Josephine G. W. S. Wong

Web-based survey of depression, anxiety and stress in first-year tertiary education students in Hong Kong

Objective: The mental health of tertiary education students is an area of increasing concern worldwide. The objective of this study is to examine the prevalence of depression, anxiety and stress in first-year tertiary education students in Hong Kong. Method: Depression, anxiety and stress were measured by the 42-item Depression Anxiety Stress Scales, completed on the web by participating students anonymously. Results: A total of 7915 students completed the survey, yielding a response rate of 27.5%. Depression, anxiety and stress levels of moderate severity or above were found in 21%, 41% and 27% of our respondents, respectively. Conclusions: The web-based survey methodology was well accepted by our sample group of tertiary education students. We found high rates of psychological morbidity in first-year tertiary education students in Hong Kong. The high prevalence of depression, anxiety and stress symptoms in the first year of college life is alarming. It illustrates the need for primary and secondary prevention measures, with development of adequate and appropriate support services for this group.

Immediate and sustained psychological impact of an emerging infectious disease outbreak on health care workers.

Objective: To assess the immediate and sustained psychological health of health care workers who were at high risk of exposure during the severe acute respiratory syndrome (SARS) outbreak. Methods: At the peak of the 2003 SARS outbreak, we assessed health care workers in 2 acute care Hong Kong general hospitals with the Perceived Stress Scale (PSS-10). One year later, we reassessed these health care workers with the PSS-10, the 21-Item Depression and Anxiety Scale (DASS-21), and the Impact of Events Scale-Revised (IES-R). We recruited high-risk health care workers who practised respiratory medicine and compared them with nonrespiratory medicine workers, who formed the low-risk health care worker control group. Results: In 2003, high-risk health care workers had elevated stress levels (PSS-10 score = 17.0) that were not significantly different from levels in low-risk health care worker control subjects (PSS-10 score = 15.9). More high-risk health care workers reported fatigue, poor sleep, worry about health, and fear of social contact, despite their confidence in infection-control measures. By 2004, however, stress levels in the high-risk group were not only higher (PSS-10 score = 18.6) but also significantly higher than scores among low-risk health care worker control subjects (PSS-10 score = 14.8, P < 0.05). In 2004, the perceived stress levels in the high-risk group were associated with higher depression, anxiety, and posttraumatic stress scores (P < 0.001). Posttraumatic stress scores were a partial mediator of the relation between the high risk of exposure to SARS and higher perceived stress. Conclusions: Health care workers who were at high risk of contracting SARS appear not only to have chronic stress but also higher levels of depression and anxiety. Front-line staff could benefit from stress management as part of preparation for future outbreaks.

Psychological effects of the SARS outbreak in Hong Kong on high-risk health care workers

Objective: To quantify stress and the psychological impact of severe acute respiratory syndrome (SARS) on high-risk health care workers (HCWs). Method: We evaluated 271 HCWs from SARS units and 342 healthy control subjects, using the Perceived Stress Scale (PSS) to assess stress levels and a structured list of putative psychological effects of SARS to assess its psychological effects. Healthy control subjects were balanced for age, sex, education, parenthood, living circumstances, and lack of health care experience. Results: Stress levels were raised in both groups (PSS = 18) but were not relatively increased in the HCWs. HCWs reported significantly more positive (94%, n = 256) and more negative psychological effects (89%, n = 241) from SARS than did control subjects. HCWs declared confidence in infection-control measures. Conclusions: In HCWs, adaptive responses to stress and the positive effects of infection control training may be protective in future outbreaks. Elevated stress in the population may be an important indicator of future psychiatric morbidity.

Stress and psychological impact on SARS patients during the outbreak.

