Physical activity, sedentary behaviour and smoking status among psychiatric patients in Singapore - a cross-sectional study.

BACKGROUND: Unhealthy behaviours such as physical inactivity, sedentary behaviour and smoking have been found to be more prevalent in people with psychiatric disorders than in the general population, leading to increased mortality risk. The present study seeks to identify correlates of physical activity and sedentary behaviour among psychiatric patients in Singapore, as well as investigate differences in their physical activity patterns by smoking status. METHODS: Participants (n = 380) were recruited from a tertiary psychiatric hospital in Singapore as part of a study on the prevalence and correlates of smoking among psychiatric patients. Physical activity levels and sedentary behaviour were measured using the Global Physical Activity Questionnaire (GPAQ) and analysed based on GPAQ guidelines. Chi-square analyses were conducted to examine differences in physical activity by smoking status, and logistic regression analyses to yield sociodemographic correlates of meeting physical activity guidelines (as recommended by the World Health Organization) and sedentary behaviour. RESULTS: Education was found to be significantly associated with meeting recommended physical activity levels, while age and marital status were significantly associated with excessive sedentary behaviour. Additionally, while no significant differences were found among current, former and non-smokers across all types of physical activity engagement levels, there was a high prevalence of inadequate physical activity (43.2%) and excessive sedentary behaviour (38.8%) among participants. CONCLUSION: Given the high prevalence of inadequate physical activity and excessive sedentary behaviour among current, former and non-smokers with psychiatric disorders, programmes aimed at increasing physical activity and lowering sedentary behaviour levels should be integrated into targeted treatment plans to improve clinical outcomes.

The potential impact of an anti-stigma intervention on mental health help-seeking attitudes among university students.

BACKGROUND: The reluctance of young adults to seek mental health treatment has been attributed to poor mental health literacy, stigma, preference for self-reliance and concerns about confidentiality. The purpose of this study was to examine the potential impact of an anti-stigma intervention that includes education about depression, information about help-seeking as well as contact with a person with lived experience, on help seeking attitudes. METHODS: A pre-post study design was employed. Changes in help-seeking attitudes were measured using the Inventory of Attitudes towards Seeking Mental Health Services (IASMHS) immediately post-intervention and after 3 months. Sociodemographic data, information on past experiences in the mental health field and contact with people with mental illness were collated. Three hundred ninety university students enrolled in the study. Linear mixed models were used to examine the effects of the intervention. RESULTS: Scores on all subscales of the IASMHS, Psychological Openness (PO), Help-seeking Propensity (HP) and Indifference to Stigma improved significantly post-intervention and at 3-month follow-up compared to pre-intervention, with HP demonstrating the highest effect size. However, a significant decline was observed on all three scales at 3-month follow-up compared to post-intervention. Gender, having friends/family with mental illness, and previous experience in the mental health field moderated the intervention effects for the PO and HP subscales. CONCLUSION: The study showed that the brief anti-stigma intervention was associated with improvements in help-seeking attitudes among university students with differential effects among certain sub-groups. As the beneficial outcomes appeared to decrease over time, booster sessions or opportunities to participate in mental health-related activities post-intervention may be required to maintain the desired changes in help-seeking attitudes.

Equipercentile linking of the Sheehan Disability Scale and the World Health Organization Assessment Schedule 2.0 scales in people with mental disorders.

BACKGROUND: The Sheehan Disability Scale (SDS) and the World Health Organization Disability Assessment Scale (WHODAS 2.0) have been widely used to measure functional impairment and disability. To ensure that the scores from these two scales are practically exchangeable across diseases, therapies, and care programmes, the current study aimed to examine the linkage of the WHODAS 2.0 with the SDS and develop a simple and reliable conversion table for the two scales in people with mental disorders. METHODS: A total of 798 patients (mean age = 36.1, SD = 12.7) were recruited from outpatient clinics of the Institute of Mental Health, and the Community Wellness Clinic in Singapore. Using a single-group design, an equipercentile equating method with log-linear smoothing was used to establish a conversion table from the SDS to the WHODAS 2.0 and vice versa. RESULTS: The conversion table showed that the scores were consistent for the entire range of scores when the scores were converted either from the SDS to the WHODAS 2.0 or from the WHODAS 2.0 to the SDS. The agreement between the WHODAS 2.0's raw and converted scores and SDS's raw and converted scores were interpreted as good with intraclass correlation coefficient of 0.711 and 0.725, respectively. CONCLUSION: This study presents a simple and reliable method for converting the SDS scores to the WHODAS 2.0 scores and vice versa, enabling interchangeable use of data across these two disability measures.

Mapping the world health organization disability assessment scale 2.0 to the EQ-5D-5L in patients with mental disorders.

