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Abstract Background Studies have confirmed the rapid antidepressant action of ketamine in depressive episodes. Nevertheless, a standardized procedure for the delivery of ketamine infusion in individuals suffering from treatment-resistant depression, particularly in terms of infusion frequency and total dosage, remains undetermined. In addition, an efficacious ketamine regimen for persistent pain management involved a continuous 10-day infusion period with no notable adverse effects. Consequently, the primary objective of this study was to evaluate the antidepressant capacity of consecutive ketamine infusions spanning over three successive days, the duration of therapeutic response, and the overall safety profile of the treatment. Methods In this randomized controlled trial, participants aged 18–64 with treatment-resistant depression were randomized to receive either intravenous ketamine or midazolam (used as an active placebo) for 40 min daily over three consecutive days. Statistical analysis using repeated measures ANOVA was employed to assess the changes in the total score of the Montgomery–Åsberg Depression Rating Scale (MADRS) and the clinical global impression-Severity from the initial assessment to 10 and 31 days post-infusion. Additionally, the duration of response and remission was evaluated using Kaplan–Meier survival analysis. Results Out of 33 randomized participants, 20 underwent the treatment as planned. By day 10th, the ketamine group had a mean reduction in MADRS score of 12.55 (95% CI = 6.70–18.09), whereas the midazolam group had a decrease of 17.22 (95% CI = 11.09–23.36). This pattern continued to day 31, with ketamine showing a mean score decrease of 13.73 (95% CI = 7.54–19.91) and midazolam a fall of 12.44 (95% CI = 5.61–19.28). Both treatments were well tolerated, with dissociative symptoms in the ketamine group being temporary and ceasing by the end of each infusion. Conclusion Intravenous ketamine given for three consecutive days did not show a notable antidepressant advantage when compared to the active placebo midazolam, highlighting the need for further research into effective treatments schedules for treatment-resistant depression. Trial registration NCT05026203, ClinicalTrials.gov, registered on 24/08/2021.

Abstract Background Sunlight contains ultraviolet B (UVB) radiation that triggers the production of vitamin D by skin. Vitamin D has widespread effects on brain function in both developing and adult brains. However, many people live at latitudes (about > 40 N or S) that do not receive enough UVB in winter to produce vitamin D. This exploratory study investigated the association between the age of onset of bipolar I disorder and the threshold for UVB sufficient for vitamin D production in a large global sample. Methods Data for 6972 patients with bipolar I disorder were obtained at 75 collection sites in 41 countries in both hemispheres. The best model to assess the relation between the threshold for UVB sufficient for vitamin D production and age of onset included 1 or more months below the threshold, family history of mood disorders, and birth cohort. All coefficients estimated at P ≤ 0.001. Results The 6972 patients had an onset in 582 locations in 70 countries, with a mean age of onset of 25.6 years. Of the onset locations, 34.0% had at least 1 month below the threshold for UVB sufficient for vitamin D production. The age of onset at locations with 1 or more months of less than or equal to the threshold for UVB was 1.66 years younger. Conclusion UVB and vitamin D may have an important influence on the development of bipolar disorder. Study limitations included a lack of data on patient vitamin D levels, lifestyles, or supplement use. More study of the impacts of UVB and vitamin D in bipolar disorder is needed to evaluate this supposition.

ABSTRACTObjectives This study aimed (1) to determine the psychometric properties of a Thai version of the Maslach Burnout Inventory–Human Services Survey for Medical Personnel (MBI-HSS [MP]) and (2) to examine the mean scores of burnout and associated factors during the COVID-19 pandemic.Methods Forward and back translations of the MBI-HSS (MP) questionnaire were performed. The Thai version was subsequently completed by 682 Thai physicians and nurses who worked during the COVID-19 pandemic. Exploratory factor analysis was performed on the first subsample (n = 341) by conducting Kaiser Mayer-Olkin sampling adequacy measurement and Bartlett’s test of sphericity whereas confirmatory factor analysis (CFA) was performed on the second subsample (n = 341) using fit indices of the normed chi-square (χ2/df), the comparative fit index, the Tucker–Lewis index, and the root mean square error of approximation. This version’s internal consistency was investigated using Cronbach’s alpha coefficient. Demographic profiles were evaluated with descriptive and analytical statistics.Results The Thai version of the MBI-HSS (MP) displayed good psychometric characteristics, as the Cronbach’s alpha values of the 3 burnout factors ranged from 0.843 to 0.945. The CFA also showed good fit indices (χ2/df = 4.473; P

