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BackgroundLittle is known about the effects of physical exercise on sleep-dependent consolidation of procedural memory in individuals with schizophrenia. We conducted a randomized controlled trial (RCT) to assess the effectiveness of physical exercise in improving this cognitive function in schizophrenia.MethodsA three-arm parallel open-labeled RCT took place in a university hospital. Participants were randomized and allocated into either the high-intensity-interval-training group (HIIT), aerobic-endurance exercise group (AE), or psychoeducation group for 12 weeks, with three sessions per week. Seventy-nine individuals with schizophrenia spectrum disorder were contacted and screened for their eligibility. A total of 51 were successfully recruited in the study. The primary outcome was sleep-dependent procedural memory consolidation performance as measured by the finger-tapping motor sequence task (MST). Assessments were conducted during baseline and follow-up on week 12.ResultsThe MST performance scored significantly higher in the HIIT (n = 17) compared to the psychoeducation group (n = 18) after the week 12 intervention (p < 0.001). The performance differences between the AE (n = 16) and the psychoeducation (p = 0.057), and between the AE and the HIIT (p = 0.999) were not significant. Yet, both HIIT (p < 0.0001) and AE (p < 0.05) showed significant within-group post-intervention improvement.ConclusionsOur results show that HIIT and AE were effective at reverting the defective sleep-dependent procedural memory consolidation in individuals with schizophrenia. Moreover, HIIT had a more distinctive effect compared to the control group. These findings suggest that HIIT may be a more effective treatment to improve sleep-dependent memory functions in individuals with schizophrenia than AE alone.

Background Psychotic disorders are associated with a high rate of relapse. In addition to medication non-adherence, some psychosocial factors have been found to be predictive of relapse (e.g., poor premorbid adjustment, high expressed emotion and substance misuse). Impairments in cognitive functions including general memory functioning, set shifting, attention, processing speed and working memory have also been indicative of a subsequent psychotic episode. As clinical appointments do not always allow for timely or accurate detection of these early warning signs, the ReMind app is developed to explore potential relapse predictors and enhance the process of relapse monitoring. Aim The ReMind app aims (1) to assess whether verbal or visual working memory predicts psychotic relapse in 1 year and (2) to determine whether social factors such as stressful life events, level of expressed emotion and medication adherence also predict relapse in 1 year. Methods This is a one-year prospective follow-up study involving 176 remitted patients diagnosed with schizophrenia or non-affective psychoses. Monthly relapse predictor assessments will be conducted via ReMind throughout the one-year study duration. These assessments include neurocognitive tasks and psychosocial questionnaires. Results Recruitment began in August 2017 and is still ongoing. Preliminary user feedback suggested an overall positive experience with the app. Conclusion The ReMind app presents a step forward to the identification and sensitive detection of reliable psychosis relapse predictors. With its anticipated success, it may offer an alternative means of monitoring relapse for the Chinese-speaking population in the future.

Aim Psychiatric comorbidity frequently occurs with at-risk mental state (ARMS) for psychosis. Its relationships with psychopathology, cognition and functioning, however, remain to be further clarified. We aimed to examine prevalence and correlates of psychiatric comorbidity, and its associations with psychosocial functioning and subjective quality-of-life (QoL) in a representative sample of Chinese ARMS individuals. Methods One hundred ten help-seeking participants aged 15 to 40 years with ARMS were recruited from a specialized early psychosis service in Hong Kong. ARMS status was verified by comprehensive assessment of at-risk mental state (CAARMS). Comorbid Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition non-psychotic psychiatric disorders at baseline were ascertained using diagnostic interview and medical record review. Assessments encompassing symptom profiles, psychosocial functioning, subjective QoL and a brief cognitive battery were conducted. Results Forty-nine (44.5%) ARMS participants were diagnosed as having comorbid non-psychotic psychiatric disorders at baseline, primarily depressive and anxiety disorders. Binary multiple logistic regression analysis revealed that female gender, more severe depressive symptoms, higher suicidality and poorer global cognitive functioning were independently associated with comorbid diagnosis status. ARMS participants with psychiatric comorbidity displayed significantly more limited extended social networks and poorer subjective QoL than those without psychiatric comorbidity. Conclusion Comorbid disorders were frequently observed in Chinese ARMS individuals, and were linked to poorer cognition and higher suicide risk. Our findings underscore a potential critical role of psychiatric comorbidity in determining social functioning and subjective QoL in at-risk individuals. Further longitudinal research is required to clarify trajectories of comorbid disorder status and its prospective impact on clinical and functional outcomes in ARMS populations.

