Easy Warning System

A team led by Professor Ng Siu Man in the Department of Social Work and Social Administration, have made a major breakthrough in the detection of risk and prevention of relapse in schizophrenia with the development of an innovative assessment scale. Unlike existing assessments, the self-report scale is concise, takes only two minutes to complete and yields results immediately. 

Professor Ng started working on a new scale – called the Concise Chinese Level of Expressed Emotion Scale – because of a long-held commitment to enhancing the outcomes of schizophrenia, a serious mental illness with psychotic symptoms including auditory hallucination and delusion. The illness is often chronic and more than 70 per cent of patients in Hong Kong’s psychiatric hospitals and community mental health services are people with schizophrenia. 

“A crucial task in the treatment is to minimise relapses which are a life-long threat to persons suffering from schizophrenia,” said Professor Ng. “In the development and validation process of the assessment scale, I worked closely with the Departments of Medical Social Work and Psychiatry of the Eastern Hospital.” 

What the scale identifies is high ‘expressed emotions’ (EE) by the patient’s family, which, together with drug non-compliance, is the biggest risk factor for a relapse. Expressed emotions are recognised as a measure of the family environment based on how relatives of a psychiatric patient spontaneously talk about that patient. 

“High expressed emotions can be defined as family members engaging in behaviour such as emotional over-involvement and protectiveness of the patient, hostility or over-criticism,” said Professor Ng. These are the crunch factors signalling a possible relapse, which can be treated, for example, by family therapy and psycho-education, if seen early enough.”

Indicator of behaviour 

A measure of the EE criterion gives an indicator of the behaviour and attitudes and coping mechanisms adopted, and high EE attitudes of family members are considered as a significant determinant of recurrence in the short term in schizophrenia. 

The most widely used existing scale is the Camberwell Family Interview (CFI) assessment, which was established in 1965 by George Brown and Michael Rutter while working at the Institute of Psychiatry in Camberwell, London. For the CFI, the initial test interview takes one to two hours and needs to be carried out by specially trained staff working with the patient plus a family member in a clinical setting. The interview is audiotaped and then assessed by other trained staff, with each assessment also taking several hours. 

“CFI is the best established assessment tool and is widely regarded as the gold standard in identifying family high expressed expressions,” said Professor Ng. “However, CFI is impractical for psychiatric clinics and community mental health centres which don’t have the expertise and/or time to administer the tests. Moreover, performing CFI requires the cooperation of a family member, which is not always possible.” 

By contrast, Professor Ng’s assessment tool only takes the patient a few minutes to respond and does not require the involvement of family members. “The clinics/community mental health centres don’t need specially trained staff to use it,” he said. “It has high agreement with CFI in detecting family high expressed emotions.” 

The scale took 10 years to develop and underwent two phases of validation. In the first phase the team recruited nearly 300 patients for refining the scale and making sure it is concise enough and comprehensible to people with chronic schizophrenia, and in parallel has excellent basic psychometric properties, such as a robust factor loading pattern and high internal consistency. 

“In the second phase of validation, we successfully followed 101 patients for one year,” said Professor Ng. “Using CFI as our benchmark, the 12-item scale achieved 90 per cent accuracy in identifying high EE. Moreover, it has been shown to be highly predictive of elevated relapse rate – patients whom the scale revealed as being in high EE families showed a one-year relapse rate 6.3 times higher than those not.” 

The scale has already been successfully implemented in psychiatric treatment and rehabilitation units in Hong Kong, and has been adopted by overseas institutions including Peking University, National Taiwan University, Taiwan Mental Health Social Work Society and the Fuhong Society of Macau. 

Professor Ng is continuing work on refining and adapting the scale. “Cultural factors play a key role in determining the cutoff point for various factors on the scale,” he said. “For example, in our Hong Kong Chinese sample, the cutoff point for ‘Emotional-Over-Involvement’, which is a component of family high expressed emotions, is 15 on a scale with a range of 4 to 16. 

“Such a cutoff point is extremely high, which seems to reflect Chinese families’ tolerance with high emotional involvement. I expect this cutoff will be significantly lower in cultures which are more individually-oriented rather than collectively-oriented. I am currently pursuing validation of my tool in different cultures.”