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New Service Model for Common Mental Disorders in Hong Kong: a Retrospective Outcome Study.

Introduction

Common mental disorders (CMD) pose a challenge to public mental health services because of their high prevalence, symptom chronicity, and impacts on patients and society. In the United Kingdom, the prevalence of CMD has been reported to be up to 15%. (1) In Hong Kong, the weighted prevalence of CMD for any past week was estimated to be 13.3%, with mixed anxiety and depressive disorder being the most frequent diagnoses. (2) According to the World Health Organization, depression is projected to be the leading cause of disease burden by 2030. (3) When treatment is deferred, CMD are often associated with significant morbidity, disability, and healthcare utilisation. Patients first presenting to the public psychiatric service with relatively mild conditions are often triaged as 'routine' new cases, with a long waiting time for the first psychiatric consultation.

To enhance service accessibility for people with CMD, the National Institute for Health and Clinical Excellence of the United Kingdom recommends a stepped care model, in which the least-intensive intervention is provided first, with subsequent step-up or step-down according to changing needs and response to treatment. (1) Such a stepped-care model is made possible by the Improving Access to Psychological Therapies programme, which is a large-scale initiative to increase the availability of low-intensity psychological interventions for mild to moderate depression and anxiety disorders. (4) The first 3-year (2009-2012) outcome of the programme was promising, with >1 million people being treated, a recovery rate of >45%, and two-thirds of patients showing reliable improvement. In addition, there were economic gains in terms of employment attainment and retention, with >45 000 people moving off sick pay and benefits. (5)

In view of the promising outcome of the programme and implementation of similar initiatives in in other Asian countries, (6) the Hospital Authority established Common Mental Disorder Clinics (CMDC) at two psychiatric outpatient clinics in Hong Kong in July 2015. This represents a new service model to enhance multidisciplinary management by engaging more psychiatric nurses and allied health professionals in providing protocol-based, personalised, low-intensity, early psychosocial interventions for patients with CMD. The primary objective is to enhance the clinical pathway so as to reduce the waiting time and achieve early intervention and recovery. Patients are empowered with new skills to handle their mental conditions.

The present study aimed to review the first 8-month outcome of this new service model in Hong Kong in terms of the patient exit status and improvement in depressive and anxiety symptoms.

Methods

This study was approved by the Kowloon West Cluster Research Ethics Committee (KW/EX-16-068[98-11]). Patients on the waiting list of the East Kowloon Psychiatric Clinic and West Kowloon Psychiatric Clinic were screened by psychiatric nurses. Inclusion criteria were: age [greater than or equal to]18 years, triage as non-urgent cases (not at high risk of suicide or violence), and understanding and accepting the new service model of CMDC (after explanation with a leaflet). Exclusion criteria were: presentation of psychotic symptoms or symptoms likely attributable to organic causes, alcohol or substance abuse, and having on-going medicolegal issues. Those who were excluded or opted for the conventional care in psychiatric outpatient clinics were offered conventional psychiatric service.

During the first appointment at CMDC, a triple intake interview session was conducted by a multidisciplinary team comprising a psychiatrist, a psychiatric nurse, and an occupational therapist for structured assessment.

A multidisciplinary case conference chaired by the psychiatrist was then conducted to discuss clinical observations, diagnosis, issues of concern, and the optimal individualised treatment plan. Low-intensity interventions (guided self-help sessions on symptom management, stress management for relationships and work) by nurses and/or occupational therapists were provided, as were optional, time-limited, protocol-based interventions (cognitive behaviour therapy for depression and worry, supportive psychotherapy) by clinical psychologists for those with mild to moderate depressive and anxiety symptoms (Table 1). Pharmacological intervention may be used when indicated. The psychiatrist may refer patients to other disciplines (eg, medical social worker, physiotherapist, dietician). Regular reports on patient progress were made to the treating psychiatrist.

