Our Department has been undertaking various mental health research projects to implement the WHO recommendation of “Integration of Mental Health into Primary care” in Chinese and Asian context. These projects aim to enhance mental health and self-efficacy for primary care patients particularly in chronic disease management, healthy ageing, youth well-being and suicide prevention.
Our team has conducted studies with the Hospital Authority, non-profit organizations, private primary care clinics, community centers, secondary schools and tertiary institutions within Hong Kong for primary care mental health research. We have identified the keys factors to facilitate help-seeking and management of mental health and psychosocial problems, and ways to promote youth well-being. We have been working with the World Health Organization in revising the primary care classification of mental and behavioural disorders for the ICD-11-PHC. We also have active international collaborations with universities in the Asia Pacific Region including Australia, Singapore and Mainland China for projects relating to depression, anxiety disorders, dementia, domestic violence, child abuse and safe sexual health.
- Professor Cindy Lo Kuen LAM
- Professor Tai Pong LAM
- Dr William Chi Wai WONG
- Dr Esther Yee Tak YU
- Dr Julie Yun CHEN
- Dr Carlos King Ho WONG
Current research projects
- Elicitation of health state utilities for paediatric populations from the general public. PI: Carlos K.H. Wong, 2019-2020, UGC-General Research Fund (GRF), HK$968,347.
- Hong Kong Youths' Attitudes Towards Suicide, Coping Strategies and Online Help-seeking. PI: Tai Pong Lam, 2018-2020, Public Policy Research Grant, HK$880,918.
Hong Kong Youths' Attitudes Towards Suicide, Coping Strategies and Online Help-seeking
Yip SFP, Lam KF, Lo TL, Chao DVK, Mak KY, Lam WW
Public Policy Research Grant. Amount awarded: HKD$880,918.
The alarming rate of youth suicide has remained a significant concern in Hong Kong since 2015. Past studies reported prevalence of suicidal thoughts and attempts between 10 to 20% of adolescents worldwide. While much had been done to identify prevalence, causes and risk factors, little was known regarding the attitudes of local youths towards suicide, how they would react to, and cope with suicidal thoughts and behaviours. The global trend that the younger generation prefers to express distress or look up self-help sources at online platforms also reflects the need to understand the role of social media in alleviating stress for the youths. The study begins with an inquiry into Hong Kong youths’ attitudes towards suicide, then goes on to explore how youths cope with suicidal ideation and attempt of their own and peers, and the relation between their attitudes and coping strategies, with special focus on the use of social media sites as a means of coping with distress and suicidal behaviours.
- Sun KS, Lam TP, Lam KF, Chan HY, Lo TL, Chao DVK, Yu YTT, Lam EWW. Associations between demographic factors and psychological distress among Chinese residents in Hong Kong: beyond socioeconomic classes. Psychology, Health & Medicine. 2020 Jan 15:1-13.
- Zhang Z, Sun KS, Jatchavala C, Koh J, Chia Y, Bose J, Li Z, Tan W, Wang S, Chu W, Wang J, Tran B, Ho R. Overview of stigma against psychiatric illnesses and advancements of anti-stigma activities in six Asian societies. International Journal of Environmental Research and Public Health. 2019 Dec 31;17(1).
- Ziebold C, Goldberg DP, Reed GM, Minhas F, Razzaque B, Fortes S, Robles R, Lam TP, Bobes J, Iglesias C, Cogo-Moreira H, Gracia JÁ, Mari JJ. Dimensional analysis of depressive, anxious and somatic symptoms presented by primary care patients and their relationship with ICD-11 PHC proposed diagnoses. Psychological Medicine. 2019 Apr;49(5):764-771.
- Ziebold C, Mari JJ, Goldberg DP, Minhas F, Razzaque B, Fortes S, Robles R, Lam TP, Bobes J, Iglesias C, García JÁ and Reed GM. Diagnostic consequences of a new category of anxious depression and a reduced duration requirement for anxiety symptoms in the ICD-11 PHC. Journal of Affective Disorders. 2019; 245:120-125.
- Sun KST, Lam TP, Kwok KW, Chong KY, Poon MK and Wu DD. Treatment of Chinese adolescents with anorexia nervosa in Hong Kong: The gap between treatment expectations and outcomes. PLoS One. 2019; 14.
- Sun KS, Lam TP, Piterman L, Lam KF, Tang WS, Kwok KW, Chan HY, Wu D, Tiwari A. Management of domestic violence by primary care physicians in Hong Kong; association with barriers, attitudes, training and practice background. Journal of Interpersonal Violence. 2019 Aug 17.
- Sun KST, Lam TP, Lo TL and Wu DD. How Chinese psychiatrists see and manage stigmatisation of psychiatric patients: a qualitative study in Hong Kong. Evidence-Based Mental Health. 2019; 22:51-55.
