Effectiveness of a universal school-based programme for preventing depression in Chinese adolescents: a quasi-experimental pilot study.

BACKGROUND: Evidence of the effectiveness, rather than efficacy, of universal school-based programmes for preventing depression among adolescents is limited. This study examined the effectiveness of a universal depression prevention programme, "The Little Prince is Depressed" (LPD), which adopted the cognitive-behavioural model and aimed to reduce depressive symptoms and enhance protective factors of depression among secondary school students in Hong Kong. METHODS: A quasi-experimental design was adopted for this pilot study. Thirteen classes were assigned to the intervention or control conditions according to the deliberation of the programme administrator of the four participating schools. Implementation was carried out in two phases, with a professional-led first phase and teacher-led programme second phase. LPD consisted of a 12-week school-based face-to-face programme with psycho-educational lessons and homework assignments. RESULTS: Students completed the programme generally showed positive development in help-seeking attitudes and self-esteem. For students who had more depressive symptoms at pre-assessment, the programme was found to be significant in enhancing cognitive-restructuring skills and support-seeking behaviours. The programme was not, however, found to be statistically significant in reducing depressive symptoms of the participants over the study period. LIMITATIONS: A small sample size, a high attrition rate, and a short follow-up time frame. CONCLUSIONS: The LPD programme was successful in building resilience of the students in general and enhancing the cognitive-behavioural skills of students with depressive symptoms. While we did not find sufficient evidence for concluding that the LPD was effective in reducing depressive symptoms, we believe that these results highlight the challenges of implementing evidence-based practices generated from highly controlled environments in real-life settings.

Research participation experiences of informants of suicide and control cases: taken from a case-control psychological autopsy study of people who died by suicide.

BACKGROUND: Ethical issues have been raised about using the psychological autopsy approach in the study of suicide. The impact on informants of control cases who participated in case-control psychological autopsy studies has not been investigated. AIMS: (1) To investigate whether informants of suicide cases recruited by two approaches (coroners' court and public mortuaries) respond differently to the initial contact by the research team. (2) To explore the reactions, reasons for participation, and comments of both the informants of suicide and control cases to psychological autopsy interviews. (3) To investigate the impact of the interviews on informants of suicide cases about a month after the interviews. METHODS: A self-report questionnaire was used for the informants of both suicide and control cases. Telephone follow-up interviews were conducted with the informants of suicide cases. RESULTS: The majority of the informants of suicide cases, regardless of the initial route of contact, as well as the control cases were positive about being approached to take part in the study. A minority of informants of suicide and control cases found the experience of talking about their family member to be more upsetting than expected. The telephone follow-up interviews showed that none of the informants of suicide cases reported being distressed by the psychological autopsy interviews. LIMITATIONS: The acceptance rate for our original psychological autopsy study was modest. CONCLUSIONS: The findings of this study are useful for future participants and researchers in measuring the potential benefits and risks of participating in similar sensitive research. Psychological autopsy interviews may be utilized as an active engagement approach to reach out to the people bereaved by suicide, especially in places where the postvention work is underdeveloped.

Internet addiction: prevalence, discriminant validity and correlates among adolescents in Hong Kong.

BACKGROUND: Despite increasing concern over the potential adverse effects of excessive internet use, especially in young people, there is some debate over its definition, magnitude and discriminant validity. AIMS: To examine the prevalence of adolescents' internet addiction in Hong Kong, China; to test its differentiation from other correlates; and to examine its relationships with correlates in a representative community sample of adolescents. METHOD: A two-wave panel household survey with 208 adolescents (aged 15-19 years) was conducted. Participants were asked to self-report their patterns of internet usage, symptoms of internet addiction, suicidal ideation, psychiatric symptoms and psychosocial conditions during the study period. RESULTS: The prevalence rate for having five or more symptoms of internet addiction was estimated to be 6.7% (95% CI 3.3-10.2). The discriminatory characteristic of internet addiction was marginally demonstrated. Positive dose-response relationships were found between the number of symptoms of internet addiction and 1-year changes in scores for suicidal ideation and depressive symptoms. CONCLUSIONS: Evidence supports the specificity of internet addiction and its symptoms seem to co-occur with individuals' suicidal ideation and depressive symptoms.

