East Asian Arch Psychiatry 2012;22:100-4

THEME PAPER

Developments in Early Intervention for Psychosis in Hong Kong

香港思觉失调早期干预的发展

GHY Wong, CLM Hui, DY Wong, JYM Tang, WC Chang, SKW Chan, EHM Lee, JQ Xu, JJX Lin, DC Lai, W Tam, J Kok, DWS Chung, SF Hung, EYH Chen
黄凯茵、许丽明、黄欣、 邓绮雯、张颖宗、陈喆烨、李浩铭、徐佳琪、林晶霞、黎狄慈、谭蕴宜、 谷翠丽、锺维寿、熊思方、陈友凯

Dr Gloria Hoi-Yan Wong, PhD, Department of Psychiatry, The University of Hong Kong; Hong Kong Early Psychosis Intervention Society (EPISO), Hong Kong SAR, China. 
Dr Christy Lai-Ming Hui, PhD, Department of Psychiatry, The University of Hong Kong; EPISO, Hong Kong SAR, China. 
Ms Desiree Yan Wong, BS, Department of Psychiatry, The University of Hong Kong, Hong Kong SAR, China. 
Ms Jennifer Yee-Man Tang, MPhil, Department of Psychiatry, The University of Hong Kong, Hong Kong SAR, China. 
Dr Wing-Chung Chang, MRCPsych, FHKCPsych, FHKAM (Psychiatry), Department of Psychiatry, The University of Hong Kong; EPISO, Hong Kong SAR, China. 
Dr Sherry Kit-Wah Chan, FHKCPsych, FHKAM (Psychiatry), Department of Psychiatry, The University of Hong Kong; EPISO, Hong Kong SAR, China. 
Dr Edwin Ho-Ming Lee, MRCPsych, FHKCPsych, FHKAM (Psychiatry), Department of Psychiatry, The University of Hong Kong; EPISO, Hong Kong SAR, China. 
Ms Jia-Qi Xu, BSocSc, Department of Psychiatry, The University of Hong Kong; EPISO, Hong Kong SAR, China. 
Dr Jessie Jing-Xia Lin, MBChB, Department of Psychiatry, The University of Hong Kong, Hong Kong SAR, China. 
Dr Dik-Chee Lai, BSW, Department of Psychiatry, The University of Hong Kong, Hong Kong SAR, China. 
Ms Wendy Tam, MSocSc, Department of Psychiatry, The University of Hong Kong, Hong Kong SAR, China. 
Ms Joy Kok, BA, EPISO, Hong Kong SAR, China. 
Dr Dicky Wai-Sau Chung, MRCPsych, FHKCPsych, FHKAM (Psychiatry), EPISO; Department of Psychiatry, Tai Po Hospital, Hong Kong SAR, China. 
Dr Se-Fong Hung, FRCPsych, FHKAM (Psychiatry), EPISO; Department of Psychiatry, Kwai Chung Hospital, Hong Kong SAR, China. 
Prof. Eric Yu-Hai Chen, MA, MBChB, MD, FRCPsych, FHKAM (Psychiatry), Department of Psychiatry, The University of Hong Kong; EPISO, Hong Kong SAR, China.

Address for correspondence:Dr Gloria Hoi-Yan Wong, Room 226, Block J, Queen Mary Hospital, The University of Hong Kong, Pokfulam, Hong Kong SAR, China.
Tel: (852) 2255 3064; Fax: (852) 2255 1345; email: ghywong@hku.hk

Submitted: 2 March 2012; Accepted: 27 April 2012


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Abstract

The year 2011 marked the 10-year milestone of early intervention for psychosis in Hong Kong. Since 2001, the landscape of early psychosis services has changed markedly in Hong Kong. Substantial progress has been made in the areas of early intervention service implementation, knowledge generation, and public awareness promotion. Favourable outcomes attributable to the early intervention service are supported by solid evidence from local clinical research studies; early intervention service users showed improved functioning, ameliorated symptoms, and decreased hospitalisation and suicide rates. Continued development of early intervention in Hong Kong over the decade includes the introduction and maturation of several key platforms, such as the Hospital Authority Early Assessment Service for Young People with Psychosis programme, the Psychosis Studies and Intervention Unit by the University of Hong Kong, the Hong Kong Early Psychosis Intervention Society, the Jockey Club Early Psychosis Project, and the postgraduate Psychological Medicine (Psychosis Studies) programme. In this paper, we reviewed some of the major milestones in local service development with reference to features of the Hong Kong mental health system. We describe chronologically the implementation and consolidation of public early intervention services as well as recent progresses in public awareness work that are tied in with knowledge generation and transfer, and outline the prospects for early intervention in the next decade and those that follow.