Achieving functional recovery in patients with psychosis is a challenge in clinical practice. Investigating the complex interplay between cognition, symptoms, insight and functional outcome in first episode psychosis will be crucial to understanding the factors leading to better functioning.In this 12-month prospective follow-up study, we investigated how cognition, clinical symptoms, and insight into illness affected overall functioning in 160 patients with first episode psychosis recruited from the Early Assessment Service for Young People with Psychosis (EASY) in Hong Kong from July 1, 2014 to June 30, 2016. Cognition was assessed at baseline while symptoms, insight, and functioning were assessed at 12-month follow-up. Structural equation modelling was used to examine the direct and indirect relationships between functioning and other latent constructs.Symptoms (negative symptoms and general psychopathology) and insight were shown to be significant mediators between cognition and functioning. The significant direct relationship between cognition and functioning (β = 0.387; p 0.001) became insignificant (β = 0.079; p = 0.578) after including symptoms and insight in the model. Symptoms and insight were significantly associated with cognition (symptoms, β = -0.469; p 0.001; insight, β = -0.372; p 0.001) and predicted functioning (symptoms, β = -0.558; p 0.001; insight, β = -0.264; p 0.01).Symptoms and insight mediated the effects of cognition on functioning. Interventions for improving functioning in patients with first episode psychosis should target not only cognition but also symptoms and insight.

Recent research on second‐generation long‐acting injectable antipsychotics (LAI SGAs) has proven its effectiveness in minimizing medication nonadherence problem and reducing relapses. Administered by medical professionals, making quick detection of nonadherence possible, long‐acting injectable antipsychotics (LAIs) facilitate immediate intervention and recovery process, and thus are favored by psychiatrists. Despite a higher initial cost with LAIs, the subsequent schizophrenia‐related health costs for hospitalizations and outpatients are greatly reduced. With reference to guidelines published by psychiatric associations around the globe, this article looks at scenarios in Hong Kong on the management of severe mentally ill patients with regard to the use of a host of psychosocial interventions as well as LAI SGAs as a preferable treatment. In particular, it examines the benefits of using LAI SGAs for Hong Kong patients who demonstrated high nonadherence treatment rates due to their social environment. It assesses the rationale behind the early usages of LAI SGAs, which help to provide better recovery outcomes for patients.

Very few data are available to demonstrate the economic benefit of early paliperidone palmitate once-monthly long-acting injectable (PP1M) treatment in patients with schizophrenia or schizoaffective disorder.This study has retrospectively compared the healthcare utilization and associated costs of pre- and post-PPIM treatment in 413 patients with schizophrenia or schizoaffective disorder recruited from three major public hospitals providing psychiatric services in Hong Kong. Patients were categorized into early treatment (≤3 years since diagnosis) and chronic (3 years) groups, and also whether they were receiving polypharmacy (POP).It was found that patients who were started on early therapy with no POP had the most favourable outcomes. Overall results of the entire cohort, including both early and late treatments, indicate that there was a slight increase in annual in-patient days (IP) per patient and outpatient visit (OP) by 3.18 and 1.87, respectively, and a decrease in emergency room visit (ER) of 0.9 (p 0.05). For non-polypharmacy (NP) patients receiving early PP1M therapy, there was a significant decrease in IP and ER of 21.56 (p 0.05) and 1.15 (p 0.05), respectively, but an increase in OP of 1.88 (p 0.05). For patients with POP, there was an all-across increase in IP and all-across decrease in OP and ER. In monetary terms, a NP patient receiving early therapy may have an overall saving of HKD40,878 (USD5,241, 1USD = 7.8HKD) per year compared to HKD6,224 (USD798) in patients where therapy was given after 3 years. For patients with POP, there was an all-across increase in overall spending despite reductions in OP and ER.From the 413 patients studied, potential annual savings is higher by early administration of PPIM in patients with NP. Analysis using multivariate linear regression based on generalized estimating equations and sensitivity analysis using a linear mixed model supported the findings.

