Asian Journal of Psychiatry

Editorial Board

2012-03-01

Early intervention in psychosis: Perspectives on Asian studies

G. Venkatasubramanian, Matcheri S. Keshavan — 2012-03-05

The Kraepelinian view of schizophrenia as a chronic debilitating disorder with uniformly poor outcome has been challenged by the observations in various prospective studies; these studies report that the clinical outcome in schizophrenia is heterogeneous with about 30–50% of patients having good outcome (). The heterogeneity in outcome is shared by heterogeneity in factors that influence outcome; duration of untreated psychosis is considered one of the more important factors. A seminal work highlighted the proposition that schizophrenia patients who received antipsychotic treatment earlier had better outcome than those who did not (). This view was supported by two comprehensive meta-analytic reviews which concluded that shorter duration of untreated psychosis was associated with modest positive effect on outcome (). These findings are significant especially because duration of untreated psychosis is a modifiable factor. Indeed, this ‘modifiability’ dimension provided the much-needed impetus towards research on methods to identify and intervene in psychotic disorders at an early stage.

Brain stimulation therapies for psychiatric disorders: The first decade of the new millennium—A review

Anand K. Pandurangi, Catherine Fernicola-Bledowski, Josef Bledowski — 2012-01-24

Abstract: Three new brain stimulation therapies have emerged in the last decade for clinical use in psychiatric disorders. Combined with electroconvulsive therapy (ECT), these therapies offer much hope to patients with medication refractory depression, obsessive–compulsive disorder and auditory hallucinations of schizophrenia. In this article we briefly review the history, development and evidence for each of the four stimulation therapies and describe the current state-of-the-art. Neuromodulation is considered as a possible common mechanism mediating the effects of these therapies. Finally, empirical guidelines are suggested for the practicing psychiatrist for the optimal utilization of stimulation therapies. It is concluded that with increasing technological sophistication, research on optimal protocols and emergence of newer modalities of stimulation, the future holds much promise for neuromodulatory therapies in psychiatric disorders.

Electroconvulsive therapy (ECT) in bipolar disorder: A narrative review of literature

Jagadisha Thirthalli, M. Krishna Prasad, Bangalore N. Gangadhar — 2012-01-16

Highlights: ► ECT is often used to treat different phases of bipolar disorder in many countries. ► Bilateral ECT is as effective as pharmacotherapy in treatment of acute mania. ► Quality evidence is lacking regarding the use of ECT in refractory bipolar disorder. ► Merits and demerits of combining ECT and mood stabilizers need to be established.Abstract: In many countries including India electroconvulsive therapy (ECT) is frequently used to treat different phases of bipolar disorder. The response to ECT is impressive in mania, depression and in mixed affective states. Preliminary evidence also suggests benefit from maintenance ECT in bipolar disorder. However, most of the literature on efficacy and adverse effects comes from case series, retrospective reports and open trials – controlled trials have been few and far between. Official guidelines recommend the use of ECT only when there is a dire emergency or when all other options have been exhausted. Concurrent use of lithium and antiepileptic drugs along with ECT is common in clinical practice. While such practice appears to be largely safe, one should be mindful about dose of lithium and possible interference of antiepileptic drugs with efficacy of ECT. The use of suprathreshold bilateral ECT and bifrontal placement of electrodes may confer some advantage over other methods.

Ethnopsychopharmacology considerations for Asians and Asian Americans

Felicia K. Wong, Edmond H. Pi — 2012-03-05

Highlights: ► Asians comprise more than 60% of the world's population and are the fastest growing minority group in the United States. ► Many factors contribute to Asians’ unique responses to psychotropic medications, in regards to dosages and side effect profiles. ► Pharmacokinetic and pharmacodynamic variations of psychotropic medications appear to be partially determined by genetic predisposition. ► Culture and social attitudes toward mental illness may also influence dosage and side effects of psychotropic medications in Asians. ► The future of psychopharmacology will likely be influenced by developments in the field of pharmacogenomics.Abstract: Asians comprise more than 60% of the world's population and are the fastest growing minority group in the United States. Today's psychiatrist must learn to recognize and appreciate the unique factors that influence mental health outcomes in this group. Asian Americans are affected by psychiatric disorders at similar rates as non-Asians, but are significantly underrepresented in psychiatric clinics. When Asians and Asian Americans do present for psychiatric treatment, they often do so with higher severity of illness, and variable levels of compliance. Studies over the past three decades have suggested that pharmacokinetic and pharmacodynamic profiles of various psychotropic medications may be different in Asians, leading to differences in dosage requirements and side-effect profiles. These variations appear to be largely determined by genetic predisposition, but are also influenced by other factors such as environment, social support, cultural perceptions, and physicians’ prescribing habits. In this paper, we provide an overview of biological and socio-cultural issues as they relate to psychopharmacology in Asians and Asian Americans, with the hope that a better understanding of these issues will lead to improved mental health care delivery to this population both in the United States, as well as in Asian countries.