OBJECTIVE: The current study aims to develop an algorithm that mapping the WHODAS 2.0 to the EQ-5D-5 L for patients with mental disorders. METHODS: This cross-sectional study was conducted at the Institute of Mental Health and the Community Wellness Clinics in Singapore between June 2019 and November 2022. We included four regression methods including the Ordinary Least Square (OLS) regression, Tobit regression model (Tobit), the robust regression with MM estimator (MM) and the adjusted limited dependent variable mixture models (ALDVMM) to map EQ-5D-5 L utility scores from the WHODAS 2.0. RESULTS: A total of 797 participants were included. The mean EQ-5D-5 L utility and WHODAS 2.0 total scores were 0.61 (SD = 0.34) and 11.96(SD = 8.97), respectively. We found that the EQ-5D-5 L utility score was best predicted by the robust regression model with the MM estimator. Our findings suggest that the WHODAS 2.0 total scores were significantly and inversely associated with the EQ-5D-5 L utility scores. CONCLUSION: This study provides a mapping algorithm for converting the WHODAS 2.0 scores into EQ-5D-5 L utility scores which can be implemented using a simple online calculator in the following web application: https://eastats.shinyapps.io/whodas_eq5d/.

Self-stigma and quality of life among people with psychosis: The protective role of religion.

AIM: The quality of life in people with psychosis has been consistently demonstrated to be lower than those without, with self-stigma contributing greatly to this impairment. Hence, it is imperative to address this gap in order to facilitate recovery-oriented and other outcomes. This study investigates the potential of religiosity in moderating the effects of self-stigma on quality of life among those with psychosis. METHODS: Adults with psychosis (n = 99) were recruited from the Early Psychosis Intervention Programme in Singapore from 2018 to 2021, and administered the self-report Religious Commitment Index, Internalized Stigma of Mental Illness scale, and Abbreviated World Health Organization Quality of Life instrument. Linear regression analyses were conducted and the interaction between self-stigma and religious commitment scores calculated to investigate the moderation effects of religiosity on the relationship between stigma and quality of life. RESULTS: Preliminary regression analyses revealed a significant association between sex and psychological quality of life. After controlling for sex, religiosity was found to moderate the relationship between self-stigma and psychological quality of life. CONCLUSIONS: The results of the study demonstrate the potential of religiosity in buffering the effects of self-stigma on quality of life. This reveals an area that can be easily targeted and addressed in treatment programs to improve outcomes beyond the clinical setting among people living with psychosis, to facilitate their recovery journey and beyond.

Validation of the 12-item World Health Organization Disability Assessment Schedule 2.0 in individuals with schizophrenia, depression, anxiety, and diabetes in Singapore.

BACKGROUND: There is limited evidence on the reliability and validity of the 12-item World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0) in an Asian patient population with mental and physical disorders. The current study aimed to examine the psychometric properties of the WHODAS 2.0 among patients with schizophrenia, depression, anxiety, and diabetes. METHODS: A total of 1076 patients (M = 40.9 years, SD = 14.7) were recruited from the outpatient clinics of a tertiary psychiatric hospital and a primary care clinic. Internal consistency and test-retest reliability, structural validity, convergent validity, agreement, and floor and ceiling effects were examined. RESULTS: Our confirmatory factor analysis (CFA) showed that the 1-factor model fits our data. Multigroup CFA demonstrated metric and scalar invariance, indicating the scores can be compared across the four conditions. The WHODAS 2.0 scale had excellent reliability in the overall sample and good to excellent reliability across conditions. The test-retest reliability and agreement between self-administered and interviewer-administered modes were good. The WHODAS 2.0 scores had moderate to strong correlations with the Social and Occupational Functioning Scale and the Sheehan Disability Scale scores in the overall sample and across four conditions. CONCLUSION: Findings suggest that the WHODAS 2.0 is a valid tool to measure functioning and disability in those with schizophrenia, anxiety, depression, and diabetes in an Asian patient population.

A Mixed-Methods Outcomes Evaluation Protocol for a Co-Produced Psychoeducation Workshop Series on Recovery from Psychosis.

Co-production in mental health is a relatively new approach to designing and delivering mental health services, which involves collaboration amongst professionals, persons in recovery, and their caregivers to provide services. The aim of this protocol paper is to detail the implementation and evaluation of a co-produced workshop series named Broken Crayons. Collaborating with an early intervention program for first-episode psychosis, the study team and peer volunteers generated a co-production framework based on their experience of co-producing 11 workshops. This paper also outlines a protocol to evaluate Broken Crayons, a psychoeducation workshop series co-created and co-delivered by mental health professionals, persons in recovery, and their caregivers. Indicators on personal recovery, mental wellbeing, community integration, etc., are included as outcomes. Two-tailed, paired t-tests will be used to compare pre- and post-workshop survey data. Focus group discussions will also be conducted to gather subjective experiences of participants of the Broken Crayons workshops. Cost-savings of co-production by Recovery Colleges are discussed. The implications of using co-production to foster citizenry in persons living with first-episode psychosis are discussed in the context of social causation and social drift theories. Taken together, we argued that co-production is not just a passing trend, but a moral imperative for inclusive and equitable mental health service design and delivery.

