Performance of the 6-item Kessler scale for measuring serious mental illness in Hong Kong.

BACKGROUND: The 6-item Kessler scale (K6) promises to be a valuable epidemiological tool for assessing serious mental illness (SMI) in communities with limited resources for psychiatric research and treatment. Its performance in Chinese community has not been studied with reference to clinically assessed SMI. METHOD: From a representative telephone-based population survey (n = 3014) that administered the K6, 153 participants were readministered the K6 and, on the same day, interviewed face-to-face by clinicians using the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorder, Fourth Edition, Axis I Disorder. Predictive indicators such as McNemar χ(2), area under receiver operating characteristic curve and stratum-specific likelihood ratios were used to investigate the concordance between the K6 and clinical status of SMI, individual-level predicted probabilities of having SMI, and the weighted prevalence of SMI in the community. RESULT: The K6 exhibited high internal consistency and test-retest reliability. Factor analysis revealed 2 correlating components composed of depression and anxiety. Matching of K6 caseness and SMI status showed that at the cutoff of 12/13, the area under receiver operating characteristic curve was moderate (0.69). The K6 had high specificity and was a stronger screen-out than screen-in tool for SMI. The weighted prevalence estimate of SMI in Hong Kong was 6.5%. A person scoring 13 or above on the K6 has a probability of at least 22.2% of having SMI. CONCLUSION: The Chinese K6 is reliable and generates the likelihood of SMI with substantial concordance with face-to-face clinical interviews in Hong Kong. It is a valuable tool for screening SMI, behavioral risk factor surveillance, and community epidemiological surveys.

Premarital mental disorders and physical violence in marriage: cross-national study of married couples.

BACKGROUND: Mental disorders may increase the risk of physical violence among married couples. AIMS: To estimate associations between premarital mental disorders and marital violence in a cross-national sample of married couples. METHOD: A total of 1821 married couples (3642 individuals) from 11 countries were interviewed as part of the World Health Organization's World Mental Health Survey Initiative. Sixteen mental disorders with onset prior to marriage were examined as predictors of marital violence reported by either spouse. RESULTS: Any physical violence was reported by one or both spouses in 20% of couples, and was associated with husbands' externalising disorders (OR = 1.7, 95% CI 1.2-2.3). Overall, the population attributable risk for marital violence related to premarital mental disorders was estimated to be 17.2%. CONCLUSIONS: Husbands' externalising disorders had a modest but consistent association with marital violence across diverse countries. This finding has implications for the development of targeted interventions to reduce risk of marital violence.

Rapid-cycling bipolar disorder: cross-national community study.

BACKGROUND: The epidemiology of rapid-cycling bipolar disorder in the community is largely unknown. AIMS: To investigate the epidemiological characteristics of rapid-cycling and non-rapid-cycling bipolar disorder in a large cross-national community sample. METHOD: The Composite International Diagnostic Interview (CIDI version 3.0) was used to examine the prevalence, severity, comorbidity, impairment, suicidality, sociodemographics, childhood adversity and treatment of rapid-cycling and non-rapid-cycling bipolar disorder in ten countries (n = 54 257). RESULTS: The 12-month prevalence of rapid-cycling bipolar disorder was 0.3%. Roughly a third and two-fifths of participants with lifetime and 12-month bipolar disorder respectively met criteria for rapid cycling. Compared with the non-rapid-cycling, rapid-cycling bipolar disorder was associated with younger age at onset, higher persistence, more severe depressive symptoms, greater impairment from depressive symptoms, more out-of-role days from mania/hypomania, more anxiety disorders and an increased likelihood of using health services. Associations regarding childhood, family and other sociodemographic correlates were less clear cut. CONCLUSIONS: The community epidemiological profile of rapid-cycling bipolar disorder confirms most but not all current clinically based knowledge about the illness.

Childhood adversities as risk factors for onset and persistence of suicidal behaviour.

BACKGROUND: Suicide is a leading cause of death worldwide, but the precise effect of childhood adversities as risk factors for the onset and persistence of suicidal behaviour (suicide ideation, plans and attempts) are not well understood. AIMS: To examine the associations between childhood adversities as risk factors for the onset and persistence of suicidal behaviour across 21 countries worldwide. METHOD: Respondents from nationally representative samples (n = 55 299) were interviewed regarding childhood adversities that occurred before the age of 18 years and lifetime suicidal behaviour. RESULTS: Childhood adversities were associated with an increased risk of suicide attempt and ideation in both bivariate and multivariate models (odds ratio range 1.2-5.7). The risk increased with the number of adversities experienced, but at a decreasing rate. Sexual and physical abuse were consistently the strongest risk factors for both the onset and persistence of suicidal behaviour, especially during adolescence. Associations remained similar after additional adjustment for respondents' lifetime mental disorder status. CONCLUSIONS: Childhood adversities (especially intrusive or aggressive adversities) are powerful predictors of the onset and persistence of suicidal behaviours.