- Lam TP, Sun KST, Chan HY, Lau WCS, Lam KF and Sanson-Fisher R. Perceptions of Chinese Towards Dementia in Hong Kong—Diagnosis, Symptoms and Impacts. International Journal of Environmental Research and Public Health. . 2019; 16:128.
- Lam TP, Lo TL, Chao DVK, Lam KF, Lam WW and Sun KST. Consultation pattern of Hong Kong primary care attenders for psychological distress. Hong Kong Medical Journal. 2019; 25:S18-20.
- Sun KS, Lam TP, Lam KF, Lo TL, Chao DVK, Lam EWW. Enablers to seeking professional help for psychological distress – a study on Chinese primary care attenders. Psychiatry Research. 2018 Jun;264:9-14.
- Sun KS, Lam TP, Wu D. Chinese perspectives on primary care for common mental disorders: Barriers and policy implications. International Journal of Social Psychiatry, 2018 Aug;64(5):417-426.
- Chin W-Y, Wan EYF, Dowrick C, Arroll B, Cindy L. K. Lam. Tree analysis modeling of the associations between PHQ-9 depressive symptoms and doctor diagnosis of depression in primary care. Psychological Medicine 2018; 1–9.
- Chin W.Y., Wan E.Y.F., Choi E.P.H., Chan K.T.Y., Cindy L. K. Lam. The 12-month incidence and predictors of PHQ-9-screened depressive symptoms in Chinese primary care patients. Ann Fam Med 2016; 14:47-53.
- Sun KS, Lam TP, Lam KF, Lo TL, Chao DVK, Lam EWW. Barriers of Chinese primary care attenders to seeking help for psychological distress in Hong Kong. Journal of Affective Disorders. 2016;196:164-170.
- Sun KS, Lam TP, Lam KF, Lo TL. Obstacles in managing mental health problems for primary care physicians in Hong Kong. Administration and Policy in Mental Health and Mental Health Services Research. 2015;42(6):714-22.
- Lam TP, Goldberg DP, Dowell AC, Fortes S, Mbatia JK, Minhas FA, Klinkman MS. Proposed New Diagnoses of Anxious Depression and Bodily Stress Syndrome in ICD-11-PHC: An International Focus Group Study. Family Practice. 2013;30(1):76-87.
- Lam TP, Mak KY, Goldberg D, Lam KF, Sun KS. Western mental health training for Traditional Chinese Medicine practitioners. Acta Psychiatrica Scandinavica 2012; 126(6):440-7.
- Cindy L. K. Lam, Fong D.,Y.T Chin W.Y. Lee, P.W.H., Lam E.T.P., Lo Y.Y.C. Brief Problem-solving treatment in Primary Care (PST-PC) was not more effective than placebo for elderly patients screened - positive of psychological problems Int J Geriatr Psychiatry 2010; 25:968-980.
- Cindy L. K. Lam, Chin W.Y. Lee P.W.H., Lo Y.Y.C., Fong D.,Y.T. Lam T.P. Unrecognized psychological problems impair quality of life and increase consultation rates in Chinese elderly patients. Int J Geriatr Psychiatry 2009; 24 (Aug):979-989.
- Cindy L. K. Lam, Pan P.C., Chan A.W.T., Chan S.Y., Munro C. Can the Hospital Anxiety and Depression (HAD) Scale be used on Chinese in general practice? Family Practice 1995; 12: 149-154.
Associations between demographic factors and psychological distress among Chinese residents in Hong Kong: beyond socioeconomic classes.
Sun KS, Lam TP, Lam KF, Chan HY, Lo TL, Chao DVK, Yu YTT, Lam EWW.
Most studies highlighted the association between psychological distress and socioeconomic status (SES). There were weaker explanations for distress found in the middle classes, especially in Asian countries. We conducted a questionnaire survey with 1626 adult Chinese primary-care attenders from 13 private and 6 public clinics in different districts of Hong Kong. Their demographic background and distress level measured by GHQ-12 were analysed. We found that respondents with younger age, better education, and lower income were more likely to be distressed. In a multiple logistic regression model, age and income, but not education, were significant predictors for distress. Highest rates of distress were found among the unemployed (45.5%) and the students (37.1%), followed by service workers and shop sales workers (33.0%), associate professionals (32.0%), and clerks (29.2%). Craftworkers (9.1%), plant and machine operators (11.5%), and retired people (12.8%) were least likely to be distressed, followed by professionals (21.0%). Apart from SES, the findings suggest that young age, academic and job stressors, and low self-esteem are significant factors for distress. These factors may be intensified in a Chinese context by peer comparison resulting in a state of relative deprivation.
Overview of stigma against psychiatric illnesses and advancements of anti-stigma activities in six Asian societies.
Zhang Z, Sun KS, Jatchavala C, Koh J, Chia Y, Bose J, Li Z, Tan W, Wang S, Chu W, Wang J, Tran B, Ho R.