Objective: To examine stress and psychological impact in severe acute respiratory syndrome (SARS) patients during the 2003 outbreak. SARS is a novel, highly infectious pneumonia, and its psychological impact is still unclear. Method: At the peak of the outbreak, SARS patients (n = 79) and healthy control subjects (n = 145) completed the Perceived Stress Scale (PSS) and documented a range of psychological responses. Groups were balanced for age, sex, education, and living circumstances. Results: Stress was significantly higher in SARS patients than in healthy control subjects. Stress correlated significantly with negative psychological effects. Of SARS patients, 39% (n = 30) were infected health care workers; these individuals reported significantly more fatigue and worries about health than did other patients. Of patients, 25% (n = 20) requested psychological follow-up. Conclusions: General stress and negative psychological effects are increased in SARS patients, particularly among infected health care workers. This may increase the risk of mood and stress-related disorders. Functional impairment is apparent in the postrecovery phase.

An instrument to assess mental patients’ capacity to appraise and report subjective quality of life

Quality of life (QOL) is increasingly recognized as an important outcome measure in treatment studies and service evaluation. However, patients or service users may sometimes lack the capacity to either evaluate or express their subjective QOL, for example due to cognitive impairment, communication disorders, symptom distress or burden of completing the assessment itself. This paper describes the development of an instrument, the capacity to report subjective quality of life inventory (CapQOL), which evaluates the ability of patients to appraise their subjective QOL and to complete related measures. The CapQOL is a simple and brief screening tool, designed for use in people with a wide range of mental disabilities. It helps researchers to identify individuals who are unable to appraise or report their subjective quality of life. We administered the CapQOL to 442 patients with early psychosis. About 89% of the participants were assessed to be able to complete a subjective QOL measure. The CapQOL demonstrated satisfactory psychometric properties. Further validation studies in people with psychosis as well as other mental disabilities are indicated.

Ethics assessment in medical students.

Medical ethics is now an important aspect of medical education. Since its emergence in the 1970s, ethics has become a core component of undergraduate and postgraduate medical training. This development stems from the recognition that ethical and moral issues present increasingly complex challenges to the medical practitioner. The goal of medical ethics training is to train better doctors, doctors who are better equipped to identify, analyse and resolve the ethical problems that arise in clinical practice (Pellegrino et al., 1990). Such training is found to be beneficial both at medical student (Self et al., 1989) and at junior doctor (Sulmasy et al., 1993; Sulmasy & Marx, 1997) levels in terms of improving knowledge, moral reasoning and confidence in one’s ability to deal with ethical dilemmas. Associated with the increasing emphasis being placed on outcome-based education (Harden, 2002; Harden et al., 1999a; Harden et al., 1999b; Rubin & Franchi-Christopher, 2002; Scottish Deans’ Medical Curriculum Group, 2002), attitudes and ethics have been emphasized as important areas of competence in medicine. Professional values, attitudes, behaviour and ethics were identified as global minimum essential requirements in medical education by the Institute for International Medical Education (2002). Other areas emphasized recently have been professionalism and altruism (McGaghie et al., 2002) and empathy (Mangione et al., 2002).

Stress and psychological distress among SARS survivors 1 year after the outbreak

Objective: Our study examined the stress level and psychological distress of severe acute respiratory syndrome (SARS) survivors 1 year after the outbreak. Method: During the SARS outbreak in 2003, we used the 10-item Perceived Stress Scale (PSS-10) to assess SARS survivors treated in 2 major hospitals (non–health care workers, n = 49; health care workers, n = 30). We invited SARS survivors from the same hospitals (non–health care workers, n = 63; health care workers, n = 33) to complete the PSS-10 again in 2004. At that time, they were also asked to complete the General Health Questionnaire (GHQ-12) and measures of depression, anxiety, and posttraumatic symptoms. PSS-10 scores were also obtained from matched community control subjects during the outbreak (n = 145) and again in 2004 (n = 112). Results: SARS survivors had higher stress levels during the outbreak, compared with control subjects (PSS-10 scores =19.8 and 17.9, respectively; P < 0.01), and this persisted 1 year later (PSS-10 scores =19.9 and 17.3, respectively; P < 0.01) without signs of decrease. In 2004, SARS survivors also showed worrying levels of depression, anxiety, and posttraumatic symptoms. An alarming proportion (64%) scored above the GHQ-12 cut-off that suggests psychiatric morbidity. During the outbreak, health care worker SARS survivors had stress levels similar to those of non–health care workers, but health care workers showed significantly higher stress levels in 2004 (PSS-10 score = 22.8, compared with PSS-10 score = 18.4; P < 0.05) and had higher depression, anxiety, posttraumatic symptoms, and GHQ-12 scores. Conclusions: One year after the outbreak, SARS survivors still had elevated stress levels and worrying levels of psychological distress. The situation of health care worker SARS survivors is particularly worrying. The long-term psychological implications of infectious diseases should not be ignored. Mental health services could play an important role in rehabilitation.