Depression and Suicidality: The Roles of Social Support and Positive Mental Health.

OBJECTIVE: Despite being preventable, suicide remains a leading cause of death globally, with depression being one of the more prominent risk factors. This study examines the roles of social support and positive mental health in the depression-suicidality pathway. METHODS: We utilized data from the Singapore Mental Health Study 2016. Social support and positive mental health were examined as mediators in the relationship between 12-month depression and 12-month suicidality using survey-weighted generalized structural equation modeling. RESULTS: Overall positive mental health was found to partially mediate the relationship between depression and suicide. Of the discrete positive mental health domains, the depression-suicidality relationship was partially mediated by general coping and fully mediated by personal growth and autonomy. CONCLUSION: While findings regarding social support were inconclusive, positive mental health may play a significant role in alleviating the effects of depression on suicidality. This highlights the multifaceted nature of suicidality and reveals positive mental health as a new area in assessing and treating at-risk people, to improve clinical outcomes.HIGHLIGHTSThe effect of depression on suicidality was partially mediated by overall positive mental health.General coping partially mediated the relationship between depression and suicidality.Personal growth and autonomy fully mediated the relationship between depression and suicidality.

Growth in the Aftermath of Psychosis: Characterizing Post-traumatic Growth in Persons With First Episode Psychosis in Singapore.

Experiencing first episode psychosis (FEP) is a highly traumatic life event. However, there is evidence to show that the outcome of psychosis is more nuanced than was conventionally thought. Young persons with FEP can grow from the experience of psychosis. In this study, we aim to characterize post-traumatic growth (PTG) in persons with FEP over 1 year. A total of 99 FEP clients receiving services from an early psychosis intervention team in Singapore were recruited. The PTG Inventory, among other scales, like Questionnaire on the Process of Recovery and Connor-Davidson Resilience Scale, were administered in this population. A total of 52 participants completed the questionnaire at two timepoints (one year apart). The Reliable Change Index was calculated for participants who completed both timepoints. Repeated measures of correlation were performed, which identified personal recovery and resilience to be associated with PTG in this sample. This clinical population exhibited PTG in the aftermath of psychosis. PTG was associated with personal recovery and resilience, but not clinical indicators, like symptoms and functioning. Data from this study suggests that recovery and growth from first episode psychosis is a possibility. Clinical implications, strengths and limitations of this study are discussed.

Dietary intake of persons with depressive and psychotic disorders in Singapore.

INTRODUCTION: Nutritional psychiatry is an emerging field of study that investigates the role of diet and nutrition in mental health. Studies conducted in the general population have linked depressive symptoms with poor dietary patterns. The aim of this study was to characterise the dietary intake and analyse the dietary pattern using the Dietary Approach to Stop Hypertension (DASH) in a sample of psychiatric patients in a multiethnic Asian nation. METHODS: Participants were recruited from an outpatient clinic and an inpatient unit at the Institute of Mental Health in Singapore. Self-reported dietary habits of a sample of psychiatric patients (N=380) were analysed using DASH. To examine the variables associated with DASH scores, a linear regression was conducted with the full sample and sociodemographic variables. RESULTS: Persons with depressive disorders had a mean DASH score of 21.3 (±4.2), while persons with psychotic disorders had a mean DASH score of 21.2 (±4.9). Respondents who were older (B=1.94, 95% confidence interval [CI] 0.91-2.96, P<0.001), female (B=1.09, 95% CI 0.07-2.11, P=0.04) and economically inactive (B=1.98, 95% CI 0.006-3.96, P=0.049) were more likely to report a higher diet quality compared with their respective counterparts, while smokers (B= -1.39, 95% CI -2.45 to -0.34, P=0.009) tended to report a lower diet quality compared with their non-smoking counterparts. CONCLUSION: Dietary patterns of persons with mental disorders were characterised. A host of sociodemographic factors, and not diagnosis of mental disorders, influenced the dietary quality of people with depressive and psychotic disorders. Clinicians treating psychiatric patients need to be aware of the nuanced reasons behind poor dietary choices and provide targeted psychoeducation to specific subgroups within the patient population.

Nicotine Dependence in Patients with Major Depressive Disorder and Psychotic Disorders and Its Relationship with Quality of Life.