Family violence influences mental health of school girls in Iran: Results of a preliminary study

Ali Fakhari, Mehdi Tabatabavakili, Yousef Sayah Javid, Sara Farhang — 2012-03-05

Highlights: ► We evaluated a cluster randomized sample of Iranian school girls regarding signs and symptoms of depression, anxiety, social function and physical situation. ► Considerable proportion of teenage Iranian school girls has noticeable mental health problems. ► Somatic symptoms were related to verbal violence at home by parents and low educational level of mother. ► Impairments of social function were predicted by lower educational level of mother. ► Depression was related to humility, neglect and discrimination at home.Abstract: Introduction: The family plays the first and may be the most important role in the development of individuals’ personality, health and function. The current study aimed to evaluate different aspects of violence against a sample of school girls of Iranian population and its effect on their mental health.Methods: A cluster, randomized sample consisting of 399 school girls was selected from all of the high schools in Tabriz city, northwest of Iran. Students were asked to participate in this study anonymously. Signs and symptoms of depression and anxiety were assessed by the General health questionnaire-28 (GHQ-28) measuring their social function and physical situation as well. Another inquiry form involving questions about different kinds of violence and neglect gathered information about their situation during the recent year.Results: The mean (SD) age of the students was 14.9 (0.8) and all were under 18. The mean (SD) total score of GHQ-28 was 24.18(13.61). The sub-threshold score in GHQ-28 (under 23) was observed in 44.1% of students which indicates considerable problems in mental health status. The type of reported violence was not significantly associated with an abnormal score of GHQ-28.A higher score of somatic symptoms was related to verbal violence at home by parents and the educational level of mother. High score on social dysfunction was predicted by lower educational level of mother. The depression scale was related to humility, neglect and discrimination at home. The factors were not predicting the score of anxiety or insomnia subscales.Discussion: The current study observed a noticeable amount of problems in the mental health of teenage girls in a sample of the Iranian population. The educational level of the mother plays an important role in the mental health of school girls.

Comparison of symptoms in African-American, Asian-American, Mexican-American and Non-Hispanic White patients with major depressive disorder

Uma Rao, Russell E. Poland, Keh-Ming Lin — 2012-03-05

Highlights: ► We compared depressive and associated symptoms in four ethnic/racial groups. ► Overall, severity of depression was comparable among the groups. ► Ethnic-minority groups had diurnal mood variation, with worsening in the evening. ► Asian-Americans and Mexican-Americans had more severe anxiety and somatic symptoms.Abstract: The study compared depressive and associated psychopathological symptoms in 17 African-American, 19 Asian-American, 22 Mexican-American and 41 Non-Hispanic White patients with unipolar major depressive disorder. Overall, severity of depression was comparable among the groups both on clinician-rated and subject-rated measures. However, ethnic-minority groups were more likely to experience diurnal variation of mood, with worsening in the evening. Furthermore, Asian-Americans and Mexican-Americans reported greater severity of anxiety and somatic symptoms. The findings suggest that clinicians should be aware of potential differences in symptom presentation when assessing and treating depressed patients from different ethnic groups.

Barriers to discharge of patients from a government-run day-care psychiatric rehabilitation center in India

2012-02-20

Abstract: Objective: Many psychiatric patients undergoing vocational training do not achieve successful transition to regular work. In this study, we evaluated the barriers for discharge from day care center to actual work place.Materials and methods: In a cross-sectional study at a government-run day-care center at National Institute of Mental Health and Neuro Sciences (NIMHANS), Bangalore, we studied 76 patients who were undergoing vocational training for more than 1 year. We did a semi-structured interview with patients, their family members, and instructors of various occupational sections. We used a questionnaire of 17 different barriers to assess the obstacles in their discharge from day-care center to actual work place.Results: The majority of them had a diagnosis of mental retardation (n=47) followed by schizophrenia (n=29), and bipolar disorder (n=9). The mean (SD) age and duration of illness was 33.6 (9.7) years and 12.5 (9.3) years, respectively. Patients had more than one diagnosis. The median duration of stay in day-care center was 5.9 years. Doubts regarding performance at a new work place (n=60), fear of performance at new work place (n=65), and the fear of transition to regular work (n=64) were the most common barriers reported by patients, their family members and instructors of various occupational sections, respectively.Discussion: Educating patients and their family members, gradual exposure to new working environment, and increased community level vocational opportunities may potentially overcome above barriers. Getting them to the actual job early in their course of treatment will improve their adjustment to a new work place and overall outcome.

