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Background Women with endometriosis (EM) have increased vulnerability to certain psychiatric disorders, including depression and anxiety, as well as bipolar disorder (BD). This study investigates the risk of BD development in EM patients. Also, the impact of EM treatment on the risk of developing BD is examined. Methods A total of 17,832 EM patients and 17,832 non-EM controls matched by age, index year, and Charlson Comorbidity Index (CCI) score were included between 2000–2012 and followed to the end of 2013. Participants newly diagnosed as BD by board-certified psychiatrist were defined as incidents. Cox regression analysis was used to calculate the hazard ratio (HR) with 95% confidence interval (CI) of the BD incidence rate between two studied groups. Results EM patients were associated with an increased risk of BD development compared with non-EM controls after adjusting for age, CCI score, and different treatment options (1.04 versus 0.56 per 1,000 person-years, HR: 2.34, 95% CI: 1.75–3.12). Also, there was no significant difference in the risk estimate between different hormonal or surgical treatment groups, suggesting a limited impact of EM treatment on the risk of BD development. Limitations This study deals with the duration of hormonal treatment, whether operated or not, which reduces the chances of showing the effect of individual EM treatment on the risk of BD development. Conclusion This study shows that EM patients are associated with an increased risk of BD development. Further studies would be needed to elucidate the mechanism linking the EM and BD.

Objectives Narcolepsy symptoms, such as excessive daytime sleepiness or cataplexy, can pose a risk to safety. Stimulants or antidepressants have been used to treat these symptoms. The study investigated the risk of bone fractures in narcolepsy patients. Also, the exposure pattern of stimulants and antidepressants to the risk of bone fractures was examined. Methods In all, 493 narcolepsy patients and 490 controls matched by gender, age, index year, and comorbidity severity were enrolled between 1998 and 2012, then followed until the end of 2013 using Taiwan's National Health Insurance Research Database. During the follow-up period, participants who developed bone fractures were identified. Cox regression analysis was used to calculate the hazard ratio (HR) with 95% confidence interval (CI) for the incidence rates of bone fractures between narcolepsy patients and unaffected controls. Results Narcolepsy patients had a significantly increased risk of bone fractures compared with unaffected controls (19.6 versus 12.3 per 1000 person-years, HR: 1.74, 95% CI: 1.29–2.35). In addition, the use of stimulants in narcolepsy patients showed lower incidence rates of bone fractures compared to non-users (incidence rates were 14.2, 11.9, and 20.0 per 1000 person-years, respectively, among frequent users, infrequent users, and non-users), but the risk estimate was not statistically significant. The evidence for associations between antidepressant use in narcolepsy patients and bone fractures was contradictory. Conclusion This study highlights the need to pay attention to the risk of bone fractures in narcolepsy patients, and the importance of adequate stimulants use might reduce the risk of bone fractures.

Patients with schizophrenia (SCZ) have a higher prevalence of known risk factors for obstructive sleep apnea (OSA). This study aims to determine if SCZ patients are at increased risk of incident OSA. A total of 5092 newly diagnosed SCZ patients and 5092 non-SCZ controls matched by gender, age, and index year were included between 2000 and 2012 and followed to 2013. Participants newly diagnosed with OSA were defined as incidents. Cox regression analysis was used to calculate the hazard ratio (HR) with 95% confidence intervals (CI) of the OSA incidence rate between the two groups studied. SCZ patients were at increased risk of OSA compared to non-SCZ controls after adjusting for gender, age, comorbidities, and duration of antipsychotic use (2.12 versus 1.01 per 1000 person-years, HR: 1.97, 95% CI: 1.36–2.85). Also, this study confirmed the existence of some known risk factors for OSA, including male gender (HR 1.65, 95% CI 1.14–2.37), obesity (HR 2.62, 95% CI 1.19–5.80), hypertension (HR 1.61, 95% CI 1.06–2.47), hyperlipidemia (HR 1.55, 95% CI 1.04–2.38), diabetes (HR 1.53, 95% CI 1.01–2.38), and antipsychotic use (duration

To investigate whether patients with polycystic ovary syndrome (PCOS) are at increased risk for incident schizophrenia and whether PCOS treatment (clomiphene, cyproterone, or metformin) affects the incidence of schizophrenia.An overall of 7146 PCOS patients and 28,580 non-PCOS controls matched by age, index year, and Charlson Comorbidity Index (CCI) score were included between 2000 and 2012 and followed up until 2013 using a validated nationally representative sample from Taiwan. Participants newly diagnosed as schizophrenia were defined as incidents. Cox regression analysis was used to calculate the hazard ratio (HR) with a 95% confidence interval (CI) of the schizophrenia incidence rate between the two studied groups.PCOS patients were at increased risk of incident schizophrenia compared to non-PCOS controls after adjusting for age, CCI score, comorbidities, and different treatment options (0.49 versus 0.09 per 1000 person-years, HR: 6.93, 95% CI: 3.25-14.7). After adjusting for above-mentioned covariates, metformin treatment had a protective effect against the incident schizophrenia compared to non-users (HR: 0.16, 95% CI: 0.06-0.41). Also, treatment with clomiphene and cyproterone had only a limited impact on the incident schizophrenia.This study shows PCOS patients are at increased risk of incident schizophrenia, and the metformin treatment has a protective effect against incident schizophrenia.

