Improving the care and support of people with serious mental illness throughout their treatment and rehabilitation journey
Mental illness accounts for more than 32% of the global burden of years lived with disability. A number of issues have been associated with poor patient outcomes and greater disabilities, and The Hong Kong Polytechnic University team addressed these unmet needs through the development of a publicly-available online eating disorders early-intervention programme, integration of evidence-based interventions in local psychiatric hospitals, and overseeing of territory-wide implementation of supported employment services for people with SMI. This research has directly improved patient outcomes and influenced local and international treatment guidelines and policies.
The key researchers are Prof H Tsang, Dr SF Leung, Dr D Bressington and Prof WT Chien. Their research was funded by a total of HK $ 3,016,772 from internal and external competitive research grant funding.
The key researchers are Prof H Tsang, Dr SF Leung, Dr D Bressington and Prof WT Chien. Their research was funded by a total of HK $ 3,016,772 from internal and external competitive research grant funding.
Facilitating access to self-help interventions for individuals with eating disorders
Early self-help interventions have been inaccessible to people with eating disorders. The Hong Kong Polytechnic University team designed and tested the effects of an online self-help programme called Smart Eating to engage people with eating disorders in early intervention. The study involved 222 service users [R1] and significantly reduced the severity of eating disorder psychopathology, reducing depression and anxiety, and improving the quality of life.
Addressing treatment non-adherence
In 2012-2013, the team incorporated a culturally-adapted adherence therapy (AT) into a nurse-led psychosocial intervention programme for >90 first-onset SMI patients [R2]. Significant improvements compared to those from usual care were seen in patients’ symptoms, insight into illness, re-hospitalisation rate, and quality of life over 12-months. A second controlled trial was conducted on a refined version of the programme in 2013-2015, with 134 community SMI patients [R3], and the results confirmed that AT was effective to reduce symptom severity and length of re-hospitalizations over 18 months. The interventions have been widely and systematically implemented in Hong Kong psychiatric care services since 2013.
Early self-help interventions have been inaccessible to people with eating disorders. The Hong Kong Polytechnic University team designed and tested the effects of an online self-help programme called Smart Eating to engage people with eating disorders in early intervention. The study involved 222 service users [R1] and significantly reduced the severity of eating disorder psychopathology, reducing depression and anxiety, and improving the quality of life.
Addressing treatment non-adherence
In 2012-2013, the team incorporated a culturally-adapted adherence therapy (AT) into a nurse-led psychosocial intervention programme for >90 first-onset SMI patients [R2]. Significant improvements compared to those from usual care were seen in patients’ symptoms, insight into illness, re-hospitalisation rate, and quality of life over 12-months. A second controlled trial was conducted on a refined version of the programme in 2013-2015, with 134 community SMI patients [R3], and the results confirmed that AT was effective to reduce symptom severity and length of re-hospitalizations over 18 months. The interventions have been widely and systematically implemented in Hong Kong psychiatric care services since 2013.
Establishing psychiatric rehabilitation needs and integrating supported employment
A study involving 163 participants with SMI [R4] showed that an Integrated Supported Employment (ISE) programme that combines individual placement and support with social skills training resulted in significantly higher employment rates and longer job tenures than traditional vocational rehabilitation. The three-year follow-up results demonstrated the long-term effectiveness of the ISE programme [R5]. A survey of 194 people with schizophrenia and 83 caregivers [R6] helped identify priorities for the development of psychiatric rehabilitation services. Our team was consequently
invited by the Hong Kong SAR Government to lead a Rehabilitation Advisory Committee and formulate the Rehabilitation Programme Plan.
A study involving 163 participants with SMI [R4] showed that an Integrated Supported Employment (ISE) programme that combines individual placement and support with social skills training resulted in significantly higher employment rates and longer job tenures than traditional vocational rehabilitation. The three-year follow-up results demonstrated the long-term effectiveness of the ISE programme [R5]. A survey of 194 people with schizophrenia and 83 caregivers [R6] helped identify priorities for the development of psychiatric rehabilitation services. Our team was consequently
invited by the Hong Kong SAR Government to lead a Rehabilitation Advisory Committee and formulate the Rehabilitation Programme Plan.