In psychiatry, stigma is an attitude of disapproval towards people with mental illnesses. Psychiatric disorders are common in Asia but some Asians receive inadequate treatment. Previous review found that Asians with mental illness were perceived to be dangerous and aggressive. There is a need for renewed efforts to understand stigma and strategies which can effectively reduce stigma in specific Asian societies. The objective of this systematic review was to provide an up-to-date overview of existing research and status on stigma experienced by psychiatric patients and anti-stigma campaigns in China, Hong Kong, Japan, Singapore, Korea, and Thailand.
A systematic literature search was conducted in the following databases, including PubMed, PsycINFO, Embase, Web of Science, and local databases. Studies published in English and the official language of included countries/territories were considered for inclusion in the systematic review. Any article on stigma related to any form of psychiatric illness in the six Asian societies was included.
One hundred and twenty-three articles were included for this systematic review. This review has six major findings. Firstly, Asians with mental illnesses were considered as dangerous and aggressive, especially patients suffering from schizophrenia and bipolar disorder; second, psychiatric illnesses in Asian societies were less socially-acceptable and were viewed as being personal weaknesses; third, stigma experienced by family members was pervasive and this is known as family stigma; fourth, this systemic review reported more initiatives to handle stigma in Asian societies than a decade ago; fifth, there have been initiatives to treat psychiatric patients in the community; and sixth, the role of supernatural and religious approaches to psychiatric illness was not prevailing.
This systematic review provides an overview of the available scientific evidence that points to areas of needed intervention to reduce and ultimately eliminate inequities in mental health in Asia.
Dimensional analysis of depressive, anxious and somatic symptoms presented by primary care patients and their relationship with ICD-11 PHC proposed diagnoses
Carolina Ziebold, David P. Goldberg, Geoffrey M. Reed, Fareed Minhas, Bushra Razzaque, Sandra Fortes, Rebeca Robles, Tai Pong Lam, Julio Bobes, Celso Iglesias, Hugo Cogo-Moreira, José Ángel García,Jair J. Mari
A study conducted as part of the development of the Eleventh International Classification of Mental Disorders for Primary Health Care (ICD-11 PHC) provided an opportunity to test the relationships among depressive, anxious and somatic symptoms in PHC.
Primary care physicians participating in the ICD-11 PHC field studies in five countries selected patients who presented with somatic symptoms not explained by known physical pathology by applying a 29-item screening on somatic complaints that were under study for bodily stress disorder. Patients were interviewed using the Clinical Interview Schedule-Revised and assessed using two five-item scales that measure depressive and anxious symptoms. Structural models of anxious-depressive symptoms and somatic complaints were tested using a bi-factor approach.
A total of 797 patients completed the study procedures. Two bi-factor models fit the data well: Model 1 had all symptoms loaded on a general factor, along with one of three specific depression, anxiety and somatic factors [x2 (627) = 741.016, p < 0.0011, RMSEA = 0.015, CFI = 0.911, TLI = 0.9]. Model 2 had a general factor and two specific anxious depression and somatic factors [x2 (627) = 663.065, p = 0.1543, RMSEA = 0.008, CFI = 0.954, TLI = 0.948].
These data along with those of previous studies suggest that depressive, anxious and somatic symptoms are largely different presentations of a common latent phenomenon. This study provides support for the ICD-11 PHC conceptualization of mood disturbance, especially anxious depression, as central among patients who present multiple somatic symptoms.
Diagnostic consequences of a new category of anxious depression and a reduced duration requirement for anxiety symptoms in the ICD-11 PHC
Carolina Ziebold, David P. Goldberg, Geoffrey M. Reed, Fareed Minhas, Bushra Razzaque, Sandra Fortes, Rebeca Robles, Tai Pong Lam, Julio Bobes, Celso Iglesias, Hugo Cogo-Moreira, José Ángel García,Jair J. Mari
A new diagnosis of anxious depression (AD), characterized by both depressive and anxious symptoms at case level, has been proposed for the classification of mental disorders for primary care for ICD-11 (ICD-11 PHC). The ICD-11 PHC proposes a duration requirement for anxiety symptoms of 2 weeks, in line with the requirement for depressive symptoms. This study examined diagnostic assignment under ICD-11 PHC as compared to the previous classification, the ICD-10 PHC, and the relationship of anxiety duration to disability and suicidal ideation.
Primary care physicians in five countries referred patients based on either perceived psychological distress or distressing somatic symptoms to a research assistant who administered a computer-guided diagnostic interview. Complete data were obtained for 2279 participants.
Under ICD-11 PHC 47.7% participants received a diagnosis of AD and had greater disability than other diagnostic groups. Under ICD-10 PHC, in addition to meeting requirements for depressive episode, most of these patients met requirements for either generalized anxiety disorder (41.5%) or mixed anxiety and depressive disorder (45.4%). One third of individuals diagnosed with AD had anxiety durations between 2 weeks and 3 months and presented as much disability and suicidal ideation as individuals with longer anxiety durations.
The study was not designed to establish prevalence of these conditions.
