YSRP0001 Lecture 1 –Introduction: Why taking this

course?

Dr. Paul Wong D.Psyc.(Clinical)

E-mail: paulw@hku.hkCentre for Suicide Research and Prevention (CSRP)

Course website: http://csrp.hku.hk/bc

This Lecture’s Overview

1. Objectives, framework, and assessment of this course

2. An overview of the content of this course

3. The epidemiology of suicidal behaviour and mental health among the general public and university students in Hong Kong;

4. Where to seek help if you are distressed? Introduction of the Centre of Development and Resources for Students (CEDARS)

Course Objectives:

To increase students’ knowledge about stress, depression and suicide.

To enhance students’ awareness and self-understanding relating to stress and well-being.

To equip students with stress-reduction techniques and other life-enhancing coping strategies to deal with possible stressors.

To cultivate a positive attitude towards life based on a holistic wellness model.

Intended Learning Outcomes - Knowledge level

Declarative Outcomes:

• discuss issues related to the definitions and causes of stress, depression, and suicide

• describe the cognitive-behavioural model of stress and depression

• describe the physiological, psychological, and social changes associated with stress, depression, and suicide

• describe and critically evaluate the concept of coping

• evaluate the different effects of daily hassles, life stress and extreme stress of peoples’ mental well being

Intended Learning Outcomes - Practical level

Functioning Outcomes:

• evaluate the role of cognitions, behaviours, and social behaviours in the individual experience of stress, depression, and suicide

• relate and explain the aetiology from the understanding and knowledge about stress, depression, and suicide onto his/her own personal experience

• teach others about the management of stress, depression, and suicidal tendencies

• apply the learned knowledge and skills onto one’s future experience

• generate individualized life skills to manage future physical and psychological demands

Intended Learning Outcomes - Value level

Value outcomes:

• becomes a more understanding person about him/herself as well as other peoples’ mental well-being;

• becomes more aware of the significance of mental wellness towards a healthy life.

Teaching method Based on a “

"Tell me, I'll forget. Show me, I'll remember. Involve me, I'll understand" principle.

Thus, I will do some lecturing, show you some skills and videos, and most importantly, you will practice the skills in five of the lectures/tutorials.

Also, I am open for comments and suggestions along the way, please do send me e-mails anytime during the course.

The last thing I want to see in lectures:

http://www.youtube.com/watch?v=k__2_Am3a9w

paulw@hku.hk

Assessment All of these assignments will be submitted to me at the last lecture on or before 14 Ap

ril, 2010. Please e-mail and hand in your assignments to your tutor. Also, you can also hand in

other materials to me if you would like to, e.g., newspaper clippings. There are three modes of assessments in this broadening course:

• One problem-based case study (25%) – students will be given a case who is stressful at school and to formulate a “helping plan”, which consists of the taught skills from this course, to help another person who are in-need from an educated person about mental health.

• Group project and presentation (50%) – students will be given a list of topics relate to stress, depression, and suicide and present their projects during the tutorials. Students are encouraged to investigate topics relating to the course but may not have thoroughly covered during lectures. This assignment is to motivate students to enhance their knowledge on mental health and mental ill-health based on the self-learning principle.

• A self-refectory report – (25%) - (i) a collection of the in-class exercises, and after-class application activities, reflection exercises, observation tasks, etc. that students do throughout this course and (ii) a brief Self-reflection Report (no less than 700 words). The exercises and activities will gradually build up students’ learning and form the backbone of the Student Learning Portfolio. The Student Learning Portfolio should be submitted on or before the last session.

To get an A Case report/Presentation - The student deeply reflects on the

concepts and issues discussed in class, and not only shows understanding of the main ideas introduced but also generate deep meaning out of such knowledge/skill. The student concretely identifies the relevance and importance of the knowledge, and describes specific ways in which the knowledge can be used for their life in general.

Self-reflection report - The student records the self-observation in a clear and organized way, and reflects deeply on the observations. The observations are explained not only with proper terms/knowledge introduced in lectures, but also in sufficient depth and/or breath.

Some feedback from ex-students

General comments about the course

“I can find comfort whenever attending the lectures as if someone understanding me is teaching me how to walk on.”

