Sandra S. M. Chan

Mental health system in China: history, recent service reform and future challenges.

This paper summarizes the history of the development of Chinese mental health system; the current situation in the mental health field that China has to face in its effort to reform the system, including mental health burden, workforce and resources, as well as structural issues; the process of national mental health service reform, including how it was included into the national public health program, how it began as a training program and then became a treatment and intervention program, its unique training and capacity building model, and its outcomes and impacts; the barriers and challenges of the reform process; future suggestions for policy; and Chinese experiences as response to the international advocacy for the development of mental health.

Prevalence of very mild and mild dementia in community-dwelling older Chinese people in Hong Kong

INTRODUCTION In this report, the results of a household survey were used to examine the prevalence of very mild and mild dementia in Chinese older persons in Hong Kong. METHODS The study adopted a two-phase design. At Phase 1, 6100 subjects were screened using the Cantonese version of the Mini-mental State Examination (MMSE) and a short memory inventory. At Phase 2, 2073 subjects were screened positive and 737 were evaluated by psychiatrists. Clinical Dementia Rating (CDR) and cognitive assessment were used for diagnosis of dementia. Very mild dementia (VMD) was defined as a global CDR of 0.5, with memory and non-memory subscale scores of 0.5 or more. Mild dementia was classified for subjects with a CDR of 1. RESULTS The overall prevalence of VMD and mild dementia for persons aged 70 years or above was 8.5% (95%CI: 7.4-9.6) and 8.9% (95%CI: 7.8-10.0) respectively. Among subjects with clinical dementia, 84.6% had mild (CDR1) dementia. Logistic regression analyses revealed that older age, lower educational level and significant cerebrovascular risk factors were risk factors for dementia, while regular physical exercise was a protective factor for dementia. CONCLUSIONS A sizable proportion of community-living subjects suffered from milder forms of dementia. They represent a high risk for early intervention to reduce potential physical and psychiatric morbidity.

Frequency and Determinants of Poststroke Dementia in Chinese

Background and Purpose— Both dementia and stroke are major health problems in Chinese societies. Stroke is a frequent cause of dementia. Only a few studies have been published on poststroke dementia (PSDE), none of which has investigated a consecutive stroke cohort in Asian patient populations. The objective of this study was to examine the prevalence and clinical correlates of PSDE in Chinese stroke patients in Hong Kong. Methods— Two hundred eighty stroke patients consecutively admitted to the medical wards of a university-affiliated regional hospital were interviewed by a psychiatrist 3 months after stroke. The presence of dementia and vascular dementia was diagnosed according to the Diagnostic and Statistical Manual, 4th edition. In addition, a wide range of demographic and clinical variables were examined. Results— Fifty-five participants (20%) had PSDE. Univariate analysis found that PSDE was associated with age; level of education; prestroke Rankin Scale score; prestroke Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE) score; National Institutes of Health Stroke Scale (NIHSS) best language score, dysarthria score, and total score; urinary incontinence; cortical infarct; leukoaraiosis; bilateral lesions; number of lesions; involvement of middle cerebral artery circulation; and cerebral atrophy index. Multivariate logistic regression suggested that prestroke IQCODE score, NIHSS total score, leukoaraiosis, involvement of middle cerebral artery territory, and cerebral atrophy index were independent risk factors of PSDE. After removal of 22 patients with prestroke dementia, which was defined as a prestroke IQCODE score ≥4.0, the frequency of PSDE dropped to 15.5%. Furthermore, involvement of the middle cerebral artery territory and cerebral atrophy index were replaced by level of education and bilateral lesions as independent predictors in the final logistic model. Conclusions— PSDE is common among Chinese stroke patients in Hong Kong. Its frequency is comparable to that in white populations. The clinical determinants of PSDE, after the exclusion of patients with prestroke dementia, include premorbid level of cognitive function, severity of stroke, leukoaraiosis, level of education, and bilateral lesions.