Background The study investigated the risk of newly developed bipolar disorder (BD) in patients with polycystic ovary syndrome (PCOS) and examined the relationship between PCOS treatment (hormone therapy (clomiphene or cyproterone) or metformin) and risk of BD development. Methods In all, 7175 PCOS patients and 28,697 non-PCOS controls matched by age, index year, and Charlson Comorbidity Index (CCI) score were included between 2000 and 2012, then followed until the end of 2013. Participants newly diagnosed as BD by board-certified psychiatrists were defined as incidents. Cox regression analysis was used to calculate the hazard ratio (HR) with 95% confidence interval (CI) of the BD incidence rate between two studied groups. Results PCOS patients had a significantly increased risk of developing BD compared to unaffected controls after adjusting for age, CCI score, and different treatment options (1.05 vs. 0.12 per 1,000 person-years, HR: 8.29, 95% CI: 4.65–14.7). Also, the use of metformin in PCOS patients showed a significantly reduced risk of developing BD compared to non-users after adjusting for the above-mentioned variables (HR: 0.36, 95% CI: 0.16–0.81). Although hormone therapy in PCOS patients showed a lower incidence rate of BD development compared to non-users, the risk estimate was not statistically significant (HR: 0.68, 95% CI: 0.35–1.32). Limitations This study didn't assess the PCOS severity, which reduced the chances of showing the effects of PCOS severity on BD development. Conclusion This study shows PCOS patients have an increased risk of developing BD, and the use of metformin may reduce its risk.

Narcolepsy is a rare brain disorder characterized by excessive daytime sleepiness (EDS), cataplexy, hypnagogic hallucinations, and sleep paralysis. Stimulants have been used to relieve the symptoms of EDS. Narcolepsy symptoms may pose a risk to burn injury. The study aimed to investigate the risk of burn injury in narcolepsy patients and to examine the relationship between the use of stimulants and the risk of burn injury. In all, 507 narcolepsy patients and 504 controls matched by gender, age, index year, and Charlson Comorbidity Index (CCI) score were enrolled between 1998 and 2012, then followed until the end of 2013 using Taiwan’s National Health Insurance Research Database. During the follow-up period, participants who developed burn injury were identified. Cox regression analysis was used to calculate the hazard ratio (HR) with 95% confidence interval (CI) of the burn incidence rate between narcolepsy patients and unaffected controls. Narcolepsy patients had a significantly increased risk of burn injury compared to unaffected controls (5.37 versus 2.69 per 1,000 person-years, HR: 2.04, 95% CI: 1.13–3.67) after adjusting for gender, age, CCI score, urbanization degree, and duration of stimulants use. Also, the use of stimulants in narcolepsy patients was associated with a lower incidence rate of developing burn injury, but the risk estimate was not statistically significant after adjusting for the above-mentioned variables. This study shows narcolepsy patients have an increased risk of burn injury and the use of stimulants may reduce the burn incidence rate, providing a reference for developing prevention interventions.

BACKGROUND Hormonal fluctuations may trigger the onset of bipolar disorder. We designed a longitudinal follow-up study to evaluate the association between hysterectomies and bipolar disorder risk. METHODS We conducted a large retrospective cohort study using Taiwan's National Health Insurance Research Database. A total of 4,337 women aged 30 to 50 years who underwent the hysterectomy during 2000-2013 were selected and 17,348 patients without hysterectomy were selected for comparison (1:4 match). Poisson regression analysis was used to calculate the incidence rate ratio (IRR) and 95% confidence interval (CI). RESULTS During the follow-up of 7.93 years, 20 participants with hysterectomy and 28 without hysterectomy developed bipolar disorder. Receiving hysterectomy was associated with the risk of developing bipolar disorder (adjusted IRR = 2.80; 95% CI = 2.54-3.09). Women with hysterectomy had a higher risk of bipolar disorder in follow-up durations of