Validation of Malaysian translated distress thermometer with problem checklist among the breast cancer survivors in Malaysia

H.W. Yong, J. Zubaidah, M. Saidi, H. Zailina — 2012-02-27

Abstract: Introduction: Distress thermometer (DT) is a single-item measure generated to assess the psychological distress among cancer patients. The aim of this study was to validate the translated DT as a tool to determine the psychological distress level and assess the factors associated with distress among the working breast cancer survivors and also to compare with the Hospital Anxiety and Depression Scale (HADS).Methods: 150 working breast cancer survivors were interviewed using the Malay and Chinese language translated version of DT and HADS.Results: Based on HADS, 23.3% were anxious, 19.3% were depressed whereas 15.3% experienced both anxiety and depression. About 14.7% of the respondents reported distress (cutoff≥5) on DT. A significant association was found between the DT and HADS which indicated that both were measuring the same construct, Hospital Anxiety and Depression Scale-T (F=71.34, p<0.001), Hospital Anxiety and Depression Scale-A (F=65.81, p<0.001), Hospital Anxiety and Depression Scale-D (F=74.28, p<0.001). This study also showed that a cut-off of ≥5 on DT yielded an area under Receiver analysis characteristic curve (AUC) of 0.95 with a sensitivity of 90.9% and specificity of 89.8% for HADS-T score defined as cases. On the problem checklist, respondents scoring above the cut-off of 5 on DT had a greater number of problems with family (70.0%), emotional (65.0%), physical (60.0%), practical (50.0%) and spiritual/religious (15.0%) issues.Discussion: Overall, DT was a useful and simple screening tool to indicate psychological distress. The translated DT has a good sensitivity and specificity for screening psychological distress among the Malaysian breast cancer survivors.

An examination of relationship between neurological soft signs and neurocognition

Ram Kumar Solanki, Mukesh Kumar Swami, Paramjeet Singh — 2012-02-27

Highlights: ► Relationship of neurological soft signs with neurocognition is explored. ► Structural equation modeling shows that soft signs have significant negative effect on cognitive functioning. ► Neurological soft signs may become useful in quick assessment of cognitive state.Abstract: Objective: Neurological soft signs (NSS) and cognitive function had been examined in schizophrenia, but their relationship has remained elusive for several years. We examined the relationship between NSS and cognitive functions in the present study.Method: A cross sectional study was carried out. Subjects were drawn from first degree relatives of schizophrenia patients, admitted as inpatient or attending as an outpatient. Controls were recruited by word of mouth from hospital staff and visitors of hospitalized patients. Those subjects who satisfied the screening process were subjected to Cambridge Neurological Inventory for soft sign assessment and digit span test, paired associate learning test (PALT) and visuo-spatial working memory matrix (VSWMM) for cognitive function assessment. Correlation analysis and structural equation modeling (SEM) was used for analysis.Result: Significant negative correlation of primitive reflexes with PALT; of motor coordination with VSWMM, working memory (WM) and cognitive index; of total NSS with WM and cognitive index among first degree relatives. SEM showed that motor soft signs have important negative influence over WM.Conclusion: The current findings indicate that NSS have significant negative effect on cognitive functioning.

Risky sexual behaviors, mental health, and history of childhood abuse among adolescents

Atsuro Tsutsumi, Takashi Izutsu, Toshihiko Matsumoto — 2012-02-23

Abstract: Although it seems evident that attention should be paid to risky sexual behaviors and their association with mental health among young people, this topic has not been thoroughly investigated. The present study aims to explore the relationship between sexual risk behaviors and mental health among adolescents. The participants were 251 adolescents in a juvenile detention facility (221 males and 31 females) as the “delinquent” group and 367 high school students (167 males and 200 females) as the “non-delinquent” group. A questionnaire including the Kessler 10, the Impact of Event Scale-Revised, and the Adolescent Dissociative Experience Scale was employed to measure mental health status as well as sexual risk behaviors, suicidal ideation/attempts, and abuse history.Having a history of sexual abuse or of physical abuse was associated with age when one first had sex among males with delinquent behaviors, while same tendency was observed among males without delinquent behaviors. Among the female with delinquent behaviors group, past abuse history was significantly associated with higher number of sex partners. In the non-delinquent group, better mental health among males and, contrarily, worse mental health among females were associated with having more sex partners. The results highlight the importance of addressing abuse history among females and males. Given that poor mental health status in the adolescents was associated with risky sexual behaviors, adolescents are a vulnerable group that requires attention in terms of sexual and reproductive health that integrates mental health and psychosocial components.

Commentary-Asian Pearls

Tarek A. Okasha — 2012-03-05

This commentary is on the accompanying article on “The study of acoustic startle reflex in male patients with chronic schizophrenia” by Zhiren Wang and colleagues (Chinese Journal of 2010, 43: 135–39). This paper, originally published in Chinese, is presented here to show examples of important research findings that are not published in the major search engines might be missed in the international literature. This study compared the acoustic startle reflex, habituation of startle reflex and pre-pulse inhibition of startle reflex between schizophrenia patients on first and second generation antipsychotics and controls and relates the results with patient symptomatology. These results need to be replicated on a sample of female Chinese patients as well as across other cultures.

