4.3.1. The socio-demographic information
Information collected included age, gender, education level, marital status, religious belief, occupation, living status and cohabit, household income in recent years, the affordable depression fee with national health insurance, history of an excessively
they feel low. We also use three one-questionnaire to assess patients' self-rated health conditions regarding treatment adherence, self-efficacy, and current recovery.
4.3.2. The five-item Brief Symptoms Rating Scale (BSRS-5)
The five-item Brief Symptoms Rating Scale (BSRS-5) is a self-report questionnaire developed from the Symptom Checlist-90-Revised (SCL-90R) and 50-item Brief Symptom Rating Scale to measure the level of psychological distress (Lee et al., 1990; Lee et al., 2003). The BSRS-5 has been demonstrated to have good reliability and validity in various settings such as psychiatric, general medical, primary care, community, and military (Chen et al., 2005; Lee et al., 2003). The respondents were asked to answer the survey contained the following five items of psychopathology and an additional item in the past week as follows: (1) insomnia; (2) anxiety; (3) hostility;
(4) depression; (5) interpersonal hypersensitivity: inferiority. The additional item assessed the following question, “Do you have any suicide ideation” to assess recent suicide risk. The participants were asked to rate symptoms on a 5-point Likert scale from 0 to 4 (not at all - extremely), and a total score was calculated by computing the first five items. The cut-off points of 5/6, 9/10, 14/15 stand for mild/moderate/severe levels of mental distress. The BSRS-5 showed moderately good predictive validity in community outpatients and daycare patients (Cronbach alpha 0.79 and 0.80, respectively). It has been reported that the BSRS-5, whether self-rated or administered by an interviewer, has satisfactory psychometric properties as a measure to detect psychiatric morbidity and suicidal ideation in both medical and community settings in Taiwan. Further, BSRS-5 is
one of the required measurements used in the aftercare program by gatekeepers in various settings in the Taiwanese Suicide Surveillance System as a screening tool with the name Mood Thermometer to identify psychiatric morbidity and recent suicide ideation as a communication tool and guiding reference to referral cases to mental health professionals (Wu et al., 2020). The study acquired approval and suggestions from Professor Ming-Been Lee and Professor Chia-Yi Wu to adopt this instrument in the Vietnamese population.
4.3.3. Suicidality
Suicidality in this study included the concepts of suicide ideation and a suicide attempt at different time points, such as lifetime, past year, past one month, recent one week, and future suicide intent. In the literature, the term suicide risks indicate a variety of risk factors that lead to completed suicide. However, suicide ideation and a history of suicide attempts are the highest risk factors leading to suicidal behavior. Therefore in this study the terms of suicidality and suicide risks were used interchangeably to indicate suicide ideation and suicide attempt at different time points.
Suicide ideation: to access suicide ideation history researcher asked, “Have you ever thought about suicide during your lifetime/ in the past year/ in the past month?”.
The answers were categorized as “Yes = 1” and “No = 0”. Recent suicide ideation means whether the patient had any suicide ideation over the past week, including today, which is included in item 6 of BSRS-5 mentioned above.
Suicide attempt: patients were asked, “Have you ever tried to hurt yourself/attempt suicide during your lifetime/ in the past year/ in the past month/ in the past week?”. The answers were categorized as “Yes = 1” and “No = 0”. If the patient answer “Yes”, researcher would ask the question to assess the frequency and lethal means with two questions “How many times have you hurt yourself/ attempted suicide in the past?” and “What kind of method that have you used to hurt yourself/ suicide attempt?”
The future suicide intent was accessed with the question “Do you have future suicide intent?” with the Yes/No answer.
Family history of suicide was also accessed with the question “Does anyone in your family (e.g., grandparents, parents, siblings, close relatives, children) havea history of suicidal behaviors?”. With the score as “No,” “Yes, but still alive,” and “Death by suicide.”
4.3.4. Hopelessness
A single-item question was used to assess hopelessness level based on standard methodology for measuring hopelessness. A 5-point Likert scale (score of 0 to 4) answers the question “How often do you have feelings of hopelessness in the past week?”.