Key words: Hong Kong; Psychotic disorders; Treatment outcome

摘要

2011年为香港思觉失调早期干预发展10周年。自2001年,香港思觉失调干预服务的景况已有 显著改变,不论在早期干预服务、知识创造和公众意识推广方面皆有实质进展。早期干预服务 能有良好效果有赖本地临床研究,而早期干预服务使用者不论其功能和症状均有改善,住院和 自杀率也减少。在过去十年,香港的思觉失调早期干预服务持续发展,引进不同平台且发展日 趋成熟,如医管局思觉失调服务计划、香港大学思觉失调研究计划、香港思觉失调学会、赛马 会思觉健康计划,以及精神医学(思觉失调学)深造课程。本文以香港精神健康系统的特质, 回顾本地服务发展的部份重要里程碑,并按时序阐述如何执行和巩固思觉失调早期干预服务, 以及以知识创造和推广报告公众意识认知状况,且概述这项服务未来十年的前景。

关键词:香港、思觉失调、治疗效果

Public Mental Health Service in Hong Kong

Hong Kong has a population exceeding 7 million, and the city is one of the most densely populated areas in the world. Approximately 95% of the population are Cantonese- speaking Chinese. According to a survey in 2007, the total health expenditure, including expenses for the mental health service, made up only 4.8% of the city’s gross domestic product.1 Although this figure may be similar within the region, Hong Kong’s mental health service is largely under- resourced when compared with other developed countries such as the United Kingdom (8.2%), the United States (15.3%), and Japan (8.1%).2 Previously, public mental health services were mainly delivered in the format of hospital-based generic care. The mental health workforce was disproportionally low to the psychiatric service users, with less than 300 psychiatrists for around 150,000 patients.3 At some busy outpatient clinics, each clinician needs to cater up to 30 patients for each 3-hour session, that is, approximately 6 minutes per consultation on average.4

Before the implementation of the early intervention service in 2001, with little support other than medication provided for early psychosis patients, many mental health needs remained undetected and unresolved. While community care for psychiatry in Hong Kong dates back to the 1970s, with a community psychiatric nursing service, 24-hour psychiatric hotline, and priority follow-up system in place, these early developments were mainly oriented towards more severe cases already within the service and crisis intervention.5,6

Therefore, early identification and intervention for psychosis has not been an area of focus in the mental health or social service system until more recently — for example, the Integrated Community Centre for Mental Wellness by the Social Welfare Department, commenced in 2010, has an outreach service for persons with suspected mental health problems.

Patients and Their Experience of Psychotic Disorder

Against a background of low mental health care resources, mental illness in Hong Kong was heavily stigmatised among the public, resulting in great reluctance for patients and their families to reveal their condition and seek appropriate help.7 Knowledge of psychotic disorders was weak in the population; a local study has shown that the public has a low level of awareness towards psychotic disorders, and the average citizen in Hong Kong fails to detect a problem even when presented with florid, first-rank symptoms of psychosisIn the past, most of the first-episode psychosis patients were treated initially as inpatients. Due to previous medication budget constraints, very few patients received second-generation antipsychotics as medical treatment. It was not uncommon for patients to show an increase in negative symptoms after hospital discharge; importantly, a high suicide rate of 4% was observed within the first 3 years of illness onset.9

Early detection of psychosis has been challenging in Hong Kong. Prolonged duration of untreated psychosis (DUP) was common among the population, with the mean DUP being 546 days.10 During this period, first-episode patients are in an uncontrolled psychotic state, which often jeopardises their quality of life and causes disruption to their relationships and functioning,11 impacting negatively on their long-term outcome. For many patients, going through this period can be a highly traumatic experience in itself, especially when the admission is crisis-driven. A frequent method of first service contact among patients with psychosis was through accident and emergency departments via the police force, sometimes requiring restraints or compulsory admission.12 Even after accessing the public mental health care service, it was not uncommon for development of secondary complications, including occupational decline and social functioning impairment, to occur during the course of the psychotic illness.13

