Cultivating psychological well-being in Hong Kong's future doctors.

There has been much recent attention on psychological well-being and pastoral care for medical students. This study examines psychological morbidity (depression, anxiety and stress) in Hong Kong medical students, as well as their concerns, coping mechanisms and their help-seeking. Medical students in Hong Kong reported a higher level of psychological morbidity as compared with other tertiary education students. Their main concerns include examinations, stress, career, adjusting to the new medical curriculum and commitment to the course. The coping skills adopted were largely adaptive. Maladaptive coping skills like 'denial', 'self-blame' and 'behavioural disengagement' were highly correlated with depression, anxiety and stress scores. Most of the students concerned wanted support services that were specifically tailored to their needs and at least partly provided by people who had been through medical training themselves. The faculty at the University of Hong Kong is establishing a Programme for Effective Transition and Student Support (PETSS) to provide a multi-faceted support system for its medical students. The findings in this study help to ensure that the services provided will be relevant, accessible and acceptable to the students.

Dopamine receptor D4 (DRD4) gene in Han Chinese children with attention-deficit/hyperactivity disorder (ADHD): increased prevalence of the 2-repeat allele.

There is an increased prevalence of the 7-repeat (7R) allele of the dopamine receptor D4 (DRD4) gene in attention-deficit/hyperactivity disorder (ADHD). However, the population prevalence of the 7R allele varies considerably across ethnicity and is very low in Asians. To test whether this 7R allele/ADHD association still held in a Chinese clinical sample, 32 Han Chinese children with a confirmed ADHD diagnosis and normal IQ who were methylphenidate-responders were genotyped. None of them had a DRD4 7R allele. Instead, we observed a significantly increased prevalence of the 2-repeat (2R) allele in this clinical sample (33%) compared to ethnically-matched controls (20%) (chi(2)(1d.f.) = 5.90, P = 0.015). This approximately 1.65-fold increase of the 2R allele in our probands is close to the observed increase of the 7R allele in European-ancestry ADHD children. Recent genetic studies have indicated that the 2R allele in Asians is likely derived from the 7R allele. Further, available biochemical data indicate that both the 2R and 7R protein have blunted responses to dopamine compared to the 4R protein. Based on these results, we propose that the observed increased prevalence of the 2R allele in our Han Chinese ADHD probands is still consistent with the 7R allele hypothesis of ADHD in European-ancestry children. Recent studies have suggested that any variant from the conserved ancestral 4R allele might potentially alter biochemistry/phenotype. We hypothesize that an increased frequency of any non-4R allele may define the association of the DRD4 gene with ADHD that holds across ethnicity. The present findings, however, obtained with a small ADHD sample size, should be replicated.

The International Consortium on Mental Health Policy and Services: objectives, design and project implementation.

The concept of the burden of disease, introduced and estimated for a broad range of diseases in the World Bank report of 1993 illustrated that mental and neurological disorders not only entail a higher burden than cancer, but are responsible, in developed and developing countries, for more than 15% of the total burden of all diseases. As a consequence, over the past decade, mental disorders have ranked increasingly highly on the international agenda for health. However, the fact that mental health and nervous system disorders are now high on the international health agenda is by no means a guarantee that the fate of patients suffering from these disorders in developing countries will improve. In most developing countries the treatment gap for mental and neurological disorders is still unacceptably high. To address this problem, an international network of collaborating institutions in low-income countries has been set up. The establishment and the achievements of this network--the International Consortium on Mental Health Policy and Services--are reported. Sixteen institutions in developing countries collaborate (supported by a small number of scientific resource centres in industrialized nations) in projects on applied mental health systems research. Over a two-year period, the network produced the key elements of a national mental health policy; provided tools and methods for assessing a country's current mental health status (context, needs and demands, programmes, services and care and outcomes); established a global network of expertise, i.e., institutions and experts, for use by countries wishing to reform their mental health policy, services and care; and generated guidelines and examples for upgrading mental health policy with due regard to the existing mental health delivery system and demographic, cultural and economic factors.

The mental health policy template: domains and elements for mental health policy formulation.