A psychological autopsy study of pathological gamblers who died by suicide.

BACKGROUND: Pathological gambling is associated with suicidal ideation and attempt. There is no known report on pathological gambling preceding suicide. By examining a series of 17 suicide cases with evidence of pathological gambling prior to death, we sought to generate hypotheses for further study of this under-researched but rapidly-increasing worldwide public health problem. METHOD: Psychological autopsy interviews using a semi-structured format were conducted with proxy respondents for suicide and control subjects aged 15-59 years in Hong Kong SAR, China. RESULTS: Of the 150 suicides and 150 controls examined, 17 suicides (11.3%) and one control case (0.6%) met criteria for the diagnosis of pathological gambling at the time of death or interview. All 17 suicide cases with pathological gambling had unmanageable debt at the time of death. Fourteen cases (82.4%) had other associated psychiatric disorders, most often major depressive disorders (n=10, 58.9%) and substance-use disorders (n=3, 17.6%). None had ever received psychiatric treatment. LIMITATIONS: Descriptive, retrospective case series with a small sample size. CONCLUSIONS: Along with unmanageable debt, a high proportion of the suicide cases with pathological gambling also experienced other psychiatric illnesses, most often depression, at the time of death. None sought treatment for their addictive behavior or psychiatric illness prior to death. Pathological gambling is a modifiable risk factor for suicide for which means to enhance case identification and engagement in treatment are urgently needed. Clinicians treating depression should explore the presence of pathological gambling behavior or unmanageable debts among their patients. Addressing pathological gambling should be one important component of a comprehensive suicide prevention strategy especially in countries where gambling activities are legalized and expanding.

Population-attributable risk of suicide conferred by axis I psychiatric diagnoses in a Hong Kong Chinese population.

OBJECTIVE: This study was conducted to determine the population-attributable risk (PAR) of completed suicide among Hong Kong Chinese with axis I psychiatric diagnoses. METHODS: With a case-control psychological autopsy method, 150 suicide decedents aged 15-59 were compared for axis I psychiatric diagnoses and psychosocial variables with 150 randomly selected age- and gender-matched persons living in the community. RESULTS: In the presence of other, non-disease-related social risk factors (unemployment and unmanageable debt), past suicide attempt independently accounted for 44% of the PAR of suicide, followed by current major depressive disorder (27%), schizophrenia spectrum disorders (22%), and substance use disorder or pathological gambling (16%). Other diagnoses (such as anxiety and phobic disorders, dysthymia, adjustment disorders, and past major depressive episode) accounted for 24% of PAR. CONCLUSIONS: Psychiatric morbidity remains the major risk factor for suicide in Hong Kong despite well-developed psychiatric services. Mental health policy should be refined to target clinical groups at high risk of suicide.

Suicide notes in Hong Kong in 2000.

Suicide notes have been regarded as one of the most informative data sources to understand the reasons why people commit suicide. However, there is a paucity of suicide note studies, leaving researchers with an assumption that this phenomenon remains static over time. This study examines this assumption by comparing the characteristics of note-leavers of the same population at 2 different points in time. The authors investigated the characteristics of 316 note-leavers in 2000 in Hong Kong and compared them to note-leavers in 1992. The proportion of people who left suicide notes increased from 20% to 35% between 1992 and 2000, a change that may be related to changes in suicide methods. Note-leavers in 2000 were characterized as individuals aged 25-59 years old, employed, with no physical illness, no psychiatric illness, and died as a result of charcoal-burning. Present data suggest that reasons for leaving suicide notes may have changed over the 8 years from 1992 to 2000.

An integrative suicide prevention program for visitor charcoal burning suicide and suicide pact.

An integrative suicide prevention program was implemented to tackle an outbreak of visitor charcoal burning suicides in Cheung Chau, an island in Hong Kong, in 2002. This study evaluated the effectiveness of the program. The numbers of visitor suicides reduced from 37 deaths in the 51 months prior to program implementation to 6 deaths in the 42 months post-implementation period. The number of visitor suicide pacts decreased from 7 pacts (15 individuals) to 1 pact (2 individuals). No statistically significant differences in the numbers of visitor suicide attempts and resident suicides were observed in the two time periods. No statistically significant changes in visitor suicides during the study period were observed on the comparison islands. The consistency and timing of reduction in visitor suicides correlated with the development and delivery of the integrative program on the intervention island, suggesting a causal association between program delivery and reduction of visitor suicides. The possibility of displacement seems small because there was no increase in visitor suicides on the comparison islands during the study period. This integrative approach in preventing target-specific suicides may serve as an example for other communities to develop suicide prevention programs that make use of the existing local resources.

