Randomized Controlled Trial on Precision Mental Health

Mental Health Issue Clinical Trial

Official title:

Randomized Controlled Trial on Precision Mental Health

Clinical Trial Details — Status: Not yet recruiting

Administrative data

• NCT number: NCT05825040
• Other study ID #: WMHICS-HK
• Status: Not yet recruiting
• Phase: N/A
• Start date: September 1, 2023
• Est. completion date: December 31, 2025

Study information

• Verified date: August 2023
• Source: Chinese University of Hong Kong
• Contact: Winnie WS Mak
• Phone: +852 39436577
• Email: wwsmak[@]cuhk.edu.hk
• Is FDA regulated: No
• Study type: Interventional

Clinical Trial Summary

The current study aims to evaluate the effectiveness of different online psychological interventions, including guided and unguided transdiagnostic cognitive behavioural therapy, and unguided mindfulness-based intervention, on mental well-being in comparison to waitlist control. It is hypothesized that participants with the guided psychological intervention will show (H1) a greater reduction in mental health symptoms, and (H2) better mental well-being compared with participants with unguided psychological intervention and the control condition.

Description:

In Hong Kong, insufficient resources in the current public health system lead to a long waiting time. Mental health services provided by the public health system mainly rely on traditional one-to-one face-to-face sessions. In the past 12 months, there were 47,879 new bookings in public psychiatry outpatient clinics and the longest waiting time was 94 weeks. Priority is always given to people with more severe mental health issues, which causes long waiting time for people with mild mental health symptoms. Untreated mental health issues can be escalated to more severe symptoms. Thus, in addition to treating mental illness, preventing common mental health issues and fostering mental health self-care in the general population are crucial to promote public mental health and reduce the illness burden in society.

Rather than resorting to mental health professionals for face-to-face service to treat common mental health concerns, digital technology provides a highly scalable and accessible means through which individuals can access mental health resources for self-care. Internet-delivered psychological therapy is one of the viable options for this situation. Internet-delivered cognitive behavioural therapy (ICBT) has been recommended by the NICE guidelines as one of the low-intensity interventions for people with depression and anxiety. Online scientific evidence-based psychological interventions provide solutions for the service users on their mental well-being issues without practical burdens resulted from long waiting time, high expenses, and stigmatization.

Internet-delivered mindfulness-based intervention (MBI) have emerged as a promising approach in reducing depressive and anxiety symptoms and improving mental well-being. A meta-analysis found that online MBIs had beneficial impact on depression, anxiety, well-being and mindfulness. It also found that guided online MBIs had larger effects on stress and mindfulness compared to unguided MBIs.

In this study, participants will be recruited through (1) advertising on online networking platforms (e.g., Facebook and Instagram), (2) mass mailing at investigator's institutions, and (3) snowball sampling.

Upon completing the screening and pre-evaluation questionnaire, participants will be randomly assigned to one of the groups based on computer-generated random digits. They will complete 5 more sets of questionnaires, including a mid-evaluation 4 weeks after group allocation, a post-evaluation 8 weeks after group allocation, and three follow-up questionnaires at 16 weeks, 6 months, and 12 months after group allocation. In experimental groups, participants will complete guided or self-guided transdiagnostic cognitive behavioural therapy, or self-guided mindfulness-based intervention within 8 weeks. In the waitlist control group, participants are to refrain from participating in psychological intervention until they finish the follow-up questionnaire.