Objectives Studies have suggested a possible autoimmune contribution in a subset of patients with schizophrenia. The purpose of this study was to determine if a history of autoimmune diseases (AD) is associated with an increased risk of later onset of schizophrenia. Methods Taiwan's National Health Insurance Research Database was used to identify a total of 64,817 AD patients and an equal number of age-matched control patients. The incidence rates of schizophrenia with a maximum follow-up period of 10 years between patients with and without AD were compared using a Cox proportional hazard model to estimate the hazard ratio (HR) and 95% confidence interval (95% CI). Results The main finding was the discovery of a higher incidence of subsequent schizophrenia in patients with AD (HR: 1.72, 95% CI: 1.23–2.4) after adjustment for other demographic characteristics. Specifically, the risk of schizophrenia was observed to be a significant increase in systemic lupus erythematosus (3.73, 2.07–6.72), rheumatoid arthritis (2.89, 1.97–4.23), dermatomyositis (5.85, 1.32–25.94) and autoimmune vasculitis (2.44, 1.17–5.06). Also, this study revealed some potential risk factors for developing schizophrenia, including younger age (less than or equal to 50 years) and some comorbidities (hypertension, chronic obstructive pulmonary disease, and alcohol use disorder). Conversely, this study found that steroid use was a potential protective factor for the development of schizophrenia. Conclusions This study found that AD were associated with an increased risk of developing schizophrenia, suggesting that the abnormal autoimmune process was associated with an increase in the expression of psychiatric disturbances.

Background: Abnormalities in the immune system of endometriosis has been demonstrated and may reflect the chronic inflammatory response or the autoimmune reaction to the presence of ectopic endometrial tissue. Rheumatoid arthritis (RA) is a chronic inflammatory joint disease of an autoimmune nature. The study aimed to investigate the risk of incident RA in patients with endometriosis. Materials and Methods: A total of 17,913 patients with endometriosis and 17,913 unaffected controls matched by age, index year, and Charlson Comorbidity Index (CCI) score were enrolled between 2000 and 2012. Patients were followed until the end of 2013 using Taiwan's National Health Insurance Research Database, at which time participants who developed RA were identified. Cox regression analysis was used to calculate the hazard ratio (HR) with a 95% confidence interval (CI) of RA incidence rate between patients with endometriosis and unaffected controls. Results: Patients with endometriosis were associated with an increased risk of incident RA compared with unaffected controls after adjusting for age, CCI score, and hormonal and surgical treatments (3.56 vs. 1.30 per 10,000 person-years, HR: 3.71, 95% CI: 2.91-5.73). Among these adjusted variables, hormonal and surgical treatments were treated as time-dependent covariates. Stratification analyses also revealed similar risk associations linking endometriosis to subsequent RA in all stratified age and CCI score subgroups (adjusted HR all >1, although not all were significant) Conclusions: Patients with endometriosis was associated with an increased risk of incident RA. Additional prospective studies that take into account genetic vulnerability and environmental exposures are warranted to confirm this relationship.

Hyperthyroidism contributes to many other disease conditions, including neurodegenerative diseases. Parkinson’s disease (PD) is one of the most common neurodegenerative diseases. The purpose of this study was to investigate the risk of PD in patients with hyperthyroidism. A total of 8788 patients with hyperthyroidism and 8788 controls (without hyperthyroidism) matched by age, gender, index year, and Charlson Comorbidity Index (CCI) score were enrolled between 2000 and 2012. Patients were then followed until the end of 2013 using Taiwan’s National Health Insurance Research Database, at which time participants who developed PD were identified. Cox regression analysis was used to calculate the hazard ratio (HR) with a 95% CI of PD incidence rate between patients with hyperthyroidism and unaffected controls. Patients with hyperthyroidism had a significantly increased risk of PD compared with unaffected controls (1.21 vs 0.45 per 1000 person-years, HR: 2.69, 95% CI: 1.08–6.66) after adjusting for age, gender, CCI score, comorbidities, and antithyroid therapy. Hyperthyroidism and PD may share common manifestations. After excluding the first year of observation, a similar result is obtained (HR: 2.57, 95% CI: 1.61–4.01). Also, this study found that older age (HR: 3.74–8.53), more comorbidities (HR: 1.58–1.63), and specific comorbidities (brain injury (HR: 1.57) and cerebrovascular disease (HR: 3.44)) were associated with an increased risk of developing PD. Patients with hyperthyroidism have an increased risk of developing PD. Additional prospective clinical studies are warranted to examine the relationship between hyperthyroidism and PD and determine if there is an intervention that could reduce PD risk.