Mental disorders are a major and rising cause of disease burden in all countries. Even when resources are available, many countries do not have the policy and planning frameworks in place to identify and deliver effective interventions. The World Health Organization (WHO) and the World Bank have emphasized the need for ready access to the basic tools for mental health policy formulation, implementation and sustained development. The Analytical Studies on Mental Health Policy and Service Project, undertaken in 1999-2001 by the International Consortium for Mental Health Services and funded by the Global Forum for Health Research aims to address this need through the development of a template for mental health policy formulation. A mental health policy template has been developed based on an inventory of the key elements of a successful mental health policy. These elements have been validated against a review of international literature, a study of existing mental health policies and the results of extensive consultations with experts in the six WHO regions of the world. The Mental Health Policy Template has been revised and its applicability will be tested in a number of developing countries during 2001-2002. The Mental Health Policy Template and the work of the Consortium for Mental Health Services will be presented and the future role of the template in mental health policy development and reform in developing countries will be discussed.

The mental health country profile: background, design and use of a systematic method of appraisal.

This article describes the construction and use of a systematic structured method of mental health country situation appraisal, in order to help meet the need for conceptual tools to assist planners and policy makers develop and audit policy and implementation strategies. The tool encompasses the key domains of context, needs, resources, provisions and outcomes, and provides a framework for synthesizing key qualitative and quantitative information, flagging up gaps in knowledge, and for reviewing existing policies. It serves as an enabling tool to alert and inform policy makers, professionals and other key stakeholders about important issues which need to be considered in mental health policy development. It provides detailed country specific information in a systematic format, to facilitate global sharing of experiences of mental health reform and strategies between policy makers and other stakeholders. Lastly, it is designed to be a capacity building tool for local stakeholders to enhance situation appraisal, and multisectorial policy development and implementation.

Brain morphological abnormality in schizophrenia is independent of country of origin.

OBJECTIVE: The disorder schizophrenia has a worldwide prevalence of 1% and is generally associated with lateral cerebral ventricular enlargement. Whether there is a relationship between these two findings is unclear but has aetiological relevance. METHOD: Consecutively admitted Chinese patients (n = 19) with first episode of schizophrenia and healthy community volunteers (n = 29) underwent magnetic resonance imaging brain scan. The groups were balanced for age, sex, best social class and handedness. These patients were similar on clinical and socio-demographic indices to those who declined participation (n = 15). Semi-automated volumetric analysis of whole brain volume, cortical grey matter, cerebrospinal fluid, sulci and lateral ventricles was performed. RESULTS: Chinese patients in their first episode of schizophrenia have significant enlargement of lateral ventricles. CONCLUSION: Brain morphological abnormality in schizophrenia is present regardless of the country of origin. The importance of genes in driving normal brain development and stable prevalence suggests that aetiology may favour genes over environment.

Genetic discrimination and mental illness: a case report.

With advances in genetic technology, there are increasing concerns about the way in which genetic information may be abused, particularly in people at increased genetic risk of developing certain disorders. In a recent case in Hong Kong, the court ruled that it was unlawful for the civil service to discriminate in employment, for the sake of public safety, against people with a family history of mental illness. The plaintiffs showed no signs of any mental health problems and no genetic testing was performed. This was the first case concerning genetic discrimination in common law jurisdictions, therefore the court's judgment has implications for how genetic discrimination cases may be considered in the future. The court considered it inappropriate to apply population statistics or lifetime risks to individuals while examining fitness for work. It recommended an individualised assessment of specific risks within the job, relative to other risks posed by that workplace.

No association between T102C polymorphism of serotonin-2A receptor gene and clinical phenotypes of Chinese schizophrenic patients.

Serotonin dysfunction has been implicated in the pathogenesis of schizophrenia. Previous studies have shown an association between the T102C polymorphism of the 5HT2a receptor gene and schizophrenia. However, negative findings have also been reported. One possible explanation for such discrepancy is disease heterogeneity due to the current limitations in the diagnosis of schizophrenia. We conducted a case-control study of the T102C polymorphism with detailed characterisation of the clinical phenotypes to investigate the possible association with schizophrenia not only at the diagnostic level, but also with reference to other clinical phenotypes potentially related to serotonin dysfunction. Four hundred and seventy-one biologically unrelated schizophrenic patients and 523 unrelated healthy controls of Han Chinese descent in Hong Kong were compared for genotypes and allele frequencies of the T102C polymorphism by PCR amplification and restriction analysis. No evidence of association was detected at the diagnostic level and various clinical phenotypes. However, we found a trend association with small effect size between genotype 102T/102C and patients with better verbal fluency and less motor co-ordination soft neurological signs. There is a need for future large-scale studies on the possible associations between genetic polymorphisms and neurocognitive function impairments in schizophrenia.