References to the research
(JCR journal impact factors and SCOPUS citations are as of 19/07/2019)
[R1] Leung, S.F., Ma, J., & Russell, J. (2013). An open trial of self-help behaviours of clients with eating disorders in an online programme. Journal of Advanced Nursing, 69 (1), 66-76. DOI: 10.1111/j.1365-2648.2012.05988.x (IF=2.38, 11 citations).
Initial conference presentation: Leung, S.F., Ma, J., Russell, J., & Spence, I (2006). The “Smart Eating” self-help programme for people with eating disorders. Proceedings of the 2006 Conference of the Institute of Mental Health, Castle Peak Hospital: From Hospital to Community – Psychiatric Care in the New Era, Hong Kong, 10 November, p. 13
[R2] Chien, W T., & Bressington, D. (2015). A randomized controlled clinical trial of a nurse-led structured psychosocial intervention program for people with first-onset mental illness in psychiatric outpatient clinics. Psychiatry Research, 229, 277-286. (IF=2.21, 5 citations).
[R3] Chien, W. T., Mui, J., Gray, R., & Cheung, E. (2016). Adherence therapy versus routine psychiatric care for people with schizophrenia spectrum disorders: a randomised controlled trial. BMC Psychiatry, 16(1), 1. (IF=2.66, 8 citations).
[R4] Tsang, H. W., Chan, A., Wong, A., & Liberman, R. P. (2009). Vocational outcomes of an integrated supported employment program for individuals with persistent and severe mental illness. Journal of Behavior Therapy and Experimental Psychiatry, 40(2), 292-305. (IF=2.19, 64 citations).
[R5] Tsang, H. W., Fung, K. M., Leung, A. Y., Li, S. M., & Cheung, W. M. (2010). Three-year follow-up study of an integrated supported employment for individuals with severe mental illness. Australian and New Zealand Journal of Psychiatry, 44(1), 49-58. (IF=5.00, 31 citations).
[R6] Tsang, H. W., Li, D., Tsui, M. C., Chung, R. C., Wong, A. H., Li, S. M., ... & Yiu, M. G. (2013). The perceived rehabilitation needs of people with schizophrenia in Hong Kong: Perspectives from consumers and caregivers. Administration and Policy in Mental Health and Mental Health Services Research, 40(3), 179-189. (IF=2.68, 8 citations).
[R1] Leung, S.F., Ma, J., & Russell, J. (2013). An open trial of self-help behaviours of clients with eating disorders in an online programme. Journal of Advanced Nursing, 69 (1), 66-76. DOI: 10.1111/j.1365-2648.2012.05988.x (IF=2.38, 11 citations).
Initial conference presentation: Leung, S.F., Ma, J., Russell, J., & Spence, I (2006). The “Smart Eating” self-help programme for people with eating disorders. Proceedings of the 2006 Conference of the Institute of Mental Health, Castle Peak Hospital: From Hospital to Community – Psychiatric Care in the New Era, Hong Kong, 10 November, p. 13
[R2] Chien, W T., & Bressington, D. (2015). A randomized controlled clinical trial of a nurse-led structured psychosocial intervention program for people with first-onset mental illness in psychiatric outpatient clinics. Psychiatry Research, 229, 277-286. (IF=2.21, 5 citations).
[R3] Chien, W. T., Mui, J., Gray, R., & Cheung, E. (2016). Adherence therapy versus routine psychiatric care for people with schizophrenia spectrum disorders: a randomised controlled trial. BMC Psychiatry, 16(1), 1. (IF=2.66, 8 citations).
[R4] Tsang, H. W., Chan, A., Wong, A., & Liberman, R. P. (2009). Vocational outcomes of an integrated supported employment program for individuals with persistent and severe mental illness. Journal of Behavior Therapy and Experimental Psychiatry, 40(2), 292-305. (IF=2.19, 64 citations).
[R5] Tsang, H. W., Fung, K. M., Leung, A. Y., Li, S. M., & Cheung, W. M. (2010). Three-year follow-up study of an integrated supported employment for individuals with severe mental illness. Australian and New Zealand Journal of Psychiatry, 44(1), 49-58. (IF=5.00, 31 citations).