The study of acoustic startle reflex in male patients with chronic schizophrenia

2012-03-05

Highlights: ► Patients had a reduction of prepulse inhibition of startle reflex in schizophrenia. ► There might be an impaired PPI in Chinese patients with schizophrenia. ► Clozapine might partly improve PPI in patients with schizophrenia.Abstract: Objective: To explore the deficits of acoustic startle reflex (ASR) that might exist in Chinese patients with schizophrenia and the effects of antipsychotics on ASR.Methods: Participants included 25 male patients with chronic schizophrenia treated with typical antipsychotics (typical group), 25 who were treated with atypical antipsychotic clozapine (clozapine group) and 25 healthy male subjects (control group) matched for age and years of education. Startle reflex to acoustic stimuli were examined in all subjects from the three groups. At the same day of startle testing, psychopathological symptoms of the patients were assessed with the Positive and Negative Syndrome Scale (PANSS).Results: (1) Startle response (SR) was significantly reduced in typical group as compared to control group [(553.6±516.9)mV vs. (942.0±447.3)mV, P=0.009]. SR of clozapine group [(755.9±439.4)mV] was greater than that of typical group and less than that of control group, but there was no significant difference between the clozapine group and the other two. (2) Habituation (HAB) of startle reflex in typical group was significantly lower than in control group [(17.8±35.8)% vs. (44.9±28.9)%, P=0.027]. HAB of clozapine group [(22.9±34.1)%] was higher than that of typical group and less than that of control group, but there was no significant difference between clozapine group and the other groups. (3) Compared with healthy controls, patients of typical group exhibited the significant reduction in prepulse inhibition (PPI) of startle reflex (P=0.024) when prepulse interval (LI) was 120ms. PPI of clozapine group was higher than typical group and less than control group, but no significant differences in PPI were found between clozapine group and the other groups. While LI was 30- or 120-ms, PPI among the three groups showed not significantly different (P>0.05). (4) No significant relationship was found between PPI of different LIs and symptom scores assessed with PANSS in patients with schizophrenia (P>0.05).Conclusion: Our findings suggest impaired PPI in Chinese patients with schizophrenia; Atypical antipsychotic clozapine might partly improve disinhibition of startle reflex in schizophrenic patients.

Intervention for first episode psychosis in India – The SCARF experience

Thara Rangaswamy, Ramamurthy Mangala, Greeshma Mohan, Jainey Joseph, Sujit John — 2012-03-05

Highlights: ► A 2-year follow-up of First Episode Psychoses from India. ► Improvement from baseline to 1st year with maximal improvement seen at 3 months. ► DUP shorter than 2 years was predictive of better outcome. ► PANSS scores and GAF at baseline are not predictive of later outcomes. ► Single episode followed by total remission for 2 years was the commonest patterns of course.Abstract: Introduction: There have been very few studies or programs in India on early intervention for first episode psychoses. This paper reports the findings of a pilot program, part of a collaboration with the Prevention and Early Intervention Program for Psychoses, Montreal.Methodology: A sample of 47 patients with first episode psychosis were followed up for 2 years. Complete data was available on 39 subjects at 2 years. This data was analyzed for socio-demographic and clinical variables and its relationship with outcomes and DUP. Those who had a PANSS score <60 and GAF >80 were categorized to be in remission (N=28) and others as continually ill (N=10).Results: There was significant improvement from baseline to 1st year with maximal improvement seen at 3 months after intake. However, improvement between 1 and 2 years was not significant. More women relapsed and more men dropped out. 25 out of 28 subjects with shorter DUP (<2 years) were in remission at 2 years as against 3 out of 10 with >2 years DUP. Three different patterns of course of the disorder were found. Single episode followed by total remission for 2 years (N=20; 52.6%) was the commonest. The others were relapses followed by remissions (N=8; 21.1%), and continuous illness (N=10; 26.3%).Conclusion: Early intervention is effective and more so if DUP is shorter. PANSS scores and GAF at baseline are not predictive of later outcomes. Medication adherence in therapeutic engagement and psychosocial needs should be considered in the implementation of early intervention programs in our cultural context.

The Singapore Early Psychosis Intervention Programme (EPIP): A programme evaluation

2012-03-05

Highlights: ► The Singapore Early Psychosis Intervention Programme (EPIP) was initiated in 2001 with the aim to reduce the duration of untreated psychosis and improve patient outcomes. ► EPIP is a part of National Mental Health Blueprint and hence has articulated a range of process and outcome indicators so as to that be accountable to stakeholders. ► At the end of 2 years of follow-up, 71.1% patients had achieved symptomatic remission and 76.5% patients had returned back to school or were gainfully employed.Abstract: The alarmingly long duration of untreated psychosis (DUP) in Singapore and probable severe consequences were the impetus for establishing the Early Psychosis Intervention Programme (EPIP) in 2001. In 2007, EPIP became a part of the National Mental Health Blueprint. Here, we report some of the programme's outcomes.Method: Consecutive patients accepted into EPIP from April 2007 to March 2011 were included. Programme inclusion criteria were: (1) age between 15 and 41 years, (2) first-episode psychotic disorder with no prior or minimal treatment, (3) no current history of substance abuse, and (4) no history of major medical or neurological illness. EPIP has incorporated an evaluation component to the clinical programme by administering regular structured assessments and generating operational statistics from our hospital's data systems.Results: Between April 2007 to March 2011, 815 patients had been accepted and 795 had baseline data. 50.8% (404/795) were males, with mean age of 27years (±6.5 years). Mean DUP (SD) was 14.6 (±25.2) months and median was 6months. At the end of two years, 71.1% (202/284) achieved symptomatic remission as defined by the Schizophrenia Working Group, 84.9% (241/284) scored 61 or more on Global Assessment of Functioning (GAF) disability and 76.5% (274/358) had returned back to school or were gainfully employed.Conclusion: Being a national programme, EPIP had articulated process and outcome indicators to our stakeholders, and a periodic report card on these outcomes makes us accountable to our funders, our patients and their families.