Suicidality in Chinese adolescents in Hong Kong: the role of family and cultural influences.

BACKGROUND: Adolescent suicidal ideation has found to predict suicidal behaviors and psychopathology in adulthood. Previous studies focused solely on the medical and environmental risk factors, which were insufficient to give a holistic picture of adolescent suicidality. OBJECTIVES: To assess the role of affective and cognitive attributes in the identification and prevention of adolescent suicidal ideation. METHOD: A community sample of 511 participants (age 15-19 years) were asked to indicate their suicidality in the 12 months and in their lifetime. Generalized estimating equation regression models were used to examine the effect of psychosocial and socio-environmental correlates in relation to adolescent suicidal ideation. RESULTS: The data show that perceived responsibilities for family was the only protective factor, while a coping mechanism by behavioral disengagement, severity of depressive symptoms, a history of deliberate self-harm, chronic physical illness or pain, media reporting of suicide news, and low household income were the risk factors for adolescent suicidal ideation. CONCLUSIONS: The results suggest that a multilayer effort for preventing adolescent suicide is needed by providing support for children in deprived families; enhancing life skills in the teens; strengthening family relationship; improving mental and health services; and promoting responsible media reporting on suicide.

Evaluating the effectiveness of barrier installation for preventing railway suicides in Hong Kong.

BACKGROUND: Railway suicide is a serious mortality issue. Most attempters are unmarried psychotic young men under psychiatric care having a high level of lethal intent. Installation of platform screen doors (PSDs) to limit access to the track has been suggested as an effective way for prevention. This study aims to examine the effectiveness of installing PSDs for preventing railway suicides; any sign of substitution of suicide location; and changes in psychiatric profile of suicide deceased after the PSD installation in the subway system of Hong Kong. METHODS: Cases of railway suicide and related information from 1997 to 2007 were provided by the railway operators and the Coroner's Court. The effectiveness of installing PSDs was assessed through a quasi-experimental setting. Poisson regression and chi-squared test were used. RESULTS: Over the 11-year study period, a total of 76 railway suicide cases (0.71% of all suicides) were reported. A significant reduction of 59.9% (p=0.0003) in railway suicides was found after the PSD installation. Analyses confirmed that there was no significant sign of substitution by displacing potential attempters to unsealed platforms (p=0.9051). Those having psychosis would be better protected as no suicide cases with such psychiatric background were reported after the installation of PSDs. LIMITATIONS: It has not considered the potential economic benefits of PSD. It is difficult if not possible to examine whether the potential attempters would substitute to an alternative method of suicide. CONCLUSIONS: This study shows that PSDs can effectively prevent suicides with no substitution by "delethalizing" the image and altering people's perception about the desirability of railway suicide. Railway operators should extend the coverage of PSD to all railway stations in Hong Kong without any delay.

What does psychological autopsy study tell us about charcoal burning suicide--a new and contagious method in Asia?

Charcoal burning suicides in Hong Kong between 2002-2004 in the 15 to 59-year-old age group were investigated using the psychological autopsy method. The psychopathological profiles of charcoal burning suicides (N = 53) were compared against "other suicides" (N = 97). The two groups did not differ significantly in the prevalence of DSM-IV axis I diagnoses with the exception of schizophrenic spectrum disorder which was less frequently associated with charcoal burning suicides. Score on "neuroticism" in the NEO-five Factor Inventory (NEO-FFI) was significantly higher in victims of charcoal burning suicide. There was also a trend toward higher score on "conscientiousness" in the NEO-FFI among charcoal burners than victims of other suicide.

Suicide among adults aged 30-49: a psychological autopsy study in Hong Kong.