Upon completion of the treatment plan, patients were reassessed by the treating psychiatrist. Discharge options were decided in the multidisciplinary case conference based on patient needs and progress. Options included discharge without psychiatric follow-up, step-up to psychiatric outpatient clinics, and step-down to services including general outpatient clinics (run by the government with general medical practitioners), Integrated Mental Health Programme (run by the government with specialists in family medicine for low-intensity psychosocial interventions), private general practitioners, and Integrated Community Centre for Mental Wellness (run by non-government organisations with primarily social workers and no medical staff). (7)

The self-administered Patient Health Questionnaire-9 (PHQ-9) (8) and Generalised Anxiety Disorder 7-item scale (GAD-7) (9) were used to assess the past 2 weeks' depressive and anxiety symptoms, respectively, at baseline and at each session. The original and translated versions of PHQ-9 have demonstrated good validity and reliability. (8-10) The GAD-7 scale has satisfactory sensitivity and specificity for screening anxiety-related disorders. (11)

Data were analysed using SPSS (Windows version 22; IBM Corp, Armonk [NY], US). Pre- and post-treatment symptom scores were compared using paired t tests and the Wilcoxon signed rank test. The association of various factors with exit status was tested using logistic regression analyses with the general linear model (R version 3.3.0 software), in which 17 independent variables were entered: sex, age, main source of income, living style, type of accommodation, marital status, education level, number of days waiting until initial intake, number of programmes received, the diagnostic given, whether psychiatric medication was prescribed during initial intake, whether psychiatric medication was prescribed when last seen, period of service received at CMDC, first GAD-7 score, first PHQ-9 score, final GAD-7 score, and final PHQ-9 score. A p value of <0.05 was considered statistically significant.

Results

From July 2015 to February 2016, 1325 Chinese patients received CMDC service. Of them, 170 men and 363 women (mean age, 52.6 [+ or -] 15.2 years) completed the treatment plan, with PHQ-9 and GAD-7 assessed at baseline and last follow-up. Of the participants, 58.9% were married; 41.7% lived in privately owned homes; 8.3% lived by themselves; 72.3% had secondary level or above education level; 45.1% were employed; and 40.2% lived on their own income. The common diagnoses were depressive disorder (23.5%), adjustment disorder (18.4%), non-organic sleep disorders (15.9%), mixed depressive and anxiety disorder (13.1%), and generalised anxiety disorder (12.2%) [Table 2].

After treatment, the mean PHQ-9 score decreased from 11.06 (moderate severity) to 7.55 (mild severity) [t (532) = 14.86, p < 0.001], and the mean GAD-7 score decreased from 9.94 (moderate severity) to 6.54 (mild severity) [t (532) = 14.36, p < 0.001] (Table 3). After treatment, 42.4% and 48.2% of the patients were within the normal range of PHQ-9 and GAD-7, respectively, compared with 16.9% and 20.8% before treatment.

The 90th percentile waiting time of new patients (non-urgent) decreased from 33.7 to 16 weeks at East Kowloon Psychiatric Clinic and from 61 to 50 weeks at West Kowloon Psychiatric Clinic. The number of patients awaiting first consultation in the respective clinics decreased from 351 to 273 and from 2287 to 1811. The mean time to implementation of the individualised treatment plan was 82.33 days.

Of the patients, 274 (51.4%) were prescribed medication before treatment, and 268 (50.3%) were prescribed medication at the last follow-up. A total of 454 (85.2%) patients attended 802 psychosocial intervention sessions.

Of the patients, 54.4% were discharged without any need for medical or psychiatric follow-up; 28% were stepped up to psychiatric outpatient clinics; and 17.3% were stepped down to Integrated Mental Health Programme (13.5%), general outpatient clinics (3.6%), or Integrated Community Centre for Mental Wellness (0.2%) [Table 2].

Logistic regression analyses were conducted to examine the associations between exit status and various independent variables. Two patients who were transferred to private sector were excluded from the analyses. To estimate the goodness-of-fit for each model, the Akaike information criterion (346) and the corresponding pseudo [r.sup.2] (0.19) were calculated from deviations, and the final model yielded five potential predictors: the number of days waiting until initial intake, whether psychiatric medication was prescribed during initial intake, whether psychiatric medication was prescribed at last follow-up, the service period at CMDC, and the GAD-7 final score (Table 4). The area under the receiver operating characteristic curve was 0.801 (95% confidence interval = 0.752-0.850, Figure), indicating good accuracy. Patients who were prescribed medication at initial intake were less likely to be discharged without follow-up or to be stepped down, compared with those without medication prescription (p = 0.011). Patients who were prescribed medication at last follow-up were also less likely to be discharged without follow-up or to be stepped down, compared with those without medication prescription at last follow-up (p<0.001). Patients with a longer service period in CMDC were less likely to be discharged without follow-up or to be stepped down, compared with those with a shorter service period in CMDC (p = 0.010). Patients with a higher GAD-7 score at last follow-up were more likely to be stepped up than discharged or stepped down, compared with those with a lower GAD-7 score at last follow-up (p = 0.005). The waiting time for initial intake was not predictive of exit status (p = 0.191).