Objective: The coronavirus disease 2019 (COVID-19) pandemic likely impacted emotional regulation and mood states. The present study aimed to investigate the perceived risk, stigma, and emotional regulation strategies of psychiatric patients, as well as the association between these characteristics, cognitive emotion regulation strategies (emotional suppression and cognitive reappraisal), and anxiety and depressive symptoms during the COVID-19 pandemic. Materials and Methods: The present cross-sectional study of 282 patients with anxiety and mood disorders was conducted during the COVID-19 pandemic in 2020. Participants completed questionnaires that investigated anxiety (hospital anxiety and depression scale [HADS]), depression (patient health questionnaire [PHQ-9]), and cognitive emotion regulation strategies (emotion regulation questionnaire [ERQ]). Descriptive statistics were used to assess the data. The t-test, chi-square test, and Mann-Whitney U test were used to compare the differences between the two groups, with cut-off scores of 11 in the HADS and nine in the PHQ-9. Results: Most participants were female (78.4%), and the median age was 31 years. A total of 23.8% of participants reported having anxiety symptoms, and 24.8% and 54.3% of participants reported having depression on the HADS-D and PHQ-9, respectively. HADS-A, HADS-D, and PHQ-9 were found to be significantly associated with emotional regulation style (P=0.002, P=0.005, P=0.006) but not with perceived risk and stigma. Patients with anxiety or depression tended to use expressive suppression more often than cognitive reappraisal. Conclusion: This study found that mood states were associated with cognitive emotional regulation strategies during the COVID-19 pandemic. Patients with anxiety or depression tended to use expressive suppression more often than cognitive reappraisal.

Abstract Background Bipolar disorder is associated with circadian disruption and a high risk of suicidal behavior. In a previous exploratory study of patients with bipolar I disorder, we found that a history of suicide attempts was associated with differences between winter and summer levels of solar insolation. The purpose of this study was to confirm this finding using international data from 42% more collection sites and 25% more countries. Methods Data analyzed were from 71 prior and new collection sites in 40 countries at a wide range of latitudes. The analysis included 4876 patients with bipolar I disorder, 45% more data than previously analyzed. Of the patients, 1496 (30.7%) had a history of suicide attempt. Solar insolation data, the amount of the sun’s electromagnetic energy striking the surface of the earth, was obtained for each onset location (479 locations in 64 countries). Results This analysis confirmed the results of the exploratory study with the same best model and slightly better statistical significance. There was a significant inverse association between a history of suicide attempts and the ratio of mean winter insolation to mean summer insolation (mean winter insolation/mean summer insolation). This ratio is largest near the equator which has little change in solar insolation over the year, and smallest near the poles where the winter insolation is very small compared to the summer insolation. Other variables in the model associated with an increased risk of suicide attempts were a history of alcohol or substance abuse, female gender, and younger birth cohort. The winter/summer insolation ratio was also replaced with the ratio of minimum mean monthly insolation to the maximum mean monthly insolation to accommodate insolation patterns in the tropics, and nearly identical results were found. All estimated coefficients were significant at p

Objective: To examine the characteristics, diagnosis and management of agitated inpatients before psychiatric consultation in a general hospital. Methods: A retrospective chart review of inpatients aged 18 years or older that were referred for psychiatric consultation due to agitation in a general hospital in Thailand. Results: Of the 188 patients, confusion was the most commonly detected early sign of agitation (63;33.5%), while fidgeting was the most common symptom/behavior that led to psychiatric consultations (94;50.0%). The average onset time of agitation after admission was 62 hours 48 minutes. The most common cause of agitation was delirium due to a medical condition (89;47.3%). Primary psychiatric disorders were only found in 9 (4.8%) of agitated patients. There was a low diagnostic concordance between attending physicians and psychiatrists (Cohen’s Kappa=0.32). Physical restraints were used in 109 (58.0%) patients, whereas 166 (88.3%) were prescribed with sedatives. Attending physicians prescribed benzodiazepine to ameliorate agitation in 32 (36.0%) of patients with delirium. However, 4 (7.3%) patients with alcohol-withdrawal delirium were untreated initially with benzodiazepine. Conclusion: Medical conditions are more common causes of agitation than psychiatric illness. There is poor diagnostic concordance between attending physicians and psychiatrists, and high rates of physical restraints and benzodiazepine injection were found. Medical education on the detection and management of agitation and the appropriate use of sedative medications and restraints is needed.

