression literacy, depression stigma, meaning in life, social support, depressive symptoms, and anxiety pre-and post-intervention and evaluated the program in open-ended questions. Results: A total of 471 in-person and 346 hybrid group participants completed the psychoeducation and post-assessment (80.4 % female, mean age = 64.73 years, SD = 7.29). Linear mixed models revealed improvements in depression literacy, depression stigma, meaning in life, social support, and anxiety (B = -1.43 to 0.13, all p < .001), with no significant difference between in-person and hybrid groups. Thematic analysis of open-ended questions identified three themes: (1) informational content with case studies, (2) hardcopy course handouts, and (3) interactive learning environment. Discussion/conclusion: Hybrid-mode and in-person psychoeducation had comparable benefits on middle-aged and older people. The TORCH principles, an acronym for Technology provision, On-site technical support, Rehearsal, Connection with group members, and Hardcopy notes, was derived from practice wisdom and qualitative findings to support older people in online learning.

Technology Affordance in an Information and Communication Technology Delivered Group Psychotherapy and Exercise Program for Older People With Depressive Symptoms: A Multiple Triangulation Qualitative Study.

Background and Objectives: Health and mental health interventions, such as psychotherapy and exercise programs, delivered via information and communication technology (ICT) may improve service access. However, adjustment among older people and in synchronous group interventions is more challenging. Technology affordance concerns the possibilities engendered by technology for various users and purposes and can help understand challenges in ICT-delivered groups and identify possible solutions. Research Design and Methods: Adopting a multiple triangulation approach, we observed ICT-delivered groups of acceptance and commitment therapy and exercise for older people with depressive symptoms, conducted focus groups with older people who had received group psychotherapy with or without an exercise component, and obtained clinical notes from interventionists. We conducted a thematic analysis of the observation notes, focus group transcriptions, and clinical notes. Results: Four focus groups were conducted with 22 participants (mean age = 72.6 years, standard deviation = 7.2, 86% female). We identified 3 challenges: (1) seeing-be seen dilemma, (2) speaking-hearing dilemma, and (3) blurred therapy-home boundary, and 2 solutions: (1) maneuvering layouts and collaborative tools, and (2) cross-platform mediated strategies. Participants struggled to observe the interventionist while simultaneously demonstrating their posture in front of a camera. Remaining silent and moderated turn-taking allowed for clearer hearing but limited interactions. Interruptions from the background environment and intersections of family living spaces disrupted audio-visual communication and jeopardized the sense of security. As a solution, interventionists maneuvered layouts and collaborative tools on teleconferencing applications to achieve intervention goals and provided support through different media. Discussion and Implications: The identified challenges and potential solutions can be understood from interactivity, portability, temporality, persistence, and multimediality. Technology affordance can guide ICT-delivered group design by matching the affordance of various technologies and communication media with the characteristics of the intervention and users to enhance efficacy and avoid an unnecessary digital divide.

Depression risk among community-dwelling older people is associated with perceived COVID-19 infection risk: effects of news report latency and focusing on number of infected cases.

Awareness of COVID-19 infection risk and oscillation patterns ('waves') may affect older people's mental health. Empirical data from populations experiencing multiple waves of community outbreaks can inform guidance for maintaining mental health. This study aims to investigate the effects of COVID-19 infection risk and oscillations on depression among community-dwelling older people in Hong Kong.A rolling cross-sectional telephone survey method was used. Screening for depression risk was conducted among 8,163 older people (age ≥ 60) using the Patient Health Questionnaire-2 (PHQ-2) from February to August 2020. The relationships between PHQ-2, COVID-19 infection risk proxies - change in newly infected cases and effective reproductive number (Rt), and oscillations - stage of a 'wave' reported in the media, were analysed using correlation and regression.8.4% of survey respondents screened positive for depression risk. Being female (ß = .08), having a pre-existing mental health issue (ß = .21), change in newly infected cases (ß = .05), and screening during the latency period before the media called out new waves (ß = .03), contributed to higher depression risk (R2 = .06, all p <.01).While depression risk does not appear alarming in this sample, our results highlight that older people are sensitive to reporting of infection, particularly among those with existing mental health needs. Future public health communication should balance awareness of infection risks with mental health protection.