BackgroundWhile qualitative studies suggested that continuity of care by primary care physicians (PCPs) facilitated consultations for psychological problems, there was limited quantitative evidence. This survey compared management of psychological distress between patients with and without a regular PCP.MethodsA questionnaire survey was conducted with 1626 adult primary care attenders from 13 private and 6 public clinics in Hong Kong. Management of psychological distress between respondents with a regular PCP and those without were compared. Effects of demographic factors were adjusted for by multivariable logistic regression.ResultsAmong the 1626 respondents, 650 (40.0%) reported that they had ever experienced psychological distress. Of the 650 respondents experienced distress, 307 (47.2%) had a regular PCP. A significantly higher proportion of patients with a regular PCP than those without reported: (i) their PCPs sometimes/often asked about psychological problems [37.7 versus 20.1%, adjusted OR = 2.241]; (ii) they sometimes/often mentioned their psychological problems to PCPs [45.2 versus 24.9%, adjusted OR = 2.503]; and (iii) their distress had been treated by PCPs [22.1 versus 13.4%, adjusted OR = 1.702].ConclusionPatients with a regular PCP have around double odds of receiving mental health care. Continuity of care by PCPs should be emphasized in mental health care delivery.

BACKGROUND To explore the prevalence and clinicians' awareness of psychiatric comorbidities, and to identify factors associated with current psychiatric comorbidities in first-episode schizophrenia (FES) patients. METHOD In this cross-sectional study, 128 patients with FES, who were in symptomatic remission, were consecutively recruited from a local early intervention clinic. All patients were interviewed using the Chinese bilingual version of the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Axis I Disorders, Positive and Negative Syndrome Scales, Scale to Assess Unawareness of Mental Disorder, Social and Occupational Functioning Assessment Scale, Simpson-Angus Scale, Barnes Akathisia Rating Scale and Abnormal Involuntary Movement Scale. Bivariate and multivariate analyses were performed to investigate factors associated with psychiatric comorbidities in FES patients. RESULTS The lifetime and point prevalence of psychiatric comorbidities among FES patients were 47.7% and 27.3%, respectively. Current psychiatric comorbidities were documented on the medical records of 39.3% of the patients. The FES patients with current psychiatric comorbidities had a lower level of functioning. Depression in FES was also associated with akathisia. CONCLUSION Psychiatric comorbidities are prevalent among community FES patients. In addition to achieving symptomatic remission in schizophrenia, both treating psychiatric comorbidities and minimizing the side-effects of treatment, particularly akathisia, are fundamental for supporting FES patients in their journey to recovery.

Background 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. Methods 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. Results 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. Limitations The findings were based on self-reported data from the respondents. Hong Kong is influenced by a mixed Chinese and Western culture. Conclusions 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.