[R6] Tsang, H. W., Li, D., Tsui, M. C., Chung, R. C., Wong, A. H., Li, S. M., ... & Yiu, M. G. (2013). The perceived rehabilitation needs of people with schizophrenia in Hong Kong: Perspectives from consumers and caregivers. Administration and Policy in Mental Health and Mental Health Services Research, 40(3), 179-189. (IF=2.68, 8 citations).
Details of the impact
Implementation of evidence-based intervention in routine care and support services
Our work has directly informed the development of a medication management training programme that has been applied to around 550 mental health professionals in the Hong Kong Hospital Authority since 2013 [S1, S2]. Further, two train-the-trainers courses have been conducted at Kwai Chung Hospital (2013, 2015) and one at Castle Peak Hospital (2018), and the intervention has been conducted with 728 acute inpatients since 2013 [S1, S2]. The General Manager (Nursing) of Castle Peak Hospital (a major psychiatric care hospital in HK) says that “staff members evaluate the training very positively, mentioning an improvement in their knowledge, skills and confidence in addressing medication non-adherence” and “The Medication Management interventions benefit our patients greatly, and are now implemented into routine clinical care” [S1]. The nurse consultant at Kwai Chung Hospital also states that the research/training: “has changed routine patient care...the intervention is still provided to all inpatients and service users in the community”.
Our work has directly informed the development of a medication management training programme that has been applied to around 550 mental health professionals in the Hong Kong Hospital Authority since 2013 [S1, S2]. Further, two train-the-trainers courses have been conducted at Kwai Chung Hospital (2013, 2015) and one at Castle Peak Hospital (2018), and the intervention has been conducted with 728 acute inpatients since 2013 [S1, S2]. The General Manager (Nursing) of Castle Peak Hospital (a major psychiatric care hospital in HK) says that “staff members evaluate the training very positively, mentioning an improvement in their knowledge, skills and confidence in addressing medication non-adherence” and “The Medication Management interventions benefit our patients greatly, and are now implemented into routine clinical care” [S1]. The nurse consultant at Kwai Chung Hospital also states that the research/training: “has changed routine patient care...the intervention is still provided to all inpatients and service users in the community”.
Thirty-eight NGO centres for psychiatric rehabilitation have set up Integrated Supported Employment (ISE) or individual placement and support services funded by the Social Welfare Department over the last six years [S3]. The Chief executive of the Baptist Oi Kwan Social Service testifies: “Trainees …were difficult to engage in open employment. ISE training helps them to well adapt…” and “trainees became more capable of managing social relationships and conflicts…the outcome is remarkably significant in our vocational service model” [S4]. Similarly, the Occupational Therapy Department Manager at Kwai Chung Hospital states that the research: “significantly enhances the work-related self-resilience, self-efficacy and return-to-work of service-users” [S5].
Influencing government policy
The Hong Kong SAR Government tasked the Rehabilitation Advisory Committee with the formulation of the Rehabilitation Programme Plan (RPP) over a two-year period (from 2017-19). Led by Prof Tsang of the UoA, the team completed the scoping stage of the project, and will liaise with the Labour and Welfare Bureau to discuss measures required to facilitate the recovery and social integration of mentally ill people, and service positioning, targets, and delivery. Over 1,000 people participated in the public consultation exercise led by The Hong Kong Polytechnic University Consulting Team during 2018 and 70 written submissions were received [S6].
Influencing government policy
The Hong Kong SAR Government tasked the Rehabilitation Advisory Committee with the formulation of the Rehabilitation Programme Plan (RPP) over a two-year period (from 2017-19). Led by Prof Tsang of the UoA, the team completed the scoping stage of the project, and will liaise with the Labour and Welfare Bureau to discuss measures required to facilitate the recovery and social integration of mentally ill people, and service positioning, targets, and delivery. Over 1,000 people participated in the public consultation exercise led by The Hong Kong Polytechnic University Consulting Team during 2018 and 70 written submissions were received [S6].
Influencing international treatment guidelines
The Hong Kong Polytechnic University research testing-supported employment intervention was cited in the 2014 NICE guidelines for the treatment and management of psychosis and schizophrenia in adults. NICE provides gold-standard health and social care guidance and is a core member of the Guidelines International Network providing evidence-based guidance and advice to 46 countries globally. The study was cited as providing moderate to strong evidence contributing towards the overall recommendation that supported employment is the most effective vocational rehabilitation method for obtaining competitive employment and for obtaining any type of paid or unpaid occupation [S7].