Collaborative community mental health and aged care services with peer support to prevent late-life depression: study protocol for a non-randomised controlled trial.

BACKGROUND: Late-life depression is common, modifiable, yet under-treated. Service silos and human resources shortage contribute to insufficient prevention and intervention. We describe an implementation research protocol of collaborative stepped care and peer support model that integrates community mental health and aged care services to address service fragmentation, using productive ageing and recovery principles to involve older people as peer supporters to address human resource issue. METHODS/DESIGN: This is a non-randomised controlled trial examining the effectiveness and cost-effectiveness of the "Jockey Club Holistic Support Project for Elderly Mental Wellness" (JC JoyAge) model versus care as usual (CAU) in community aged care and community mental health service units in 12 months. Older people aged 60 years and over with mild to moderate depressive symptoms or risk factors for developing depression will be included. JoyAge service users will receive group-based activities and psychoeducation, low-intensity psychotherapy, or high-intensity psychotherapy according to the stepped care protocol in addition to usual community mental health or aged care, with support from an older peer supporter. The primary clinical outcome, depressive symptoms, and secondary outcomes, self-harm risk, anxiety symptoms, and loneliness, will be measured with the Patient Health Questionnaire-9 (PHQ-9), Self-Harm Inventory, Generalized Anxiety Disorder 7-item scale (GAD-7), and UCLA Loneliness 3-item scale (UCLA-3) respectively. Cost-effectiveness analysis will assess health-related quality of life using the EQ-5D-5L and service utilisation using the Client Service Receipt Inventory (CSRI). We use multilevel linear mixed models to compare outcomes change between groups and calculate the incremental cost-effectiveness ratio in terms of quality-adjusted life years. DISCUSSION: This study will provide evidence about outcomes for older persons with mental health needs receiving collaborative stepped care service without silos and with trained young-old volunteers to support engagement, treatment, and transitions. Cost-effectiveness findings from this study will inform resource allocation in this under-treated population. TRIAL REGISTRATION: ClinicalTrials.gov NCT03593889. Registered on 20 July 2018.

Depressive Symptoms and Coping Strategies in Community-Dwelling Older People Amidst the COVID-19 Pandemic: A Mixed-Method Study.

This study aimed to examine depressive symptoms of community-dwelling older people amidst COVID-19 and explore how naturally occurring coping strategies were associated with depression. A mixed-method cross-sectional telephone survey was conducted with 375 older people aged 60 years and above between March and May 2020 in Hong Kong. Trained social workers interviewed participants and assessed depressive symptoms with the Patient Health Questionnaire-9 (PHQ-9). Attribute coding and thematic analysis were adopted for qualitative data analyses. Generalized linear models (GLM) were used to examine the effects of demographics, self-reported risk factors and coping strategies on PHQ-9 scores. Participants' average PHQ-9 score was 1.9 (SD = 2.9), suggesting a low risk for depression in general. Over half of the participants reported adaptive coping strategies, including learning new things, staying physically, mentally, and socially active, and having a positive mind-set. GLM results indicated that living with family members (other than spouse) and/or others, maladaptive coping, and self-reported risk factors were significantly associated with higher PHQ-9 scores, while adaptive coping was significantly associated with lower PHQ-9 scores. Our study contributed to the growing literature on older people's resilience and adaptive coping during the pandemic, and the results may have implications for mental health promotion and community care.

Associations between depressive symptom clusters and care utilization and costs among community-dwelling older adults.

