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School-based programs are recommended by the World Health Organization (WHO) to promote mental health for young people. However the effectiveness of such programs varies, and there are multi-level challenges to embedding mental health education in schools. Further, critical scholarship has focused on the ways in which such programs can contribute to neoliberal goals, rather than empowering students meaningfully. Our research used focus group interviews to capture the perspectives and experiences of teachers and children participating in a school-based program in Hong Kong. We applied Bernstein's theory of pedagogic practices to analyze the interview data, in particular the concepts of boundaries and framing. We identified rigid boundaries between classrooms, the wider school, and home. Boundaries between academic and wider learning, and between school leaders and teachers, hindered cultural change towards mental wellbeing in schools. The program in this study reduced boundaries between students, and between students and teachers. This enhanced students' communication, and bonding with peers and teachers. School culture about mental health education was found to have weak framing, with students having more influence on the learning process in this program than they currently do in other subjects. We argue that understanding boundaries and framing underpins development of better pedagogic practices in mental health education. When rooted in careful analysis of power relationships with school cultures, mental health promotion is not necessarily aligned with dominant values in society that privilege academic success over wellbeing. School-based programs can provide co-learning spaces for teachers and students, that encourage learning about mental health. [ABSTRACT FROM AUTHOR]

Background: Suicide is one of the leading causes of death in children and youth. Using a sample of fatal suicides among school-aged students in Hong Kong, this study aimed to demonstrate how the classification of children and adolescent suicides into distinct subgroups using cluster analysis can alert us to the heterogeneous nature of the student suicide population and increase our understanding of multidimensional underlying causes.  METHODS: Deaths by suicide of Hong Kong primary and secondary school students occurring between 2013-16 were identified. Reports were acquired from the Coroner's Court, Police Force, and Education Bureau in Hong Kong. Information about students' sociodemographic characteristics, suicide circumstances, stressors, and risk factors was extracted and organized for analysis. Based on the indicated stressors (school, family, close relationship, social challenge, finance, risk behaviour, suicide exposure, others) and risk factors (health and mental health, history of self-harm, suicidality, and psychological maladjustment), cluster analysis was conducted to derive distinct profiles of student suicides.Results: A four-cluster solution was found. Patterns of stressors, risk factors, background characteristics and suicide circumstances within each cluster were examined. Four distinct and meaningful profiles of student suicides were characterised as "school distress", "hidden", "family and relationship", and "numerous issues".Conclusions: Findings highlighted the need to approach student suicides in meaningfully differentiated ways. Gathering suicide report data and generating evidence that advances our knowledge of student suicide profiles are important steps towards early identification and intervention. [ABSTRACT FROM AUTHOR]

The Chinese Health Questionnaire (CHQ) is a 12-item assessment tool of psychological distress. The present study systematically evaluated the psychometric properties of the CHQ in a large sample of 1968 young people in Hong Kong. The participants completed the CHQ online in 2018 and 869 of them completed a follow-up survey on the CHQ, suicidal ideation, hikikomori, and help-seeking in 2019. Dimensionality of the CHQ was assessed via confirmatory factor analysis using the robust weighted least square estimator in 2018 and 2019. Measurement invariance was investigated across gender, age groups, and time between 2018 and 2019. Convergent validity of the CHQ factors were evaluated with respect to the mental health outcomes in the multiple indicators and multiple causes (MIMIC) approach. Confirmatory factor analyses shortened the CHQ into 10 items and revealed a superior fit for the bifactor model with a general factor and two specific factors on somatic and depressive symptoms in both 2018 and 2019. The general factor demonstrated substantial factor loadings (λ = 0.58–0.91), good reliability (ΩH = 0.85), and temporal stability (r = 0.62), and scalar measurement invariance across gender, age groups, and time. The general factor was significantly and positively associated with suicidal ideation, hikikomori, and help-seeking. The two specific factors displayed lower factor loadings, reliability, temporal stability, and weaker associations with the mental health outcomes. The present findings lend support to a valid and stable bifactor structure with a strong general factor for the CHQ-10 among young people in Hong Kong. Public Significance Statement: The 10-item Chinese Health Questionnaire (CHQ) showed a bifactor structure with a strong general factor and 2 weak specific factors in young people in Hong Kong. The CHQ-10 demonstrates satisfactory reliability, measurement stability across gender, age groups, and time across 2018 and 2019, and good convergent validity with suicidal ideation, hikikomori, and help-seeking. [ABSTRACT FROM AUTHOR]