Lifetime Prevalence of Suicidal Ideation, Suicide Plans and Attempts in Rural and Urban Regions of Beijing, China

Objective: There has been no large-scale survey of suicide-related behaviours including suicidal ideations, plans and attempts in China involving both rural and urban areas and using standardized assessment tools. The aim of the present study was to determine the lifetime prevalence of suicide-related behaviour and its relationship with sociodemographic factors and psychiatric disorders in the rural and urban regions of Beijing, China. Methods: A total of 5926 subjects were randomly selected in Beijing and interviewed using the Composite International Diagnostic Interview. Basic sociodemographic and clinical data and data on suicide-related behaviour were also collected. Results: The overall lifetime prevalence estimates of suicidal ideation, plans and attempts were 2.3%, 1.4%, and 1.0%, respectively; the corresponding figures were 2.8%, 1.6%, and 1.3% in the rural sample, and 1.8%, 1.3%, and 0.9% in the urban sample. Age (>25years), female sex, unmarried status, lower education level, lower (RMB2000month−1) monthly income and presence of major medical disorders were significantly associated with increased risk of suicide-related behaviour. 36.2% of subjects with suicide-related behavior consulted a medical practitioner and 20.7% consulted a psychiatrist. Conclusions: The prevalence of lifetime suicide-related behaviour in Beijing is lower than in Western countries, but the low percentage of subjects treated for suicide-related behaviour indicates a major public health problem that should be addressed. National surveys are needed to further explore the prevalence of suicide-related behaviour in China.

Poststroke Depression in Chinese Patients: Frequency, Psychosocial, Clinical, and Radiological Determinants:

This study attempted to evaluate the psychosocial, clinical, and radiological predictors of poststroke depression (PSD) in Chinese patients. One hundred eighty-nine patients participated in the study. Three months after the index stroke, a psychiatrist administered the Structured Clinical Interview for DSM-IV to all of the patients and made a DSM-IV diagnosis of depression. In addition, a host of demographic, clinical, and radiological variables were examined. Thirty-one (16.4%) of the patients had a diagnosis of PSD that included major depression (n = 11, 5.8%,), minor depression (n = 16, 8.5%), or dysthymia (n = 4, 2.1%). Univariate analysis revealed that PSD was associated with female gender, a lower level of education, a lower Lubben Social Network Scale (LSNS) score, subcortical infarcts, and lesions in the anterior cerebral artery (ACA) territory, and the Modified Life Event Scale (MLES) score was borderline for statistical significance. Multivariate logistic regression analysis suggested that female gender, a high MLES score, and subcortical and ACA lesions were independent risk factors for PSD and that a high LSNS score was a protective factor. (J Geriatr Psychiatry Neurol 2005; 18:45-51)

Postdelivery screening for postpartum depression.

Objective Postpartum depression (PPD) is a serious psychiatric disorder affecting 10% to 20% of women after childbirth. Research has shown that systematic screening for PPD using self-report questionnaires helps improve the identification of PPD and expedite treatment. Most studies on PPD screening have been conducted in the second and third postpartum months; little is known about whether PPD screening can be carried out on the days immediately after delivery. Methods A prospective cohort of 145 women completed the Edinburgh Postnatal Depression Scale (EPDS), Beck Depression Inventory (BDI), and General Health Questionnaire (GHQ) within 2 days of delivery. Six weeks after delivery, the participants were interviewed by a psychiatrist, who used the Structured Clinical Interview for DSM-III-R (SCID, nonpatient version) to establish the diagnosis. The psychometric performance of the EPDS, BDI, and GHQ in detecting PPD was assessed using the SCID diagnosis as the gold standard. Results When the cutoffs of the EPDS, BDI, and GHQ were lowered to achieve a sensitivity of 80%, the positive predictive values of these scales were to 13%, 18%, and 21%, respectively. When the cutoffs were raised to achieve a positive predictive value of 50%, the sensitivity rates were 6% (EPDS), 14% (GHQ), and 36% (BDI). Conclusions When commonly used depression rating scales were administered to identify PPD immediately after delivery, their psychometric properties were unsatisfactory. Healthcare providers should not screen for PPD in the first few days after delivery.

Can the Geriatric Depression Scale detect poststroke depression in Chinese elderly

BACKGROUND Little is known about the performance of the Geriatric Depression Scale (GDS) in the screening of post-stroke depression (PSD) among Chinese elderly. METHODS Three months after the index stroke, a research assistant administered the 15-item GDS to 127 Chinese elderly patients with acute stroke who were consecutively admitted to a general hospital. A psychiatrist, who was blind to the GDS scores, administered the Structured Clinical Interview for DSM-IV to all patients and made DSM-IV diagnosis of depression, which served as the benchmark for judging the performance of GDS in screening PSD. RESULTS The optimal cut-off point of GDS was 6/7. The sensitivity, specificity, positive and negative predictive values of GDS and the area under the receiver operating characteristic curve, were 89, 73, 37, 98 and 90%, respectively. LIMITATIONS The sample size was small and there was no separate analysis of the performance of GDS for subtypes of PSD. CONCLUSIONS Due to its low positive predictive value, a more specific instrument should supplement GDS in screening PSD in Chinese elderly.