“My parents and I appreciate this course much as we have never thought of certain daily life related course would appear in the university which cares much about students’ mental health. We have used the problem-solving and anger management exercises together.”

“The most important thing I enjoy this course because it emphasizes expression of real feeling without critiquing by Paul”.

“Dr. Wong not only taught us to use the skills ourselves but also told us how to teach them to others. I think this is the most important element of the course”.

Some feedback from ex-students Skills that like and use most

Communication and anger management skills and practice on conflicts with boyfriend.

The brain-storming step of problem-solving skill – “To kill Paul, or to ask all the classmates not to hand in assignments”. Some creative ideas generated to solve the deadline problem.

Some feedback from ex-students Examples of helping others by what’s been learned from the course

Teach mother to use computer using the problem-solving method because mom was anxious about learning computer

Teach a depressed and hopeless friend to use the ABC model, he found the exercise calming and help to raise self-esteem

Helping a patient from a nursing student. “One of my patients had suicidal ideation so that his movement had to be reduced as he was very agitated. The next day I brought along with the problem-solving exercise to see whether I can help him with this tool. He had such suicidal ideation because his face got burned due to an industrial accident that he was afraid others may discriminate him due to his altered appearance. We brainstormed some solutions and we found some of them like “perform plastic surgery after his condition stabilized” and “skin grafting” are more feasible. I reflected the problem to the nurse and doctors and they thought the solutions could be feasible but they said time is still needed to observe the condition of the patient. Few days later, good news happened. The doctor decided to do the skin grafting for the patient. He was delighted and thanked for my help. The next day his restrainers were off and he was preparing his skin grafting surgery”.

Comments on education methodThis course is like a cookery programme which introduces its audiences the

ingredients and demonstrates the method of cooking once. After that, the audiences will try to cook the dishes if they think the recipe is good. Whereas other cultural courses are like food and beverages programme which tell its audiences about the comments after tasting the dishes, there is no way for the audience to experience that at all.

This type of lectures seems to be the combination of normal lectures and PBL. They allow us to have enough information before thinking it through and practicing the knowledge on ourselves and people around us.

I think the “intentional learning outcomes” approach used in this course does help students to understand better the techniques which are being taught in class through practicing them in classes.

“I would like to praise the good organization of this course – the in-class activities gave us opportunity to practice individually; the after class activities provided us with chances to use and practice what was learnt in class and develop an automatic-processing system in our mind; the report-writing tasks enabled us to reflect what we learned and real-life applications.”.

The content of this course

The organization of this course is based on a therapeutic model called “Cognitive-Behavioural Therapy”

Its approach to tackling mental disorders/disturbances is based on the assumption that emotional responses are mediated through the interpretations, or meanings, that we give to experience.

Thus, in order to improve one's mental health, the behaviour and the cognition of an individual need to be educated or trained.

The content External Stressors

Working on AssignmentsExametc

Cognitive Processes

“I am going to fail” or “ I will surely get an A for it”

Behavioural Reactions: Got into an argument with your course coordinator because you are one mark less to get an A

Emotional Reactions – Happy, upset, depressed

Physiological Reactions – Sleep problems, reduced immune response or increased risk of blood clots etc.

External Stressors

Lecture 2 & 3

Cognitive Processes

Lecture 4-7

Behavioural Reactions

Lecture 9 & 10

Emotional Reactions

Lecture 8 & 11

Physiological Reactions

Lecture 11

Epidemiology of Suicidal Behaviour and Mental

Health among the General Public

Magnitude of the problem

Global suicide rate: over 800,000 per year with a rate 14.5 per 100,000 (WHO, 2003)

Hong Kong: 1264 suicide deaths with a rate of 18.6 per 100,000 in 2003 and 1053 deaths with a rate of 15.3 per 100,000 in 2004 – a 18% reduction;

Hong Kong: estimated to be 14.0 per 100,000 in 2005 (provisional figure)

Mainland China: 250,000 with a high rate in rural region (22 per 100,000) and urban (7 per 100,000)