4.3.5. The Revised Community Integration Questionnaire (CIQ-R)
The original version of the Community Integration Questionnaire with 15-item (Willer et al., 1994) has been translated into a dozen different languages and widely utilized to assess outcomes of rehabilitation following traumatic brain injury, stroke, spinal cord injury, developmental disabilities, mental illness and provide further direction for clinical or research settings. Through the years, normative CIQ data has provided an anchor to understand how well an individual has re-integrated into their home, social, and productivity roles the following neurotrauma. Then, the revision of the CIQ (CIQ-R) has been expanded to include three questions about the use of technology (e.g., cell phones and social media) since 2014 (Callaway et al., 2014). The 18-item CIQ-R was used to assess life conditions across four dimensions: home integration (1-5), social integration (6-11), productivity (12-15), and electronic social networking (items 16-18) The home integration component had scores ranging from 0 to 2 points, which reflected a person's autonomy in performing home activities; a score of 2 indicates that the majority of home activities were performed by the individual, a score of 1 indicates that some home activities were performed by the individual or family, and a score of 0 indicates that all home activities were performed by the family. The evaluation of social engagement or productivity in the previous month was based on frequency of performance and was scored as 0 (never), 1 (1-4 times), or 2 (five or more times) (over 5 times). Electronic social networking included the frequency of contact with others via the internet, online video links, or text messages, with scores of every day or most days
= 2, nearly every week = 1, and rarely/never = 0. The potential score of CIQ-R range from 0 to 35, with higher scores stand for better integration level or social activity
involvement in actual or online community settings. The researcher has approval from Professor Barry Willey to use this instrument in the Vietnamese population.
4.3.6. Family support
The APGAR is a 5-item instrument used to measure five aspects of family function, e.g., Adaptability, Partnership, Growth, Affection, and Resolve (Smilkstein, 1978). Each item is rated by a 3-point Likert rating scale from 0 (Hardly ever) to 2 (Almost always). The total score is obtained by adding the responses of the five items with a range from 0 to 10, which a higher score indicating better family functioning. The total score is classified into three levels: severely dysfunctional family (0 – 3) , moderately dysfunctional family (4 – 7) , and highly functional family (8 – 10). In Vietnam, the APGAR instrument has been applied as routine screening for mental health disorders such as anxiety, depression, insomnia, and substance abuse in primary healthcare and family medical practice. A recent study shows good internal consistency reliability of the instrument among methadone maintenance patients with Cronbach’s alpha of 0.92 (Long et al., 2020), and 0.83 in present study.
4.3.7. The Brief Resilient Coping Scale (BRCS)
The 4-item scale was designed to assess a person's tendency to deal with stress in a resilient manner, including the evaluation of active loss coping, positive growth, problem-solving, and self-control. (Sinclair & Wallston, 2004). The BRCS includes four items that reflect cognitive and behavioral coping strategies: “I look for creative ways to
alter difficult situations;” “Regardless of what happens to me, I believe I can control my reaction to it;” “I believe I can grow in positive ways by dealing with difficult situations;”
and “I actively look for ways to replace the losses I encounter in life.” Participants are asked to rate the items in response to the following statement: “Consider how well the following statements describe your behavior and actions on a scale from 1 to 5, where 1 means the statement does not describe you at all and 5 means it describes you very well.”
Item ratings are summed to yield a total score ranging from 4 to 20; scores of 4–13, 14–
16, and 17–20 indicate low, medium, and high resilient coping, respectively. Cronbach's alpha (0.69) and test-retest reliability (0.71) demonstrated satisfactory reliability for the BRCS among patients with rheumatoid arthritis in a prior study. In addition, the BRCS was found to have significant associations with supplementary personal coping resources, adaptive pain-coping behaviors, and psychological well-being (Sinclair &
Wallston, 2004). The researcher has approval from Professor Vaughn G Sinclair to apply this instrument to the Vietnamese population.
4.3.8. EuroQoL 5-Dimensions 5-Levels (EQ-5D-5L)
The EQ-5D-5L instrument comprises a descriptive system and a visual analog scale (EQ-VAS). The questionnaire classifies health into five dimensions: mobility, self-care, usual activities, pain/discomfort, and anxiety/ depression. Respondents were asked to describe their current health using five levels of severity (code 1 to code 5 stand for no problems to unable to/ extreme problems). The result states from 5 (perfect health) to 25 (worse health). The score of EQ-VAS ranges from 0 to 100, from “the worst health
you can imagine” to “the best health you can imagine”. The EQ-5D-5L was introduced in Vietnam in 2012 with a wide range of target populations for example, people living with HIV, the elderly, people with non-communicable diseases, and young people suffering from internet addiction. However, until 2020 the EQ-5D-5L was developed value set based on social preferences obtained from a nationally representative sample in Vietnam (Mai et al., 2020). The researcher got permission to apply the EQ-5D-5L Vietnamese version in the present study by the author Vu Quynh Mai.
4.3.9. The Patient Health Questionnaire (PHQ-9)
The Patient Health Questionnaire (PHQ-9) (Kroenke et al., 2001) is a self-administered version of PRIME-MD diagnostic instrument for common mental health disorders. The PHQ-9 is the depression module which scores each of the 9 DSM-IV criteria as 0=Not at all, 1=Several days, 2=More than half the days, 3=Nearly every day in the past two weeks. In Vietnam, the validity and reliability of the Vietnamese version of PHQ-9 were assessed by Dang Duy Thanh et al. in 2011 (Dang D.T, 2011). The internal consistency of the scale returned to a Cronbach’s alpha coefficient of around 0.82 to 0.86 both in the community and hospital. We only used this questionnaire for validation purposes.