Decision-making capacity of inpatients with schizophrenia in Hong Kong.

This is a prospective study examining decision-making abilities in Chinese schizophrenia patients in Hong Kong. We interviewed patients before their discharge from hospital after a psychotic relapse, examining their decision regarding whether or not they would take maintenance neuroleptic treatment. Decision-making abilities were assessed by the MacArthur Competence Assessment Tool-Treatment, a semistructured questionnaire. We examined their relationships with demographic, clinical, and cognitive variables, measured by standardized instruments. Eighty-one participants were seen. Weaknesses were noted in a range of relevant decision-making abilities. Positive and negative schizophrenic symptoms, specifically lack of judgment and insight, difficulty in abstract thinking, unusual thought content, and conceptual disorganization, were found to be correlated with performance in decision-making abilities, as were cognitive deficits. Verbal working memory was a moderate predictor of the ability to understand treatment information. Decision-making impairments and negative treatment attitude were related to the decision not to adhere to medication.

“I can put the medicine in his soup, Doctor!”

The practice of covertly administering medication is controversial. Although condemned by some as overly paternalistic, others have suggested that it may be acceptable if patients have permanent mental incapacity and refuse needed treatment. Ethical, legal, and clinical considerations become more complex when the mental incapacity is temporary and when the medication actually serves to restore autonomy. We discuss these issues in the context of a young man with schizophrenia. His mother had been giving him antipsychotic medication covertly in his soup. Should the doctor continue to provide a prescription, thus allowing this to continue? We discuss this case based on the “four principles” ethical framework, addressing the conflict between autonomy and beneficence/non-maleficence, the role of antipsychotics as an autonomy restoring agent, truth telling and the balance between individual versus family autonomy.

The epidemiology and natural history of depressive disorders in Hong Kong's primary care

BackgroundDepressive disorders are commonly managed in primary care and family physicians are ideally placed to serve as central providers to these patients. Around the world, the prevalence of depressive disorders in patients presenting to primary care is between 10-20%, of which around 50% remain undiagnosed. In Hong Kong, many barriers exist preventing the optimal treatment and management of patients with depressive disorders. The pathways of care, the long term outcomes and the factors affecting prognosis of these patients requires closer examination.Methods/DesignThe aim of this study is to examine the prevalence, incidence and natural history of depressive disorders in primary care and the factors influencing diagnosis, management and outcomes using a cross-sectional study followed by a longitudinal cohort study.Doctors working in primary care settings across Hong Kong have been invited to participate in this study. On one day each month over twelve months, patients in the doctors waiting room are invited to complete a questionnaire containing items on socio-demography, co-morbidity, family history, previous doctor-diagnosed mental illness, recent mental and other health care utilization, symptoms of depression and health-related quality of life. Following the consultation, the doctors provide information regarding presenting problem, whether they think the patient has depression, and if so, whether the diagnosis is new or old, and the duration of the depressive illness if not a new diagnosis. If the doctor detects a depressive disorder, they are asked to provide information regarding patient management. Patients who consent are followed up by telephone at 2, 12, 26 and 52 weeks.DiscussionThe study will provide information regarding cross-sectional prevalence, 12 month incidence, remission rate, outcomes and factors affecting outcomes of patients with depressive disorders in primary care. The epidemiology, outcomes, pathways of care, predictors for prognosis and service needs for primary care patients with depressive disorders will be described and recommendations made for policy and service planning.