Suicide among adults aged 30–49: A psychological autopsy study in Hong Kong

BackgroundA surge in suicide rates in middle age people in Hong Kong and many Asian countries was recently observed. However, there is a paucity of suicide research on this subgroup of people in Asia.MethodsThe next-of-kin of 85 suicide cases and 85 community subjects aged 30–49 years were interviewed by a psychological autopsy approach. Information was triangulated by interview notes, coroners court files, and police investigation reports.ResultsA multiple logistic regression analysis identified the following risk factors for suicide among the middle age people in Hong Kong: the presence of at least one psychiatric disorder (OR = 37.5, 95% CI 11.5–121.9, p < 0.001), indebtedness (OR = 9.4, 95% CI 2.2–40.8, p < 0.01), unemployment (OR = 4.8, 95% CI 1.3–17.5, p < 0.05), never married (OR = 4.2, 95% CI 1.1–16.3, p < 0.05), and lived alone (OR = 3.9, 95% CI 1.2–13.4, p < 0.05).ConclusionThe data show that socio-economical factors had a strong impact on suicide in the target group. Further research is needed to explore any positive qualities that protect the middle-aged from suicide. The prevention of suicide in the middle-aged requires multiple strategies.

Neuropsychiatric symptoms are associated with increased risks of progression to dementia: a 2-year prospective study of 321 Chinese older persons with mild cognitive impairment

BACKGROUND studies have suggested that neuropsychiatric (NP) symptoms influence the development of dementia among older adults. But, the results are inconsistent and there is limited information about NP symptoms in population-based samples. OBJECTIVE to explore the association between NP symptoms and risk of cognitive decline in Chinese older persons residing in the community. DESIGN prospective study. SETTING community sample. SUBJECTS a total of 321 community-dwelling Chinese older persons aged 60 or over with mild cognitive impairment participated in the study. METHODS at baseline, each subject was assessed with Clinical Dementia Rating (CDR), Mini-Mental State Examination, list learning and delayed recall, and Category Verbal Fluency Test. Severity of NP symptoms was evaluated with Neuropsychiatric Inventory (NPI). Global cognitive status at the end of 2-year study period was determined by CDR. RESULTS at baseline, 40.5% of participants exhibited one or more NP symptoms (NPI total score ≥ 1). Night-time behaviours (22.1%), depression (16.8%), apathy (14.0%) and anxiety (12.8%) were the most common NP symptoms. At the end of 2-year follow-up, 27.5% of participants with depression at baseline developed dementia, compared with 14.8% of those without depression (χ² = 4.90, P= 0.03). Aberrant motor behaviour was also significantly associated with deterioration in cognition (χ² = 5.84, P= 0.02), although it was an infrequent occurrence. On logistic regression analysis, only depression at baseline was shown to be a risk factor for progression to dementia (OR= 2.40, 95% CI 1.05-5.46, P= 0.04). CONCLUSION depression in non-demented older persons may represent an independent dimension reflecting early neuronal degeneration. Further studies should be conducted to assess whether effective management of NP symptoms exerts beneficial effects on cognitive function.

Emotional Incontinence in Chinese Stroke Patients

Abstract.Of the few studies published on poststroke emotional incontinence (PSEI), none has investigated a consecutive stroke cohort in a Chinese patient population. The objective of this study was to examine the frequency and the clinical and radiological correlates of PSEI in Chinese stroke patients in Hong Kong.Three months after their admission, a psychiatrist interviewed 127 stroke patients who were consecutively admitted to the medical wards of a university-affiliated regional hospital. The presence of PSEI was defined according to both Kim’s and House’s criteria.The frequency of PSEI was 17.9% according to Kim’s criteria and 6.3% according to House’s criteria. The kappa between the two sets of criteria was 0.34. Univariate analysis found that PSEI was associated with a younger age, previous history of depression, a higher National Institute of Health Stroke Scale total score and cortical infarcts. Multivariate logistic regression suggested that past history of depression and cortical infarcts were independent predictors for PSEI.In conclusion, PSEI is relatively common among Chinese stroke survivors. A previous history of depression or cortical lesions were independent predictors for PSEI. There is a need for a revision of the diagnostic criteria for PSEI.