Discussion

The CMDC is a new service model aimed to address the growing demand for psychiatric services for CMD. The clinical pathways and exit mechanisms are explained to patients during initial intake; severity of symptoms is measured; and time-limited, protocol-based, low-intensity psychosocial interventions are provided by psychiatric nurses and allied health professionals. The first 8-month outcome was remarkable in terms of shortened waiting time, reduced severity of symptoms, and better exit status, consistent with the outcomes of the Improving Access to Psychological Therapies programme. (12)

Women have almost twice the lifetime rates of depression and anxiety disorders as those of men. (13) In our study, the PHQ-9 and GAD-7 scores improved significantly after treatment, and 54.4% of patients were discharged without follow-up. These results were compatible with those of a UK study that reported a recovery rate of 55% to 56% in people who attended at least two sessions. (14) Nonetheless, some patients with depression and/or anxiety disorders can recover without major professional help. (14) The natural recovery rate is associated with the duration of the disorder. The recovery rate was 50% to 70% in patients with recent-onset depression and/or anxiety while receiving 'treatment as usual' from general practitioners, whereas the recovery rate was about 20% for depression and <5% for anxiety disorders in those with disease duration >6 months. (14) The high recovery rate in our patients was not only caused by natural recovery, as the mean waiting time for initial intake was 159.52 days.

Patients with milder symptoms (lower PHQ-9 and/or GAD-7 scores) at intake were more likely to be discharged without follow-up or stepped down. Patients who were prescribed medication at intake or last follow-up were less likely to be discharged without follow-up or stepped down. This could be because those who were prescribed medication in addition to psychosocial treatment had more severe illness. Alternatively, some patients may prefer medication treatment rather than psychological treatment. The likelihood of discharge without follow-up was smaller in those who were prescribed medication at last follow-up than in those who were prescribed medication at intake. This may be because patients who were prescribed medication had more severe illness and needed continued specialist care and/or treatments not available in the primary care setting.

Although panic disorder/agoraphobia, generalised anxiety disorder, mixed anxiety depressive disorder, and non-organic insomnia are considered to be less complex and lower-risk disorders, the percentage of such patients stepped up to psychiatric outpatient clinics was relatively high. This may be related to the limited psychiatric treatment available in primary care settings, apart from that for psychosocial stressors (eg, death of significant others, unemployment, injury on duty, and other physical illnesses).

The present study has some limitations. Only 40% of the 1325 admitted patients completed the treatment at CMDC. Many patients were still receiving psychosocial interventions when this paper was written. Thus, the sample analysed may have included a higher proportion of less severe cases. Thus, they had a mean of only 1.5 sessions of psychosocial intervention. Generalisation of the findings should be undertaken with caution. In addition, a longer follow-up period is needed to ascertain the patient recovery status (eg, remission period or relapse rate) before more definite conclusions can be drawn regarding the effectiveness of this new service model. As CMDs are recurring conditions, a longitudinal study with more samples throughout an extended period may help determine whether and how recovery can be maintained. There was great variation in the numbers of patients with certain diagnoses, and interpretation of such findings should be undertaken with caution. This study was retrospective, which may have caused bias. Patients who opted out of the CMDC programme were excluded; future analysis to understand the characteristics and underlying reasons of the opt-out group is warranted. Future studies should investigate the fidelity and efficacy of specific psychosocial interventions.

Conclusions

The first 8-month outcome of the CMDC service model was encouraging, with high recovery and step-down rates. The collected data may help to facilitate resource allocation by estimating the demand for specialist support in psychiatric outpatient clinics. This study highlights the need to enhance training of and communication with other service providers (eg, specialists in family medicine, general outpatient clinic doctors, private general practitioners, and mental health workers) in treating patients with CMD in a stepped-care model.

Declaration

All authors report no financial relationships with commercial interests.

