Mortality risk and mood stabilizers in bipolar disorder: a propensity-score-weighted population-based cohort study in 2002-2018.

AIMS: Accumulating studies have assessed mortality risk associated with mood-stabilizers, the mainstay treatment for bipolar disorder (BD). However, existing data were mostly restricted to suicide risk, focused on lithium and valproate and rarely adequately adjusted for potential confounders. This study aimed to assess comparative mortality risk with all, natural and unnatural causes between lithium, valproate and three frequently prescribed second-generation antipsychotics (SGA), with adjustment for important confounders. METHODS: This population-based cohort study identified 8137 patients with first-diagnosed BD, who had exposed to lithium (n = 1028), valproate (n = 3580), olanzapine (n = 797), quetiapine (n = 1975) or risperidone (n = 757) between 2002 and 2018. Data were retrieved from territory-wide medical-record database of public healthcare services in Hong Kong. Propensity-score (PS)-weighting method was applied to optimize control for potential confounders including pre-existing chronic physical diseases, substance/alcohol use disorders and other psychotropic medications. PS-weighted Cox proportional-hazards regression was conducted to assess risk of all-, natural- and unnatural-cause mortality related to each mood-stabilizer, compared to lithium. Three sets of sensitivity analyses were conducted by restricting to patients with (i) length of cumulative exposure to specified mood-stabilizer ≥90 days and its medication possession ratio (MPR) ≥90%, (ii) MPR of specified mood-stabilizer ≥80% and MPR of other studied mood-stabilizers <20% and (iii) monotherapy. RESULTS: Incidence rates of all-cause mortality per 1000 person-years were 5.9 (95% confidence interval [CI]: 4.5-7.6), 8.4 (7.4-9.5), 11.1 (8.3-14.9), 7.4 (6.0-9.2) and 12.0 (9.3-15.6) for lithium-, valproate-, olanzapine-, quetiapine- and risperidone-treated groups, respectively. BD patients treated with olanzapine (PS-weighted hazard ratio = 2.07 [95% CI: 1.33-3.22]) and risperidone (1.66 [1.08-2.55]) had significantly higher all-cause mortality rate than lithium-treated group. Olanzapine was associated with increased risk of natural-cause mortality (3.04 [1.54-6.00]) and risperidone was related to elevated risk of unnatural-cause mortality (3.33 [1.62-6.86]), relative to lithium. The association between olanzapine and increased natural-cause mortality rate was consistently affirmed in sensitivity analyses. Relationship between risperidone and elevated unnatural-cause mortality became non-significant in sensitivity analyses restricted to low MPR in other mood-stabilizers and monotherapy. Valproate- and lithium-treated groups did not show significant differences in all-, natural- or unnatural-cause mortality risk. CONCLUSION: Our data showed that olanzapine and risperidone were associated with higher mortality risk than lithium, and further supported the clinical guidelines recommending lithium as the first-line mood-stabilizer for BD. Future research is required to further clarify comparative mortality risk associated with individual SGA agents to facilitate risk-benefit evaluation of alternative mood-stabilizers to minimize avoidable premature mortality in BD.

Prevalence and correlates of depression, anxiety and trauma-like symptoms in Chinese psychiatric patients during the fifth wave of COVID-19 pandemic: a cross-sectional study in Hong Kong.