OBJECTIVES: Whether and how symptom clusters are associated with care utilization remains understudied. This study aims to investigate the economic impact of symptom clusters. METHODS: We conducted cross-sectional analyses of data collected from 3255 older adults aged 60 years and over in Hong Kong using the Patient Health Questionnaire-9 and the Client Service Receipt Inventory to measure depressive symptoms and service utilization to calculate 1-year care expenditure. Based on Research Domain Criteria framework, we categorized depressive symptoms into four clusters: Negative Valance Systems and Externalizing (NVSE; anhedonia and depression), Negative Valance Systems and Internalizing (guilt and self-harm), Arousal and Regulatory Systems (sleep, fatigue, and appetite), and Cognitive and Sensorimotor Systems (CSS; concentration and psychomotor). Two-part models were used with four symptom clusters to estimate economic impacts on care utilization. RESULTS: Core affective symptoms had the largest economic impact on non-psychiatric care expenditure; a one-point increase in NVSE was associated with USD$ 571 additional non-psychiatric care expenditure. The economic impacts of CSS on non-psychiatric care expenditure was attenuated when the severity level of NVSE was higher. CONCLUSIONS: Our findings highlight the importance of understanding economic impacts on care utilization based on symptom profiles with a particular emphasis on symptom combinations. Policymakers should optimize care allocation based on older adults' depressive symptom profiles rather than simply considering their depression sum-score or the severity defined by cut-off points.

Consuming Information Related to COVID-19 on Social Media Among Older Adults and Its Association With Anxiety, Social Trust in Information, and COVID-Safe Behaviors: Cross-sectional Telephone Survey.

BACKGROUND: COVID-19-related information on social media is overabundant and sometimes questionable, resulting in an "infodemic" during the pandemic. While previous studies suggest social media usage increases the risk of developing anxiety symptoms, how induced anxiety affects attitudes and behaviors is less discussed, let alone during a global pandemic. Little is known about the relationship between older adults using social media during a pandemic and their anxiety, their attitudes toward social trust in information, and behaviors to avoid contracting COVID-19. OBJECTIVE: The goal of this study was to investigate the associations between using social media for COVID-19-related information and anxiety symptoms as well as the mediation effect of anxiety symptoms on social trust in information and COVID-safe behaviors among older adults. METHODS: A cross-sectional telephone survey was conducted in Hong Kong between May and August 2020. A rapid warm-call protocol was developed to train social workers and volunteers from participant nongovernmental organizations to conduct the telephone surveys. Questions related to COVID-safe behaviors, social trust in information, social media use, anxiety and depressive symptoms, and sociodemographic information were asked. The number of confirmed COVID-19 cases at the community level was used to account for the risk of contracting COVID-19. Ordinary least squares regressions examined the associations between social media use and anxiety symptoms, and how they were associated with social trust in information and COVID-safe behaviors. Structural equation modeling further mapped out these relationships to identify the mediation effects of anxiety symptoms. RESULTS: This study collected information regarding 3421 adults aged 60 years and older. Use of social media for COVID-19-related information was associated with more anxiety symptoms and lower social trust in information but had no significant relationship with COVID-safe behaviors. Anxiety symptoms predicted lower social trust in information and higher COVID-safe behaviors. Lower social trust in information was predicted by using social media for COVID-19 information, mediated by anxiety symptoms, while no mediation effect was found for COVID-safe behaviors. CONCLUSIONS: Older adults who rely on social media for COVID-19-related information exhibited more anxiety symptoms, while showing mixed effects on attitudes and behaviors. Social trust in information may be challenged by unverified and contradictory information online. The negligible impact on COVID-safe behaviors suggested that social media may have caused more confusion than consolidating a consistent effort against the pandemic. Media literacy education is recommended to promote critical evaluation of COVID-19-related information and responsible sharing among older adults.

Health and social care service utilisation and associated expenditure among community-dwelling older adults with depressive symptoms.