The proposed ICD-11 PHC encourages early identification and management of significant anxiety symptoms in primary care, particularly when these co-occur with depression. This study provides support for the clinical relevance of these symptoms and the importance of early identification.
Treatment of Chinese adolescents with anorexia nervosa in Hong Kong: The gap between treatment expectations and outcomes
Kai Sing Sun, Tai Pong Lam, Kit Wing Kwok, King Yee Chong, Man Kay Poon, Dan Wu
Background and Objective:
Anorexia nervosa (AN) is one of the most difficult-to-treat psychiatric disorders. AN is associated with individual vulnerability, societal and family factors. There has been limited research in Asia regarding the patients or their families' perceptions on its treatment. This study explored the perceived treatment outcomes among Chinese families having adolescents with AN.
Qualitative interviews were conducted on parents of adolescents with AN recruited through an eating disorder association in Hong Kong to understand their views and experiences regarding the help-seeking and treatment process.
The parents expressed dissatisfaction towards help-seeking and treatment outcomes, including relationships with health professionals, hospitalization, health professionals' knowledge of AN, understanding of the treatment model and parents' role, amount of psychological support, and coordination among health professionals. The parents were unclear about the treatment plan as they received little explanation from the health professionals. The parents perceived that the AN treatment only focused on weight restoration with limited psychological support. Home diet monitoring was seen as a harsh task which worsened the relationship with their children. The parents often needed to take up the coordinator role and search around for different health professionals and integrate their advices by themselves.
The study shows that limited psychoeducation, communication and coordination in the treatment for AN are major problems in a Chinese context. Open communication between the health professionals and the parents about the expected treatment outcomes and limitations is needed to enhance their mutual trust. Besides, treatment should emphasize not only family involvement but also empower them to fight against AN.
Management of Domestic Violence by Primary Care Physicians in Hong Kong: Association With Barriers, Attitudes, Training, and Practice Background.
Sun KS, Lam TP, Piterman L, Lam KF, Tang WS, Kwok KW, Chan HY, Wu D, Tiwari A.
While primary care physicians (PCPs) have opportunities to recognize patients who encounter domestic violence (DV) by intimate partners, warning symptoms such as unexplained physical injury, bruising, anxiety, and depression are often missed during clinic visits. This study investigated the barriers of Hong Kong PCPs toward managing DV, including recognition, management, and referrals of these patients. Four focus group interviews were conducted to explore the in-depth opinions of PCPs on managing DV in Hong Kong. The themes identified were investigated in a questionnaire survey with data from 504 PCPs working in public and private sectors. Factor analysis of the survey data suggested four major barrier factors: (a) worries about the potential harms of intervening in patients' domestic affairs and DV issues, (b) lack of guidelines and support services, (c) limited skills and time in managing DV, and (d) patients' reluctance in disclosing DV issues. PCPs with more years of practice had more worries about intervening in domestic issues (Factor 1), while the younger PCPs tended to perceive limited skills and time in managing DV cases as barriers (Factor 3). PCPs working in the public setting were more likely to ask patients about DV (M = 5.4 vs. 2.9), suspected DV (M = 3.8 vs. 2.3), and managed DV (M = 1.7 vs. 1.0) in the past 5 years compared with the private PCPs. Some PCPs in the focus groups expressed the view that DV cases should be handled by social workers instead of doctors. Survey respondents who held such views about doctors' limited role in DV management also scored higher in all of the barrier factors. The findings suggest that there are boundaries between domestic and medical realms, especially in a Chinese context. Resolving PCPs' worries by training, provision of DV management guidelines, and referral pathway to social workers may be good starting points to bridge the gaps.
How Chinese psychiatrists see and manage stigmatisation of psychiatric patients: a qualitative study in Hong Kong
Kai Sing Sun, Tai Pong Lam, Tak Lam Lo, Dan Wu
Health professionals including psychiatrists were reported to have stigmatising opinions on psychiatric patients. Their views may be affected by clinical, social and cultural factors.
This study explored the views of Chinese psychiatrists on stigmatisation of psychiatric patients.
Focus group discussions with psychiatrists were conducted in Hong Kong. Their views towards stigmatisation of psychiatric patients and strategies to reduce stigmatisation were discussed.
The psychiatrists perceived the clinical needs to classify the patients according to the diagnoses and they did not see it as stigmatisation. They believed that some mental illnesses are characterised with violence or deviance, and were not completely curable. Instead of trying to eliminate stigma, they managed in ways that took social expectations into consideration. They might offer a relative vague diagnostic label to save the ‘face’ of the patients and secure greater acceptance for the illness from the public. They tended to accept family members to make decisions on behalf of the patients. Reconciling public interest and patients’ autonomy, they encouraged stable psychotic patients to live in the community but agreed to institutionalise those patients with violent behaviours.
While the psychiatrists argued that the diagnosis was not a form of stigma, they were sensitive enough and framed responses to patients in ways to minimise stigma. They tended to believe that stigma was inevitable given the nature of some psychotic disorders. Disguising the stigma appeared to be the common approach to deal with stigma in a Chinese context.