Objective: Falls are a significant health problem which affects quality of life in the elderly. This study was undertaken to study mortality and prevalence of falls, and their associations with psychiatric diagnoses and psychotropic medications. Methods: The study was a retrospective 10-year data analysis of a general hospital database from 2006-2015. Prevalence, odds ratio, hazard ratio, and survival analysis were analyzed to study the association. Results: The overall prevalence of falls was 3.6%. Subjects with psychiatric diagnoses were with 3.28 more chance of falls. Subjects with psychotropic medication prescriptions were with 1.76 more chance of falls. Survival analysis revealed mean survival of 6.84 years after falls. The average survival years after falls was age related. Subjects with history of falls and carrying psychiatric diagnoses were with mean survival of 6.55 years and the hazard ratio of 0.84. Subjects with history of falls and psychotropic medication prescriptions were with means survival 6.15 years and the hazard ratio of 1.27. Conclusion: Psychiatric diagnoses and psychotropic medication prescriptions were associated with falls. Subjects with history of psychotropic medication prescriptions were associated with higher risk of mortality.

ObjectivesTo explore the prevalence and factors that contribute to burnout among Thai psychiatrists.BackgroundThe practice of psychiatry can lead to emotional fatigue. As rates of emotional illness in Thailand continue to climb, increasing demands are placed on a limited number of psychiatrists. This can lead to burnout, and multiple negative physical and mental health outcomes.Materials and methodsElectronic questionnaires were sent to all 882 Thai psychiatrists and residents via a private social media group managed by the Psychiatric Association of Thailand. The questionnaire included demographic data, the Maslach Burnout Inventory (MBI), the Proactive Coping Inventory, and questions about strategies that Thai psychiatrists believed reduce/prevent burnout.ResultsQuestionnaires were sent and 227 (25.7%) responded. According to MBI, 112 (49.3%) of respondents reported high level of emotional exhaustion, and 60 (26.4%) had a high level of depersonalization. Nearly all respondents (99.6%) maintained a high level of personal accomplishment. Working more than 50 hours per week (p = 0.003) and more patients per day (p = 0.20) were associated with higher levels of burnout. Feeling satisfied with work (pConclusionsCompared to a previous study on burnout among Thai psychiatrists in 2011, in this study, the prevalence of high levels of burnout had increased dramatically from 17.1% to 49.3%. An intervention to decrease workload, strengthen social support and encourage proactive coping mechanisms may be beneficial for relieving burnout.

Objective: This study aimed to understand the internet users’ perspectives towards doctors’ and medical students’ Facebook use. Methods: This was a cross-sectional online survey among internet users conducted from December 2015 to March 2016 to understand their perspectives towards doctors’ and medical students’ Facebook use. The author-constructed questionnaires were in Thai and included the participants’ online activities, their witness to inappropriate Facebook posts by doctors or medical students in the past month, and 39 mock public Facebook post screenshots. The participants were asked to rate the appropriateness of each mock post on a 5-point-Likert scale. Results: Among all participants (n=1,200), 63.4% had searched through Facebook profiles of physicians or medical students before and 53.7% had seen or heard of inappropriate contents. The characteristics of doctors’ and medical students’ Facebook posts which were rated as inappropriate or less appropriate by most participants were related to patients’ privacy, including de-identified patients’ data, substance use behaviours, negative criticism of patients, colleagues, hospitals or universities, and advertisement of their own private practice. Conclusion: Doctors and medical students should be aware of the public view towards their social media posts and be mindful of what they post and the potential negative consequences because they can impact the public image of medical professions. Considering professionalism guidelines and public’s perspectives may obviate the potential negative consequences of social media use.

Background: Studies have confirmed the rapid antidepressant action of ketamine in depressive episodes. Nevertheless, a standardized procedure for the delivery of ketamine infusion in individuals suffering from treatment-resistant depression, particularly in terms of infusion frequency and total dosage, remains undetermined. In addition, an efficacious ketamine regimen for persistent pain management involved a continuous 10-day infusion period with no notable adverse effects. Consequently, the primary objective of this study was to evaluate the antidepressant capacity of consecutive ketamine infusions spanning over three successive days, the duration of therapeutic response, and the overall safety profile of the treatment., Methods: In this randomized controlled trial, participants aged 18-64 with treatment-resistant depression were randomized to receive either intravenous ketamine or midazolam (used as an active placebo) for 40 min daily over three consecutive days. Statistical analysis using repeated measures ANOVA was employed to assess the changes in the total score of the Montgomery-Åsberg Depression Rating Scale (MADRS) and the clinical global impression-Severity from the initial assessment to 10 and 31 days post-infusion. Additionally, the duration of response and remission was evaluated using Kaplan-Meier survival analysis., Results: Out of 33 randomized participants, 20 underwent the treatment as planned. By day 10th, the ketamine group had a mean reduction in MADRS score of 12.55 (95% CI = 6.70-18.09), whereas the midazolam group had a decrease of 17.22 (95% CI = 11.09-23.36). This pattern continued to day 31, with ketamine showing a mean score decrease of 13.73 (95% CI = 7.54-19.91) and midazolam a fall of 12.44 (95% CI = 5.61-19.28). Both treatments were well tolerated, with dissociative symptoms in the ketamine group being temporary and ceasing by the end of each infusion., Conclusion: Intravenous ketamine given for three consecutive days did not show a notable antidepressant advantage when compared to the active placebo midazolam, highlighting the need for further research into effective treatments schedules for treatment-resistant depression., Trial Registration: NCT05026203, ClinicalTrials.gov, registered on 24/08/2021., (© 2024. The Author(s).)

