Increased psychological distress among young people before and during the fifth wave of COVID-19 after two years of pandemic in Hong Kong: a 6-month longitudinal study.

BACKGROUND: Despite over two years of COVID-19 worldwide, the outbreak of the Omicron variant has given rise to an unprecedented surge of infection with diverse lockdown measures implemented globally. Whether the emergence of a new wave of COVID-19 could further affect mental health in the population after nearly two years of the pandemic remains to be addressed. Furthermore, whether changes in smartphone overuse behaviours and physical activity - both of which are particularly relevant to young people - would together contribute to changes in distress symptoms during this wave of COVID-19 was also examined. METHODS: A total of 248 young people from an ongoing household-based epidemiological study in Hong Kong who completed their baseline assessments prior to the Omicron variant outbreak, i.e., fifth wave of COVID-19 (July-November 2021), were invited for a 6-month follow-up study during this wave of infection (January-April 2022) (mean age = 19.7 years, SD = 2.7; 58.9% females). At both time points, levels of global distress symptoms, perceived stress, smartphone overuse, frequency of engagement in vigorous physical activity, and other potential risk and protective factors were assessed. RESULTS: The proportion of young people presenting moderate-to-severe distress (6-item Kessler Psychological Distress Scale ≥ 5) significantly increased from 45.6 to 54.4% during the fifth wave of COVID-19 (p < 0.010). Significantly increased levels of smartphone overuse and reduced days of vigorous physical activity were also observed during the fifth wave. Notably, increased smartphone overuse and reduced physical activity both additively and interactively contributed to elevated distress at 6 months, even after accounting for demographic characteristics, psychiatric history, childhood adversity, as well as baseline distress symptoms, resilience, and recent personal stressors. CONCLUSIONS: The findings suggest that the emergence of a new wave of COVID-19, specifically the Omicron outbreak, can further aggravate mental distress even after a protracted period of the pandemic. Awareness of the dynamic nature of COVID-19 is necessitated to address the pressing mental health needs of populations. Supporting young people in healthier patterns of smartphone use and physical activity can be helpful.

Impact of smartphone overuse on 1-year severe depressive symptoms and momentary negative affect: Longitudinal and experience sampling findings from a representative epidemiological youth sample in Hong Kong.

Smartphone overuse can have detrimental impacts on youth mental health. How it may be longitudinally associated with depressive symptoms and functioning, and with daily momentary affect, remains to be investigated. A total of 3,033 young people were consecutively recruited from a large-scale epidemiological youth mental health study in Hong Kong. A subsample (n = 936) was followed-up after 1 year, with experience sampling data collected from 177 participants. Separate multivariable logistic regression models were applied to examine the prospective associations between smartphone overuse and depressive symptoms, with multilevel models fitted to examine its associations with momentary affect. The prevalence of smartphone overuse in the Hong Kong youth population was 29.3%. Smartphone overuse was significantly associated with more depressive symptoms and functional impairments both cross-sectionally and longitudinally. The associations between smartphone overuse and 1-year depressive symptoms were significant, even when accounting for baseline symptoms, social media use, and other risk and protective factors. Baseline depressive symptoms, in contrast, were not associated with 1-year smartphone overuse after adjusting for baseline smartphone overuse. Smartphone overuse was also significantly associated with higher levels of momentary negative affect, even when accounting for depressive symptoms. Strategies to mitigate the impact of smartphone overuse can have important long-term implications.

The impact of social unrest and pandemic on mental health of young people in Hong Kong: The transdiagnostic role of event-based rumination.