BACKGROUND Research suggests that a whole‐school approach to mental health promotion can be more effective than a compartmentalized approach. In particular, student‐led initiatives have demonstrated a positive impact on students' mental health, though not without systemic and individual barriers. Factors that lead to successful implementation and sustaining of student‐led initiatives are currently not well understood. METHODS: A case study is presented to demonstrate how a student‐led intervention came about, inspired changes in the school organization and members, and transformed the school's approach to mental health promotion. Analysis of in‐depth interviews with student leaders and adult advisors was informed by theories of innovation diffusion and human motivation. RESULTS: Key factors and mechanisms of change were identified for the initiation, transformation, and institutionalization stages of the student‐led initiative. Changes in students' identity and adult advisors' mindset were found to be integral to the successful conversion to a whole‐school approach in mental health promotion. CONCLUSIONS: This study confirms the value of mobilizing the student body as an active resource in promoting mental health in school and the importance of input from school management, advisors, and intervention expert. Recommendations on how to implement a student‐led initiative and sustain the positive changes are given. [ABSTRACT FROM AUTHOR]

Objective: Cancer patients have elevated suicide risk compared to the general population. However, little is known about the characteristics of cancer patients who have died by suicide. The objectives of the study were to compare the characteristics of suicide cases with, and without cancer, and determine whether age was associated with differences in characteristics. Methods: A total of 14,446 suicide cases between 2003 and 2017 in Hong Kong were identified using Coroner's Court reports. Cases were grouped by cancer status, based on medical history in the reports. Information extracted from the reports included sociodemographic variables and detailed descriptions of the suicide event. Univariate analyses and overall and subgroup multiple logistic regressions were performed to compare characteristics between the two groups. Results: Of the 14,446 suicide cases, 1,461 (10.11%) had a cancer history. Compared to noncancer cases, cancer patients were generally older and less likely to live alone; more likely to use violent methods; less likely to have histories of physical and psychiatric problems; and more likely to communicate about their suicidal intent before death. Age was significantly associated with differences between cancer and noncancer cases. Conclusions: Cancer suicide cases have different characteristics from noncancer cases. Mental health screening may not be sufficient for suicide prevention among cancer patients. Healthcare professionals and caregivers should be aware of cancer patients' suicide risk, even when there are no signs of psychiatric disturbance. [ABSTRACT FROM AUTHOR]

Background: Transgender, including gender diverse and non-binary people, henceforth referred to collectively as trans people, are a highly marginalised population with alarming rates of suicidal ideation, attempted suicide and self-harm. We aimed to understand the risk and protective factors of a lifetime history of attempted suicide in a community sample of Australian trans adults to guide better mental health support and suicide prevention strategies. Methods: Using a non-probability snowball sampling approach, a total of 928 trans adults completed a cross-sectional online survey between September 2017 and January 2018. The survey assessed demographic data, mental health morbidity, a lifetime history of intentional self-harm and attempted suicide, experiences of discrimination, experiences of assault, access to gender affirming healthcare and access to trans peer support groups. Logistic regression was used to examine the risk or protective effect of participant characteristics on the odds of suicide. Results: Of 928 participants, 85% self-reported a lifetime diagnosis of depression, 63% reported previous self-harm, and 43% had attempted suicide. Higher odds of reporting a lifetime history of suicide attempts were found in people who were; unemployed (adjusted odds ratio (aOR) 1.55 (1.05, 2.29), p = 0.03), had a diagnosis of depression (aOR 3.70 (2.51, 5.45), p < 0.001), desired gender affirming surgery in the future (aOR 1.73 (1.14, 2.61), p = 0.01), had experienced physical assault (aOR 2.01 (1.37, 2.95), p < 0.001) or experienced institutional discrimination related to their trans status (aOR 1.59 (1.14, 2.23), p = 0.007). Conclusion: Suicidality is associated with barriers to gender affirming care, gender based victimisation and institutionalised cissexism. Interventions to increase social inclusion, reduce transphobia and enable timely access to gender affirming care, particularly surgical interventions, are potential areas of intervention. [ABSTRACT FROM AUTHOR]