Coping with spinal cord injury: personal and marital adjustment in the Hong Kong Chinese setting.

STUDY DESIGN: A cross-sectional retrospective study was carried out with structured questionnaires and semi-structured interviews on 66 persons with spinal cord injury (SCI) and 40 spouses. OBJECTIVES: The study aimed to explore the psychosocial adjustment of Hong Kong Chinese couples at the post SCI stage. An important study interest was the impact of care-giving in spouses of persons with SCI. SETTING: Three major regional rehabilitation centres and one community resource centre in Hong Kong. METHODS: A set of psychometric measures tapping different aspects of psychological functioning was included. These were locus of control (Levenson's Internality, Powerful Others, and Chance Scale), perceived social support (Provision of Social Relationship), coping strategies (Ways of Coping Checklist), marital adjustment (Dyadic Adjustment Scale), caregiving burden (Caregiver Burden Inventory), depression (Beck Depression Inventory), life satisfaction (Satisfaction with Life Situation), and social role adjustment (Katz Adjustment Scale - Relative Form). RESULTS: Persons with SCI with pre-injury marriage were more depressed (P<0.05) as compared with those with post-injury marriage. However, the two groups did not differ in terms of satisfaction with life situation and social role dissatisfaction. The spouses in the preinjury marriage reported a significantly higher score in time-dependent burden than those in the post-injury marriage (P<0.05). Care-giving burden was associated with locus of control, social support, and modes of coping (P<0.05). CONCLUSION: The impact of SCI is a long-lasting effect not limited to the patients but also extending to their spouses. Findings from the adjustment outcomes and coping styles of persons with SCI and their spouses indicate that they are not passive victims. A similar injury may produce different outcomes in different individuals. Rehabilitation professionals should thus be alert to both the couple's differing needs and idiosyncrasies in their helping process.

The pattern of coping in persons with spinal cord injuries.

PURPOSE: To examine the modes of coping and adjustment of persons with spinal cord injuries (SCI) in Hong Kong. METHOD: A cross-sectional design was adopted. Structured questionnaires and semi-structured interviews on 66 persons with SCI were completed. Cluster analysis was performed to identify persons with SCI who are at risk for psychosocial morbidity. RESULTS/CONCLUSION: The group at risk for developing psychological difficulties is characterized by high scores on external locus of control, inadequate coping modes, and low perceived social support. High levels of depression, social role dissatisfaction, care-giving burden, low levels of life satisfaction, and marital maladjustment are commonly noted. Rehabilitation of persons with SCI should also aim at promoting perceived personal control, acceptance of physical status, and realistic appraisal of stressful situations to facilitate better adjustment and coping with commonly identified stresses and difficulties. Counselling should be initiated at an early stage to reduce the development of distorted perceptions so that the needs and concerns of individuals with SCI may be better met and resolved. The frustrations due to unmet expectations may be prevented at an early stage through build-up of more realistic understandings related to the illness and living with the illness.

Semantic verbal fluency deficit as a familial trait marker in schizophrenia.

This study examined neurocognitive deficits as familial vulnerability factors to schizophrenia. Twenty-three Chinese schizophrenic patients, 21 of their non-psychotic siblings and 26 healthy volunteers, matched for age, sex and education, were assessed by using a battery of neurocognitive tests including: Wisconsin Card Sorting Test (WCST), semantic verbal fluency, logical memory, digit span, information, comprehension and similarity. The results showed that siblings had significantly less word output in the verbal fluency test as compared to controls. No significant difference was found between siblings and controls for other tests except that a trend difference was noted for the performance on the similarity test and number of categories completed on the WCST. The verbal fluency abnormality can be considered as a familial trait marker for schizophrenia. Relationships between the residual symptoms after an acute psychotic episode and the magnitude of familial risk were examined. More severe residual symptoms of probands at clinical remission could be predicted by their older age of onset and by better verbal fluency performance in their non-psychotic siblings. This tentatively suggests that patients with a milder genetic form of schizophrenic illness may have a more severe environmental contribution to cerebral insult according to the multifactorial/threshold model. The environmental cerebral insult may cause structural abnormalities leading to incomplete remission of clinical symptoms.