BACKGROUND: A surge in suicide rates in middle age people in Hong Kong and many Asian countries was recently observed. However, there is a paucity of suicide research on this subgroup of people in Asia. METHODS: The next-of-kin of 85 suicide cases and 85 community subjects aged 30-49 years were interviewed by a psychological autopsy approach. Information was triangulated by interview notes, coroner's court files, and police investigation reports. RESULTS: A multiple logistic regression analysis identified the following risk factors for suicide among the middle age people in Hong Kong: the presence of at least one psychiatric disorder (OR = 37.5, 95% CI 11.5-121.9, p < 0.001), indebtedness (OR = 9.4, 95% CI 2.2-40.8, p < 0.01), unemployment (OR = 4.8, 95% CI 1.3-17.5, p < 0.05), never married (OR = 4.2, 95% CI 1.1-16.3, p < 0.05), and lived alone (OR = 3.9, 95% CI 1.2-13.4, p < 0.05). CONCLUSION: The data show that socio-economical factors had a strong impact on suicide in the target group. Further research is needed to explore any positive qualities that protect the middle-aged from suicide. The prevention of suicide in the middle-aged requires multiple strategies.

A cluster analysis of the circumstances of death in suicides in Hong Kong.

Classification of suicides is essential for clinicians to better identify self-harm patients with future suicidal risks. This study examined potential subtypes of suicide in a psychological autopsy sample (N = 148) in Hong Kong. Hierarchical cluster analysis extracted two subgroups of subjects in terms of expressed deliberation assessed by the Beck Suicide Intent Scale (SIS). The first group was associated with charcoal burning suicide, no psychiatric illness, indebtedness, better problem-solving ability, chronic stress, and higher overall SIS scores. The second group was associated with jumping from a height, psychotic disorders, psychiatric treatment, acute stress, and lower overall SIS score. The existence of a substantial cluster of subjects with lower expressed intent and preparation has important implications for the performance of the SIS as a predictive tool. Suicide prevention strategy may have to target potential subgroups with specific approaches.

Suicide and unemployment: what are the missing links?

The suicide rate has been paralleled by an upward trend of unemployment in Hong Kong since 1997. This study aims to explore the unknown suicide-related factors among the unemployed. This information is useful in developing culturally specific suicide prevention initiatives related to unemployment. Seventy-six suicide deceased and 15 life subjects who were unemployed were selected from a previous psychological autopsy study. Logistic regression models were employed to estimate the relative suicide risks among the unemployed people. Among the unemployed, the suicide deceased were more likely to be male, had suffered from psychiatric illness, and had attempted suicide before. They also had acquired less competent social problem solving skills. Comparison with a small control group creates a generalizability problem. Suicide prevention for the unemployed could be done through mental health awareness programs; problem-solving skills training for attempters and males; and vocational training and job opportunities for discharged psychiatric patients and rehabilitees.

What can we do to help and understand survivors of suicide in Hong Kong?

Survivors of suicide or people bereaved by suicide are underresearched and underserviced. This report contains preliminary data, collected from a psychological autopsy study, which examines the characteristics of suicide survivors in Hong Kong. This paper considers the preliminary data currently available and attempts to suggest a way forward toward understanding and help for this underrecognized group of individuals in Hong Kong.

Suicide in Hong Kong: a case-control psychological autopsy study.

BACKGROUND: The relative contribution of psychosocial and clinical risk factors to suicide among Chinese populations is an important issue. In Hong Kong, this issue requires vigorous examination in light of a 50% increase in suicide rate between 1997 and 2003. METHOD: Using a case-control psychological autopsy method, 150 suicide deceased were compared with 150 living controls matched by age and gender. Semi-structured interviews were conducted with the next-of-kin of the subjects. Data were collected on a wide range of potential risk and protective factors, including demographic, life event, clinical and psychological variables. The relative contribution of these factors towards suicide was examined in a multiple logistic regression model. RESULTS: Six factors were found to significantly and independently contribute to suicide: unemployment, indebtedness, being single, social support, psychiatric illness, and history of past attempts. CONCLUSIONS: Both psychosocial and clinical factors are important in suicides in Hong Kong. They seem to have mediated suicide risk independently. In addition, socio-economic adversities seem to have played a relatively important role in the increasing suicide rate in Hong Kong.