BACKGROUND: Psychiatric patients are susceptible to adverse mental health outcome during COVID-19 pandemic, but its associated factors are understudied. This observational cross-sectional study aimed to comprehensively examine prevalence and correlates of psychological distress, in terms of depression, anxiety and post-traumatic-stress-disorder (PTSD)-like symptoms, among Chinese adult psychiatric outpatients amidst the peak of fifth COVID-19 wave in Hong-Kong. METHODS: A total of 415 patients (comprising 246 patients with common-mental-disorders [CMD] and 169 with severe-mental-disorders [SMD]) and 399 demographically-matched controls without mental disorders were assessed with self-rated questionnaires between 28-March and 8-April-2022, encompassing illness profile, mental health symptoms, psychosocial measures (loneliness, resilience, coping styles) and COVID-19 related factors. Univariate and multivariable logistic regression analyses were conducted to determine variables associated with moderate-to-severe depressive, anxiety and PTSD-like symptoms among psychiatric patients. RESULTS: Our results showed that CMD patients had the greatest psychological distress relative to SMD patients and controls. Approximately 40-55% CMD patients and 25% SMD patients exhibited moderate-to-severe depression, anxiety and PTSD-like symptoms. Multivariable regression analyses revealed that female gender, lower educational attainment, single marital status, being housewife, more severe insomnia, psychotic-like symptoms and cognitive complaints, self-harm behavior, lower resilience, avoidance coping, never contracting COVID-19 infection, greater fear of contagion, and longer exposure to pandemic-related information were independently associated with depression, anxiety and/or PTSD-like symptoms in psychiatric patients. CONCLUSIONS: Our results affirm increased vulnerability of psychiatric patients toward psychological distress during pandemic. An array of identified correlates facilitates early detection of high-risk psychiatric patients for targeted strategies to minimize pandemic-related negative psychological impact.

Network analysis on psychopathological symptoms, psychological measures, quality of life and COVID-19 related factors in Chinese psychiatric patients in Hong Kong.

BACKGROUND: Psychiatric patients are susceptible to adverse mental health impacts during COVID-19, but complex interplays between psychopathology and pandemic-related variables remain elusive. This study aimed to investigate concomitant associations between psychopathological symptoms, psychological measures and COVID-19 related variables in Chinese psychiatric patients during the peak of fifth pandemic wave in Hong Kong. METHODS: We employed network analysis to investigate inter-relationships among psychopathological symptoms (including depression, anxiety, post-traumatic stress disorder-like [PTSD-like] symptoms, insomnia, psychotic symptoms), cognitive complaints, health-related quality of life, loneliness, resilience and selected pandemic-related factors in 415 psychiatric outpatients between 28 March and 8 April, 2022. Network comparisons between genders, diagnosis (common mental disorders [CMD] vs. severe mental disorders [SMD]), and history of contracting COVID-19 at fifth wave were performed as exploratory analyses. RESULTS: Our results showed that anxiety represented the most central node in the network, as indicated by its highest node strength and expected influence, followed by depression and quality of life. Three comparatively strong connections between COVID-19 and psychopathological variables were observed including: fear of contagion and PTSD-like symptoms, COVID-19 stressor burden and PTSD-like symptoms, and COVID-19 stressor burden and insomnia. Network comparison tests revealed significant network structural difference between participants with history of contracting COVID-19 and those without, but showed no significant difference between genders as well as between CMD and SMD patients. CONCLUSIONS: Our findings suggest the pivotal role of anxiety in psychopathology network of psychiatric patients amidst COVID-19. Pandemic-related variables are critically associated with trauma/stress and insomnia symptoms. Future research is required to elucidate potential network structural changes between pandemic and post-COVID periods.

The prevalence and correlates of suicidal ideation in Chinese psychiatric patients during the fifth wave of COVID-19 in Hong Kong.

People with mental disorders have increased risk of psychological distress during COVID-19. However, there is limited research comprehensively examining factors associated with suicidal ideation, the strongest predictor of suicidal behavior, among psychiatric patients amidst pandemic. We investigated prevalence and correlates of suicidal ideation in 407 Chinese psychiatric outpatients (diagnosed with mood, anxiety or schizophrenia-spectrum disorders) aged 18-64 years during the peak of fifth COVID-19 wave in Hong Kong between 28 March and 8 April, 2022, based on a comprehensive array of variables encompassing socio-demographics, illness profile, psychopathological symptoms, psychological measures and pandemic-related factors. Univariate and multivariate logistic regression analyses were conducted to determine correlates of suicidal ideation. Results showed that 128 (31.4%) participants exhibited suicidal ideation. Univariate analyses revealed that being unemployed or full-time student, more severe depressive, anxiety, PTSD-like, insomnia and psychotic symptoms, higher levels of loneliness, avoidant-coping, greater pandemic-related stress burden and distress by social-distancing measures were related to suicidal ideation. Conversely, participants with higher monthly household-income, better quality-of-life, and greater resilience were less likely to have suicidal ideation. Notably, only depressive symptom severity was retained in final multivariate model as a factor significantly associated with suicidal ideation. Hence, we observed that approximately one-third of Chinese psychiatric patients experienced suicidal ideation during fifth pandemic wave. Our findings underscore the influence of depressive symptoms being above and beyond that of other psychopathological symptoms, psychological and pandemic-related variables on suicidal ideation. Longitudinal research is required to clarify suicidal ideation trajectories and predictors of persistent suicidal ideation across pandemic and post-pandemic periods.