Early intervention for psychotic disorders: Real-life implementation in Hong Kong

2012-03-05

Highlights: ► Early intervention (EI) improved functioning, hospitalization, symptoms, suicides, and engagement in Hong Kong. ► Extra cost in EI was offset by decreased costs in domains such as inpatient costs. ► Renaming psychosis improved patients and public acceptance. ► Misconception and discrimination were still pervasive. ► Further works are needed in service perfection, professional development, and awareness.Abstract: Hong Kong is among the first few cities in Asia to have implemented early intervention for psychosis in 2001. Substantial changes in psychosis service have since taken place. We reviewed available outcome data in Hong Kong, with reference to the philosophy of early intervention in psychosis, discussing experience and lessons learned from the implementation process, and future opportunities and challenges. Data accumulated in the past decade provided evidence for the benefits and significance of early intervention programmes: patients under the care of early intervention service showed improved functioning, milder symptoms, and fewer hospitalizations and suicides. Early intervention is more cost-effective compared with standard care. Stigma and misconception remains an issue, and public awareness campaigns are underway. In recent years, a critical mass is being formed, and Hong Kong has witnessed the unfolding of public service extension, new projects and organizations, and increasing interest from the community. Several major platforms are in place for coherent efforts, including the public Early Assessment Service for Young people with psychosis (EASY) programme, the Psychosis Studies and Intervention (PSI) research unit, the independent Hong Kong Early Psychosis Intervention Society (EPISO), the Jockey Club Early Psychosis (JCEP) project, and the postgraduate Psychological Medicine (Psychosis Studies) programme. The first decade of early intervention work has been promising; consolidation and further development is needed on many fronts of research, service and education.

Are neurocognitive, clinical and social dysfunctions in schizotaxia reversible pharmacologically? Results from the Changsha study

2012-02-23

Abstract: The Changsha study identifies adult, non-psychotic relatives of patients with schizophrenia who show deficits in neurocognitive, social, clinical and other dimensions, and who meet provisional criteria for a liability syndrome for schizophrenia (‘schizotaxia’). In this study, we investigated whether negative symptoms, neurocognitive deficits, or other measures of clinical and social function in subjects who met our research criteria for schizotaxia were amenable to pharmacological remediation with a low dose (2.0mg) of risperidone, a second generation antipsychotic medication. One hundred eighty nine relatives were assessed at the Mental Health Institute, Second Xiangya Hospital of Central South University, Changsha (Hunan Province, China), between 12/06 and 12/08. Eighty six of these individuals met modified criteria for schizotaxia, and 36 agreed to enter a 6-week, double-blind, placebo-controlled protocol. ANCOVAs using age and gender as covariates showed significant improvement in the risperidone group (n=20) on neurocognitive function (Wisconsin Card Sorting Test Total Errors and Perseverative Errors) and on a self-report measure of social function (Social Adjustment Scale), compared to the placebo-control group (n=16). Effect sizes were small to medium. Notably, risperidone effect sizes were larger (medium to large) in a subset of subjects (risperidone=15; placebo=10) whose membership in the schizotaxic group was supported empirically by cluster analysis. Negative symptoms did not change significantly in either analysis. The results are generally consistent with previous open-label investigations of risperidone administration in subjects with schizotaxia, and provide evidence that some neurocognitive and clinical problems are amenable to remediation in non-psychotic relatives of people with schizophrenia.

Neurocognitive and clinical dysfunction in adult Chinese, nonpsychotic relatives of patients with schizophrenia: Findings from the Changsha study and evidence for schizotaxia

2012-02-23

Abstract: Many first-degree relatives of patients with schizophrenia demonstrate deficits in neurocognitive, social, clinical and other dimensions, in the absence of psychosis. Based on a reformulation of Meehl's concept of “schizotaxia” as a clinically meaningful syndrome reflecting liability to schizophrenia, we proposed research criteria in relatives focused on negative symptoms and neurocognitive deficits. Here we assess validity of the syndrome in a sample of Chinese adult relatives by assessing measures of concurrent validity, and by using cluster analysis to test the hypothesis that relatives could be grouped into distinct schizotaxic and non-schizotaxic subgroups based on our diagnostic criteria. Thirty community comparison subjects (CCS) and 189 relatives were evaluated with measures of clinical, cognitive, medical and social function at the Mental Health Institute, Second Xiangya Hospital of Central South University, Changsha (Hunan, China), as part of a larger study to identify and ameliorate symptoms of schizotaxia. Using modified research criteria based on negative symptoms and neurocognitive deficits, 103 relatives did not meet criteria for schizotaxia, and 86 did. The cluster analysis confirmed a two-group solution that corresponded to our non-schizotaxic and schizotaxic groups, but it increased the non-schizotaxic group to 135, and reduced the schizotaxic group to 53. Both schizotaxic groups, but especially the cluster-derived group, showed significant impairment in a variety of independent (i.e. non-criterion related) measures of clinical and social function. These findings provide additional validity for a liability syndrome, and for its utility as an intervention target for strategies aimed at ameliorating both its core and its associated symptoms.