Higher than

• USA 11 per 100,000

• Australia 12 per 100,000

• UK 10 per 100,000

Number of suicide deaths in Hong Kong by method used (1997 – 2006)

0

100

200

300

400

500

600

1997 1998 1999 2000 2001 2002 2003 2004 2005 2006Year

Suicides

Poisoning CO Hanging Jumping Others

Rank 1981 Rank 1991 Rank 2001

1 Diseases of the circulatory system 1 Neoplasm 1 Neoplasm

2 Neoplasm 2 Diseases of the circulatory system 2 Diseases of the circulatory

system

3 Diseases of the respiratory system 3 Diseases of the respiratory

system 3 Diseases of the respiratory system

4 Injury & poisoning (excludes suicide) 4 Diseases of the

genitourinary system 4 Diseases of the genitourinary system

5 Symptoms, signs & ill-defined conditions 5 Diseases of the digestive

system 5 Diseases of the digestive system

6 Diseases of the digestive system 6 Infectious & parasitic

diseases 6 Suicide death

7 Diseases of the genitourinary system 7 Injury & poisoning (excludes

suicide) 7 Infectious and parasitic diseases

8 Infectious & parasitic diseases 8 Suicide death 8 Diseases of blood & blood-

forming organs

9 Suicide death 9 Symptoms, signs & ill-defined conditions 9 Injury & poisoning (excludes

suicide)

10 Certain conditions originating in the perinatal period 10

Endorine nutritional & metabolic diseases & immunity disorders

10 Diseases of the nervous system and sense organs

Ten leading causes of death in HK

Comparison of suicide rates (some Asian countries)

14.0

4.0

10.0

10.7

13.9

15.3

25.3

22.8

25.5

0 10 20 30 40 50

HK (2005) Prov isional f igure

Thailand

Singapore

India

China

Taiwan (2004)

Japn (2004)

S. Korea (2003)

Ski Lanka

Risk Factors for Suicide in Hong Kong

Psychiatric illness (i.e., depression, anxiety, and schizophrenia)

Physical illness (i.e., chronic pain)

History of suicide attempt

Financial Problem

Unemployment

Now, let’s look at those who have thought about killing themselves of who have

attempted suicide

Suicidal Behaviors (Suicidal ideation and attempt) among the General Population of Hong Kong

What is a Prevalence Study?

• An accurate estimation of its prevalence and the associated risk and protective factors are needed in order to formulate effective intervention and prevention strategies

• Majority of people who make suicide attempts do not seek professional care

Objective:

• To obtain the prevalence of suicidality among aged 15-59 in HK

• To investigate the associated risk and protective factors

• To understand the pattern of service utilization

Method

A representative community sample of 2,220 participants aged between 15 to 59 years, and an additional booster sample of 511 participants aged between 15 to 19

Face-to-face interview

Representative to a total of 4,759,000 people aged 15-59 years

Prevalence of Suicidal Behavior in the past year

6.6

2.4

1.7

0.2

0

1

2

3

4

5

6

7

Suicide ideation Plan for attemptingsuicide

Suicide attempt Attempt that requiredmedical care

%

考慮過自殺 為自殺作出計劃 企圖自殺 因自殺而接受治療

Prevalence of Suicidal Ideation by Age and Gender

6.5

12.3

6.0

9.5

3.2

6.3

0

2

4

6

8

10

12

14

15-24 25-39 40-59

Male Female

%

Prevalence of Suicide Attempt 企圖自殺 “Have you attempted to commit suicide in the past 12 months?”

在過去十二個月內，你曾經企圖自殺？ 38 (1.7%) out of 2,219 respondents

1.0% of males

2.4% of females

Prevalence of Suicide Attempt by Age and Gender

2.8

4.8

0.8

2.7

0.6

1.2

0.0

1.0

2.0

3.0

4.0

5.0

15-24 25-39 40-59

Male Female

%

What relate to suicidal ideation and attempt?