Childhood adversities and adult psychopathology in the WHO World Mental Health Surveys.

BACKGROUND: Although significant associations of childhood adversities with adult mental disorders are widely documented, most studies focus on single childhood adversities predicting single disorders. AIMS: To examine joint associations of 12 childhood adversities with first onset of 20 DSM-IV disorders in World Mental Health (WMH) Surveys in 21 countries. METHOD: Nationally or regionally representative surveys of 51 945 adults assessed childhood adversities and lifetime DSM-IV disorders with the WHO Composite International Diagnostic Interview (CIDI). RESULTS: Childhood adversities were highly prevalent and interrelated. Childhood adversities associated with maladaptive family functioning (e.g. parental mental illness, child abuse, neglect) were the strongest predictors of disorders. Co-occurring childhood adversities associated with maladaptive family functioning had significant subadditive predictive associations and little specificity across disorders. Childhood adversities account for 29.8% of all disorders across countries. CONCLUSIONS: Childhood adversities have strong associations with all classes of disorders at all life-course stages in all groups of WMH countries. Long-term associations imply the existence of as-yet undetermined mediators.

Individual and societal impact on earnings associated with serious mental illness in metropolitan China.

To evaluate individual-level and societal-level losses of income associated with serious mental illness in metropolitan China, a multi-stage probability survey was administered to adults aged 18-70 years in Beijing and Shanghai. We used data to estimate individual-level expected earnings from a model that included information about the respondents' education level, marital status, age, and gender. Expected earnings were compared to observed earnings among respondents with mental illness and serious disability. The result shows that the 12-month prevalence of such serious mental illness was 0.6%. Its impact on earnings was significant in the total sample and was higher for males (76% of gender-specific expected salary was lost) than for females (32%). When projected to societal level, the annual impact was estimated to be 466 million Renminbi (RMB 8.27=USD 1), less than 0.2% of the gross domestic product (GDP) of the two cities. Serious mental illness was associated with a substantial decrease in individual-level earnings, but the burden that resulted from societal-level loss of earnings was not large enough to help drive mental health policy and programs in China.

Impaired role functioning and treatment rates for mental disorders and chronic physical disorders in metropolitan China.

OBJECTIVES: To compare impairments in role functioning and treatment rate of mental disorders and chronic physical disorders in the general population of metropolitan China. METHOD: Face-to-face household interviews of 5201 people aged 18 to 70 years in Beijing and Shanghai were conducted from November 2001 to February 2002, using a multistage household probability sampling method. The World Mental Health version of the Composite International Diagnostic Interview (WMH-CIDI) was used for assessing sociodemographic characteristics, diagnoses, and treatment. The Sheehan Disability Scale (SDS) was used to measure disorder-specific role impairment. RESULTS: Respondents generally attributed greater impairment to mental disorders than to chronic physical disorders, although there were some variations among specific disorders. This general pattern was supported by within-person comparison of impairment associated with a mental disorder versus any chronic physical disorder. Depression, generalized anxiety disorder, and specific phobia were the most impairing mental disorders. Diabetes, headaches, and asthma were the most impairing physical disorders. Comorbid mental and physical disorders were associated with more severe impairment. A much lower percentage of respondents with mental disorders (3.0%) than chronic physical disorders (42.8%) received treatment in the previous 12 months. CONCLUSION: Common mental disorders were associated with greater impairment than chronic physical disorders but were markedly undertreated. They warrant prioritization in the allocation of healthcare resources in China.

Association of headache with childhood adversity and mental disorder: cross-national study.