Verbal fluency in schizophrenia: reduction in semantic store.

OBJECTIVE: This is a study of the word production of patients with schizophrenia using a semantic verbal fluency task to address the unresolved issue of retrieval or storage impairment. METHOD: Twenty-one patients with schizophrenia and 11 matched healthy subjects performed a semantic verbal fluency task on 'food', 'animal' and 'transport' categories in Cantonese for 3 minutes each on five separate trials. RESULTS: Patients generated significantly fewer numbers of words compared with control on each trial. The estimated lexicon size of the patients was significantly smaller than that of the equivalent group. The amount of shared words and variable words generated in all five trials were reduced in the patient group. CONCLUSIONS: Our results suggest that poor verbal fluency in patients with schizophrenia may partly be attributable to reduction in semantic store. The importance of temporal lobe involvement on verbal fluency deficits needs to be emphasised as an integral part of the neurobiological basis of schizophrenia research.

Parent management training in a Chinese population: application and outcome.

OBJECTIVE: To examine the applicability and outcome of parent management training in a group of Chinese children referred for aggressive and defiant behaviors. METHOD: Twenty-five children (aged 4-10 years) were assigned to a standardized 8 to 12 sessions of parent management training. Trained child and adolescent psychiatric nurses conducted the treatment. Measures taken at pretreatment, posttreatment, and 4-month follow-up period included the Child Behavior Checklist, direct observation of parent-child interactions, and a parent perception inventory. RESULTS: Significant therapeutic gains occurred in parent-child interactions, externalizing behaviors, and parents' perception of their parenting behaviors. These were maintained at 4-month follow-up. Fifty-two percent of cases improved to a level below clinical cutoffs. Poor parent-child interactions had stronger correlation with externalizing disturbances than internalizing disturbances. The changes in parent-child interactions had low correlation with the changes in the symptom profiles. CONCLUSIONS: The data provide preliminary evidence for the efficacy of parent management training for Chinese children with conduct problems. The rationale for its success and modifications to improve its cultural sensitivity are discussed.

The 15-year outcome of Chinese patients with schizophrenia in Hong Kong.

OBJECTIVE: To explore the differential outcome of schizophrenia in developed and developing countries. The 15-year outcome of patients with schizophrenia in Hong Kong is reported. METHOD: In a 15-year retrospective outcome study, 100 patients with first-onset schizophrenia in 1977-1978 were randomly selected for outcome assessment from a pool of 797 patient files. The patterns of outcome were assessed by the same set of instruments and methodology as in other centres, since Hong Kong is 1 of the World Health Organization (WHO) centres for the International Study of Schizophrenia (ISoS). RESULTS: Nineteen subjects were untraceable, and 10 subjects committed suicide. More than one-half of the subjects had a good symptomatic outcome, while about 20% of the subjects were rated as having a good psychosocial adjustment. Over the entire 15-year period, 96% of the subjects were maintained on medications, and 79% were living with family members. CONCLUSION: Despite Hong Kong's developed economy, its schizophrenia outcome is similar to that in developing countries. The existence of good family support and active follow-up treatment may be important contributory factors to better outcome.

Psychological interventions in general hospitals: background, current status and clinical guidelines.

PURPOSE: To promote the systematic development, interests, practice, research and clinical applications of health psychology in general hospitals in Hong Kong and the mainland of China. DATA SOURCES: The targets and aims of therapeutic work with patients in pain, cancer patients, child and adolescent patients, patients with chronic illnesses, the elderly, and patients requiring organ transplantation are highlighted. STUDY SELECTION: The psychological interventions described are experiences derived from routine clinical services carried out in the Clinical Health Psychology Unit where the authors are affiliated, and can be seen as an example of a more comprehensive psychological intervention program for physically ill patients in Hong Kong. RESULTS: Psychological interventions have intrinsic values in reducing patients' distress and sufferings. The services are also an integral part of modem day comprehensive patient care with positive effects on treatment effectiveness and eventual illness outcome. CONCLUSIONS: Physical illnesses affect a person physically as well as psychologically. Psychological care in general hospitals is cost effective and beneficial in reducing undue psychological complications precipitated by physical afflictions as well as in promoting better overall outcomes.