Objective Previous case reports have linked Graves' disease to incident systemic lupus erythematosus (SLE). It has also been reported that antithyroid drugs used to treat Graves' disease can induce SLE development. The purpose of this study was to investigate the risk of SLE in patients with Graves' disease. Methods A total of 8779 patients with Graves' disease and 8779 controls (without Graves' disease) matched by age, gender, index year, and Charlson Comorbidity Index (CCI) score were enrolled between 2000-2012. Patients were then followed until the end of 2013 using Taiwan's National Health Insurance Research Database, at which time participants who developed SLE were identified. Cox regression analysis was used to calculate the hazard ratio (HR) with a 95% confidence interval (CI) of SLE incidence rate between patients with Graves' disease and unaffected controls. Results Patients with Graves' disease had a significantly increased risk of SLE than unaffected controls (8.81 vs 2.83 per 10 000 person-years, HR: 5.45, 95% CI: 1.74-17.0) after adjusting for antithyroid therapies (antithyroid drugs, radioactive iodine ablation, and surgery). Diagnostic bias may be present as patients with Graves' disease may seek more help from healthcare providers. After excluding the first 0.5 and 1 year of observation period, similar results were obtained (excluding 0.5 year - HR: 4.30, 95% CI: 2.78-8.57; excluding 1 year - HR: 4.63, 95% CI: 2.33-7.79). Conclusion This study shows that Graves' disease is associated with an increased risk of incident SLE. Further studies on the underlying pathogenesis linking Graves' disease and SLE are warranted.

Introduction Continuous positive airway pressure (CPAP) is the main treatment for obstructive sleep apnea (OSA). To date, the link between CPAP usage and incident stroke has been inconsistent. Objective This nationwide population study is designed to examine the effect of CPAP on stroke incidence in OSA patients. Methods Using Taiwan's National Health Insurance Research Database (NHIRD), this study collected data from 4275 OSA patients diagnosed between 2000 and 2011 and divided them into two groups according to whether they received CPAP treatment. After matching baseline demographics and comorbidities, both cohorts contained 959 OSA patients and were followed to a newly diagnosed stroke or until the end of 2013. Cox regression analysis was performed to examine the incidence of stroke between patients with OSA receiving CPAP or no CPAP treatment. Results CPAP treatment for OSA patients predicted a lower incidence rate (3.41 vs 5.43 per 1000 person-years) and tended to protect against the development of stroke (hazard ratio (HR): 0.68, 95% confidence interval (95% CI): 0.38-1.23) compared to those without CPAP treatment, but the estimate was not statistically significant. Similar results were also observed by dividing stroke into ischemic (2.65 vs 4.30 per 1000 person-years; HR: 0.67, 95% CI: 0.35-1.31) or hemorrhagic origin (0.76 vs 1.12 per 1000 person-years; HR: 0.67, 95% CI: 0.19-2.40). Conclusions It is possible that treatment with CPAP might be beneficial for protection against stroke, but this conclusion should be interpreted with caution. Future studies with satisfactory CPAP quality and duration are needed to validate this observation.

The etiology of endometriosis is mostly under-explored, but abnormalities in the immune system leading to an autoimmune reaction have been suggested. The systemic lupus erythematosus (SLE) is one of the most common autoimmune diseases. The purpose of this study was to investigate the risk of SLE in patients with endometriosis. A total of 17,779 patients with endometriosis and 17,779 controls (without endometriosis) matched by age, index year, and Charlson Comorbidity Index (CCI) score were enrolled between 2000 and 2012. Patients were then followed until the end of 2013 using Taiwan’s National Health Insurance Research Database, at which time participants who developed SLE were identified. Cox regression analysis was used to calculate the hazard ratio (HR) with a 95% confidence interval (CI) of SLE incidence rate between patients with endometriosis and unaffected controls. After adjusting for age, CCI score, and different treatment options, patients with endometriosis were at increased risk of SLE compared to unaffected controls (0.85 versus 0.57 per 1000 person-years, HR 1.86, 95% CI 1.36–2.53). Also, higher baseline CCI scores (CCI score 1–2 and ≥ 3 vs. 0—HR 2.33–4.98) were at increased risk of SLE. During follow-up, hormonal treatment for endometriosis could reduce the risk of SLE (short-term and long-term vs. non-use HR 0.48–0.62), while surgical treatment appeared to have a limited impact on the risk of SLE. Patients with endometriosis were at increased risk of SLE, and adequate hormonal treatment could reduce the risk of SLE, providing a reference for developing prevention interventions.