Providing optimal care to patients with recent‐onset psychosis can improve outcomes and reduce relapse. However, there is a lack of consistency of the implementation of guidelines for such patients across the Asia‐Pacific region. We determined a pragmatic set of recommendations for use on a day‐to‐day basis to help provide optimal care at this crucial stage of illness. The recommendations were developed over a series of meetings by an international faculty of 15 experts from the Asia‐Pacific region, Europe, and South Africa. A structured search of the PubMed database was conducted. This was further developed based on the faculty's clinical experience and knowledge of the literature into 10 key aspects of optimal care for patients during the first five years of a diagnosis of a psychotic disorder, with particular relevance to the Asia‐Pacific region. Several common principles emerged: adherence to antipsychotic medications is crucial; substance abuse, psychiatric and medical comorbidities should be addressed; psychosocial interventions play a pivotal role; and family members can play a vital role in overall patient care. By following these recommendations, clinicians may improve outcomes for patients with recent‐onset psychosis.

Background Most of the previous studies of help seeking for psychological distress were conducted in Western countries. Chinese studies have had a stronger emphasis on psychosis. Objective This study aims to understand how Hong Kong Chinese primary care attenders see psychological distress, including its causes, management approaches and recovery, and whether their views are different from Western views. Method Nine focus groups and six individual interviews were conducted in Hong Kong among Chinese primary care attenders with/without known distress, patients' significant others and the general public, and a questionnaire survey was conducted with 1626 primary care attenders recruited from 13 private clinics and 6 public clinics. Results More survey respondents agreed with psychological counselling (95.3%) than drugs (69.0%) to relieve psychological distress. Despite the belief in self-resilience (77.7%), only 34.8% respondents agreed that psychological distress could get better without professional help. Respondents with younger ages, better education and higher incomes tended to have stronger trust in counselling and self-resilience than drugs. Qualitative interviews revealed that although participants regarded psychological distress as a common problem in modern societies, distressed patients might be seen as being weak and troublesome. Some distressed patients found their recovery process painful because of discouragement from family and personnel at their workplace. Conclusions Hong Kong Chinese patients' views of the causes and management approaches of psychological distress are similar to Western findings. However, help seeking and recovery are of greater concern in a Chinese context where patients may receive limited empathy for their conditions of psychological distress.

Summary Background The long-term consequences of discontinuing antipsychotic medication after successful treatment of first-episode psychosis are not well studied. We assess the relation between early maintenance therapy decisions in first-episode psychosis and the subsequent clinical outcome at 10 years. Methods This is a 10 year follow-up study, spanning Sept 5, 2003, to Dec 30, 2014, of a randomised, double-blind trial in seven centres in Hong Kong in which 178 patients with first-episode psychosis with full positive symptom resolution after at least 1 year of antipsychotic treatment were given maintenance treatment (n=89; oral quetiapine 400 mg daily) or early treatment discontinuation (n=89; placebo) for 12 months. After the trial, patients received naturalistic treatment. Overall this cohort of patients will have received about 3 years of treatment before entering the follow-up phase of the study: about 2 years of maintenance treatment before study entry and 1 year of treatment in the trial. The primary outcome of this follow-up was the proportion of patients in each group (including those for whom direct follow-up was not available) with good or poor long-term clinical outcomes at 10 years, with poor outcome defined as a composite of persistent psychotic symptoms, a requirement for clozapine treatment, or death by suicide. The randomised trial was registered with ClinicalTrials.gov, number NCT00334035, and the follow-up study was registered with ClinicalTrials.gov, number NCT01926340. Findings Poor 10 year clinical outcome occurred in 35 (39%) of 89 patients in the discontinuation group and 19 (21%) of 89 patients in the maintenance treatment group (risk ratio 1·84, 95% CI 1·15–2·96; p=0·012). Suicide was the only serious adverse event that occurred in the follow-up phase (four [4%] patients in the early discontinuation group vs two [2%] in the maintenance group). Interpretation In patients with first-episode psychosis with a full initial response to treatment, medication continuation for at least the first 3 years after starting treatment decreases the risk of relapse and poor long-term clinical outcome. Funding Food and Health Bureau, Research Grants Council of Hong Kong, and AstraZeneca.