References

(1.) National Institute for Health and Clinical Excellence. Common mental health disorders: identification and pathways to care. NICE guideline (CG123). Leicester and London: The British Psychological Society and The Royal College of Psychiatrists; 2011.

(2.) Lam LC, Wong CS, Wang MJ, Chan WC, Chen EY, Ng RM, et al. Prevalence, psychosocial correlates and service utilization of depressive and anxiety disorders in Hong Kong: the Hong Kong Mental Morbidity Survey (HKMMS). Soc Psychiatry Psychiatr Epidemiol 2015;50:1379-88. Crossref

(3.) World Health Organization and World Organization of Family Doctor. Integrating mental health into primary care: a global perspective. 2008.

(4.) Department of Health, United Kingdom. Realising the benefits: IAPT at full roll out. 2010. Available at: https://www.bl.uk/britishlibrary/~/media/bl/global/social-welfare/pdfs/non-secure/r/e/a/realising-the-benefits-iapt-at-full-roll-out.pdf. Accessed 14 March 2018.

(5.) Department of Health, United Kingdom. IAPT three-year report: the first million patients. 2012. Available at: https://www.mhinnovation.net/sites/default/files/downloads/innovation/reports/Three-year-report.pdf. Accessed 14 March 2018.

(6.) Cheang KM, Cheok CC. A 17-month review of the care model, service structure, and design of THRIVE, a community mental health initiative in northern Singapore. East Asian Arch Psychiatry 2015;25:168-74.

(7.) Kwai Chung Hospital. Practice Guide: Common Mental Disorder Clinic in Kowloon West Cluster. 2017.

(8.) Kroenke K, Spitzer RL, Williams JB. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med 2001;16:606-13. Crossref

(9.) Spitzer RL, Kroenke K, Williams JB, Lowe B. A brief measure for assessing generalized anxiety disorder: the GAD-7. Arch Intern Med 2006;166:1092-7. Crossref

(10.) Yu X, Tam WW, Wong PT, Lam TH, Stewart SM. The Patient Health Questionnaire-9 for measuring depressive symptoms among the general population in Hong Kong. Compr Psychiatry 2012;53:95-102. Crossref

(11.) Kroenke K, Spitzer RL, Williams JB, Monahan PO, Lowe B. Anxiety disorders in primary care: prevalence, impairment, comorbidity, and detection. Ann Intern Med 2007;146:317-25. Crossref

(12.) Gyani A, Shafran R, Layard R, Clark DM. Enhancing recovery rates: lessons from year one of IAPT. Behav Res Ther 2013;51:597-606. Crossref

(13.) Gater R, Tansella M, Korten A, Tiemens BG, Mavreas VG, Olatawura MO. Sex differences in the prevalence and detection of depressive and anxiety disorders in general health care settings: report from the World Health Organization Collaborative Study on Psychological Problems in General Health Care. Arch Gen Psychiatry 1998;55:405-13. Crossref

(14.) Clark DM, Layard R, Smithies R, Richards DA, Suckling R, Wright B. Improving access to psychological therapy: initial evaluation of two UK demonstration sites. Behav Res Ther 2009;47:910-20. Crossref

WK Lee, FRCPsych (UK), FHKAM (Psychiatry), FHKCPsych, Chief of Service & Consultant Psychiatrist, Division II, Kwai Chung Hospital, Hong Kong SAR, China

Alison Lo, FRCPsych, FHKAM (Psychiatry), FHKCPsy, Chief of Service, Division I, Kwai Chung Hospital, HKSAR

George Chong, PhD (Clin Psy), Senior Clinical Psychologist, Kwai Chung Hospital, Hong Kong SAR, China

SYS Chang, PhD, FHKPS Reg Psych (Clin), BPS CPsychol, Deputizing Senior Clinical Psychologist, Kwai Chung Hospital, Hong Kong SAR, China Vivien Lu, FHKAM (Psychiatry), FHKCPsych, MRCPsych, MBBS (HK), Kwai Chung Hospital, Hong Kong SAR, China

PLI Yip, FHKAM (Psychiatry), FHKCPsych, MBBS (HK), MRes (Med) (HK), Kwai Chung Hospital, Hong Kong SAR, China

CMK Liu, MSocSc (Clin Psy), Clinical Psychologist, Kwai Chung Hospital, Hong Kong SAR, China