Age- and Gender-adjusted Associations Between Suicide Ideation and Related Factors (1)

Factor Levels OR 95% CI

Mental health / Psychiatric

Depressive symptoms 抑鬱徵兆 Low 1.00

Moderate/high 10.16 6.73-15.34

Anxiety symptoms 焦慮徵兆 Low 1.00

High 5.70 2.85-11.40

Psychosocial

Impulsivity 衝動 Low 1.00

High 2.83 1.91-4.18

Irrational thinking 不理性想法 Low 1.00

High 2.72 1.82-4.06

Hopelessness 無望 Low 1.00

High 4.22 2.84-6.26

Age- and Gender-adjusted Associations Between Suicide Ideation and Related Factors (2)

Factor Levels OR 95% CI

Psychosocial (con’t)

Loneliness 孤獨 Low 1.00

High 4.40 2.97-6.53

Coping 解決問題的能力 High 1.00

Low 2.38 1.59-3.57

Goal-directed thinking 應付逆境的信心 High 1.00

Low 3.75 2.53-5.54

Self-esteem 自尊 High 1.00

Low 2.22 1.40-3.52

Reason for living 生存意義 High 1.00

Low 2.27 1.50-3.42

Age- and Gender-adjusted Associations Between Suicide Ideation and Related Factors (3)

Factor Levels OR 95% CI

Psychosocial (con’t)

Social support 社會支持 High 1.00

Low 3.27 2.20-4.84

Difficulty in help seeking 求助遇上困難 No 1.00

Yes 2.37 1.60-3.49

Demographic

Marital status 婚姻狀況 Married 1.00

Single, etc 2.15 1.34-3.44

Employment 就業狀況 Full-time 1.00

Unemployed 2.17 1.24-3.83

Debts (not mortgage) 債務 ( 非按揭 ) No 1.00

Yes 2.17 1.24-3.83

What about the mental health and suicidal behaviour among

university students?

There are limited number of studies on mental health about university students in Hong Kong

The closer one is this “Web-based survey of depression, anxiety, and stress in first year tertiary education students in Hong Kong” by Wong et al., (2006)

Ref: Wong, J., Cheung, E., Chan, K., Ma, K., & Tang, S. (2006). Web-based survey of depression, anxiety, and stress in first year tertiary education students in Hong Kong. Australian and New Zealand Journal of Psychiatry, 40, 777-782.

They found:

Subjects: 10 tertiary education institutes in HK, n=7915 first year students (response rate=27.5%)

Methodology: questionnaires sent through e-mails, questionnaire named “Depression Anxiety Stress Scale (DASS)”

Results: Sample size Subscale Mean score (SD) Severity

All Students (n=7,915)Depression 8.66 (7.54) NormalAnxiety 9.36 (6.42) MildStress 13.97 (8.15) Normal

Male students (n=2,949)Depression 9.02 (7.85) NormalAnxiety 8.93 (6.51) MildStress 13.17 (8.21) Normal

Female students (n=4,966 )Depression 8.45 (7.35) NormalAnxiety 9.62 (6.34) ModerateStress 14.45 (8.08) Normal

Severity of the DAS among HK university students

Depression – about 8% (634/7915) scored severe and extremely severe

Anxiety – about 18.9% (1499/7915) scored severe and extremely severe

Stress – about 9.5% (747/7915) scored severe and extremely severe

Self-assessment!!

Depression, Anxiety, and Stress Scale

Scoring of DASS

1.S

2.A

3.D

4.A

5.D

6.S

7.A

8.S

9.A

10.D

11.S

12.S

13.D

14.S

15.A

16.D

17.D

18.S

19.A

20.A

21.D

University Student Suicide No local study on this population – a few cases per year.

According to overseas study, most university student suicides were related to depression and drug use.

Here is a video clip of university student suicide:

http://www.youtube.com/watch?v=apbene7XaU8

We have one HKU student completed suicide two weeks ago

http://hk.apple.nextmedia.com/template/apple/art_main.php?iss_id=20100102&sec_id=4104&art_id=13585814

Where to seek help if you are distressed?

Centre of Development and Resources for Students (CEDARS)

http://cedars.hku.hk/

http://www.hku.hk/sdcsc/

Q & A

After-class activity Please read:

“Suicide among adults aged 30-49: a psychological autopsy study in Hong Kong”

http://www.biomedcentral.com/1471-2458/8/147