Recruitment information / eligibility

• Status: Not yet recruiting
• Enrollment: 320
• Est. completion date: December 31, 2025
• Est. primary completion date: May 31, 2025
• Accepts healthy volunteers: No
• Gender: All
• Age group: 17 Years and older

Eligibility

Inclusion Criteria:

• 17 years old or above

• Able to read Chinese or English

• With internet connection and able to access the internet

• Does not register to Jockey Club TourHeart+ Project or participate in related research projects

• With moderate-severe GAD-7 a/o moderate-severe PHQ-9

Exclusion Criteria:

• People who are under 17 years old

• Cannot access the internet

• Existing users of Jockey Club TourHeart+ Project or participate in related research

• Without moderate-severe depressive or anxiety symptoms

• With suicidal risk

Related Conditions & MeSH terms

• Mental Health Issue
• Mental Health Wellness 1
• Mental Well-being

Intervention

Behavioral:
• Online guided transdiagnostic cognitive behavioural therapy
The contents of guided transdiagnostic cognitive behavioural therapy are developed by clinical psychologists and psychological well-being officers. The intervention consists of 8 modules. Contents include emotional awareness, physical sensation, emotion-driven behavior, behavioral activation, worry, cognitive restructuring, behavioral experiment, and relapse prevention. Customized guidance will be provided by coaches once a week based on participants' performance
• Online self-guided transdiagnostic cognitive behavioural therapy
The contents of self-guided transdiagnostic cognitive behavioural therapy are developed by clinical psychologists and psychological well-being officers. The intervention consists of 8 modules. Contents include emotional awareness, physical sensation, emotion-driven behavior, behavioral activation, worry, cognitive restructuring, behavioral experiment, and relapse prevention. No customized guidance will be provided to participants in the self-guided group.
• Online self-guided mindfulness-based intervention
The contents of online self-guided mindfulness-based intervention are developed by clinical psychologists and psychological well-being officers. The intervention consists of 6 modules. Contents include mindfulness and auto-pilot, react and respond, aversion, craving, equanimity, and 'suffering', thoughts and letting go, starting with loving kindness, and mindfulness in life.

Locations

Country	Name	City	State
Hong Kong	Diversity and Well-being Lab, Dept of Psychology, CUHK	Sha Tin	N.t.

Sponsors (1)

Lead Sponsor	Collaborator
Chinese University of Hong Kong

Country where clinical trial is conducted

Hong Kong, 

References & Publications (26)

Abd-Alrazaq AA, Alajlani M, Alalwan AA, Bewick BM, Gardner P, Househ M. An overview of the features of chatbots in mental health: A scoping review. Int J Med Inform. 2019 Dec;132:103978. doi: 10.1016/j.ijmedinf.2019.103978. Epub 2019 Sep 25. — View Citation

Carleton RN, Norton MA, Asmundson GJ. Fearing the unknown: a short version of the Intolerance of Uncertainty Scale. J Anxiety Disord. 2007;21(1):105-17. doi: 10.1016/j.janxdis.2006.03.014. Epub 2006 May 2. — View Citation

Chio, F. H., Lai, M. H., & Mak, W. W. (2018). Development of the Nonattachment Scale-Short Form (NAS-SF) using item response theory. Mindfulness, 9, 1299-1308.

Choi I, Andrews G, Sharpe L, Hunt C. Help-seeking characteristics of Chinese- and English-speaking Australians accessing Internet-delivered cognitive behavioural therapy for depression. Soc Psychiatry Psychiatr Epidemiol. 2015 Jan;50(1):89-97. doi: 10.1007/s00127-014-0956-3. Epub 2014 Sep 6. — View Citation

Dorow M, Lobner M, Pabst A, Stein J, Riedel-Heller SG. Preferences for Depression Treatment Including Internet-Based Interventions: Results From a Large Sample of Primary Care Patients. Front Psychiatry. 2018 May 17;9:181. doi: 10.3389/fpsyt.2018.00181. eCollection 2018. — View Citation

Gamez W, Chmielewski M, Kotov R, Ruggero C, Suzuki N, Watson D. The brief experiential avoidance questionnaire: development and initial validation. Psychol Assess. 2014 Mar;26(1):35-45. doi: 10.1037/a0034473. Epub 2013 Sep 23. — View Citation

Gross JJ, John OP. Individual differences in two emotion regulation processes: implications for affect, relationships, and well-being. J Pers Soc Psychol. 2003 Aug;85(2):348-62. doi: 10.1037/0022-3514.85.2.348. — View Citation