The psychiatrists, especially those practicing in a Chinese context, may consider a wider perspective of community mental health rehabilitation which is not limited to social stability but also social life.
Perceptions of Chinese Towards Dementia in Hong Kong—Diagnosis, Symptoms and Impacts
Tai Pong Lam, Kai Sing Sun, Hoi Yan Chan, Chak Sing Lau, Kwok Fai Lam and Robert Sanson-Fisher
The increasing prevalence of dementia has become a public health issue worldwide including China. This study aims to explore the perception of Chinese in Hong Kong towards the diagnosis, symptoms and impacts of dementia. A cross-sectional survey was conducted among outpatients (without diagnosed dementia) attending a regional public hospital using a standard questionnaire. The results from 290 respondents showed that most preferred to be told about the diagnosis of dementia as soon as possible if they got it, in order to deal with the news and to access treatment and support early. Nearly two thirds of the respondents perceived practical issues (61.3%), physical health (61.0%), and emotional distress (58.4%) as their most fearful impacts, while legal issues (7.4%) were their least concerns. Family history/genes (79.1%) and brain injury (75.9%) were the most commonly perceived causes of dementia. For symptoms, respondents were more likely to identify cognitive impairments than undesirable behaviours. The accepting and proactive attitudes of the public indicate that there is a timely need of more public education about the disease, early screening and better continuity of care to fulfil the anticipated increase of the dementia patient population
Enablers to seeking professional help for psychological distress – a study on Chinese primary care attenders
Sun KS, Lam TP, Lam KF, Lo TL, Chao DVK, Lam EWW.
This study investigated enablers to seeking professional help for psychological distress among Chinese primary care attenders in Hong Kong. Nine focus groups and six individual interviews were conducted among adult patients with/without known distress, significant others of the distressed, and the general public. The identified potential enablers were further investigated in a questionnaire survey with data from 1626 patients. Survey respondents who had sought professional help for distress (n = 231) and those without this experience (n = 1395) showed similar attitudes to the enabler items. However, the first group had more “strongly agree” responses and their top five enablers were: crisis caused by distress, distress affecting daily life, wanting to treat associated physical symptoms, having trust in doctor, and encouragement by family/friends to seek help. Qualitative interviews found that the patients often somatised distress and they felt comfortable to consult for somatic symptoms. There was strong family involvement in help-seeking whereas the doctors were the authoritative figures to convince the patients for treatment. The findings, in line with Western literature, indicate that crisis and interference in daily life due to distress are the top enablers to seeking professional help. The other three key enablers are likely to be influenced by Chinese culture.
Chinese perspectives on primary care for common mental disorders: Barriers and policy implications.
Sun KS, Lam TP, Wu D.
The World Health Organization (WHO) has called for integration of mental health into primary care for a decade. In Western countries, around 15% to 25% of patients with common mental disorders including mood and anxiety disorders seek help from primary care physicians (PCPs). The rate is only about 5% in China.
This article reviews the Chinese findings on the barriers to primary care for common mental disorders and how they compared with Western findings.
A narrative literature review was conducted, focusing on literature published from mid-1990s in English or Chinese. Patient, PCP and health system factors were reviewed.
Although Chinese and Western findings show similar themes of barriers, the Chinese have stronger barriers in most aspects, including under-recognition of the need for treatment, stigma on mental illness, somatization, worries about taking psychiatric drugs, uncertainties in the role, competency and legitimacy of PCPs in mental health care and short consultation time.
Current policies in China emphasize enhancement of mental health facilities and workforce in the community. Our review suggests that patients' intention to seek help and PCPs' competency in mental health care are other fundamental factors to be addressed.
Tree analysis modeling of the associations between PHQ-9 depressive symptoms and doctor diagnosis of depression in primary care.
Chin WY, Wan EYF, Dowrick C, Arroll B, Lam CLK.
The aim of this study was to explore the relationship between patient self-reported Patient Health Questionnaire-9 (PHQ-9) symptoms and doctor diagnosis of depression using a tree analysis approach.
This was a secondary analysis on a dataset obtained from 10 179 adult primary care patients and 59 primary care physicians (PCPs) across Hong Kong. Patients completed a waiting room survey collecting data on socio-demographics and the PHQ-9. Blinded doctors documented whether they thought the patient had depression. Data were analyzed using multiple logistic regression and conditional inference decision tree modeling.
PCPs diagnosed 594 patients with depression. Logistic regression identified gender, age, employment status, past history of depression, family history of mental illness and recent doctor visit as factors associated with a depression diagnosis. Tree analyses revealed different pathways of association between PHQ-9 symptoms and depression diagnosis for patients with and without past depression. The PHQ-9 symptom model revealed low mood, sense of worthlessness, fatigue, sleep disturbance and functional impairment as early classifiers. The PHQ-9 total score model revealed cut-off scores of >12 and >15 were most frequently associated with depression diagnoses in patients with and without past depression.