Youth Early Intervention Service

In light of the pressing need to address the above concerns in the care of patients with early psychosis, an initiative for phase-specific early intervention in Hong Kong was launched by the Hospital Authority in 2001. The Early Assessment Service for Young People with Psychosis (EASY) programme has 3 core objectives, which are: (1) to raise public awareness of psychosis; (2) to provide rapid assessment for individuals with suspected psychotic disorders; and (3) to provide phase-specific early intervention for individuals with confirmed psychosis. Lately, there has been an extension to the EASY service, which will be discussed below (see Consolidating Early Intervention Service: EASY Service Extension); the following descriptions concern mainly the programme processes and outcomes before 2011. The EASY service targets adolescents and young adults aged between 15 and 25 years with a first-episode psychosis. Within the public health care system, patients presenting with early psychosis receive medical care plus case management services, which are delivered by a specialised EASY team. The case management service is provided for the first 2 years of illness, followed by step-down care for 1 year before returning to standard care by the general adult psychiatric service teams.14 There are 600 to 700 new EASY patients annually, and each case manager (with a background in psychiatric nursing or social work) has an average caseload of 80 to 100 patients. Collaborating non-governmental organisations (NGOs) also provide day centre support to further improve the functioning outcomes of these patients. As part of the public awareness programme, a more accurate and less stigmatising Chinese translation for the term ‘psychosis’ was introduced (「思覺失調」). A hotline was also set up for direct screening, enquiry, and public referral as a means to facilitate service access and help seeking to reduce the DUP; at-risk individuals who do not yet fulfil a diagnosis of psychotic disorder are followed up regularly for early detection in the event of onset.

Outcome evaluation of EASY has been conducted at 1 year, 3 years, and 10 years since the commencement of the programme. At 1 year, patients who have received phase-specific early intervention have shown significant improvements in terms of negative symptoms and functioning, as well as a reduction in suicide rate.10 In 2006, a case-control study examined the 3-year outcomes for the EASY service.13 The study compared 700 patients in the EASY programme with 700 historical control cases. The 2 groups were matched for age, sex, diagnoses, and initial symptom presentation. Favourable outcomes were more attributable to the EASY service, even after adjusting for potential confounding factors, including DUP and increased use of atypical antipsychotics. Positive outcomes of early intervention included substantially reduced length of hospitalisation and hospital admissions, less severe positive / negative symptoms, fewer suicides, fewer disengagements, and better occupational functioning (p < 0.001). In particular, the reduced hospital stay may have consequently reduced occupational disruption, leading to the improved occupational functioning observed in EASY patients.

Interestingly, the study did not find any effect of early intervention on reducing the relapse rate; when interpreting this information with the above findings of better outcome and fewer hospitalisations and re-hospitalisations, it may be concluded that the early intervention service has a role in minimalising the negative impacts brought about by relapses.13 On the other hand, DUP did not differ between the 2 groups, despite efforts in public awareness and case detection by the EASY service. A possible explanation is that the 2 cohorts in this study were too close in time to allow the full effects of public awareness to be observed, and that a number of patients who might have difficulty accessing the service previously (thus having a long DUP) might have been taken up by this EASY cohort.13 Forthcoming longer- term data will help to elucidate this observation.

In terms of cost-effectiveness, the EASY service incurred similar direct economic cost compared with that of conventional care, but with better overall clinical outcomes. The increased costs from more regular outpatient contacts and increased use of atypical antipsychotic medications for EASY patients were offset by the decrease in inpatient and accident and emergency service costs.15

A decade has passed since the first patient intake by EASY, and a 10-year outcome study is now underway for an extensive and comprehensive evaluation of the programme. This longitudinal study aims to compare the 10-year outcomes of patients with early intervention with those in the standard care service.16 Results from this study will help to identify areas for further improvements in the early intervention service for psychosis. Among the possible areas for improvement, the optimal duration of case management is a key issue. As mentioned above, upon completion of 2 years of case management, patients in the EASY programme are prepared for stepping down to receive standard psychiatric care by the general adult psychiatric team. However, a significant proportion of patients reported ongoing experience of an eventful third year (e.g. relapse). Theoretically, the third year after psychosis onset may still fall within the ‘critical period’,17 and it is not certain whether the initial benefits observed will be sustained if the early intervention service is terminated prematurely. A randomised controlled study is therefore being conducted to investigate the effectiveness of providing phase-specific case management with an additional year for early psychosis patients (ClinicalTrials.gov Identifier: NCT01202357). Patients in the step-down stage of the EASY programme are being randomised to receive either an additional year of case management or to terminate case management for the next 12 months. Outcomes of the 2 groups are compared at the end of year 3. Findings from this study, which will be available towards the end of 2012, will attempt to answer important questions recurring throughout the course of the EASY programme: Will longer intervention lead to a better outcome? For how long should intervention be offered?