This paper explored the effectiveness of Assertive Community Treatment (ACT) for severely ill mental patients during a period of rapid deinstitutionalization in Hong Kong. We employed a flanking historical control design. The treatment group comprised 70 participants with 3 or more admissions to psychiatric hospitals within the preceding 12 months, and received ACT. Two historical control groups (C1 and C2), each 70 participants, with similar inclusion criteria flanking the recruitment period of treatment group, were identified and received Treatment as Usual (TAU). Outcome data were measured at baseline, 6, 12 and 18 months of intervention. Readmission rates, bed-days, emergency room visits and days of missing medical appointments improved with time during the deinstitutionalization process, irrespective of treatment modality. In addition, ACT had superior effect in most of these outcome parameters, compared to the control groups. We reported that the current model of ACT, with a relatively small case load per case manager, round the clock services, multidisciplinary team approach, with psychiatrists integrated in the services and case managers responsible for health and social care, is an effective intervention for helping people with mental illness who pursue their chosen independent living in the community.

Background The stepped care model for psychological distress has been promoted in recent years, leading to the enhancing roles of primary care professionals and alternative sources of help. However, most of the research findings come from Western countries. This study investigates help-seeking behaviours of Chinese patients among different types of professional and alternative sources for psychological distress in Hong Kong. Methods A questionnaire survey was conducted with 1626 adult primary care attenders from 13 private and 6 public clinics, 650 (40.0%) reported that they had ever experienced psychological distress. Their help-seeking behaviours, demographic background and current distress level (measured by GHQ-12) were analysed. Results Among the respondents with experience of psychological distress, 48.2% had sought help from professional and/or alternative sources for their distress [10.2% from professionals only, 12.6% from alternative sources only, and 25.4% from both]. Those who had sought help from professionals only were more likely to be less educated and with lower income. In contrast, those using alternative sources only were more likely to be younger, better educated, and have higher income. Allowing multiple responses, psychiatrists (22.3%) was reported to be the most popular professional source, followed by primary care physicians (17.5%), clinical psychologists (12.8%) and social workers/counsellors (12.0%). Family members/friends (28.6%) was the top alternative source, followed by exercise/sports (21.8%), religious/spiritual support (16.9%) and self-help websites/books/pamphlets (8.9%). Conclusion While psychiatrists remain the most popular professional source of help to the Chinese patients in Hong Kong, primary care professionals and alternative sources also play significant roles. Distressed patients who are younger, better educated and have higher income are more likely to use alternative sources only. The outcomes need further research.

Kwai Chung Hospital has undergone the deinstitutionalisation process with a number of projects, beginning with a pilot to test the case management model and psycho-education for the care of people with chronic mental illness, followed by a RCT (randomised control trial) study which confirmed the efficacy of case management, and the Intervention for Frequent Readmitters project which confirmed the efficacy of assertive community treatment for a group of patients who had problems living in the community. Since 2010, the hospital has adopted the recovery movement that involves shifting its paradigm, altering its environment, training staff, and developing recovery practices and peer support for the betterment of living for the people it serves.

To test empirically the Substance Abuse and Mental Health Services Administration (SAMHSA) recovery model.Two hundred and four attendants aged 18-60, with schizophrenia spectrum disorder, from two participating outpatient clinics were interviewed with a number of inventories, including health-related quality of life measure (WHOQOL-BREF (HK)). Canonical correlation analysis was performed on two sets of variables (SAMHSA recovery components and QoL domain scores).There were significant correlations between most recovery components proposed in the SAMHSA recovery statement and the health-related quality of life measure. Age, duration of untreated psychosis, the degree of social support, the interaction of singlehood and the number of confidants, engagement in competitive careers, and the duration of participation in community support services were all found to be important predictors.The SAMHSA consensus statement appeared to contain valid concepts for Chinese subjects. It presented new challenges for psychiatric rehabilitation and reminded the policy makers that there is much more psychiatric rehabilitation can achieve beyond symptom control and patient management. It also demonstrated that resolve and the commitment of resources to combat stigma, develop resilience, and foster patient empowerment were very much needed in Hong Kong and perhaps in Asia and elsewhere.