AIMS: Late-life depression has substantial impacts on individuals, families and society. Knowledge gaps remain in estimating the economic impacts associated with late-life depression by symptom severity, which has implications for resource prioritisation and research design (such as in modelling). This study examined the incremental health and social care expenditure of depressive symptoms by severity. METHODS: We analysed data collected from 2707 older adults aged 60 years and over in Hong Kong. The Patient Health Questionnaire-9 (PHQ-9) and the Client Service Receipt Inventory were used, respectively, to measure depressive symptoms and service utilisation as a basis for calculating care expenditure. Two-part models were used to estimate the incremental expenditure associated with symptom severity over 1 year. RESULTS: The average PHQ-9 score was 6.3 (standard deviation, s.d. = 4.0). The percentages of respondents with mild, moderate and moderately severe symptoms and non-depressed were 51.8%, 13.5%, 3.7% and 31.0%, respectively. Overall, the moderately severe group generated the largest average incremental expenditure (US$5886; 95% CI 1126-10 647 or a 272% increase), followed by the mild group (US$3849; 95% CI 2520-5177 or a 176% increase) and the moderate group (US$1843; 95% CI 854-2831, or 85% increase). Non-psychiatric healthcare was the main cost component in a mild symptom group, after controlling for other chronic conditions and covariates. The average incremental association between PHQ-9 score and overall care expenditure peaked at PHQ-9 score of 4 (US$691; 95% CI 444-939), then gradually fell to negative between scores of 12 (US$ - 35; 95% CI - 530 to 460) and 19 (US$ -171; 95% CI - 417 to 76) and soared to positive and rebounded at the score of 23 (US$601; 95% CI -1652 to 2854). CONCLUSIONS: The association between depressive symptoms and care expenditure is stronger among older adults with mild and moderately severe symptoms. Older adults with the same symptom severity have different care utilisation and expenditure patterns. Non-psychiatric healthcare is the major cost element. These findings inform ways to optimise policy efforts to improve the financial sustainability of health and long-term care systems, including the involvement of primary care physicians and other geriatric healthcare providers in preventing and treating depression among older adults and related budgeting and accounting issues across services.

Adapting the UCLA 3-item loneliness scale for community-based depressive symptoms screening interview among older Chinese: a cross-sectional study.

OBJECTIVE: Loneliness is a significant and independent risk factor for depression in later life. Particularly in Asian culture, older people may find it less stigmatising to express loneliness than depression. This study aimed to adapt a simple loneliness screen for use in older Chinese, and to ascertain its relevance in detecting depressive symptoms as a community screening tool. DESIGN, SETTING AND PARTICIPANTS: This cross-sectional study was conducted among 1653 older adults aged 60 years or above living in the community in Hong Kong. This was a convenient sample recruited from four local non-governmental organisations providing community eldercare or mental healthcare services. All data was collected by trained social workers through face-to-face interviews. MEASURES: Loneliness was measured using an adapted Chinese version of UCLA 3-item Loneliness Scale, depression symptoms were assessed using the Patient Health Questionnaire-9 (PHQ-9), and social support with emotional and instrumental support proxies (number of people who can offer help). Basic demographics including age, gender, education and living arrangement were also recorded. RESULTS: The average loneliness score was 3.9±3.0, and it had a moderate correlation with depressive symptoms (r=0.41, p<0.01). A loneliness score of 3 can distinguish those without depression from those with mild or more significant depressive symptoms, defined as a PHQ-9 score of ≥5 (sensitivity 76%, specificity 62%, area under the curve=0.73±0.01). Loneliness explained 18% unique variance of depressive symptoms, adding to age, living arrangement and emotional support as significant predictors. CONCLUSION: A 3-item loneliness scale can reasonably identify older Chinese who are experiencing depressive symptoms as a quick community screening tool. Its wider use may facilitate early detection of depression, especially in cultures with strong mental health stigma. TRIAL REGISTRATION NUMBER: ClinicalTrials.gov NCT03593889.

Ruminative and catastrophizing cognitive styles mediate the association between daily hassles and high anxiety in Hong Kong adolescents.

This study assessed rumination, catastrophizing and daily hassles as predictors of anxiety when controlling for depressive symptoms in a community sample of adolescents reporting high anxiety. Adolescents aged 12-18 (N = 2,802, mean age of 14.9) completed the Screen For Child Anxiety-Related Emotional Disorders. With a total score of 30 as the cutoff, a group of high anxiety adolescents was identified (a prevalence rate of 28.02%). Path analyses results showed that amongst the high anxiety boys, catastrophizing but not rumination was a positive predictor of anxiety and it mediated the effects of daily hassles on anxiety. In the high anxiety girls, both rumination and catastrophizing predicted anxiety but only catastrophizing was the mediator between daily hassles and anxiety. It is suggested that such gender differences in cognitive responses styles should be considered in cognitive-behavioral therapeutic approaches designed to help adolescents showing high anxiety.