He J, Liu Y, Cheng C, Fang S, Wang X, Yao S. Psychometric Properties of the Chinese Version of the 10-Item Ruminative Response Scale Among Undergraduates and Depressive Patients. Front Psychiatry. 2021 May 26;12:626859. doi: 10.3389/fpsyt.2021.626859. eCollection 2021. — View Citation

Hospital Authority. (n.d.). Waiting time for new case booking at Psychiatry specialist out-patient clinics. Retrieved March 20, 2022, from https://www.ha.org.hk/visitor/sopc_waiting_time.asp?id=7&lang=ENG

Hou J, Wong SY, Lo HH, Mak WW, Ma HS. Validation of a Chinese version of the Five Facet Mindfulness Questionnaire in Hong Kong and development of a short form. Assessment. 2014 Jun;21(3):363-71. doi: 10.1177/1073191113485121. Epub 2013 Apr 16. — View Citation

Lam LC, Wong CS, Wang MJ, Chan WC, Chen EY, Ng RM, Hung SF, Cheung EF, Sham PC, Chiu HF, Lam M, Chang WC, Lee EH, Chiang TP, Lau JT, van Os J, Lewis G, Bebbington P. 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 Sep;50(9):1379-88. doi: 10.1007/s00127-015-1014-5. Epub 2015 Feb 8. — View Citation

Mak WW, Chan AT, Cheung EY, Lin CL, Ngai KC. Enhancing Web-based mindfulness training for mental health promotion with the health action process approach: randomized controlled trial. J Med Internet Res. 2015 Jan 19;17(1):e8. doi: 10.2196/jmir.3746. — View Citation

Mak WW, Chio FH, Chan AT, Lui WW, Wu EK. The Efficacy of Internet-Based Mindfulness Training and Cognitive-Behavioral Training With Telephone Support in the Enhancement of Mental Health Among College Students and Young Working Adults: Randomized Controlled Trial. J Med Internet Res. 2017 Mar 22;19(3):e84. doi: 10.2196/jmir.6737. — View Citation

Mak WW, Tong AC, Yip SY, Lui WW, Chio FH, Chan AT, Wong CC. Efficacy and Moderation of Mobile App-Based Programs for Mindfulness-Based Training, Self-Compassion Training, and Cognitive Behavioral Psychoeducation on Mental Health: Randomized Controlled Noninferiority Trial. JMIR Ment Health. 2018 Oct 11;5(4):e60. doi: 10.2196/mental.8597. — View Citation

Manos RC, Kanter JW, Luo W. The behavioral activation for depression scale-short form: development and validation. Behav Ther. 2011 Dec;42(4):726-39. doi: 10.1016/j.beth.2011.04.004. Epub 2011 Jun 1. — View Citation

Ng SS, Lo AW, Leung TK, Chan FS, Wong AT, Lam RW, Tsang DK. Translation and validation of the Chinese version of the short Warwick-Edinburgh Mental Well-being Scale for patients with mental illness in Hong Kong. East Asian Arch Psychiatry. 2014 Mar;24(1):3-9. — View Citation

NICE Guidance. (2018). Common mental health problems: Identification and pathways to care. Retrieved from https://www.nice.org.uk/guidance/cg123/resources/common-mental-health-problems-identification-and-pathways-to-care-pdf-35109448223173

Resnicow K, Zhou Y, Hawley S, Jimbo M, Ruffin MT, Davis RE, Shires D, Lafata JE. Communication preference moderates the effect of a tailored intervention to increase colorectal cancer screening among African Americans. Patient Educ Couns. 2014 Dec;97(3):370-5. doi: 10.1016/j.pec.2014.08.013. Epub 2014 Sep 3. — View Citation

Schoofs, H., Hermans, D., & Raes, F. (2010). Brooding and reflection as subtypes of rumination: Evidence from confirmatory factor analysis in nonclinical samples using the Dutch Ruminative Response Scale. Journal of Psychopathology and Behavioral Assessment, 32, 609-617.