Objectives: This study aimed (1) to determine the psychometric properties of a Thai version of the Maslach Burnout Inventory-Human Services Survey for Medical Personnel (MBI-HSS [MP]) and (2) to examine the mean scores of burnout and associated factors during the COVID-19 pandemic., Methods: Forward and back translations of the MBI-HSS (MP) questionnaire were performed. The Thai version was subsequently completed by 682 Thai physicians and nurses who worked during the COVID-19 pandemic. Exploratory factor analysis was performed on the first subsample ( n  = 341) by conducting Kaiser Mayer-Olkin sampling adequacy measurement and Bartlett's test of sphericity whereas confirmatory factor analysis (CFA) was performed on the second subsample ( n  = 341) using fit indices of the normed chi-square (χ 2 /df), the comparative fit index, the Tucker-Lewis index, and the root mean square error of approximation. This version's internal consistency was investigated using Cronbach's alpha coefficient. Demographic profiles were evaluated with descriptive and analytical statistics., Results: The Thai version of the MBI-HSS (MP) displayed good psychometric characteristics, as the Cronbach's alpha values of the 3 burnout factors ranged from 0.843 to 0.945. The CFA also showed good fit indices (χ 2 /df = 4.473; P  < 0.001; RMSEA = 0.075 (95%CI = 0.055-0.079); CFI = 0.946; and TLI = 0.936). The physicians' mean EE, DP, and PA scores were 25.28 ± 13.27, 7.15 ± 6.11, and 36.83 ± 8.13, respectively, whereas The nurses' mean EE, DP, and PA scores were 23.10 ± 14.14, 4.43 ± 5.06, and 35.67 ± 10.24, respectively. Healthcare professionals who were younger, single, had fewer years of practice, and had more working hours per week tended to express more burnout scores., Conclusions: The Thai version of the MBI-HSS (MP) demonstrates good psychometric properties in assessing burnout among healthcare professionals. Several factors may be pivotal in intensifying burnout., Competing Interests: No potential conflict of interest was reported by the author(s)., (© 2023 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group.)

Psychotic symptoms are rarely concurrent with the clinical manifestations of depression. Additionally, whether psychotic major depression is a subtype of major depression or a clinical syndrome distinct from non-psychotic major depression remains controversial. Using data from the Research on Asian Psychotropic Prescription Patterns for Antidepressants, we developed a machine-learning-algorithm-based prediction model for concurrent psychotic symptoms in patients with depressive disorders. The advantages of machine learning algorithms include the easy identification of trends and patterns, handling of multi-dimensional and multi-faceted data, and wide application. Among 1171 patients with depressive disorders, those with psychotic symptoms were characterized by significantly higher rates of depressed mood, loss of interest and enjoyment, reduced energy and diminished activity, reduced self-esteem and self-confidence, ideas of guilt and unworthiness, psychomotor agitation or retardation, disturbed sleep, diminished appetite, and greater proportions of moderate and severe degrees of depression compared to patients without psychotic symptoms. The area under the curve was 0.823. The overall accuracy was 0.931 (95% confidence interval: 0.897-0.956). Severe depression (degree of depression) was the most important variable in the prediction model, followed by diminished appetite, subthreshold (degree of depression), ideas or acts of self-harm or suicide, outpatient status, age, psychomotor retardation or agitation, and others. In conclusion, the machine-learning-based model predicted concurrent psychotic symptoms in patients with major depression in connection with the "severity psychosis" hypothesis.