BACKGROUND: Community studies about the association of headache with both childhood family adversities and depression/anxiety disorders are limited. AIMS: To assess the independent and joint associations of childhood family adversities and early-onset depression and anxiety disorders with risks of adult-onset headache. METHOD: Data were pooled from cross-sectional community surveys conducted in ten Latin and North American, European and Asian countries (n=18 303) by using standardised instruments. Headache and a range of childhood family adversities were assessed by self-report. RESULTS: The number of childhood family adversities was associated with adult-onset headache after adjusting for gender, age, country and early-onset depression/anxiety disorder status (for one adversity, hazard ratio (HR)=1.22-1.6; for two adversities, HR=1.19-1.67; for three or more adversities, HR=1.37-1.95). Early and current onset of depression/anxiety disorders were independently associated (HR=1.42-1.89) with adult-onset headache after controlling for number of childhood family adversities. CONCLUSIONS: The findings call for a broad developmental perspective concerning risk factors for development of headache.

Generalized anxiety disorder with and without excessive worry in Hong Kong.

BACKGROUND: Two previous U.S. studies found that although generalized anxiety disorder (GAD) without self-perceived excessive worry was milder than GAD with excessive worry, its persistence, impairment, and risk for subsequent onset of other mental disorders were still substantial. This study examined the implications of relaxing the "excessiveness" criterion on the prevalence and socio-demographic profile of GAD in a Chinese population sample by considering both self and others' perception of excessive worry. METHOD: 2,005 respondents aged 15-65 years participated in a structured telephone interview that covered socio-demographic profile, 12-month DSM-IV diagnosis of GAD, core depressive symptoms, longest duration of worry episode, number of domains of worry, impairment measured by the Sheehan Disability Scale, and treatment-seeking. Excessive worry was assessed from the perception of both respondents and others as reported by respondents. RESULT: The 12-month prevalence of GAD increased from 3.4 to 4% when the excessiveness requirement was relaxed. Excessive GAD and nonexcessive GAD had similar socio-demographic, symptom, chronicity, impairment, depressive symptom, and treatment-seeking profiles. CONCLUSION: GAD without excessive worry was less common than GAD with excessive worry but was likely to be a valid nosological entity. Future iterations of the DSM-IV should clarify whether excessive worry should be retained and, if so, how individuals who only reported excessive worries perceived by others should be optimally assessed.

A population-based study of depression and three kinds of frequent pain conditions and depression in Hong Kong.

OBJECTIVE: To investigate the relationship between three frequent pain conditions and depression among Chinese adults in Hong Kong. METHOD: A cross-sectional telephone-based survey examined the prevalence and correlates of three kinds of frequent pain and their association with Diagnostic and Statistical Manual of Mental Disorders major depression in a random sample of 5,004 adults (2,371 males and 2,634 females). RESULT: The 1-year prevalence rates of frequent spinal pain, headache, and joint pain were 37.2%, 26.7% and 19.9%, respectively. Although all three kinds of pain were more common in females and the unemployed, the sociodemographic profile of risk correlates and association with depression varied across each kind of pain. Spinal pain was more strongly associated with headache and joint pain than headache was associated with joint pain. In logistic regression, the relative risk of depression with the three kinds of pain as predictors varied between 1.6 and 3.4. CONCLUSION: Depression is strongly associated with pain in Hong Kong, though the pattern of association varies across specific pain conditions. Comprehensive evaluation of pain complaints may improve the recognition of depression as well as the outcome of pain management.

Prevalence and correlates of depression with atypical symptoms in Hong Kong.

OBJECTIVE: Previous studies of atypical depression have been conducted in Western communities. There has been no community-based epidemiological study of atypical depression that covers the entire spectrum of bipolar disorders. The aim of the present study was to examine the 12 month prevalence of atypical depression and the differences in demographic and clinical profiles between depressed patients with and without atypical symptoms in the Chinese adult population of Hong Kong. METHOD: A random sample of 3016 Chinese adults completed a telephone-based structured interview that examined their 12 month prevalence of major depressive episode. Atypical depression was defined as major depressive episode with hypersomnia and increased weight or appetite. Major depressive episode with and without atypical symptoms were compared on sociodemographic variables, number of depressive and manic/hypomanic symptoms, proportion of having lifetime mania/hypomania, suicidality, family psychiatric history, help-seeking behaviour, level of distress and role impairment. RESULTS: The 12 month prevalence of atypical depression was 1.3%. Compared to non-atypical depression, atypical depression was associated with female gender, soft (subthreshold) bipolar II disorder, family psychiatric history, higher suicidality, more help-seeking from psychiatrists, and more depressive and manic/hypomanic symptoms. There was no difference in levels of distress or impairment. CONCLUSIONS: Although limited by the lack of detailed information on comorbidity, bipolar family history, and age of onset, the findings support the hypothesis that atypical depression among Chinese people in Hong Kong exhibited prevalence and correlates similar to those found in Western epidemiological and clinical studies. Further research is warranted to examine its association with hypomania and how atypical depression may occupy a nosological position between typical unipolar depression and bipolar spectrum disorders.