Michelle Leung, MSocSc (Clin Psy), Clinical Psychologist, Kwai Chung Hospital, Hong Kong SAR, China

CM Chung, M (Nursing), Ward Manager, Kwai Chung Hospital, Hong Kong SAR, China

KY Wong, BSc (Nursing), Advanced Practice Nurse (Psy), Kwai Chung Hospital, Hong Kong SAR, China

YYE Yeung, MSc (Health Education and Health Promotion), Occupational Therapist, Kwai Chung Hospital, Hong Kong SAR, China

SMA Chan, MPhil (Rehabilitation Science), Occupational Therapist, Kwai Chung Hospital, Hong Kong SAR, China

YS Ngai, M (Nursing), Advanced Practice Nurse (Psy), Kwai Chung Hospital, Hong Kong SAR, China

PS Wong, BN, MN, Kwai Chung Hospital, Hong Kong SAR, China

TL Lo, FRCPsych, FHKAM (Psychiatry), FHKCPsy, Hospital Chief Executive, Kwai Chung Hospital, Hong Kong SAR, China.

Address for correspondence: Dr George Chong, Senior Clinical Psychologist, Room 408, Block J, Kwai Chung Hospital, Lai King Hill Road, Kwai Chung, Hong Kong. Email: chonhc01@ha.org.hk

Submitted: 14 March 2018; Accepted: 3 August 2018

https://doi.org/10.12809/eaap1822
Table 1. Psychosocial intervention programme.

Intervention                                  Details

Nursing intervention
 Supportive counselling    Provide a safe and reliable environment for
                           patients to talk about feelings and develop
                           empathy, trusting relationships, and
                           effective communication
 Psychiatric nurse clinic  Provide education and skill training to
 (insomnia)                facilitate sleep hygiene
 Medication management     Enhance patients' understanding of the
                           treatment plan to improve treatment adherence
 Guided self-help for
 worry
 Guided self-help for      Provide evidence-based, time-limited,
 depression                low-intensity psychological intervention
 Guided self-help for      using psychoeducational materials for target
 assertiveness             symptom management with regular direct
 Guided self-help for      guidance from trained mental health
 sleep problems            professionals
 Guided self-help for
 anxiety (relaxation)
 Guided self-help for
 mood management
 (irritability)

Occupational therapy
intervention
 Changeways programme for  Explore emotional management and develop
 positive thinking         adaptive alternatives

 Discover the new ME for   Explore personal strengths and meaning via
 strength development      positive psychology

 Stress management for     Use of appropriate stress management and
 relationship and work     positive psychology skills to deal with
                           problems in work and interpersonal
                           relationships
 Lifestyle redesign
 programme for positive    Assist patients to restructure lifestyle for
 living                    leisure development and enhance their
                           functional roles for meaningful engagement
 Resilience and optimism   Improve patients' ability to withstand stress
 for motivation and        by enhancing resilience and positive thinking
 change                    for life skills development

Clinical psychology
intervention
 Cognitive behavioural     For patients with mild to moderate panic
 therapy for panic         attacks
 disorder
 Cognitive behavioural     For patients with mild to moderate
 therapy for generalised   generalised anxiety disorder
 anxiety disorder
 Cognitive behavioural     For patients with mild to moderate depressive
 therapy / interpersonal   mood
 psychotherapy for
 depression
 Cognitive behavioural     For patients with mild to moderate specific
 therapy for specific      phobia
 phobias
 Supportive psychotherapy  For patients with mild to moderate adjustment
                           disorder

Table 2. Diagnoses and exit status of patients after treatment at
Common Mental Disorder Clinics.