The augmentation of clozapine with electroconvulsive therapy (ECT) has been an optimal treatment option for patients with treatment- or clozapine-resistant schizophrenia. Using data from the Research on Asian Psychotropic Prescription Patterns for Antipsychotics survey, which was the largest international psychiatry research collaboration in Asia, our study aimed to develop a machine learning algorithm-based substantial prediction model for the augmented use of clozapine with ECT in patients with schizophrenia in terms of precision medicine. A random forest model and least absolute shrinkage and selection operator (LASSO) model were used to develop a substantial prediction model for the augmented use of clozapine with ECT. Among the 3744 Asian patients with schizophrenia, those treated with a combination of clozapine and ECT were characterized by significantly greater proportions of females and inpatients, a longer duration of illness, and a greater prevalence of negative symptoms and social or occupational dysfunction than those not treated. In the random forest model, the area under the curve (AUC), which was the most preferred indicator of the prediction model, was 0.774. The overall accuracy was 0.817 (95% confidence interval, 0.793−0.839). Inpatient status was the most important variable in the substantial prediction model, followed by BMI, age, social or occupational dysfunction, persistent symptoms, illness duration > 20 years, and others. Furthermore, the AUC and overall accuracy of the LASSO model were 0.831 and 0.644 (95% CI, 0.615−0.672), respectively. Despite the subtle differences in both AUC and overall accuracy of the random forest model and LASSO model, the important variables were commonly shared by the two models. Using the machine learning algorithm, our findings allow the development of a substantial prediction model for the augmented use of clozapine with ECT in Asian patients with schizophrenia. This substantial prediction model can support further studies to develop a substantial prediction model for the augmented use of clozapine with ECT in patients with schizophrenia in a strict epidemiological context.

Objective: Pharmacotherapy including mood stabilizers and antipsychotics are frequently used in bipolar disorder (BD); however, the lack of consensus regarding the definition of polypharmacy hinders conducting comparative studies across different settings and countries. Research on Asian Prescription Pattern (REAP) is the largest and the longest lasting international collaborative research in psychiatry in Asia. The objective of REAP BD was to investigate the prescription patterns of psychotropic medications across Asian countries. The rates of polypharmacy and psychotropic drug load were also analyzed., Methods: The data collection was web-based. Prescription patterns were categorized as (1) mood stabilizer monotherapy: one mood stabilizer; (2) antipsychotic monotherapy: one antipsychotic; (3) simple polypharmacy: one mood stabilizer and one antipsychotic; and (4) complex polypharmacy: ≥ 2 mood stabilizers or/and antipsychotics. The psychotropic drug load in each patient was calculated using the defined daily dose method., Results: Among 2003 patients with BD (52.1% female, 42.4 years) from 12 countries, 1,619 (80.8%) patients received mood stabilizers, 1,644 (82.14%) received antipsychotics, and 424 (21.2%) received antidepressants, with 14.7% mood stabilizer monotherapy, 13.4% antipsychotic monotherapy, 48.9% simple polypharmacy, 20.3% complex polypharmacy, and 2.6% other therapy. The average psychotropic drug load was 2.05 ± 1.40. Results varied widely between countries., Conclusion: Over 70% of psychotropic regimens involved polypharmacy, which accords with the high prevalence of polypharmacy in BD under a permissive criterion (2 or more core psychotropic drugs) worldwide. Notably, ≥ 80% of our sample received antipsychotics, which may indicate an increasing trend in antipsychotic use for BD treatment.

Objectives: To explore the prevalence and factors that contribute to burnout among Thai psychiatrists., Background: The practice of psychiatry can lead to emotional fatigue. As rates of emotional illness in Thailand continue to climb, increasing demands are placed on a limited number of psychiatrists. This can lead to burnout, and multiple negative physical and mental health outcomes., Materials and Methods: Electronic questionnaires were sent to all 882 Thai psychiatrists and residents via a private social media group managed by the Psychiatric Association of Thailand. The questionnaire included demographic data, the Maslach Burnout Inventory (MBI), the Proactive Coping Inventory, and questions about strategies that Thai psychiatrists believed reduce/prevent burnout., Results: Questionnaires were sent and 227 (25.7%) responded. According to MBI, 112 (49.3%) of respondents reported high level of emotional exhaustion, and 60 (26.4%) had a high level of depersonalization. Nearly all respondents (99.6%) maintained a high level of personal accomplishment. Working more than 50 hours per week (p = 0.003) and more patients per day (p = 0.20) were associated with higher levels of burnout. Feeling satisfied with work (p<0.001) and having a good support system from family (p = 0.027) and colleagues (p = 0.033) were associated with lower levels of burnout. The coping mechanisms related to lower levels of burnout included more emotional support seeking (p = 0.005), more proactive coping (p = 0.047), and less avoidance (p = 0.005)., Conclusions: Compared to a previous study on burnout among Thai psychiatrists in 2011, in this study, the prevalence of high levels of burnout had increased dramatically from 17.1% to 49.3%. An intervention to decrease workload, strengthen social support and encourage proactive coping mechanisms may be beneficial for relieving burnout., Competing Interests: The authors have declared that no competing interests exist.