OBJECTIVE: Co-occurring population-level events, such as social unrest and coronavirus disease 2019, are observed in many societies today. Few studies have explored their combined mental health effects on young people. While self-focused rumination has been suggested to be a key mechanism underlying depression, the role of event-based rumination in mediating the impact of population stressors has yet to be elucidated. METHODS: Data were collected from 6988 young people in a large-scale community online survey in Hong Kong. The survey assessed symptoms of post-traumatic stress disorder and depression, direct exposure to social unrest-related traumatic events, coronavirus disease 2019 pandemic-related events, personal stressful life events, event-based rumination and other individual risk factors. RESULTS: High levels of comorbid post-traumatic stress disorder and depressive symptoms were observed. Logistic regression analysis revealed that probable post-traumatic stress disorder was associated with traumatic events (odds ratio = 1.73, 95% confidence interval = [1.64, 1.82]), pandemic-related events (odds ratio = 1.08, confidence interval = [1.01, 1.16]), stressful life events (odds ratio = 1.20, confidence interval = [1.21, 1.37]), high event-based rumination (odds ratio = 3.00, confidence interval = [2.58, 3.48]), lower resilience (odds ratio = 1.18, confidence interval = [1.15, 1.21]), higher smartphone reliance (odds ratio = 1.09, confidence interval = [1.05, 1.13]) and financial concerns (odds ratio = 1.25, confidence interval = [1.18, 1.33]). The odds for probable post-traumatic stress disorder was also significantly higher when two or more traumatic events were experienced (odds ratio = 4.03, confidence interval = [3.52, 4.62]). Factors associated with moderate-to-severe level depressive symptoms were similar. Event-based rumination significantly mediated between different types of external events (traumatic events, pandemic-related events, stressful life events) and both post-traumatic stress disorder and depressive symptoms. CONCLUSION: These findings suggest that diverse types of stressful events during population-level crises could add to personal stressors to affect mental health outcomes in young people. Among other protective and risk factors, event-based rumination presented as a prominent transdiagnostic mediator for different symptom dimensions which may be a potentially important target for early risk detection and intervention.

LevelMind@JC: Development and evaluation of a community early intervention program for young people in Hong Kong.

AIM: Hong Kong's existing mental health services are inadequate in addressing young people's needs. The LevelMind@JC project established an early intervention platform of community-based youth-specific mental health centres involving youth workers, cross-disciplinary professionals, and young people. The project intends to (1) pilot a community platform that incorporates a youth-friendly early screening tool with preventative intervention capabilities, (2) set up a state-of-the-art training system for youth mental health workers, (3) establish a community clinical support team and (4) develop a timely evaluation system to monitor the service and evaluate its outcome and cost-effectiveness against generic youth services. METHODS: Six hundred LevelMind@JC service users will be assessed alongside 600 young people visiting generic youth centres and 100 young people in the community. Participants will be matched according to age, gender, years of education, socioeconomic status, and level of distress. Assessments, administered at baseline and at 3, 6 and 12 months, will cover demographic characteristics, psychological distress, quality of life, depressive and anxiety symptoms, functioning, physical health and lifestyle, personality and social measures, cognitive measures and health economics. Mixed-model ANOVAs will be used to indicate interactions between services and between time points. CONCLUSION: Built upon a community-based support model, LevelMind@JC aims to promote positive mental health in young people through the collaboration of cross-disciplinary mental health professionals. If efficacy and cost-effectiveness are established, the project could be scaled up, implicating a wider reach of care. We anticipate its success to be critical in combatting mental health issues stemming from both personal and population-level stressors.

Characterization and prediction of clinical pathways of vulnerability to psychosis through graph signal processing.

Causal interactions between specific psychiatric symptoms could contribute to the heterogenous clinical trajectories observed in early psychopathology. Current diagnostic approaches merge clinical manifestations that co-occur across subjects and could significantly hinder our understanding of clinical pathways connecting individual symptoms. Network analysis techniques have emerged as alternative approaches that could help shed light on the complex dynamics of early psychopathology. The present study attempts to address the two main limitations that have in our opinion hindered the application of network approaches in the clinical setting. Firstly, we show that a multi-layer network analysis approach, can move beyond a static view of psychopathology, by providing an intuitive characterization of the role of specific symptoms in contributing to clinical trajectories over time. Secondly, we show that a Graph-Signal-Processing approach, can exploit knowledge of longitudinal interactions between symptoms, to predict clinical trajectories at the level of the individual. We test our approaches in two independent samples of individuals with genetic and clinical vulnerability for developing psychosis. Novel network approaches can allow to embrace the dynamic complexity of early psychopathology and help pave the way towards a more a personalized approach to clinical care.