Diagnosis                          No. (%) of  Exit status, No. (%) of
                                    patients          patients
                                   (n = 533)   Step-down  Discharge
                                                           without
                                                          follow-up

Depressive disorder                125 (23.5)  23 (18.4)   55 (44)
Adjustment disorder                 98 (18.4)  14 (14.3)   70 (71.4)
Non-organic sleep disorders         85 (15.9)  17 (20)     52 (61.2)
Mixed anxiety depressive disorder   70 (13.1)  16 (22.9)   34 (48.6)
Generalised anxiety disorder        65 (12.2)  12 (18.5)   32 (49.2)
Other anxiety disorders             24 (4.5)    5 (20.8)   11 (45.8)
Other psychiatric diagnosis         19 (3.6)    0 (0.0)     4 (21.1)
Panic disorder/agoraphobia          17 (3.2)    4 (23.5)    7 (41.2)
Obsessive compulsive disorder        3 (0.6)    1 (33.3)    0 (0.0)
Post-traumatic stress disorder       2 (0.4)    0 (0.0)     1 (50.0)
No psychiatric diagnosis            25 (4.7)    0 (0.0)    24 (96.0)
Total                              533 (100)   92 (17.3)  290 (54.4)

Diagnosis                          Exit status, No. (%) of
                                          patients
                                     Step-up     Others
                                                (private)

Depressive disorder                  47 (37.6)   0 (0)
Adjustment disorder                  14 (14.3)   0 (0)
Non-organic sleep disorders          14 (16.5)   2 (2.4)
Mixed anxiety depressive disorder    20 (28.6)   0 (0)
Generalised anxiety disorder         21 (32.3)   0 (0)
Other anxiety disorders               8 (33.3)   0 (0)
Other psychiatric diagnosis          15 (78.9)   0 (0.0)
Panic disorder/agoraphobia            6 (35.3)   0 (0.0)
Obsessive compulsive disorder         2 (66.7)   0 (0.0)
Post-traumatic stress disorder        1 (50.0)   0 (0.0)
No psychiatric diagnosis              1 (4.0)    0 (0.0)
Total                               149 (28.0)   2 (0.4)

Table 3. Patient Health Questionnaire-9 (PHQ-9) and Generalized Anxiety
Disorder 7-item scale (GAD-7) scores before and after treatment.

Depressive and anxiety symptom          Pre-treatment (n = 533) (*)

PHQ-9 score for depressive symptoms          11.06 [+ or -] 6.45
Severity
 Normal (0-4)                                90 (16.9)
 Mild (5-9)                                 149 (28)
 Moderate (10-14)                           134 (25.1)
 Moderately severe (15-19)                   96 (18)
 Severe ([greater than or equal to]20)       64 (12)
GAD-7 score for anxiety symptoms              9.94 [+ or -] 5.97
Severity
 Normal (0-4)                               111 (20.8)
 Mild (5-9)                                 159 (29.8)
 Moderate (10-14)                           135 (25.3)
 Severe ([greater than or equal to]15)      128 (4.0)

Depressive and anxiety symptom          Post-treatment (n = 533) (*)

PHQ-9 score for depressive symptoms           7.55 [+ or -] 6.64
Severity
 Normal (0-4)                               226 (42.4)
 Mild (5-9)                                 131 (24.6)
 Moderate (10-14)                            93 (17.4)
 Moderately severe (15-19)                   42 (7.9)
 Severe ([greater than or equal to]20)       41 (7.7)
GAD-7 score for anxiety symptoms              6.54 [+ or -] 5.86
Severity
 Normal (0-4)                               257 (48.2)
 Mild (5-9)                                 136 (25.5)
 Moderate (10-14)                            78 (14.6)
 Severe ([greater than or equal to]15)       62 (11.6)

(*) Data are presented as mean [+ or -] standard deviation or No. (%)
of patients.

Table 4. Predictors for exit status (n = 531).

Predictor                              Odds ratio (95%     p Value
                                     confidence interval)

(Intercept)                          3.008 (1.536-6.029)
Service period at Common Mental
Disorder Clinics                     0.993 (0.988-0.998)    0.010
No. of days waiting until
initial intake                       0.999 (0.998-1.000)    0.191
Whether psychiatric medication was
prescribed during initial intake     2.952 (1.301-6.969)    0.011
Whether psychiatric medication was
prescribed at last follow-up         4.538 (1.994-11.126)  <0.001
Generalised Anxiety Disorder 7-item
scale score at last follow-up        1.078 (1.025-1.383)    0.005
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Title Annotation:Original Article
Author:Lee, W.K; Lo, Alison; Chong, George; Chang, S.Y.S.; Lu, Vivien; Yip, P.L.I.; Liu, C.M.K.; Leung, Mic
Publication:East Asian Archives of Psychiatry
Article Type:Report
Geographic Code:9CHIN
Date:Sep 1, 2019
Words:3856
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