Adult Early Intervention Programme

At the launch of the EASY programme in 2001, resource limitations restricted service provision to adolescents and young adults with early psychosis. This was a difficult decision, which was based on observed higher disease burden and poorer outcomes in this group of patients.18,19

Adult-onset psychosis patients of older than 25 years were therefore not included in the early intervention service within the public health care system. In 2009, in an effort to bridge this service gap, the Hong Kong Jockey Club Charities Trust funded a 5-year early psychosis project, the Jockey Club Early Psychosis Project (JCEP), for adult- onset psychosis patients. Implemented by the Psychosis Studies and Intervention Unit at The University of Hong Kong, the project consists of 3 core components, namely: (1) to provide case management intervention for 1000 adult patients aged between 26 and 55 years presenting to the public psychiatric service with early psychosis; (2) to compare functioning outcomes for standard care versus 2-year or 4-year case management in a randomised controlled trial, and to provide a health economic evaluation (ClinicalTrials.gov Identifier: NCT00919620); and (3) to promote public awareness to the general population and specific gatekeeper training for frontline workers.

The JCEP trial has recently completed recruitment of the targeted 1000 cases, and is now fully enrolled into the follow-up phase of the project. A major characteristic of the project is the pioneering case management model using a life-coaching approach. Under this model, intervention officers play a vital role in delivering tailor-made therapeutic intervention for early psychosis patients. It is also the goal of JCEP to build up a pool of expertise in early psychosis case management, and to pave the way for further developments in the adult early intervention service in the public health care system in the long term. Professional intervention officers in JCEP undergo intensive integrated training, which has an emphasis on psychosocial and motivational intervention. Intervention officers in the project also help to match patients with appropriate resources, such as group support sessions provided by collaborating NGOs. Initial data are becoming available from the JCEP trial. At 6 months, outcomes of patients receiving case management versus standard care were reviewed, results of which have been released in a local press conference.20 Specifically, immediately after illness stabilisation, no major difference can yet be observed in terms of functioning, symptoms, and cognitive outcomes between the case management group (n = 84) and the standard care group (n = 39). However, in a subgroup of patients with a long DUP, those who are receiving case management early intervention showed significantly greater improvement in their overall social and occupational functioning from baseline compared with those who are receiving standard care. The change in functioning was significant (t = 2.38, p = 0.02) at 6 months, while the 2 groups were initially comparable at baseline.20 Patients in the case management group were also more likely to achieve symptom remission in contrast to a higher proportion of treatment resistance observed in the standard care group.

Consolidating Early Intervention Service: EASY Service Extension

The positive outcomes of EASY, together with the implementation and initial findings from the JCEP trial, have no doubt facilitated local early intervention service development. In 2011, an extension of the EASY service was implemented. While remaining concordant with the core service philosophy of EASY to provide phase-specific professional intervention services, the extension aims to cover a much broader age-group of patients with early psychosis. The EASY service is now extended to all patients aged between 18 and 64 years who are first contacting the public health care system for early psychosis. Before the extension, there were 5 EASY teams divided between the catchment areas in Hong Kong; with the new service, the number of early intervention teams has increased to 7 across the local districts. Additionally, the case management service has been extended from 2 years to 3 years, and the target caseload ratio has been adjusted downward to 1:50 to ensure the quality of the case management service delivered.21 With these new developments, there is an increasing need to improve the quantity and quality of case managers for early psychosis intervention in Hong Kong; this has opened up new opportunities as well as demands for professional training in this field locally.