A past history of depression is the most significant factor associated with the diagnosis of depression. PCPs appear to utilize a hypothetical-deductive problem-solving approach incorporating pre-test probability, with different associated factors for patients with and without past depression. Diagnostic thresholds may be too low for patients with past depression and too high for those without, potentially leading to over and under diagnosis of depression.
The 12-Month Incidence and Predictors of PHQ-9– Screened Depressive Symptoms in Chinese Primary Care Patients.
Chin W.Y., Wan E.Y.F., Choi E.P.H., Chan K.T.Y., Lam CLK.
Evidence regarding the onset of depressive symptoms in primary care is rarely available but can help inform policy development, service planning, and clinical decision making. The objective of this study was to estimate the 12-month cumulative incidence and predictors of a positive screen for depressive symptoms on the 9-item Patient Health Questionnare-9 (PHQ-9) among primary care patients with no history of physician-diagnosed depression.
We monitored a cohort of 2,929 adult primary care patients with no past history of physician-diagnosed depression and with baseline PHQ-9 scores of 9 or lower by telephone interview at 3, 6, and 12 months. A generalized linear mixed effects Poisson Model was used to explore factors associated with the incidence of PHQ-positive symptoms.
The cumulative incidence of positive screening on the PHQ-9 over 12 months was 5.23% (95% CI, 3.83%-6.64%). Positive predictors included being female, coming from a lower-income household, being a smoker, having at least 2 comorbidities, having a family history of depression, and having consulted a physician at least twice in the past 4 weeks. Consulting a physician with qualifications in both family medicine and psychological medicine was a negative predictor.
The cumulative incidence of PHQ-9–screened depressive symptoms in this study population was higher than those reported for depressive disorders in earlier systematic reviews. Groups who may warrant greater treatment attention include women, patients with multimorbidity, smokers, patients with recent high rates of medical consultations, and those who are from lower-income households or who have a family history of depression. Greater physician training may have a protective effect.
Barriers of Chinese primary care attenders to seeking help for psychological distress in Hong Kong.
Sun KS, Lam TP, Lam KF, Lo TL, Chao DV, Lam EW.
Most of the previous studies on help seeking for psychological distress were derived from Western countries. This study investigated the barriers to help-seeking for psychological distress among Chinese primary care attenders in Hong Kong.
Nine focus groups and 6 individual interviews were conducted among Chinese primary care attenders with/without known distress, patients' significant others and the general public. The identified barriers were investigated in a questionnaire survey with data from 1626 primary care attenders recruited from 13 private clinics and 6 public clinics.
Worries about side effects of drugs (79.9%, 95% CI:(77.9%, 81.8%)) and drug dependency (74.7%, 95% CI:(72.5%, 76.8%)) were rated as the top barriers in the survey. Qualitative interviews found both worries and actual experience of the side effects of drugs, which weakened patients' trust in the treatment. Factor analysis on all barrier items suggested three factors: 1) worries of treatment, 2) uncertainties on primary care physicians' capacity, 3) public's limited knowledge on distress and sources of help. Distress level, education level and age were associated with factor 1, whereas distress level and healthcare setting were associated with the other two factors. Qualitative interviews revealed that not having a regular primary care physician in the public setting discouraged disclosure of psychological problems.
The findings were based on self-reported data from the respondents. Hong Kong is influenced by a mixed Chinese and Western culture.
Relevant public education in a Chinese context should target at reducing patients' worries of drug treatment and strengthening the image of primary care physicians as a feasible source of help.
Obstacles in managing mental health problems for primary care physicians in Hong Kong.
Sun KS, Lam TP, Lam KF, Lo TL.
This study investigated the obstacles for primary care physicians (PCPs) to managing mental health problems in Hong Kong. Focus group data collected from PCPs and psychiatrists were used to construct a questionnaire for a quantitative survey with 516 PCPs respondents. The results showed that their commonly perceived obstacles were lack of timely access to public psychiatrists, lack of feedback from both public and private psychiatrists after referrals; as well as patients’ reluctance to be referred. Factor analysis and correlational analysis found that the numbers of mental health patients treated by the PCPs were mainly determined by the PCPs’ own clinical constraints, including limited confidence in diagnosis and management, time constraint, and limited job satisfaction.
Proposed New Diagnoses of Anxious Depression and Bodily Stress Syndrome in ICD-11-PHC: An International Focus Group Study.
Lam TP, Goldberg DP, Dowell AC, Fortes S, Mbatia JK, Minhas FA, Klinkman MS.
The World Health Organization is revising the primary care classification of mental and behavioural disorders for the International Classification of Diseases (ICD-11-Primary Health Care (PHC)) aiming to reduce the disease burden associated with mental disorders among member countries.
To explore the opinions of primary care professionals on proposed new diagnostic entities in draft ICD-11-PHC, namely anxious depression and bodily stress syndrome (BSS).