Cognitive deficit measures in schizophrenia: factor structure and clinical correlates.

OBJECTIVE: The authors aimed to delineate the "common denominators" across a representative number of cognitive measures by administering such measures to a large number of schizophrenic subjects. The authors also aimed to study the consistency of the subjects' performance over a 1-year period and to look into the relationship between cognitive task performance and clinical status. METHOD: One hundred fifty-seven schizophrenic subjects with a DSM-III-R diagnosis of schizophrenia were assessed under standardized testing conditions on the dichotic listening and shadowing task, the span of apprehension task, the simple reaction time tasks, the critical stimulus duration, and the interstimulus interval in which they would become free from the masking effect. The clinical status of the subjects was assessed during index assessment, and 97 subjects were reassessed at the end of 1 year. Forty-seven subjects were randomly selected for reassessment on the cognitive tasks administered 1 year earlier. The subjects' performance was compared to that of 56 nonschizophrenic patients with nasopharyngeal carcinoma who had undergone radiation therapy. RESULTS: The cognitive task scores were factor analyzed, giving five distinct factors made up of the span of apprehension accuracy scores, simple reaction time scores, shadowing accuracy scores, span of apprehension error scores, and susceptibility to interference scores. At index assessment, the subjects' shadowing accuracy and reaction time were significantly related to their quality of life, social adjustment, and positive symptoms. The subjects' span of apprehension scores were related to their negative symptoms, measured in terms of work and daily life functions. The initial relationship between the subjects' cognitive test scores and their outcome status remained consistent at follow-up. CONCLUSIONS: The documented cognitive deficits in schizophrenic patients probably reflect a more enduring trait-like status with correlations with outcome status. These results also indicate that the cognitive measures may be simplified in complexity without a corresponding reduction in their clinical significance.

Situational versus pervasive hyperactivity in a community sample.

Groups of home and school situational hyperactive primary schoolboys identified from the community were compared with pervasive hyperactive and non-hyperactive controls on a wide range of measures. The hyperactive groups tended to persist in the same category over a half-year period. Both situational hyperactive groups had lower measured activity levels than the pervasive hyperactive group and only the latter differed from non-hyperactive controls. Home hyperactivity was characterized by poor family relationships and was not distinguishable from non-hyperactive home-antisocial controls. School hyperactive boys had specific correlates of low intelligence, motor clumsiness, poor reading and academic abilities. Pervasive hyperactive subjects differed from both situational groups in showing a higher percentage of delayed language development. While home hyperactivity has dubious identity, the distinct pattern of external correlates in school and pervasive hyperactivity speak for the need to regard these as separate entities.

Coping strategies of schizophrenic patients and their relationship to outcome.

The experience and perception of effective sources of help of 101 schizophrenic patients were studied. A combination of professional help, social support, and self-coping efforts was listed as helpful. The more experiences patients had with the various sources of help, the better were their outcomes. Premorbid adjustment, exposure to the magnitude and nature of helpful sources, as well as the patients' own ability and motivation to make use of available helpful sources were thought to be important mediating variables for a better outcome. Apart from psychotropic medications, over half of the patients were not using any one of the sources of help mentioned. It remains an important research question whether or not schizophrenic patients may benefit from direct coaching in self-help skills in conjunction with making optimal use of professional and environmental supports.

Language screening in preschool Chinese children.

The incidence of language delay in Chinese preschool children was studied by a stratified proportional sampling of all 3 year olds in Hong Kong. The Developmental Language Screening Scale (DLSS) devised for use with Cantonese speaking children was used to identify children with language delay. Of 855 children sampled in the stage I screening procedure, 4%, 2.8% and 3.3% were identified as having delay in verbal comprehension, expression or both respectively. The stage II clinical diagnostic study included a randomly selected group of children screened in stage I with or without any associated behavioural problem. Among these, 3.4% were identified as having a language delay using the Reynell Language Developmental Scale (RDLS) with a criterion of language age of less than or equal to two-thirds of the chronological age; 3% had specific language delay using the criteria of language age less than or equal to two-thirds the chronological age and developmental age more than or equal to two-thirds the chronological age. More boys were found to have language delay, although this was not statistically significant.