Intimate partner violence is an important public health issue affecting the well-being of the young adults. However, there is little epidemiological evidence on the incidence and associated mental health problems of both intimate partner violence perpetration and victimization in Chinese context. Using one representative community sample of 1,227 young adults aged 18-27 years in 2016, this study aimed to examine the prevalence, sociodemographic characteristics, and possible mental health consequences of intimate partner violence among young adults in Hong Kong. It is found that the prevalence of preceding 1-year intimate partner violence perpetration and victimization was 5.3% and 9.1% respectively. The perpetrators were worse educated, unemployed, and married, while the victims were also unemployed and cohabited. Compared with those without involving in any intimate partner violence, perpetrators of intimate partner violence were more likely to engage in frequent smoking and alcohol use, and victims of intimate partner violence reported lower life satisfaction, more self-harm behaviors, higher suicide ideation and attempt, and heavy alcohol use. Both perpetrators and victims were more likely to report the worst mental health problems and high risky behaviors. [ABSTRACT FROM AUTHOR]

Purpose: In global forensic practice, some suicides were misclassified as undetermined deaths, leading to suicide underreporting. In this study, we aimed to explore the influence of undetermined deaths on suicides in Shanghai, China.Methods: The police records on suicide verdicts and undetermined deaths in Pudong, Shanghai, from 2004 to 2016 were used. In this study, undetermined deaths have been classified into three levels of suicide possibilities namely, probable, possible, and highly unlikely. Probable suicides were presumed as misclassified suicides. Poisson regression was used to calculate the rate ratio ("RR") of probable suicides compared to suicide verdicts. Poisson regression was also used to calculate the annual percentage change ("APC") of the original suicide rates (crude suicide rates based on the suicide verdicts) and adjusted suicide rates (crude suicide rates based on the suicide verdicts and probable suicides).Results: Among the 1,318 underdetermine deaths, 560 (42.5%) were classified as probable suicides. The overall RR was 0.23 (95% CI 0.21-0.26): 0.15 (0.13-0.17) for the locals' RR and 0.22 (0.19-0.26) for the migrants' RR. The APCs of the original and adjusted suicide rates were - 2.0 (- 3.1 to - 0.9) and - 2.9 (- 3.8 to - 2.0), respectively, for the overall population.Conclusions: The number of suicides could be 23% higher than the reported cases. Suicides were more likely to be underreported in migrants than in the locals. Thus, it is important to improve suicide monitoring and the surveillance systems in China. [ABSTRACT FROM AUTHOR]

Background: This paper is to examine the associations between religion, bereavement and depression among nursing professionals using a cross-sectional survey design. There is little empirical evidence in Asia suggesting that religion may either increase or lower the likelihood of nursing professionals being depressed. Methods: We analyzed the results of a Mental Health Survey soliciting data from 850 Hong Kong nurses (aged 21-59, 178 males) regarding their mental well-being and associated factors, including participants' socio-economic profile and recent life-events. Multiple linear regression analyses examined associations between religion, bereavement and depression. Results: Religious faith is weakly associated with lower self-reported depression in bereavement. Conclusions: Our findings confirm those studies suggesting that religion positively affects mental health and yet healthcare providers have yet to assimilate this insight. [ABSTRACT FROM AUTHOR]