Shek DTL, Dou D, Zhu X. Prevalence and Correlates of Mental Health of University Students in Hong Kong: What Happened One Year After the Occurrence of COVID-19? Front Public Health. 2022 Jun 29;10:857147. doi: 10.3389/fpubh.2022.857147. eCollection 2022. — View Citation

Smit ES, Zeidler C, Resnicow K, de Vries H. Identifying the Most Autonomy-Supportive Message Frame in Digital Health Communication: A 2x2 Between-Subjects Experiment. J Med Internet Res. 2019 Oct 30;21(10):e14074. doi: 10.2196/14074. — View Citation

Spijkerman MP, Pots WT, Bohlmeijer ET. Effectiveness of online mindfulness-based interventions in improving mental health: A review and meta-analysis of randomised controlled trials. Clin Psychol Rev. 2016 Apr;45:102-14. doi: 10.1016/j.cpr.2016.03.009. Epub 2016 Apr 1. — View Citation

Stewart-Brown S, Tennant A, Tennant R, Platt S, Parkinson J, Weich S. Internal construct validity of the Warwick-Edinburgh Mental Well-being Scale (WEMWBS): a Rasch analysis using data from the Scottish Health Education Population Survey. Health Qual Life Outcomes. 2009 Feb 19;7:15. doi: 10.1186/1477-7525-7-15. — View Citation

Sun Y, Luk TT, Wang MP, Shen C, Ho SY, Viswanath K, Chan SSC, Lam TH. The reliability and validity of the Chinese Short Warwick-Edinburgh Mental Well-being Scale in the general population of Hong Kong. Qual Life Res. 2019 Oct;28(10):2813-2820. doi: 10.1007/s11136-019-02218-5. Epub 2019 May 29. — View Citation

Taylor S, Zvolensky MJ, Cox BJ, Deacon B, Heimberg RG, Ledley DR, Abramowitz JS, Holaway RM, Sandin B, Stewart SH, Coles M, Eng W, Daly ES, Arrindell WA, Bouvard M, Cardenas SJ. Robust dimensions of anxiety sensitivity: development and initial validation of the Anxiety Sensitivity Index-3. Psychol Assess. 2007 Jun;19(2):176-88. doi: 10.1037/1040-3590.19.2.176. — View Citation

Treynor, W., Gonzalez, R., & Nolen-Hoeksema, S. (2003). Rumination reconsidered: A psychometric analysis. Cognitive therapy and research, 27, 247-259.