Qualitative study with focus groups of primary health-care workers, using standard interview schedule after draft ICD-11-PHC criteria for each proposed entity was introduced to the participants.
Nine focus groups with 4-15 participants each were held at seven locations: Austria, Brazil, Hong Kong, New Zealand, Pakistan, Tanzania and United Kingdom. There was overwhelming support for the inclusion of anxious depression, which was considered to be very common in primary care settings. However, there were concerns about the 2-week duration of symptoms being too short to make a reliable diagnosis. BSS was considered to be a better term than medically unexplained symptoms but there were disagreements about the diagnostic criteria in the number of symptoms required.
Anxious depression is well received by primary care professionals, but BSS requires further modification. International field trials will be held to further test these new diagnoses in draft ICD-11-PHC.
Western mental health training for Traditional Chinese Medicine practitioners.
T. P. Lam, K. Y. Mak, D. Goldberg, K. F. Lam, K. S. Sun.
To investigate the impact of a Western mental health training course for Traditional Chinese Medicine (TCM) practitioners.
A combined qualitative and quantitative approach was applied to examine the changes in the TCM practitioners’ clinical practice characteristics and attitudes. Focus groups and structured questionnaire surveys were conducted to compare their responses before and after the Course.
After a 10‐week training course conducted by psychiatrists and family physicians, there were significant changes in confidence of the TCM practitioners for diagnosis (33% being confident before the Course vs. 76% after the Course) and management (24% vs. 55%) of common mental health problems. The causal effects of better classifications to recognition of mental health problems were explained by the qualitative responses. Proportion of TCM practitioners being confident of referring mental health patients to other healthcare professionals doubled from 25% to 50% after the Course. Nonetheless, there was no significant change in percentage of these patients being recommended to Western doctors owing to a lack of formal referral channel.
Western mental health training for TCM practitioners has positive impact on their clinical practice. However, the practical barriers in making referrals highlight the need of closer collaboration between conventional and traditional medicine.
Brief Problem-solving treatment in Primary Care (PST-PC) was not more effective than placebo for elderly patients screened - positive of psychological problems.
Lam C.L.K., Fong D.,Y.T Chin W.Y. Lee, P.W.H., Lam E.T.P., Lo Y.Y.C.
To evaluate whether screening followed by brief problem‐solving treatment by primary care doctors (PST‐PC) could improve health‐related quality of life (HRQOL) and reduce consultation rates in the elderly.
A single‐blind randomized placebo controlled trial (RCT).
Two government funded primary care clinics in Hong Kong.
Two hundred and ninety nine Chinese patients aged 60 years or over, with positive screening scores for psychological problems by the Hospital Anxiety and Depression Scale (HADS).
One hundred and forty nine subjects were randomized to receive brief PST‐PC from primary care doctors (treatment) and 150 to group video‐viewing (placebo). All subjects were followed up by telephone at 6, 12, 26 and 52 weeks.
Main Outcome Measures:
Changes in SF‐36 HRQOL scores, HADS scores and monthly consultation rates were compared within and between groups.
Study completion rates were 69–71%. There was significant improvement in the SF‐36 role‐emotional (RE) and mental component summary (MCS) scores at week 6 in the PST‐PC group but not in the placebo group. Several SF‐36 scores improved significantly in the placebo (video) group at week 6–52. Mixed effects analysis adjusting for baseline values and cofounders did not show any difference in any of the outcomes between the PST‐PC and placebo (video) groups.
Screening followed by brief PST‐PC was associated with a short‐term improvement in HRQOL in Chinese elderly patients screened positive of psychological problems, but the HRQOL benefit was not greater than those found in the placebo group who participated in group‐viewings of health education videos. Copyright © 2009 John Wiley & Sons, Ltd.
Unrecognised psychological problems impair quality of life and increase consultation rates in Chinese elderly patients
Cindy L. K. Lam, Weng Yee Chin, Peter W. H. Lee, Yvonne Y. C. Lo, Daniel Y. T. Fong, Tai Pong Lam
Studies have shown that psychological problems in elderly patients are often unrecognised in primary care. The aim of this study was to investigate the quality of life and consultation rates of Chinese elderly patients with unrecognised psychological problems in primary care. The prevalence and risk factors of unrecognised psychological problems were also determined.
A cross‐sectional study on consecutive patients aged ≥60 with no known psychological diseases were screened by the Hospital Anxiety and Depression Scale (HADS) when they consulted at two primary care clinics in Hong Kong. Data on socio‐demographic characteristics, chronic morbidity, consultation rates, and health‐related quality of life (HROQL) were collected. Multivariable regressions were used to determine the effect of a positive HADS score on HRQOL scores and consultation rates, and the risk factors of unrecognised psychological problems.