Early psychosis in Asia: Insights from Japan

2012-03-05

Highlights: ► The largest task for psychiatry in Japan today is the deinstitutionalization. ► In Japan, there is still no category for early intervention in the national health reimbursement schedule. ► The slow and incomplete transition to community-based psychiatry has been prevented from becoming an inclusive society. ► The mean duration of untreated psychosis (DUP) of recent research in Japan was 17.6 months. ► The concept of an ARMS/prodromal state might not yet be widely recognized among Japanese psychiatrists.Abstract: The largest task for psychiatry in Japan today is the deinstitutionalization of patients with psychiatric disorders. In Japan, all citizens are covered by a national health plan, and about 70% of the total cost is covered by the national health insurance scheme. At present, however, there is still no category for early intervention in the national health reimbursement schedule. Recent research has shown that the mean duration of untreated psychosis (DUP) at seven university hospitals in Japan was 17.6 months. We present data using case vignettes suggesting that pharmacotherapy might be overused in prodromal cases. The concept of an At-Risk Mental State (ARMS)/prodromal state might not yet be widely recognized among Japanese psychiatrists. We outline early intervention initiatives in Japan; The Japanese Society for Prevention and Early Intervention in Psychiatry (JSEIP), and a representative early intervention facility for young people is the “Il Bosco” in Tokyo. There are several leading centers for early intervention research and practice in Japan. Most of them are driven by university departments of psychiatry with respect to both research and clinical activities. The development of services for early intervention is expected to reduce stigmatization, prevent suicide among young persons, and promote general knowledge about mental health. There are several common or similar issues among Asian countries, including service systems, community attitudes to psychiatric illness including stigma, and dependence on pharmacotherapy.

Early intervention in psychosis: Insights from Korea

Jun Soo Kwon, Min Soo Byun, Tae Young Lee, Suk Kyoon An — 2012-03-05

Highlights: ► We describe our clinical and neurobiological studies of clinical high risk (CHR) subjects in Korea. ► We also discuss critical issues in clinical practice and research of CHR based on our experience in Korea. ► High false positive rate of current CHR criteria raises common ethical concerns in Korea as well as other countries. ► Further investigations are needed to refine the diagnostic criteria and develop phase-specific interventions.Abstract: Subjects at clinical high risk (CHR) for psychosis have been the focus of clinical attention in psychiatry for the last 15years, leading to the development of valid and reliable diagnostic instruments to detect these individuals early in the course of their illness. These efforts have resulted in research into optimal preventive measures. Our experiences at and data from the Seoul Youth Clinic support the validity of the CHR concept and its underlying neurobiological basis and provide valuable information related to the determination of appropriate clinical interventions. The limitations of the current criteria for CHR, such as the relatively low transition rates to psychosis and the “false-positive” problem, are also common critical issues in Korea. Additionally, concerns about social stigmatization and the potential side effects of pharmacotherapy render individuals at CHR reluctant to visit clinical settings. Therefore, further investigations using a combination of predictive markers based on clinical and neurobiological studies of those at CHR are needed to refine the diagnostic criteria, overcome their current limitations including ethical issues, and develop phase-specific and individualized therapeutic interventions.

Early intervention in the Asian Century

Patrick McGorry — 2012-03-01

Mental health care around the world is struggling to emerge from 19th century concepts and models of care, to transcend stigma and neglect, and to create a humane and effective approach fit for the complexity and challenges of the 21st century. This century has been labelled the “Asian Century” and so it is tremendously exciting and heartening, as reflected in the pages of this issue of the Asian Journal of Psychiatry, that so many pioneering Asian psychiatrists have recognised that prevention and early intervention are key potential strategies in the struggle to reduce the burden of mental illness on our rapidly changing societies. Apart from the human cost, the economic impact of untreated or poorly treated mental disorders is a huge threat to happiness and prosperity. The World Economic Forum, in its 2011 report on the impact of non-communicable diseases, used three independent types of economic analysis to show that mental illness will equal cardiovascular disease as the major threat to GDP in both developed and developing economies over the next two decades (). This is because mental disorders are the chronic diseases of the young, with 75% of onsets before the age of 25 years, and most between puberty and the mid twenties (). This hits hardest in developing countries with young populations.