Background: There has been little previous research on self-harm among people of Chinese origin living in the UK, although this population has grown substantially in recent years and China is now the largest source of international students at UK universities. Methods: We conducted a prospective cohort study using self-harm presentation data (1997-2011) collected from three hospitals in the City of Manchester, which has the largest Chinese population across all UK Local Authorities. Rate ratios between the Chinese and White groups were calculated using Poisson regression models. Chi-square tests (or Fisher's exact tests), logistic regression, and log-binomial regression were used to examine differences in characteristics and clinical management between groups. Results: Ethnicity was known in the study cohort for 23,297 (87%) amongst 26,894 individuals aged 15 years and above. A total number of 97/23,297 (0.4%) people of Chinese ethnic origin presented with self-harm over the study period and 20,419 (88%) were White people. Incidence of self-harm in the Chinese group (aged 16-64 years) was less than one fifth of that found in White people (0.6 versus 3.2 per 1000 person-years; rate ratio 0.18, 95% confidence interval 0.13-0.24), and was particularly low amongst men of Chinese origin. Individuals of Chinese origin who presented with self-harm were younger, more likely to be female and students, and more likely to self-injure and describe relationship problems as a precipitant than White people. They were less likely to have clinical risk factors such as drug/alcohol misuse and receiving psychiatric treatment, and were rated to have lower risk of self-harm repetition by treating clinicians. Conclusion: Future research needs to investigate whether the low incidence of self-harm presenting to hospitals amongst people of Chinese origin truly reflects a lower frequency of self-harm, or alternatively is due to markedly different post-episode help-seeking behaviours or student overrepresentation in this ethnic group. Relevant healthcare professionals need to be aware of the risk characteristics of people of Chinese origin who self-harm. [ABSTRACT FROM AUTHOR]

Background: There has been a dramatic increase in internal migrant workers in China over recent decades, and there is a recent concern of poor mental health particularly amongst younger or "new generation" migrants who were born in 1980 or later.Methods: A cross-sectional study was conducted in Guangzhou city between May and July in 2012. Mental wellbeing was measured using the World Health Organization Five-item Well-Being Index Scale and the 36 Item Short Form Health Survey mental health scale. Linear and logistic regression models were used to investigate the differences between migrant workers and their urban counterparts and between younger and older migrants.Results: Migrant workers (n = 914) showed a small but significant advantage in mental wellbeing compared to their urban counterparts (n = 814). There was some evidence for age modification effect (p for interaction = 0.055-0.095); better mental wellbeing in migrants than urbanites were mainly seen in the older compared to the younger group, and the difference attenuated somewhat after controlling for income satisfaction. Older migrants showed better mental health than younger migrants. Factors that were independently associated with poor mental health in migrants included being male, longer working hours, and income dissatisfaction, whilst older age, factory job, high income, and increased use of social support resources were associated with reduced risk.Conclusions: Efforts to promote mental health amongst migrant workers may be usefully targeted on younger migrants and include measures aimed to improve working conditions, strengthen the social support network, and address age-specific needs. [ABSTRACT FROM AUTHOR]

Background Repeat self-harm is an important risk factor for suicide. Few studies have explored risk factors for non-fatal repeat self-harm in Asia. Aims To investigate the risk of non-fatal repeat self-harm in a large cohort of patients presenting to hospital in Taipei City, Taiwan. Method Prospective cohort study of 7601 patients with self-harm presenting to emergency departments (January 2004-December 2006). Survival analysis was used to examine the rates, timing and factors associated with repeat self-harm. Results In total 778 (10.2%) patients presented to hospital with one or more further episodes of self-harm. The cumulative risk of non-fatal repetition within 1 year of a self-harm episode was 9.3% (95% CI 8.7-10.1). The median time to repetition within 1 year was 105 days. Females had a higher incidence of repeat self-harm than males (adjusted hazard ratio 1.25, 95% CI 1.05-1.48) but males had shorter median time to repetition (107 v. 80 days). Other independent risk factors for repeat self-harm within 1 year of an index episode were: young age, self-harm by medicine overdose and increasing number of repeat episodes of self-harm. Conclusions The risk of non-fatal repeat self-harm in Taipei City is lower than that seen in the West. Risk factors for repeat non-fatal self-harm differ from those for fatal self-harm. The first 3 months after self-harm is a crucial period for intervention. Declaration of interest None. [ABSTRACT FROM AUTHOR]