One thousand eight hundred and fifty‐four subjects (mean age 72.6 years and 52% male) were screened and the estimated prevalence of unrecognised psychological diseases was 23% (95% CI = 13.1–33.8%). A positive screening result was associated with poorer SF‐36 HROQL scores and higher episodic consultation rates. An increased risk of unrecognised psychological problems was associated with the presence of more than two chronic diseases. Other risk factors included female gender, no formal education and having chronic pulmonary disease or heart disease. Living with a spouse increased the risk in elderly women.
Unrecognised psychological problems are common in Chinese elderly patients in primary care. They are clinically important because they impair quality of life and increase the utilization of consultations. Copyright © 2009 John Wiley & Sons, Ltd.
Can the Hospital Anxiety and Depression (HAD) Scale be used on Chinese in general practice?
Cindy LK Lam, Pey-Chyou Pan, Aylwin WT Chan, Sai-Yin Chan, Clarke Munro
A study was carried out in a general practice in Hong Kong to find out if the Hospital Anxiety and Depression (HAD) Scale could be used to detect psychological problems in Chinese elderly. The HAD Scale was translated into Cantonese and administered by an interviewer to 298 Chinese aged 60 or above before their doctor consultations. The acceptance rate of the Scale was 96% and each interview took only 5–10 min to complete. All 298 elderly understood and completed the HAD Scale. Validation of the results of the HAD Scale by the Clinical Interview Schedule (CIS) was done on a random sample of 100 elderly. Relative operating characteristic (ROC) analysis showed that the optimal cut-off points of the HAD Scale was a depression score of 6 and an anxiety score of 3. The sensitivity was 80%, specificity was 90%, OMR (overall misclassification rate) was 12%, positive predictive value was 67% and negative predictive value was 95%. Thirty-six per cent of the elderly had scores above these cut-off points. More females than males had high anxiety scores. Nearly half of those with positive HAD scores were not known to have any psychological illness. The HAD Scale has great potential to be used as a screening instrument for psychological illnesses in Cantonese-speaking Chinese elderly all over the world.
Past research projects
- The epidemiology and natural history of depressive disorders in primary care. PI: Weng-Yee Chin, 2010-2013, Commissioned Research on Mental Health Policy and Services (HK$1,399,186, May 1, 2010).
- In-depth exploration of a bidirectional parent-child health relationship and its mediating and moderating factors among low-income families in Hong Kong. PI: Esther Yee-tak Yu, 2017-2019, Health and Medical Research Fund (#14151571, HK$1,183,868).
- A randomised controlled trial on the effectiveness of screening and brief counselling for elderly patients with undiagnosed psychological problems in primary care. PI: Cindy L. K. Lam, 2002-2004, Health Care & Promotion Fund # 218016 ($806,990, 02-07-2002).
- What are the enablers and barriers of help-seeking among the psychologically distressed in primary care setting? - Promoting mental well-being in Hong Kong. PI: Tai Pong Lam, 2013-2014, Health and Medical Research Fund - Full Grant. Amount awarded: HKD$602,400.
- Depression and Anxiety in Global Primary Care Settings - A Field Study for the ICD-11-PHC. PI: Tai Pong LAM, 2014-2015. Small Project Funding. Amount awarded: HK$63,957.
- E-health Mobile Application to Improve Testing and Control of Sexually Transmitted Infections Amongst Hong Kong’s Youth: A Randomised Controlled Trial.. PI: Wong, WCW, 2018-2018, Seed Fund for Basic Research for Resubmission of GRF/ECS Proposals >3.5, HK$56,000.
- What are the facilitators and obstacles to promote mental health help-seeking in primary care? – views of family physicians and psychiatrists. PI: Tai Pong LAM, 2011-2012. Small Project Funding. Amount awarded: HK$50,411.
- Self-reported health, health service utilization, mental health status, and sleeping quality: Results from Population Health Survey 2014/15. PI: Cindy L. K. Lam, 2018-2019, Unfunded.
- Exploring the views of hospital outpatients about the impact of dementia in Hong Kong. PI: Tai Pong Lam, 2018-2019.
- Moral distress in medical students: A qualitative analysis of ethical issues identified in the clinical clerkships. PI: Weng-Yee Chin, 2017-2018, unfunded.
- Psychometric properties of the Copenhagen Burnout Inventory in Hong Kong doctors. PI: Weng-Yee Chin, 2017-2019, unfunded.
Exploring the views of hospital outpatients about the impact of dementia in Hong Kong
KF Lam, PL Ho
Lau CS, Sanson-Fisher R
Years of study:
The increasing prevalence of dementia has become a public health issue worldwide including China. As a consequence of the staggering ageing rate, dementia will inevitably put a heavy burden on the social and healthcare system in Hong Kong. There is growing awareness for the need to raise public literacy and to plan effective service deliveries in this respect. This study aims to explore the perception of Chinese in Hong Kong towards the diagnosis, symptoms and impacts of dementia. This is an international collaborative study with Priority Research Centre for Health Behavior, University of Newcastle, Australia. Our findings will be compared with that of Australia and other countries.