Public Awareness and Destigmatisation

The heavy stigma associated with psychotic disorders in Hong Kong mandates stepping up of the local public awareness efforts. In this regard, many local workforces have contributed, including the EASY programme, NGOs, and the JCEP. On the basis of many years of solid destigmatisation work, a notable addition to the scene is the campaigns organised by an independent charitable organisation, the Hong Kong Early Psychosis Intervention Society (EPISO).

Founded in 2007, the Hong Kong EPISO strives to reduce the negative attitudes about psychosis among the general public and emphasises the effectiveness of early detection and treatment. The EPISO is an initiative maintained by a group of volunteer mental health professionals and community members. As an independent charitable organisation, the Society is self-sustained by means of fund-raising activities and donations. In the past few years, the EPISO has gained good media exposure through various campaigns, ranging from youth awareness programmes such as school drama tours to professional training for frontline workers. The workshops and scientific conferences organised through this platform provided an arena to transfer and synergise scientific and clinical knowledge. Signature events are organised annually to boost public awareness; the event highlight in 2012 is the FitMind Programme, which demonstrates how the latest scientific knowledge, early intervention, and public awareness can be synergised; this city-wide movement aims to promote physical exercise among patients and caregivers in a package of simple and enjoyable exercises performed under a coaching system. The idea originated from preliminary findings of an ongoing randomised controlled trial in Hong Kong (ClinicalTrials.gov identifier: NCT01207219), which showed improvements in neurocognitive functions in early psychosis patients after 12 weeks of physical exercise.22 In conjunction with raising public awareness on the benefits of physical exercise for mental health, researchers are continuing to explore the potential of physical exercise intervention as an add-on non-invasive cognitive remediation therapy.

Future Prospects

The early intervention service in Hong Kong has come a long way. Limitations, including a low level of resources in mental health care, a stigmatising culture towards mental illness, and many other challenges, have either been overcome or continued to be confronted. In terms of stigma and public awareness, with renewed efforts by various NGOs and others, including those mentioned above, there is hope that the situation will be improving. A public attitude survey scheduled for towards the end of the JCEP trial will test this impression. The latest results from the JCEP trial have shown a median DUP of around 98 days20; if similar findings can be confirmed in other local cohorts, including the upcoming 10-year follow-up study of the EASY service, this represents an encouraging piece of evidence for improved awareness and help-seeking for psychosis in Hong Kong. However, it is unknown how sustainable are the effects of anti-stigma and awareness campaigns on influencing public attitudes and behaviours, and it is imperative that more lasting means are found, with concerted efforts involving health care and education systems, as well as the media, in the near future. In terms of resources, while the EASY service extension is a welcomed and much-needed support from the government, it is apparent that continued dialogue between policy-makers and mental health specialists is necessary for the early intervention service to catch up with standards in other developed countries. It is reassuring that clinical experience and research evidence accumulated over the past decade have confirmed the benefit and cost-effectiveness of early intervention for psychosis. By communicating these empirical findings in a comprehensible and accessible way to all stakeholders, including the public, it is hoped that policy, practice, and resource allocation decisions can be informed and positively influenced. However, as the early intervention services continue to develop, the demand for a local pool of highly specialised, skilled, and informed frontline professionals is increasing. Workforce development and capacity building is thus foreseen to be a major focus in the years to come.

Certain measures are underway to cater for this need. While the Hospital Authority provides training for case managers and case manager assistants, formal education has recently become available through a new postgraduate programme in psychosis. The programme, named Psychological Medicine (Psychosis Studies), has been offered by The University of Hong Kong since 2011 and covers various aspects of psychotic disorders and their treatment at the levels of certificate, diploma, and master’s degree. Areas that are explored in depth in the programme include epidemiology, psychopathology, course and outcome, neurobiology, and cognitive dysfunction in psychosis, as well as specific skill sets such as pharmacological, psychosocial, and case intervention for psychosis. The programme is expected to introduce new members into the early intervention workforce. In summary, a decade of experience and research has indicated that early psychosis intervention should be a key feature of the local mental health system. In Hong Kong, several key platforms have been formed and are maturing; this is a time for those in the field to utilise these assets and further enhance the early intervention service. A sustainable future for the field of early psychosis intervention will rely on good use of accumulated local experience, focused research efforts to generate knowledge, mobilisation of community resources, and quality development of a long-term workforce. All of these factors pave the way towards one ultimate goal — better patient outcomes.

References

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