Background The capacity to regulate emotion is important for individuals' ability to adapt to society, the long-term lack of which can lead to related emotional disorders. However, evaluating whether an emotion-regulation strategy is appropriate requires consideration of the individual's distinct culture and situation. In this study, we compared the anger regulation strategies employed in various interpersonal situations by psychiatric outpatients and a community control group in Taiwan. Methods We surveyed 150 psychiatric outpatients (mean age = 45.30, SD = 12.48, 73.3% female) and 150 community controls (mean age = 45.05, SD = 12.24, 73.3% female) congruent in age and sex. Participants evaluated their emotion regulation in two interpersonal contexts by completing a set of questionnaires related to a recent incident of anger they experienced with family and friends, respectively. Results Outpatients used the emotion-regulation strategies of cognitive reappraisal and expressive suppression equally in various relationships; while the community control group made more use of cognitive reappraisal to regulate anger, which arose in their relationships with both family and friends. Relationship intimacy influenced the strategy adopted, and the community control group was more likely to use suppression to regulate anger towards friends than family members, which reflected a cultural belief—maintaining harmony in social relationships. Limitations Context-specific emotion regulation was assessed via a retrospective self-report measure, which is subject to recall bias. Conclusions Our findings highlight the importance of considering interpersonal contexts when studying emotion regulation and developing psychological interventions that target anger or other negative emotion regulation., Psychology; Emotion regulation; Cognitive reappraisal; Suppression; Depressed mood

Hypothyroidism has been implicated in many other disease conditions, including neurodegenerative diseases. Parkinson's disease (PD) is one of the most common neurodegenerative diseases. The purpose of this study was to investigate the risk of PD in patients with hypothyroidism.A total of 4725 patients with hypothyroidism and 4725 controls (without hypothyroidism) matched by age, gender, index year, and Charlson Comorbidity Index (CCI) score were enrolled between 2000 and 2012. Patients were then followed until the end of 2013 using Taiwan's National Health Insurance Research Database, at which time participants who developed PD were identified. Cox regression analysis was used to calculate the hazard ratio (HR) with a 95% confidence interval (CI) of PD incidence rate between patients with hypothyroidism and unaffected controls.Patients with hypothyroidism had a significantly increased risk of PD compared with unaffected controls (2.00 versus 1.10 per 1,000 person-years, HR: 1.77, 95% CI: 1.13-2.76) after adjusting for age, gender, CCI score, physical comorbidities (brain injury, cerebrovascular disease, hypertension, dyslipidemia, and diabetes mellitus), and duration of levothyroxine use. Also, older age (≥50 vs.50 - HR:14.83), higher CCI score (CCI score 1-2≥3 vs. 0 - HR: 1.66-1.74), and specific comorbidities (brain injury (HR: 1.78) and cerebrovascular disease (HR: 2.46)) significantly increased the risk of PD after adjusting for the variables mentioned above.Patients with hypothyroidism have an increased risk of developing PD. Other prospective studies that take into account genetic vulnerability and environmental exposures are warranted to confirm their relationship.

Obstructive sleep apnea (OSA), a sleep disorder, results in decreased daytime alertness and neurocognitive dysfunction. Obesity is considered a major risk factor for the development and progression of OSA and the resulting cognitive dysfunction. However, the effect of obesity on neurocognitive dysfunction in OSA has been rarely investigated. Eighty-three patients with moderate to severe OSA syndrome were recruited in our study. After matching for education, age, and body mass index (BMI), 40 patients were enrolled into our study with matched obese (BMI ≧ 30) and non-obese (BMI

Background Studies suggested autoimmunity plays a role in the etiology of bipolar disorder (BD). This study aimed to investigate the association between systemic autoimmune diseases (SADs) and the subsequent development of BD, and examine the potential risk factors for developing BD. Methods Patients with SADs were identified in the Taiwan National Health Insurance Program (NHIP). A comparison cohort was created by matching patients without SADs with age. The SADs cohort consisted of 65,498 while the comparison cohort consisted of 261,992 patients. The incidence of BD was evaluated in both cohorts. Results The major finding was the discovery of a higher incidence of subsequent BD among patients with SADs (adjusted hazard ratio: 1.98). Specifically, the risk of BD was observed to be significant increase in systemic lupus erythematosus, rheumatoid arthritis, autoimmune vasculitis, Sicca syndrome and Crohn's disease. Furthermore, our study revealed some potential risk factors for developing BD including female, younger age and patients who lived in eastern Taiwan. Also, some comorbidities including dyslipidemia, chronic obstructive pulmonary disease, diabetes mellitus, asthma, cerebrovascular disease, alcohol used disorder, liver cirrhosis, and malignancies were potential risk factors for incident BD. Limitations The diagnosis of SADs was based on the catastrophic illness certificate defined by Taiwanese NHIP. Thus, not every form of SADs was explored for subsequent developing BD. Conclusion This study confirms that SADs are associated with higher incidence of BD, suggesting that abnormal autoimmune process is associated with increased expression of psychiatric disturbances.