How to come up with a research idea

Matcheri S. Keshavan — 2012-03-01

There is no dearth of interesting research questions in the world of medicine, and especially in psychiatry. The critical task, however, is to find an important question that you can answer easily, and ethically. Many aspiring clinical researchers have trouble at this starting point, and often give up, thinking that they do not have the innate ability, or aptitude for research. In my view, having a research “bent” is not an inborn trait, but an acquired skill. In this paper, I discuss some key considerations for the beginning researcher.

3rd Annual International Scientific Conference of the Indian Global Psychiatric Initiative (IGPI)

Sandeep Grover — 2012-03-05

The Indian Global Psychiatric Initiative that was established in 2010 is an endeavor to bring together the over 15,000 psychiatrists of Indian origin from the world over. It provides a platform for sharing scientific and scholarly knowledge, experience and the developing of new collaborations in the enhancement of mental health care. Under the leadership of Prof Russell D'souza the President IGPI, the 3rd Annual International Scientific Conference of Indian Global Psychiatric Initiative took place at Amrita Institute of Medical Sciences, Cochin, Kerala on 17th and 18th January 2012 with a Pre Congress Early Career Psychiatrists Fellowship and Training program on 15–16th of January 2012. This conference had a participation of about 250 delegates from USA, UK, Australia, New Zealand, Canada, Germany, France, Russia China, Bangladesh, Egypt, Indoneasia, Iraq, Malaysia, Nepal, India and Singapore. The Scientific program included 28 renowned researchers and professional leaders from various countries of the globe. The plenary sessions included Psychiatric Services and Mental Health Delivery, Neuro-biology and Pharmacological Treatment, Psychiatric Diagnosis and Classification, Schizophrenia, Psychotherapy and Recovery and special topics. All the sessions were very well attended and generated a lot of interactive discussion. The outstanding scientific content included a session on Psychiatric Services and Mental Health Delivery which had speakers discussing the mental health delivery system in USA, UK and India offering an opportunity for discussion and comparison. A session included the neurobiology of schizophrenia and treatment issues related to treatment resistant schizophrenia, pharmacological treatment of dementia and child psychiatric disorders offering questions and discussion in these areas. A further session of interest addressed the current progress in the development of DSM-5 classification system. The session on psychotherapy and recovery, examined the role of yoga in mental health, cognitive remediation in schizophrenia and psychiatric rehabilitation in India reflecting on psycho-social rehabilitation in a resource poor region. Other important topics of interest presented and discussed included human rights, Bioethics and Six Sigma in Health Care Management. The conference ended with a contemplative valedictory session chaired by Professor Keshavan, the conference Scientific Chair and Professor Dilip Jeste the conference Program Director. This session was a short interactive discussion of participants reviewing the sessions and content of the conference with suggestions and thoughts for the future IGPI scientific meetings.

Conference proceedings – ANCIPS 2012

Rishikesh V Behere — 2012-03-01

The annual national conference of the Indian Psychiatric Society (IPS) was held at Kochi from 19th to 22nd January 2012. The conference was jointly organized by the IPS Kerala state branch and Cochin local branch. This annual conference is a forum for meeting of mental health professionals and discusses issues pertaining to mental health in the Indian subcontinent. The conference saw participation from delegates not only from India but also SAARC countries Srilanka, Nepal, Pakistan, Bangladesh; members of Indian American Psychiatric Association and British Indian Psychiatric Association.

Combination of CBT with fluoxetine works better for obsessive–compulsive disorder

2011-12-26

Obsessive–compulsive disorder (OCD) is a common mental health problem. We conducted an open label, controlled, prospective and comparative study in the Department of Psychiatry, Bangabandhu Sheikh Mujib Medical University (BSMMU) to assess and compare the efficacy of fluoxetine and combined fluoxetine and cognitive behavioural therapy (CBT) in the treatment of OCD. The participants were diagnosed by a psychiatrist and were randomly divided into two groups, each consisting of 15 patients. We used a local instrument, Dhaka University Obsessive Compulsive Scale (DUOCS) () to measure OCD severity. The medication only group received capsule fluoxetine 20–60mg after dose titration; follow up was done weekly in the 1st and 2nd months and fortnightly during the third and fourth months. The combination group received CBT in addition to capsule fluoxetine. The CBT regimen consisted of 13 visits over 13weeks’ time and each session lasted approximately 1h. All patients were assessed at baseline and at weeks 5, 9 and 13. Twenty-six patients completed the 13-week long study. The mean age of the study population was 30.23±8.67years, analysis did not find any statistically significant mean age difference between the two groups (p=.524). The difference between mean duration of OCD in the two groups (7.53±8.11 and 9.47±5.47years, respectively) was not significant (p=.451). In the medication alone group, the means of DUOCS scores in 5th, 9th and 13th weeks were 39.21±15.21, 34.46±16.21 and 28.23±12.96, respectively. In the combination group, the means of DUOCS scores in 5th, 9th and 13th weeks were 30.64±10.98, 23.92±8.43, and 18.77±6.3, respectively. The comparisons between groups for the DUOCS scores were carried out using the ANOVA with post hoc analysis using the Bonferroni correction and independent sample t test (). The mean difference for the DUOCS score for the two groups at baseline was 9.9 (SE ±5.3; 95% CI −.94 to 20.8) which was not statistically significant. As the two groups did not differ significantly at baseline for DUOCS scores, they were comparable for the severity of illness. The mean difference at 5th week was 8.6 (SE ±5.0; 95% CI −1.7 to 18.9). This difference was also not statistically significant. The mean difference for the DUOCS for the two groups at 9th week was 10.5 (SE ±5.0; 95% CI .1–21.0; p<.05) and at 13th week it was 9.5 (SE ±3.9; 95% CI 1.2–17.7; p<.05), with the combination group having a higher reduction in scores as compared to fluoxetine alone. The mean differences between the two groups were statistically significant at the 9th and 13th weeks. This represents that combination of CBT and fluoxetine produces a greater improvement in severity of OCD as compared to fluoxetine alone.