* Note: There are 26 references in all — Click here to view all references

Outcome

Type	Measure	Description	Time frame	Safety issue
Primary	Patient Health Questionnaire	It includes 9 items to assess the extent to which respondents are bothered by depression-related symptoms using a 4-point scale from 0 (not at all) to 3 (nearly every day). PHQ-9 has been validated and used widely in the general population for screening and measuring depression severity. Scores of 5, 10, 15, and 20 denote mild, moderate, moderately severe, and severe levels of depression respectively (range: 0-27). PHQ-9 has sensitivity of 0.88 and specificity of 0.88 in detecting major depressive disorder (MDD) at a cut-off of 10. The internal consistency reliability of the Chinese version of the scale was 0.86.	8th week
Primary	Patient Health Questionnaire	It includes 9 items to assess the extent to which respondents are bothered by depression-related symptoms using a 4-point scale from 0 (not at all) to 3 (nearly every day). PHQ-9 has been validated and used widely in the general population for screening and measuring depression severity. Scores of 5, 10, 15, and 20 denote mild, moderate, moderately severe, and severe levels of depression respectively (range: 0-27). PHQ-9 has sensitivity of 0.88 and specificity of 0.88 in detecting major depressive disorder (MDD) at a cut-off of 10. The internal consistency reliability of the Chinese version of the scale was 0.86.	16th week
Primary	Generalized Anxiety Disorder Assessment	It is a 7-item scale to assess the extent to which respondents are bothered by anxiety-related symptoms using a 4-point scale from 0 (not at all) to 3 (nearly every day). Scores of 5, 10, and 15 denote the mild, moderate, and severe levels of anxiety respectively (range: 0-21). At a cut-off of 10, GAD-7 has sensitivity of 0.89 and specificity of 0.82 in detecting generalized anxiety disorder (GAD). The internal consistency of the Chinese version was 0.93.	8th week
Primary	Generalized Anxiety Disorder Assessment	It is a 7-item scale to assess the extent to which respondents are bothered by anxiety-related symptoms using a 4-point scale from 0 (not at all) to 3 (nearly every day). Scores of 5, 10, and 15 denote the mild, moderate, and severe levels of anxiety respectively (range: 0-21). At a cut-off of 10, GAD-7 has sensitivity of 0.89 and specificity of 0.82 in detecting generalized anxiety disorder (GAD). The internal consistency of the Chinese version was 0.93.	16th week
Primary	The Short Warwick-Edinburgh Mental Wellbeing Scale	It contains 7 positively phrased items on a 5-point Likert scale from 1 (none of the time) to 5 (all of the time). Total scores ranged from 7 to 35, where higher scores indicated higher overall mental well-being. SWEMWBS satisfies the strict criteria for measurement demanded by the RASCH model and is preferable to the original 14-item WEMWBS scale. The Chinese version of SWEMWBS is reliable (Cronbach's alpha = 0.89) and has been validated among a sample in Hong Kong.	8th week
Primary	The Short Warwick-Edinburgh Mental Wellbeing Scale	It contains 7 positively phrased items on a 5-point Likert scale from 1 (none of the time) to 5 (all of the time). Total scores ranged from 7 to 35, where higher scores indicated higher overall mental well-being. SWEMWBS satisfies the strict criteria for measurement demanded by the RASCH model and is preferable to the original 14-item WEMWBS scale. The Chinese version of SWEMWBS is reliable (Cronbach's alpha = 0.89) and has been validated among a sample in Hong Kong.	16th week
Secondary	The Brief Experiential Avoidance Questionnaire (BEAQ)	The Brief Experiential Avoidance Questionnaire includes 15 items to measure experiential avoidance in 2 subscales: cognitive avoidance and behavioral avoidance. Items are rated on a 6-point Likert scale from 1 (strongly disagree) to 6 (strongly agree). Item 6 is reverse-coded. The BEAQ shows good reliability (Cronbach's alpha = 0.80-0.89) for various samples.	8th week
Secondary	The Brief Experiential Avoidance Questionnaire (BEAQ)	The Brief Experiential Avoidance Questionnaire includes 15 items to measure experiential avoidance in 2 subscales: cognitive avoidance and behavioral avoidance. Items are rated on a 6-point Likert scale from 1 (strongly disagree) to 6 (strongly agree). Item 6 is reverse-coded. The BEAQ shows good reliability (Cronbach's alpha = 0.80-0.89) for various samples.	16th week