Prospective prediction of PTSD and depressive symptoms during social unrest and COVID-19 using a brief online tool.

Large-scale protracted population stressors, such as social unrest and the coronavirus disease 2019 (COVID-19), are associated with increased symptoms of post-traumatic stress disorder (PTSD) and depression. Cost-effective mental health screening is prerequisite for timely intervention. We developed an online tool to identify prospective predictors of PTSD and depressive symptoms in the context of co-occurring social unrest and COVID-19 in Hong Kong. 150 participants completed baseline and follow-up assessments, with a median duration of 29 days. Three logistic regression models were constructed to assess its discriminative power in predicting PTSD and depressive symptoms at one month. Receiver-operating characteristic analysis was performed for each model to determine their optimal decision thresholds. Sensitivity and specificity of the models were 87.1% and 53.8% for probable PTSD, 77.5% and 63.3% for high-risk depressive symptoms, and 44.7% and 96.4% for no significant depressive symptoms. The models performed well in discriminating outcomes (AUCs range: 0.769-0.811). Probable PTSD was predicted by social unrest-related traumatic events, high rumination, and low resilience. Rumination and resilience also predicted high-risk and no significant depressive symptoms, with COVID-19-related events also predicting no significant depression risk. Accessible screening of probable mental health outcomes with good predictive capability may be important for early intervention opportunities.

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.

Psychiatrists' opinion towards medication discontinuation in remitted first-episode psychosis: A multi-site study of the Asian Network for Early Psychosis.

AIM: The study investigated psychiatrists' views towards the issue of medication discontinuation for patients in remission from first-episode psychosis in four countries (Hong Kong, Korea, Singapore and Japan) that are part of the Asian Network for Early Psychosis, focusing on whether the views of these countries differ with one another. METHODS: A questionnaire was distributed to psychiatrists for completion. The questionnaire contained three sections: direct questions probing at views on medication discontinuation, case vignettes to assess applied decision-making and a checklist of criteria psychiatrists may view as necessary for the patient to satisfy before discontinuation. Total of 484 psychiatrists (97 from Hong Kong, 88 from Korea, 64 from Singapore and 233 from Japan) completed the questionnaire. RESULTS: We found that (a) Asian psychiatrists believed that 1% to 19% of remitted patients can discontinue medication, an estimation that was lower than Western psychiatrists; (b) in agreement with clinical guidelines, Asian psychiatrists believed that patients should remain on medication for at least 1 to 2 years following the absence of psychotic symptoms; (c) "Absence of any relapsing episode following first episode" was considered the most important criterion when making a decision; and (d) there were significant differences in clinicians' perceptions across the four countries: for instance, Korean psychiatrists were more conservative with the duration of antipsychotics maintenance, while Singaporean psychiatrists were more open-minded towards clinical trials. CONCLUSIONS: Culture and social norms appear to determine the relative importance of factors that psychiatrists might consider during the decision-making process, thereby producing variations in the views held in different countries.

Examining gender difference in adult-onset psychosis in Hong Kong.