Providing drug abuse treatment in prison: A call for action

Sonali Jhanjee — 2012-02-23

Drug abuse problems are over-represented in prison and it has been estimated that in some countries around three quarters of people in prison have alcohol or other drug-related problems, and more than one-third may be opioid dependent (). The link between drug abuse and crime is complex and economic, pharmacological and lifestyle mechanisms are some of the various factors which contribute to the development of these problems. Imprisonment of drug users for crimes they commit – often to support their addiction – contributes to prisoners’ high prevalence of drug dependence (). Prevalence of HIV infection among prisoners in many countries is substantially higher than in the general population (). Many prisoners continue to use drugs while they are in prison, despite attempts to prevent the entry of illicit substances ().

Risk factors for suicidal ideations in bipolar depression

Uma Maheswari, Ajit Avasthi, Sandeep Grover — 2012-02-23

The issue of assessment of risk factors of suicide raised in editorial by is very important in the context of high suicide rates in the developing countries. As pointed out in the editorial there is a meagre research in this area from the developing countries especially India. In view of lack of research we conducted a study in patients with bipolar depression to assess the risk factors for suicidal ideations () and suicide attempts (). The study sample included 52 subjects with bipolar depression diagnosed as per DSM-IV criteria selected by purposive sampling and aged between 18 and 60 years. The study was approved by the Institute Ethics Committee and all the patients were enrolled after obtaining written informed consent. Most of the study participants were males (N=32; 61.5%) and married (N=46; 88.5%). There was a similar distribution of subjects from urban versus rural background (50% each), nuclear versus non-nuclear family (50% each), Hindus versus non-Hindus (52% versus 48%) and those employed versus unemployed (55.8% versus 44.2%).

Diagnostic and statistical manual of mental disorders (DSM): A culture bound syndrome?

Abhijit Nadkarni, Alastair Santhouse — 2012-03-05

Highlights: ► Proposed DSM V raises several contentious issues. ► Cross cultural applicability and receding boundaries of ‘normality’ are a concern. ► A renewal of the debate on use of DSM beyond the country of its origin is called for.

The Gap Between Theory and Practice of Psychiatry in Developing countries of Asia

M. Parameshvara Deva, Russell D'Souza — 2012-03-01

Psychiatry at the turn of the 21st century has made great progress in science and research. The old institutions have largely been superseded by general hospital units and community units in the developed countries of the world. But these have yet to filter into many of the developing countries of Asia. Instead some disturbing trends are occurring in these countries. These regions to begin with are countries where mental health care is often marginalized in terms of priority in health care. There at least 5 Pacific Island countries that do not even have a single psychiatrist or psychiatric nurse. Acute mental health problems are treated routinely in cells of local police stations. In many island countries there may be a single psychiatrist for dozens of populated islands hundreds of kilometers apart.

The second training and educational fellowship program of AFECP

Daria Smirnova, Hussien Elkholy, Sandeep Grover — 2012-03-01

The 2nd fellowship program of Asian Federation of Early Career Psychiatrists (AFECP) took place under the guidance of Prof. Russell D'Souza, due to support of distinguished faculty and as a pre-congress activity of Indian Global Psychiatric Initiative (IGPI) on the 15th–16th of January 2012 in Kochi, Kerala, India. Eighteen participants from Asian countries including Russia, Egypt, Indonesia, Malaysia, China, Bangladesh, Iraq, Singapore, Australia and 18 from India took part in the training. The theme was “Image of modern psychiatrist: professionalism, humanism and leadership”; faculty from Australia, USA, Malaysia, France and UK participated in interactive training and team building tasks among ECPs during 2 days. A visit to Amrita Institute of Medical Sciences, Hospital Complex and Psychiatry and Behavior Medicine Department was an interesting event for non-indian colleagues and stimulated discussion about Mental Health Care systems functioning in transition. The topics of development of professional competence within studying and teaching with diagnostic and communication skills, biological approach in psychiatry on the model of psychotic disorders, clinical trials management and publishing of scientific papers, vivid discussions about existential concept of mental disorders, well-being theories and creativity in idea management and inspiration in everyday work emphasized the unity and equal importance of noticed directions for the professional growth of contemporary specialists.