Secondary	Behavioral Activation for Depression Scale - Short Form	The 9-item short version of Behavioral Activation for Depression Scale measures changes in activation and avoidance in the previous week. Items are rated on a 7-point Likert scale from 0 (not at all) to 6 (completely). Items 1, 6, 7, and 8 are reverse-coded. Higher scores on the total score represent increased activation. The BADS-SF has demonstrated good internal consistency (Cronbach's alpha = 0.82), construct validity, and predictive validity.	8th week
Secondary	Behavioral Activation for Depression Scale - Short Form	The 9-item short version of Behavioral Activation for Depression Scale measures changes in activation and avoidance in the previous week. Items are rated on a 7-point Likert scale from 0 (not at all) to 6 (completely). Items 1, 6, 7, and 8 are reverse-coded. Higher scores on the total score represent increased activation. The BADS-SF has demonstrated good internal consistency (Cronbach's alpha = 0.82), construct validity, and predictive validity.	16th week
Secondary	Intolerance of Uncertainty Scale (Short version)	The Intolerance of Uncertainty Scale - Short Version contains 12 items on a 5-point Likert scale from 1 (not at all characteristic of me) to 5 (entirely characteristic of me). It includes 2 subscales, prospective anxiety and inhibitory anxiety, which measure the approach-oriented and avoidance-oriented responses to uncertainty respectively. IUS-12 shows good reliability (Cronbach's alpha = 0.91) and convergent validity	8th week
Secondary	Intolerance of Uncertainty Scale (Short version)	The Intolerance of Uncertainty Scale - Short Version contains 12 items on a 5-point Likert scale from 1 (not at all characteristic of me) to 5 (entirely characteristic of me). It includes 2 subscales, prospective anxiety and inhibitory anxiety, which measure the approach-oriented and avoidance-oriented responses to uncertainty respectively. IUS-12 shows good reliability (Cronbach's alpha = 0.91) and convergent validity	16th week
Secondary	Emotion Regulation Questionnaire (ERQ)	It is a 10-item survey to assess two emotion-regulation strategies: cognitive reappraisal and expressive suppression. Items are rated on a 7-point Likert scale ranging from 1 (strongly disagree) to 7 (strongly agree). It demonstrated acceptable levels of reliability.	8th week
Secondary	Emotion Regulation Questionnaire (ERQ)	It is a 10-item survey to assess two emotion-regulation strategies: cognitive reappraisal and expressive suppression. Items are rated on a 7-point Likert scale ranging from 1 (strongly disagree) to 7 (strongly agree). It demonstrated acceptable levels of reliability.	16th week
Secondary	Anxiety Sensitivity Index-3	It includes 18 items to measure the degree of physical, cognitive and social concerns about anxiety using a 5-point Likert scale from 0 (very little) to 4 (very much). ASI-3 is reliable (Cronbach's alpha = 0.79-0.91) with good convergent, discriminant and criterion-related validity and is preferable to the original ASI scale.	8th week
Secondary	Anxiety Sensitivity Index-3	It includes 18 items to measure the degree of physical, cognitive and social concerns about anxiety using a 5-point Likert scale from 0 (very little) to 4 (very much). ASI-3 is reliable (Cronbach's alpha = 0.79-0.91) with good convergent, discriminant and criterion-related validity and is preferable to the original ASI scale.	16th week
Secondary	Ruminative response scale-short version	5 items from the brooding subscale are adopted to assess the passive thoughts to compare the current state with unrealistic standards using a 4-point Likert scale from 1 (almost never) to 4 (almost always). The brooding subscale demonstrated reliability (Cronbach's alpha = 0.77) and significant predictivity in depressive symptoms. The Chinese version of the scale was reliable and valid in examining rumination	8th week
Secondary	Ruminative response scale-short version	5 items from the brooding subscale are adopted to assess the passive thoughts to compare the current state with unrealistic standards using a 4-point Likert scale from 1 (almost never) to 4 (almost always). The brooding subscale demonstrated reliability (Cronbach's alpha = 0.77) and significant predictivity in depressive symptoms. The Chinese version of the scale was reliable and valid in examining rumination	16th week
Secondary	Nonattachment Scale-Short Form	Nonattachment Scale-Short Form (NAS-SF) includes 8 items to measure nonattachment using 6-point Likert scale from 1 (strongly disagree) to 6 (strongly agree). It yielded satisfactory internal consistency and validity.	8th week
Secondary	Nonattachment Scale-Short Form	Nonattachment Scale-Short Form (NAS-SF) includes 8 items to measure nonattachment using 6-point Likert scale from 1 (strongly disagree) to 6 (strongly agree). It yielded satisfactory internal consistency and validity.	16th week