Aim Under-management of diabetes can lead to a hyperglycaemic episode (HCE), which could be further strengthened in the presence of schizophrenia and the use of antipsychotics. This study aims to investigate the risk of HCE in diabetic patients with schizophrenia. Additionally, the duration of antipsychotic use on the risk of HCE is examined. Materials and methods A total of 13858 diabetic patients with schizophrenia and 55407 controls (without schizophrenia) matched by gender, age, index year, and Charlson Comorbidity Index score were included between 1999 and 2010 and followed to the end of 2013 using from the Taiwan National Health Insurance Research Database. During the follow-up period, participants who developed HCE were identified. Cox regression analysis was used to calculate the hazard ratio (HR) with 95% confidence interval (95% CI) of the HCE incidence rate between the two groups studied. Results Diabetic patients with schizophrenia were associated with an increased risk of HCE compared with unaffected controls after adjusted for baseline demographics and duration of antipsychotic use (4.73 versus 2.43 per 1,000 person-years, HR: 2.16, 95% CI: 1.85-2.51). Also, in diabetic patients with schizophrenia, a longer duration of antipsychotic use was associated with a lower risk of HCE after adjustment for the above-mentioned variables, suggesting a protective effect of antipsychotics against HCE during prolonged use. Conclusion This study highlights the need to pay more attention to the risk of HCE in diabetic patients with schizophrenia and the importance of proper use of antipsychotics may reduce the risk of HCE.

Background Suboptimal management of diabetes can lead to a hyperglycemic crisis episode (HCE), which could be further enhanced in the presence of bipolar disorder (BD) and the prescription of antipsychotics. This study aims to investigate the risk of HCE in diabetic patients with BD. Additionally, the duration of antipsychotic prescription on HCE risk is examined. Methods Using the Taiwan National Health Insurance Research Database, 6099 diabetic patients with BD and 24,378 diabetic patients without BD matched by gender, age, index year, and Charlson Comorbidity Index score were enrolled between 1999 and 2010 and followed to the end of 2013. Participants who developed HCE during the follow-up period were identified. Cox regression analysis was used to calculate the hazard ratio (HR) with 95% confidence interval (CI) of the HCE incidence rate between two groups studied. Results Diabetic patients with BD were associated with an increased risk of HCE compared with unaffected controls after adjusted for baseline demographics and duration of antipsychotic prescription (3.84 versus 2.71 per 1,000 person-years, HR: 1.41, 95% CI: 1.15–1.71). Also, this study revealed that male gender, more comorbidities, and a longer duration of antipsychotic prescription were potential risk factors for developing HCE. Limitations This study only deals with data on the duration of antipsychotic prescription, without showing the effects of different antipsychotics on HCE risk. Conclusion This study highlights the need to pay attention to the risk of HCE in diabetic patients with BD and the importance of careful prescription of antipsychotics to reduce the HCE incident.

Introduction Violent motor tics or severe self-harm behaviors have been reported in patients with Tourette's syndrome (TS) and leading to traumatic brain injury (TBI). The study aimed to determine the risk of TBI in TS patients, the effects associated with concurrent psychiatric disorders (attention-deficit/hyperactivity disorder (ADHD), obsessive-compulsive disorder (OCD), or depressive disorder), and the effects of medication treatment (antipsychotics, antidepressants, or clonidine) on the risk of TBI. Methods Using the National Health Insurance Research Database of Taiwan, 2261 TS patients and 20349 non-TS controls matched by gender and age were enrolled between 2000 and 2012, and followed until the end of 2013. Participants who developed TBI during the follow-up period were identified. Cox regression analysis was performed to examine the risk of TBI between TS patients and non-TS controls. Results TS patients were associated with an increased risk of TBI compared to non-TS controls (hazard ratio (HR): 1.59, 95% confidence interval (95% CI): 1.37–1.85). Also, this study revealed TS patients with ADHD, OCD, or depressive disorder predicted a higher TBI incidence rate than those who did not, but the estimate was not statistically significant. Moreover, this study found that TS patients with frequent use of antipsychotics were associated with a lower risk of TBI than infrequent users (HR: 0.76, 95% CI: 0.57–0.99). Conclusions This study highlights the need to pay more attention to the risk of TBI in TS patients, and the importance of adequate antipsychotic medication may reduce the risk of TBI.

Arachnoid cyst is a benign, congenital space-occupying brain lesion, which has been found in patients with schizophrenia. The association between arachnoid cyst and schizophrenia remains controversial, but the location of the arachnoid cyst may give rise to a specific symptom presentation in schizophrenia. We present a 31-year-old woman with an established diagnosis of schizophrenia coexisting with a large cerebellar arachnoid cyst who presented mainly with delusions of control. This cerebellar arachnoid cyst and schizophrenia may have been found together coincidentally or brain dysfunction due to this cerebellar arachnoid cyst may have caused or contributed to the appearance of psychotic symptoms. The patient had an unsteady gait accompanied by delusions of control, and she showed a poor response to high-dose olanzapine treatment, suggesting the arachnoid cyst was associated with her schizophrenic symptoms. The cyst was over the right posterior fossa with cerebellum compression, which may have caused abnormality in the cerebellar–parietal network resulting in her delusions of control. This case indicates that there might be relationships between cerebellar lesions, schizophrenia, and delusions of control.