Prevalence and the factors associated with binge drinking, alcohol abuse, and alcohol dependence: a population-based study of Chinese adults in Hong Kong.

AIMS: To examine the patterns of drinking, the relationship between binge drinking, alcohol abuse, and dependence, and the sociodemographic factors associated with problem drinking among Hong Kong Chinese. METHOD: An anonymous, random telephone survey was conducted on 9860 Hong Kong Chinese adults from April to June, 2006. RESULTS: The age-adjusted prevalence amongst men for binge drinking was 14.4% with 5.3% of males being alcohol abusers and 2.3% dependent on alcohol. The corresponding figures for women were all lower at 3.6%, 1.4%, and 0.7%, respectively. Younger age groups showed the highest prevalence of these drinking problems. Among male binge drinkers, 18.7% were also alcohol abusers and 12.3% were alcohol dependent. Among female binge drinkers, 16% reported alcohol abuse and 9.9% reported dependence. Male binge drinkers were less likely to be older, less likely to be students but more likely to be employed in the service industry. Female binge drinkers were less likely to be over 60 years of age or married but more likely to be smokers. In both genders, smoking was significantly associated with the likelihood of binge drinking (OR = 3.6-12.3), alcohol abuse (OR = 3.0-12.1), and dependence (OR = 5.2-20.6). CONCLUSIONS: Although binge drinking has been well tolerated in Chinese culture, it is strongly associated with alcohol abuse and dependence in both genders in Hong Kong. Our findings suggest that prevalence of problematic alcohol consumption warrants greater promotion of alcohol harms awareness. Higher rates of heavy drinking in younger-aged individuals may reflect changing lifestyle behaviors and herald higher future levels of alcohol-related health and social problems.

Concordance between telephone survey classification and face-to-face structured clinical interview in the diagnosis of generalized anxiety disorder in Hong Kong.

Telephone surveys of estimating mental disorders have been found to generate comparable findings to large-scale community surveys but the concordance between telephone instruments and clinical interviews is rarely examined. In this study, 100 Chinese respondents who had taken part in a telephone-based population survey of generalized anxiety disorder (GAD) in Hong Kong were administered the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I) by clinical interviewers. The discriminability and predictive indicators of the telephone survey instrument were assessed using receiver operating characteristic analysis. Results showed that the telephone survey instrument identified individuals with a positive SCID diagnosis of GAD better than those without. Although its individual questions performed well in identifying the endorsement of the corresponding core SCID criterion of GAD, further studies are needed to find out the optimal combination of questions in the telephone instrument for identifying GAD in community surveys.

Twelve-month prevalence, correlates, and treatment preference of adults with DSM-IV major depressive episode in Hong Kong.

BACKGROUND: The most recent large-scale community mental health survey of depression among adults in Hong Kong was conducted over two decades ago. The lifetime prevalence rates of DSM-III major depressive disorder (females 2.44% and males 1.29%) in that study do not tally with several indices of worsened social health and clinical prevalence studies of depression in contemporary Hong Kong. METHODS: Each of 5004 adults randomly drawn from the general population completed a telephone interview that generated the DSM-IV-based diagnosis of major depressive episode (MDE), sociodemography, help-seeking, and other epidemiological data. RESULTS: Twelve-month prevalence of MDE was 8.4%. The female-to-male ratio was low but typical of surveys in Chinese communities. Female sex and unemployment were associated with increased risk. 32.5% of respondents with MDE reported frequent thoughts of suicide. Recognition of the need for treatment of depression was high but actual treatment rate and preference for mental health specialists were low. LIMITATIONS: Response rate was low though cooperation rate was moderately high. Detailed demography, comorbidity, and clinical reappraisal interviews were not covered. CONCLUSIONS: Resolving issues of stigma and mode of symptom elicitation may lead to more valid prevalence estimates of depression among Chinese people. Although longitudinal studies are needed to confirm a genuine increase in prevalence, depression is likely to be more common in Hong Kong than previously suggested. High recognition of the need for treatment but low rate of actual treatment calls for policy and programs that improve access to treatment.

Arthritis and physical-mental comorbidity in metropolitan China.