COVID-19 perseverative cognition and depressive symptoms in Hong Kong: The moderating role of resilience, loneliness and coping strategies.

BACKGROUND: The COVID-19 pandemic significantly increased depression prevalence in general population. However, the relationship between persistent dysfunctional thinking associated with COVID-19 (perseverative-cognition) and depression, and its potential moderators are understudied. We aimed to examine the association between COVID-19 perseverative-cognition and depression, and the moderating effect of potential risk and protective factors on this association in general public during the peak of fifth COVID-19 wave in Hong Kong. METHODS: This survey recruited 14,269 community-dwelling adults between March 15-April 3, 2022 to investigate association between COVID-19 perseverative-cognition and depression, and the moderating effect of resilience, loneliness and three coping strategies (including emotion-focused, problem-focused and avoidant coping) on this association, using hierarchical regression models and simple slope analyses. COVID-19 perseverative cognition was assessed by the Obsession with COVID-19 Scale (OCS) and depressive symptoms were measured by the Patient Health Questionnaire-9 (PHQ-9). RESULTS: Perseverative-cognition was positively associated with depression severity. Resilience, loneliness and three coping strategies moderated the association between perseverative-cognition and depression. Specifically, greater resilience and emotion-focused coping ameliorated the association between perseverative-cognition and depression, while higher levels of loneliness, avoidant and problem-focused coping accentuated such association. LIMITATIONS: Cross-sectional design precluded establishing causality among variables. CONCLUSION: This study affirms that COVID-19 perseverative-cognition is significantly related to depression. Our findings indicate the potential critical role of enhanced personal resilience and social support, and adoption of emotion-focused coping in mitigating negative effect of COVID-19 related maladaptive thinking on depression severity, thereby facilitating development of targeted strategies to reduce psychological distress amidst the prolonged pandemic.

Prevalence and correlates of suicidal ideation in the general public during the fifth wave of COVID-19 pandemic in Hong Kong.

Introduction: Literature reveals increased suicidal ideation in the general population during pandemic. However, few COVID-19 studies comprehensively assessed factors associated with suicidal ideation, and mixed findings were observed. We aimed to examine prevalence and correlates of suicidal ideation in general public during the peak of fifth COVID-19 wave in Hong Kong based on a broad array of relevant measures. Methods: This survey assessed 14,709 community-dwelling adults during March 15-April 3, 2022. Comprehensive assessment was administered including socio-demographics, pre-existing mental/physical morbidity, mental-health symptoms, resilience, loneliness, coping strategies, and pandemic-related factors. Presence of suicidal ideation was evaluated by ratings of item 9 on Patient-Health-Questionnaire-9. Results: A total of 2,249 (15.3%) participants exhibited suicidal ideation. Multivariable-regression analysis found that being single and unemployed, pre-existing mental disorder, more severe depressive and anxiety symptoms, higher levels of loneliness and engagement in avoidant coping were significantly associated with suicidal ideation. Conversely, attaining tertiary educational level or above, greater resilience and adopting problem-focused coping were associated with lower likelihood of suicidal ideation. Although univariate-analyses revealed that a number of pandemic-related factors were linked to suicidal ideation, none remained significant in the multivariable model. Conclusion: A significant proportion of people experienced suicidal ideation during the peak of fifth COVID-19 wave. Risk and protective factors identified would facilitate early identification of high-risk individuals and provision of targeted interventions to minimize suicidal ideation and risk of self-harm. Caution should be exercised due to study limitations of a cross-sectional design which precluded establishing causality among variables, and reliance on self-reported data.