Objectives The present study reviews the delivery of a pilot curriculum-mentorship-based peer vocational support workers training in a Hong Kong public psychiatric hospital. The present paper reports (1) on the development of a peer vocational support workers training − Job Buddies Training Program (JBTP) in Hong Kong; and (2) preliminary findings from both quantitative and qualitative perspectives. Method The curriculum consists of 15-session coursework, 8-session storytelling workshop and 50-hour practicum to provide Supported Employment Peer Service (SEPS) under the mentorship of occupational therapists. Six trainees were assessed using three psychosocial assessments and qualitative methods. Findings Compared to the baseline, the Job Buddies (JB) trainees showed an increase in awareness of their own recovery progress, occupational competence and problem-solving skills at the end of the training. Their perceived level of self-stigma was also lessened. In post-training evaluation, all Job Buddies trainees said they perceived positive personal growth and discovered their own strengths. They also appreciated the help from their mentors and gained mutual support from other trainees and from exposure with various mini-projects in the training. Conclusions and implications This pilot study provides an example of incorporating peer support and manualized training into existing work rehabilitation service for our JB trainees. Further studies on the effectiveness of service provided by peer support workers and for development on the potential use of peer support workers in other clinical and rehabilitation settings with larger subjects will be fruitful.

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.

Aim In view of the clinical importance of the adherence issues in schizophrenia management, a consensus group of experienced local psychiatrists and nurse specialists gathered to outline a number of consensus statements for clinicians to consider enhancing adherence in their patients. Process Prior to the consensus group meeting, three core members drafted eight statements on the issue of adherence in schizophrenia. Using a modified Delphi method, published literature and published guidelines regarding the management of schizophrenia were reviewed by the full panel during the group meeting. After discussion and reflection from each individual member of the consensus group, the eight statements were reworded and electronically voted on anonymously in two steps: acceptance on quality of evidence and practicability in implementation. Results After modifications of the original statements, there was very high overall level of agreement and acceptance (reaching international standard) on all the five areas of adherence within the eight statements of the finalised statement. Conclusions The present consensus statements are the first in Hong Kong to address systematically adherence issues in schizophrenia management. They include areas on adherence assessment and definition, treatment strategies in enhancing adherence, and treatment considerations at specific phases of schizophrenia. They are tailored to be of practical utility in the local Hong Kong setting.

Introduction This study investigated the barriers and facilitators for psychiatrists in managing mental health patients under a Chinese context and a mixed private-public health system. Methods Two focus group interviews were conducted to explore the in-depth opinions of psychiatrists in Hong Kong. The themes identified from the focus groups were investigated in a questionnaire survey with data from 83 psychiatrists working in public and private sectors. Results No insurance coverage of mental health problems, patients' poor compliance of medication, and stigma of seeing psychiatrists were rated as the top barriers in the survey. Some psychiatrists mentioned in focus groups that they might write down the associated physical symptoms of the patients rather than the mental disorder diagnoses on the medical certificate. They observed some patients suspecting that psychiatric drugs were prescribed to control their behavior and make them more muddleheaded. The survey also found that consultation time constraint, long patient waiting list, and difficulty in discharging patients to primary care mostly affected public psychiatrists rather than private ones. However, they perceived similar facilitators, including public campaign to promote positive results of help-seeking, adequate explanation by other health professionals to the patients before referrals, handling severe cases by casework approach, and having a regular primary care physician. Discussion The top barriers are related to insufficient public awareness and negative attitudes towards mental illness and its treatment. Major solutions include promoting positive results of help seeking, enhancing collaboration with primary care physicians, and follow-up of severe cases by a casework approach.