BACKGROUND: This study estimates psychiatric and physical comorbidity among people reporting arthritis and related role impairment in metropolitan China. METHODS: Data were derived from a large-scale and representative household survey of adult respondents in Beijing and Shanghai. Arthritis and other chronic physical conditions were assessed by self-report. Mental disorders were assessed by the World Mental Health version of the World Health Organization Composite International Diagnostic Interview. RESULTS: Of the respondents reporting arthritis in Beijing (8.6%) and Shanghai (15.3%), the vast majority (Beijing, 85.2%; Shanghai, 79.9%) also reported at least one other comorbid condition, including chronic pain (Beijing, 73.4%; Shanghai, 64.8%), chronic physical diseases (Beijing, 54.7%; Shanghai, 57.2%), and mental disorders (Beijing, 10.5%; Shanghai, 10.0%). Arthritis was significantly associated with role impairment, but the association disappeared after controlling for demographic variables and comorbidities. CONCLUSIONS: Physical-mental comorbidity is common and has important clinical and public health implications in China. Reasons for regional differences in prevalence and pattern of comorbidity require further study.

Attitudes toward suicide among Chinese people in Hong Kong.

Since suicide in Chinese people exhibits certain distinctive characteristics, it is important to develop indigenous measures to assess Chinese attitudes toward suicide that may be used to inform suicide reduction programs. Combining qualitative and quantitative methods, we developed a Hong Kong version of the Chinese Attitude toward Suicide Questionnaire (CASQ-HK) which assesses attitudes toward suicide, suicidal inclination under 12 hypothetical scenarios, and prior suicidal experience. A convenience sample of 1,226 people completed the self-report questionnaire. In keeping with Chinese tradition, respondents revealed both tolerant and condemning attitudes that varied with their sociodemographic characteristics. Generally, they were not strongly inclined to consider suicide in the presence of difficult scenarios. Female gender, older age, and the presence of suicidal ideation were associated with more contemplation of suicide.

Treatment-related stresses and anxiety-depressive symptoms among Chinese outpatients with type 2 diabetes mellitus in Hong Kong.

Based on focus group findings, a descriptive instrument was developed to examine the relationship among treatment-related stress, anxiety and depressive symptoms, distress, and impairment of 333 Chinese outpatients with type 2 diabetes mellitus (DM) in Hong Kong. It was found that the main stresses included fears of diabetes complications, work impairment, lifestyle adjustment, stigmatization, and discrimination. Over 1/4 of patients concealed their DM from family members in order not to make the latter worry. 28.3% felt that life was not worth living. 33.6% of patients exhibited four or more anxiety and depressive symptoms accompanied by significant distress and/or impairment. These patients were more likely to be female, of lower educational level, and unemployed. Diabetes complications, concealment of DM, and feeling of being a burden to the family predicted anxious-depressed status. The study showed that treatment-related stresses and anxiety-depressive symptoms were common and associated among Chinese diabetes outpatients in Hong Kong.

Stigmatizing experience and structural discrimination associated with the treatment of schizophrenia in Hong Kong.

This research examines the experience of stigma associated with psychiatric treatment among Chinese patients with schizophrenia in Hong Kong. In focus groups patients described stigma experiences related to clinic visits and the side effects of antipsychotic medications. Additionally, they revealed various adverse treatment experiences during hospitalization which point to the presence of structural discrimination. Based on the focus group findings, a questionnaire was developed and completed by 320 and 160 patients with schizophrenia and diabetes mellitus, respectively. Results showed that patients with schizophrenia were more likely to anticipate stigma, conceal illness, and default on clinic visits than patients with diabetes. Medication-induced stigma occurred in 48% of patients with schizophrenia. It brought about the unwelcome disclosure of illness, workplace difficulties, family rejection, and treatment non-adherence. Adverse experiences during hospitalization were reported by 44% of patients with schizophrenia. They included negative staff attitudes, excessive physical/chemical restraints, inadequate information/complaint systems, and limited rights. We conclude that stigma, at both individual and structural levels, represents a central experience of the treatment of schizophrenia in Hong Kong. Because inequitable health policy, resource allocation, and service organization privilege service providers' control over users, treatment-related stigma may be a prime example of the social production of stigma and discrimination based on power difference between the stigmatizers and the stigmatized. To examine this critically we need to redirect stigma research to tractable clinical circumstances and structural mechanisms that produce and maintain stigmatizing and discriminatory psychiatric practice. Destigmatization programs must be evaluated not only by change in public attitudes but also by how much they reduce structural stigma and improve patients' lives.