Secondary	Need for autonomy	Two items adopted previous studies measure the need for autonomy. Items are rated on a 5-point Likert scale from 1 (completely disagree) to 5 (completely agree)	8th week
Secondary	Patient Health Questionnaire	It includes 9 items to assess the extent to which respondents are bothered by depression-related symptoms using a 4-point scale from 0 (not at all) to 3 (nearly every day). PHQ-9 has been validated and used widely in the general population for screening and measuring depression severity. Scores of 5, 10, 15, and 20 denote mild, moderate, moderately severe, and severe levels of depression respectively (range: 0-27). PHQ-9 has sensitivity of 0.88 and specificity of 0.88 in detecting major depressive disorder (MDD) at a cut-off of 10. The internal consistency reliability of the Chinese version of the scale was 0.86.	6 months
Secondary	Patient Health Questionnaire	It includes 9 items to assess the extent to which respondents are bothered by depression-related symptoms using a 4-point scale from 0 (not at all) to 3 (nearly every day). PHQ-9 has been validated and used widely in the general population for screening and measuring depression severity. Scores of 5, 10, 15, and 20 denote mild, moderate, moderately severe, and severe levels of depression respectively (range: 0-27). PHQ-9 has sensitivity of 0.88 and specificity of 0.88 in detecting major depressive disorder (MDD) at a cut-off of 10. The internal consistency reliability of the Chinese version of the scale was 0.86.	12 months
Secondary	Generalized Anxiety Disorder Assessment	It is a 7-item scale to assess the extent to which respondents are bothered by anxiety-related symptoms using a 4-point scale from 0 (not at all) to 3 (nearly every day). Scores of 5, 10, and 15 denote the mild, moderate, and severe levels of anxiety respectively (range: 0-21). At a cut-off of 10, GAD-7 has sensitivity of 0.89 and specificity of 0.82 in detecting generalized anxiety disorder (GAD). The internal consistency of the Chinese version was 0.93.	6 months
Secondary	Generalized Anxiety Disorder Assessment	It is a 7-item scale to assess the extent to which respondents are bothered by anxiety-related symptoms using a 4-point scale from 0 (not at all) to 3 (nearly every day). Scores of 5, 10, and 15 denote the mild, moderate, and severe levels of anxiety respectively (range: 0-21). At a cut-off of 10, GAD-7 has sensitivity of 0.89 and specificity of 0.82 in detecting generalized anxiety disorder (GAD). The internal consistency of the Chinese version was 0.93.	12 months
Secondary	The Short Warwick-Edinburgh Mental Wellbeing Scale	It contains 7 positively phrased items on a 5-point Likert scale from 1 (none of the time) to 5 (all of the time). Total scores ranged from 7 to 35, where higher scores indicated higher overall mental well-being. SWEMWBS satisfies the strict criteria for measurement demanded by the RASCH model and is preferable to the original 14-item WEMWBS scale. The Chinese version of SWEMWBS is reliable (Cronbach's alpha = 0.89) and has been validated among a sample in Hong Kong.	6 months
Secondary	The Short Warwick-Edinburgh Mental Wellbeing Scale	It contains 7 positively phrased items on a 5-point Likert scale from 1 (none of the time) to 5 (all of the time). Total scores ranged from 7 to 35, where higher scores indicated higher overall mental well-being. SWEMWBS satisfies the strict criteria for measurement demanded by the RASCH model and is preferable to the original 14-item WEMWBS scale. The Chinese version of SWEMWBS is reliable (Cronbach's alpha = 0.89) and has been validated among a sample in Hong Kong.	12 months
Secondary	The Five Facet Mindfulness Questionnaire	It includes 20 items to measure mindfulness in 5 subscales: observing, describing, acting with awareness, nonjudging, and nonreacting. Items are rated on a 5-point scale from 1 (never or very rarely true) to 5 (very often true or always true). The FFMQ-C shows good test-retest reliability (0.88) and high internal consistency (Cronbach's alpha = 0.80-0,83) for various samples.	8th week
Secondary	The Five Facet Mindfulness Questionnaire	It includes 20 items to measure mindfulness in 5 subscales: observing, describing, acting with awareness, nonjudging, and nonreacting. Items are rated on a 5-point scale from 1 (never or very rarely true) to 5 (very often true or always true). The FFMQ-C shows good test-retest reliability (0.88) and high internal consistency (Cronbach's alpha = 0.80-0,83) for various samples.	16th week