Aims This study aims to investigate the risk of hyperglycemic crisis episode (HCE) in diabetic patients with depression and to examine the relationship between the duration of antidepressants use and the risk of HCE. Methods In all, 26,746 diabetic patients with depression and 106,853 controls (without depression) matched by gender, age, index year, and Charlson Comorbidity Index (CCI) score were included between 1999 and 2010, then followed until the end of 2013. During the follow-up period, participants who developed HCE were identified. Cox regression analysis was used to calculate the hazard ratio (HR) with 95% confidence interval (CI) of the HCE incidence rate between the two groups studied. Results Diabetic patients with depression had a significantly increased risk of HCE compared to unaffected controls after adjusted for gender, age, CCI score, and duration of antidepressants use (2.87 versus 2.50 per 1000 person-years, HR: 1.78, 95% CI: 1.56–2.03). Also, long-term use of antidepressants in diabetic patients with depression showed a significantly reduced risk of HCE compared to non-users after adjusting for the above-mentioned variables (HR: 0.44, 95% CI: 0.35–0.55). Conclusions This study shows diabetic patients with depression have an increased risk of HCE, and the use of antidepressants may reduce its risk.

BackgroundSeveral features of borderline personality disorder (BPD) are likely to be associated with sexual health problems, such as unstable attachment, unstable sexual identity and sexual impulsivity. Since the issue of sex is not openly discussed in Taiwanese society, sexual health needs, including screening and prevention of sexually transmitted infections (STI), are often neglected in this population.ObjectiveThe study aims to determine whether BPD is associated with an increased risk of subsequent STI in Taiwan.MethodsOverall 669 patients with BPD and 2676 controls matched by gender and age were enrolled between 2000 and 2012 and followed until the end of 2013 using Taiwan’s National Health Insurance Research Database. During the follow-up period, participants who developed STI (human immunodeficiency virus, syphilis, genital warts, gonorrhoea, chlamydia and trichomoniasis) were identified. Cox regression analysis was used to calculate the hazard ratio (HR) with 95% confidence interval (CI) of the STI incidence rate between patients with BPD and unaffected controls.ResultsPatients with BPD were predisposed to developing STI (HR: 4.17, 95% CI 1.62 to 10.8) after adjusting for demographic data and psychiatric comorbidities. The stratification analysis revealed a similar risk trend with BPD and subsequent STI in each gender and age group and was significant in the subgroups of male (HR: 11.3, 95% CI 2.97 to 42.7) and those aged 18–34 years (HR: 4.85, 95% CI 1.71 to 13.7). Also, the comorbidity stratification analysis revealed that, when the effect of comorbidities was excluded, patients with pure BPD significantly exhibited the risk association for subsequent STI after adjusting for all variables (HR: 4.24, 95% CI 1.25 to 14.4).ConclusionGiven the greater potential of BPD to be associated with an increased risk of STI, there should be direct implications for the development of targeted prevention interventions in Taiwan’s mental health clinics.

Since many studies have shown a reduction in the incidence of rheumatoid arthritis (RA) in patients with schizophrenia (SCZ), little effort has been devoted to studying this link in the Asian population. Moreover, the relationship between these two disorders could be bidirectional, but the influence of RA on the SCZ incidence is unclear. The study aims to determine whether there is a bidirectional association between RA and SCZ in an Asian population. We analyzed a 10-year population- based longitudinal cohort using the National Health Insurance Research Database of Taiwan. In the first analysis, we included a total of 58,847 SCZ patients and 235,382 non-SCZ controls, and in the second analysis, a total of 30,487 RA patients and 121,833 non-RA controls, both matched by gender, age, and index date. Cox regression analyses were performed to examine the risk of RA incidence in the first analysis and the risk of SCZ incidence in the second analysis. The main finding of this study was the discovery of a lower incidence of RA in patients with SCZ (hazard ratio (HR): 0.48, 95% confidence interval (95% CI): 0.31–0.77) after adjustment for baseline demographics and comorbidities. Additionally, the presence of RA predicted a reduced incidence rate for SCZ, but the estimate was not statistically significant (HR: 0.77, 95% CI: 0.44–1.37). The study found a unidirectional association between RA and SCZ. However, RA has an age of onset later than RA, and the protective effect of RA on SCZ incidence would be biased due to the limited number of cases.