Background: Considerable attention has been focused on the study of suicides among those who have received help from healthcare providers. However, little is known about the profiles of suicide deceased who had psychiatric illnesses but made no contact with psychiatric services prior to their death. Behavioural model of health service use is applied to identify factors associated with the utilization of psychiatric service among the suicide deceased. Methods: With respect to completed suicide cases, who were diagnosed with a mental disorder, a comparison study was made between those who had (contact group; n = 52; 43.7%) and those who had not made any contact (non-contact group; n = 67; 56.3%) with a psychiatrist during the final six months prior to death. A sample of 119 deceased cases aged between 15 and 59 with at least one psychiatric diagnosis assessed by the Structured Clinical Interview for DSM-IV-TR (SCID I) were selected from a psychological autopsy study in Hong Kong. Results: The contact and non-contact group could be well distinguished from each other by "predisposing" variables: age group & gender, and most of the "enabling", and "need" variables tested in this study. Multiple logistic regression analysis has found four factors are statistically significantly associated with non-contact suicide deceased: (i) having non-psychotic disorders (OR = 13.5, 95% CI:2.9-62.9), (ii) unmanageable debts (OR = 10.5, CI:2.4-45.3), (iii) being full/partially/self employed at the time of death (OR = 10.0, CI:1.6-64.1) and (iv) having higher levels of social problem-solving ability (SPSI) (OR = 2.0, CI:1.1-3.6). Conclusion: The non-contact group was clearly different from the contact group and actually comprised a larger proportion of the suicide population that they could hardly be reached by usual individual-based suicide prevention efforts. For this reason, both universal and strategic suicide prevention measures need to be developed specifically in non-medical settings to reach out to this non-contact group in order to achieve better suicide prevention results. [ABSTRACT FROM AUTHOR]

Gender ratios of suicide rates differ greatly across countries. Victoria has a high male:female ratio in suicide that is typical in English-speaking and European countries, while in Hong Kong the low ratio is similar to other SouthEast Asian countries. This study investigates the effect of gender in the psychiatric and non-psychiatric populations to examine how psychiatric history may modulate the effect of gender in these two different communities. Review of coronial documentation of all suicide cases in 2000 in Hong Kong and Victoria, Australia. Log-linear model was used to test the gender-psychiatric history-location interaction. Gender difference in suicide was narrower in victims with psychiatric history than those without in both communities, albeit gender remained to have an effect even among those with a psychiatric history in Victoria. The impact of cultural- and gender-specific factors is most apparent in suicide cases with no prior psychiatric history in Victoria: the male:female ratio was as high as 8:1 in this group of victims. Log-linear model results show that the gender-psychiatric history-location interaction was statistically significant. The gender differentials in suicide rates in these two communities are mainly driven by gender’s effect in the population with no psychiatric history. Severe clinical conditions can override some, but not all, of gender’s effects in Victoria. Suicide prevention effort should target gender-specific factors to prevent suicides in men without history of psychiatric disorders. [ABSTRACT FROM AUTHOR]

Objective: With its anonymity and accessibility, text-based online counseling has shown great potential in reaching people with mental health needs. One strategy adopted to meet the service gap is concurrent counseling, that is, each counselor attending to more than one client at a time. To date, there is no reported evidence supporting its rationality and effectiveness. This study investigated the potential opportunities, effectiveness, and caveats in concurrent service delivery and identified the optimal cutoff number of concurrent sessions while maintaining the quality of service at or above a set threshold. Method: We analyzed the transcript of 54,716 online counseling sessions from Open Up, a free, 24/7 text-based counseling service, to develop an attention score that measures the attention allocation of counselors and examined the impact of the counselor's attention allocation on client satisfaction and service outcomes. Results: On average, compared to nonconcurrent sessions, concurrent sessions were longer, more likely to end prematurely, and had lower client satisfaction. We also identified an optimal attention score of approximately 0.4 (out of 1.0, which denotes full attention), which translates to two to three concurrent sessions. Conclusions: This study provides empirical evidence for the feasibility of conducting multiple text-based sessions concurrently without compromising service quality and client experience. Our method of measuring the counselor attention allocation offers a way to systematically assess and evaluate concurrent sessions. What is the public health significance of this article?: The rapid increase in the availability of online counseling services continues to be outpaced by the growth in their demand. This study is the first to provide evidence for the possibility and effectiveness of concurrent counseling, that is, treating more than one client at a time. It highlights the feasibility of reaching more people with psychological distress without substantially sacrificing the service quality. The resulting attention score calculation is potentially relevant to a wide range of contexts. [ABSTRACT FROM AUTHOR]