Improving public access to early self-help interventions for eating disorders across international settings
The ongoing Smart Eating online programme was awarded the maximum score of 5 stars for clarity, reliability, comprehensiveness, and research basis of content by the Commonwealth of Australia [S8]. It has a very positive impact on users’ recovery, as users’ testimonials show: “…has helped me to ensure I think rationally and don’t let bulimia get the best of me” and “Thanks to the programme my journey has ended in a recovered state…”. The programme has received 89,000 visitors since 2013 [S9] and since December 2014, the programme has been used by members of the public who self-referred to the integrative health clinic at The Hong Kong Polytechnic University [S10].
The Hong Kong Polytechnic University research testing-supported employment intervention was cited in the 2014 NICE guidelines for the treatment and management of psychosis and schizophrenia in adults. NICE provides gold-standard health and social care guidance and is a core member of the Guidelines International Network providing evidence-based guidance and advice to 46 countries globally. The study was cited as providing moderate to strong evidence contributing towards the overall recommendation that supported employment is the most effective vocational rehabilitation method for obtaining competitive employment and for obtaining any type of paid or unpaid occupation [S7].
Improving public access to early self-help interventions for eating disorders across international settings
The ongoing Smart Eating online programme was awarded the maximum score of 5 stars for clarity, reliability, comprehensiveness, and research basis of content by the Commonwealth of Australia [S8]. It has a very positive impact on users’ recovery, as users’ testimonials show: “…has helped me to ensure I think rationally and don’t let bulimia get the best of me” and “Thanks to the programme my journey has ended in a recovered state…”. The programme has received 89,000 visitors since 2013 [S9] and since December 2014, the programme has been used by members of the public who self-referred to the integrative health clinic at The Hong Kong Polytechnic University [S10].
Sources to corroborate the impact
[S1] Letter from Contact 1: Jolene Mui – General Manager, Castle Peak Hospital, Hong Kong. Email: muihc@ha.org.hk
[S2] Letter from Contact 2: Glendy Ip – Nurse Consultant, Kwai Chung Hospital, Hong Kong. Email: ipsh@ha.org.hk
[S3] Social Welfare Department document listing 38 NGO centres using supported employment intervention (as at 2018): https://www.swd.gov.hk/storage/asset/section/382/en/SE_List_of_Capacity_by_District_E_102018.pdf
[S4] Letter from Contact 3: Chief Executive Officer of Baptist Oi Kwan Social Service confirming the impact.
[S5] Letter from Contact 4: IP Yee-chiu – Occupational therapy department Manager at Kwai Chung Hospital confirming the impact.
[S6] Hong Kong Government’s Labor and Welfare Bureau’s information
Hong Kong Government’s Labor and Welfare Bureau website press-release announcing the public consultation exercise lead by The Hong Kong Polytechnic University team to seek views from members of the public on the formulation of a new Hong Kong Rehabilitation Programme Plan (RPP): https://www.lwb.gov.hk/eng/press/12032018.htm
Full report on scoping stage: http://www6.rs.polyu.edu.hk/rpp/wp-content/uploads/sites/8/2018/12/Report_on_Scoping_Stage_eng.pdf
Hong Kong Government’s Labor and Welfare Bureau website press-release launching the second stage (Formulation of Recommendations Stage) of the public consultation exercise: https://www.lwb.gov.hk/eng/press/19112018.htm
[S7] National Collaborating Centre for Mental Health. Psychosis and Schizophrenia in Adults: Treatment and Management. NICE Clinical Guideline 178. NICE, 2014. (Pages 537, 538, 541, 676) (https://www.nice.org.uk/guidance/cg178/evidence/full-guideline-490503565)
[S8] “Eating Disorders Information and Support for Australians – Resource review 2010” (p. 75), accessible from https://www.nedc.com.au/assets/NEDC-Publications/NEDC-Resources-Review-Final.pdf
[S9] Smart Eating website usability statistics.
[S10] Smart Eating website: http://www.smart-eating.com/en/Introduction/Welcome.asp
Smart Eating website recovery stories (website): http://www.smart-eating.com/en/recovery_story/recovery_story.asp
(Posted at July-2021)