The aim of the current study was to examine the associations between nicotine dependence and quality of life (QOL) among individuals diagnosed with major depressive disorder (MDD) or psychotic disorders. Methods: A total of 378 participants diagnosed with either MDD or psychotic disorders were recruited. The Fagerstorm Test for Nicotine Dependence was used to measure the level of nicotine dependence. The SF-12 health survey questionnaire was used to measure the QOL. Results: The prevalence of nicotine dependence was 23.3% in this sample population. For those diagnosed with MDD, moderate level of nicotine dependence was negatively associated with Vitality and Mental Component Score. For those diagnosed with a psychotic disorder high nicotine dependence was negatively associated with Role Emotional, Mental Health and Mental Component Score. Discussion: Compared to the general population, the prevalence of smoking in this psychiatric population was 2.4 times higher, while that of nicotine dependence was seven times higher. Individuals with psychotic disorder generally reported better QOL as compared to individuals with MDD. QOL differed across diagnostic groups with regards to socio-demographics, such as age, ethnicity, marital status, education, employment status and monthly income. Among individuals with MDD and psychotic disorders, different levels of nicotine dependence resulted in different levels of association with QOL. More research is needed to better understand the differences in QOL among the varying levels of nicotine dependence.

Smoking-Related Health Beliefs in a Sample of Psychiatric Patients: Factors Associated with the Health Beliefs and Validation of the Health Belief Questionnaire.

This study examined the (a) health beliefs and emotions (perception of risk, benefits, severity, and worry) about smoking among current and former smokers, (b) their awareness of health warnings, (c) factors associated with smoking-related health beliefs, and (d) the factor structure of the health belief questionnaire. Participants (n = 184) were recruited from a tertiary psychiatric care hospital. Current smokers showed a significantly higher risk perception and lower perceived benefits compared to former smokers. Younger age (<40 years), nicotine dependence (ND), a history of smoking-related diseases (SRD), and intention to quit were significantly associated with a higher risk perception in current smokers. Younger age, a history of SRDs, and motivation to quit were positively associated with health beliefs, while the latter two were associated with worry. Motivation and younger age were associated with a better perception of benefits and severity. Information on the cigarette packets was the major source of awareness for the sample, and 69% reported that existing campaigns were not effective in discouraging their smoking. Personalized risk communication and educational initiatives must focus on improving the knowledge of risk, benefits, and increase motivation to promote health cognition and thus smoking cessation.

The use of complementary and alternative medicine in a multi-ethnic Asian population: results from the 2016 Singapore Mental Health Study.

BACKGROUND: This study seeks to investigate factors associated with using complementary and alternative medicine (CAM) for a mental illness among the three major ethnic groups (Chinese, Indians and Malays) in the general population of Singapore. METHODS: Data from the 2016 Singapore Mental Health Study was used; responses from the "Services" section of the Composite International Diagnostic Interview version 3.0 (CIDI 3.0) administered during face-to-face household interviews with participants were analyzed to establish prevalence of CAM use among Singaporeans. Additionally, sociodemographic variables of interest were selected for sub-group regression analyses to yield correlates of CAM use among the three ethnic groups. RESULTS: 6.4% of Singaporeans used at least one form of CAM in the past 12 months for their mental illness. Malays reported using CAM the most, followed by Indians and Chinese. Sociodemographic variables such as education and employment were differently associated with CAM use among the ethnicities. Across all three ethnic groups, CAM users were more likely to report poorer mental health-related quality of life. CONCLUSION: Despite the significant differences in CAM use among Chinese, Malays and Indians, those who had a mental illness were significantly more likely to use CAM regardless of ethnicity. This highlights the need for communication between CAM practitioners and conventional mental healthcare providers for early referral when appropriate which would lead to improved healthcare delivery and better clinical outcomes.

Smoking and Mental Illness: Prevalence, Patterns and Correlates of Smoking and Smoking Cessation among Psychiatric Patients.

This study aims to understand (a) the prevalence and correlates of smoking in a psychiatric population, (b) factors that encourage smoking cessation, and (c) awareness towards cessation programmes. This study captured data (n = 380) through a modified version of the Global Adult Tobacco Survey (GATS). A descriptive analysis of the data was performed. The prevalence of smoking was 39.5% (n = 150) and 52.3% of the smokers were dependent on nicotine. More than half of the smokers had made at least one attempt to quit in the past 12 months and 56% reported no immediate plans to quit smoking. The awareness towards institutional smoking cessation programmes was fair (44%), with 49.7% of smokers having indicated that they were willing to use the service upon referral. Smokers endorsed that increasing the cost of cigarettes, restricting availability, and increasing knowledge of health harms could encourage smoking cessation. Past smokers reported that self-determination/willpower followed by substitution of smoking with other types of foods and drinks were factors that helped them achieve successful cessation. Given that the readiness to quit and awareness towards cessation programmes are low among the smokers, concerted efforts through educational programmes and policy changes are crucial to achieve successful cessation.