AIM: Gender-specific treatment strategies for psychosis have been suggested in recent years. Data on gender difference were largely consistent regarding premorbid functioning, age of onset and negative symptoms; however, results regarding neurocognitive function and duration of untreated psychosis were mixed and inconclusive. In this study, we aimed at a thorough examination on the gender differences in 360 Chinese patients with first-episode psychosis in Hong Kong. METHODS: From June 2009 to August 2011, participants were consecutively recruited from a population-based territory-wide study of early psychosis targeting first-episode psychosis in Hong Kong. Comprehensive data on basic demographics, premorbid functioning and schizoid and schizotypal traits, clinical, functioning, medication side effects and a battery of neurocognitive measures were collected upon entry into the service. RESULTS: In 360 patients with first-episode psychosis aged between 26 and 55 years, 43.6% (n = 157) were male and 56.4% (n = 203) were female. Males had poorer premorbid functioning and adjustment, earlier age of onset, more negative symptoms and poorer functioning in terms of work productivity, independent living and immediate social network relationships at presentation of first-episode psychosis. Interestingly, our data indicate that males tend to be more educated, and also characterized by higher IQ, better neurocognitive performance on visual domain compared with females. Duration of untreated psychosis was not different between the two genders. CONCLUSION: Data from this homogeneous cohort of Chinese populations enabled tailored and culturally sensitive recommendation on gender-specific treatment strategies, hence improving patients' care and facilitate better diagnostic and interventional decisions for patients with psychosis.

Aerobic exercise and yoga improve neurocognitive function in women with early psychosis.

Impairments of attention and memory are evident in early psychosis, and are associated with functional disability. In a group of stable, medicated women patients, we aimed to determine whether participating in aerobic exercise or yoga improved cognitive impairments and clinical symptoms. A total of 140 female patients were recruited, and 124 received the allocated intervention in a randomized controlled study of 12 weeks of yoga or aerobic exercise compared with a waitlist group. The primary outcomes were cognitive functions including memory and attention. Secondary outcome measures were the severity of psychotic and depressive symptoms, and hippocampal volume. Data from 124 patients were included in the final analysis based on the intention-to-treat principle. Both yoga and aerobic exercise groups demonstrated significant improvements in working memory (P<0.01) with moderate to large effect sizes compared with the waitlist control group. The yoga group showed additional benefits in verbal acquisition (P<0.01) and attention (P=0.01). Both types of exercise improved overall and depressive symptoms (all P⩽0.01) after 12 weeks. Small increases in hippocampal volume were observed in the aerobic exercise group compared with waitlist (P=0.01). Both types of exercise improved working memory in early psychosis patients, with yoga having a larger effect on verbal acquisition and attention than aerobic exercise. The application of yoga and aerobic exercise as adjunctive treatments for early psychosis merits serious consideration. This study was supported by the Small Research Funding of the University of Hong Kong (201007176229), and RGC funding (C00240/762412) by the Authority of Research, Hong Kong.

A 3-year retrospective cohort study of predictors of relapse in first-episode psychosis in Hong Kong.

OBJECTIVE: Relapses in psychosis are costly and may have irreversible consequences. Relapse prevention is thus critical in the treatment of schizophrenia. Apart from medication discontinuation, a consistent relapse predictor has not been identified due to limitations in previous studies. We aim to investigate relapse predictors in a large cohort of patients with first-episode psychosis. METHOD: This is a retrospective cohort study designed to evaluate relapses in first-episode psychosis patients in 3 years. A total of 1400 patients' case records were retrieved from a hospital database. Potential relapse predictors including demographic variables, baseline clinical measures, medication adherence, and residual positive symptoms upon clinical stabilization were collected. RESULTS: The cumulative relapse rates were 19.3% by year 1, 38.4% by year 2, and 48.1% by year 3. Multivariate Cox-proportional hazards regression analysis revealed that medication non-adherence, smoking, schizophrenia diagnosis, younger age, and shorter baseline hospitalization were associated with an increased risk of relapse in 3 years. CONCLUSIONS: Nearly half of patients relapsed after 3 years following their first-episode psychosis. Smoking as a predictor of relapse is an intriguing new finding supportive of a link between nicotinic receptors and the dopamine system. Their relationship deserves further investigations with potential clinical implications for relapse prevention.

Naming psychosis: the Hong Kong experience.

AIM: Schizophrenia translates in Chinese as 'Mind Split Disease' which is heavily stigmatizing. The narrow conceptualization for schizophrenia alone was insufficient, in the context of early detection and intervention for psychosis. The need for an effective Chinese translation for psychotic disorders was imminent upon the launch of the Early Assessment Service for Young People with Psychosis in Hong Kong, where public awareness strategies had to be built upon effective communication of the disorder. METHODS: 'Si Jue Shi Tiao', the new term for psychosis, described 'thought and perceptual dysregulation'. This new terminology and concept was strategically introduced to the local community. RESULTS: The term 'Si Jue Shi Tiao' was taken up well locally and had demonstrated interactions within the Chinese and East Asian communities. The public has taken in the broader concept of psychosis, in contrary to the previous concept of schizophrenia per se. CONCLUSIONS: In Hong Kong, the restrictive view of perceiving psychotic disorders as schizophrenia was broadened upon the introduction of a more embracing, less stigmatizing term 'Si Jue Shi Tiao'. Effective establishment of this term to the local vocabulary allowed a basis for communication as well as public education work. Further evaluation is necessary to determine the effectiveness of the naming and to guide further public awareness strategies.

Potential endophenotype for schizophrenia: neurological soft signs.

INTRODUCTION: Neurological soft signs (NSS) are suggested as a candidate endophenotype for schizophrenia. This article aims to review relevant literature and discuss the role of NSS in understanding schizophrenia. METHODS: This is an update on a review article published in 2003. Articles from 2003 onwards were specifically reviewed and discussed with relevance to the role of NSS as endophenotype for schizophrenia. RESULTS: Consistent data suggest an excess of NSS in schizophrenic patients. NSS appear to be related to schizophrenic symptoms, in particular negative symptoms and disorganisation. Information on NSS and demographic correlates is scarce, and the confounding effects between age, education and intelligence on NSS constitute an important gap in current knowledge. Longitudinal data suggest NSS as both a trait and state variable in the course of disease. NSS are not specific with regard to diagnosis, although there are claims that individual sub-components may be more specific. The weight of evidence raises question on the specificity of NSS for schizophrenia. CONCLUSIONS: The usefulness and feasibility of NSS as a specific endophenotype target for schizophrenia is unclear. However, NSS remain an important feature and symptom correlate of schizophrenia. Future research should focus on delineating the effects of NSS from those of confounding demographic variables, and the stability of NSS over the course of illness to elucidate its role in schizophrenia.

Anti-psychotics adherence among out-patients with schizophrenia in Hong Kong.

OBJECTIVE: Adherence to antipsychotic treatment is an important aspect of long term management of schizophrenia and other related psychotic disorders. The evaluation of adherence is often difficult in clinical settings. This study compared patients self-reports and clinician judgment of adherence behavior and explored their relationship with attitudes toward taking medication. METHODS: Clinician rated questionnaire and matching patient self rated questionnaires were administered to 508 consecutive outpatients and their clinicians in four hospital clinic sites in Hong Kong. Items in the questionnaires address adherence behaviors as well as attitudes toward medication. In addition, clinicians also estimate the presence of factors unfavorable to adherence such as substance abuse, cognitive impairments etc. RESULTS: Non-adherence was reported in at least 26% of patients. Clinician's detection of non-adherence behaviors achieved relative high specificity (0.84) but has low sensitivity (0.33). A logistic regression analysis on patients' decision to stop medication revealed that significant predictors include patients' reported lack of perception from the benefits of medication, patients' reported negative feelings associated with regular medication and younger age. CONCLUSION: Non-adherence is a widespread phenomenon affecting a significant proportion of outpatients under treatment. Clinicians have relatively low sensitivity in detecting which patients are non-adherent. Non-adherence behavior is predicted by level of awareness of illness, perceived benefits of medication, negative feelings toward medication and age.