Background Previous studies have suggested that sexually transmitted infections (STI) tend to increase in patients with bipolar disorder during a manic or hypomanic episode. However, in the long-term course of this disease, it is unclear whether patients with bipolar disorder have a higher risk of incident STI. Methods Using the National Health Insurance Research Database of Taiwan, 3721 patients with bipolar disorder and 14,884 controls without bipolar disorder matched by gender and age were enrolled between 2000 and 2010 and followed up until the end of 2013. Participants who developed any STI (human immunodeficiency virus [HIV], syphilis, genital warts, gonorrhea, chlamydial infection, and trichomoniasis) during the follow-up period were identified. Cox regression analysis was performed to examine the risk of STI between patients with bipolar disorder and comparative controls. Results Patients with bipolar disorder were prone to develop STI (hazard ratio [HR], 1.67, 95% confidence interval [95% CI], 1.27-2.18) especially for HIV (HR, 3.59; 95% CI, 1.16-11.08) and syphilis (HR, 2.26; 95% CI, 1.06-4.85). In addition, this study found that the incidence of STI was higher among women than men (HR, 1.83; 95% CI, 1.41-2.39). Conclusions This study shows that bipolar disorder is associated with an increased risk of developing STI, which has direct implications for the development of targeted prevention interventions or regular sexual health screening in mental health clinics to reduce the disproportionate burden of HIV and other STI in patients with bipolar disorder.

Obstructive sleep apnoea (OSA) is a sleep disorder involving repeated nocturnal desaturation and sleep fragmentation. OSA can result in decreased daytime alertness and neurocognitive dysfunction. Hypercapnia status is also related to neurocognitive dysfunction in patients with pulmonary diseases. We evaluated the effects of hypercapnia on cognitive performance and memory function in a prospective case-controlled study. We enrolled thirty-nine obese patients with OSA and collected their arterial blood samples. All the participants provided arterial blood samples, and completed two questionnaires (the Pittsburgh Sleep Quality Index and the Epworth Sleepiness Scale) and six cognitive tasks (the psychomotor vigilance task [PVT], the Stroop task, the Eriksen flanker task, processing speed [DSST], and verbal and visual memory [LM&FM]), which were used to evaluate daytime sleepiness, cognitive function, and memory function within one week of a polysomnographic study. When compared to the OSA without diurnal hypoventilation, the patients with stable hypercapnia (OHS) had increased reaction times in the PVT, Stroop task, and flanker task. Hypercapnic obese patients with OSA also had comparatively significantly lower scores in the processing speed and logical memory tests. OHS had increased reaction times in the attention and cognitive function assessments, and deficits in the logical memory, when compared to those with OSA without diurnal hypoventilation.

Objectives In Taiwan, there has been a growing emphasis on physical health screening, health education and improving access to treatment in patients with schizophrenia (SCZ). However, sexual health needs, including screening and prevention of sexually transmitted infections (STI), are neglected in this population. The study aimed to investigate the association between SCZ and the subsequent incident STI and to examine potential risk factors. Methods Using the National Health Insurance Research Database of Taiwan, 58,948 SCZ patients and 235,784 controls matched by gender and age were enrolled between 2000 and 2010 and followed until the end of 2011. Participants who developed any STI (HIV, syphilis, genital warts, gonorrhea, chlamydial infection, and trichomoniasis) during the follow-up period were identified. Cox regression analysis was performed to examine the risk of STI between SCZ patients and controls. Results SCZ patients were predisposed to developing STI (hazard ratio (HR): 1.11, 95% confidence interval (95% CI): 1.01–1.21) that could be caused by syphilis (HR: 2.58, 95% CI: 2.14–3.10) or possibly HIV (Crude HR: 1.39, 95% CI: 1.04–1.86; adjusted HR: 1.11, 95% CI: 0.81–1.52). Additionally, this study found that female, young adults, low-income, living in less urbanized areas, and comorbid substance abuse were potential risk factors for developing STI. Conclusion This study shows that SCZ is associated with an increased risk of developing STI, which has direct implications for the development of targeted prevention interventions or regular sexual health screening in mental health clinics to reduce the disproportionate burden of HIV and other STI in SCZ patients.

Studies suggested autoimmunity plays a role in the etiology of obsessive–compulsive disorder (OCD). The purpose of this study was to determine if a history of systemic autoimmune diseases (SADs) is associated with an increased risk of subsequent onset of OCD. Patients with or without SADs were identified in the Taiwan National Health Insurance Program. The SADs cohort consisted of 63,165, while the comparison cohort consisted of 315,825 patients. The incidence rates of OCD with a maximum follow-up period of 10 years between patients with and without SADs were compared using a Cox proportional hazard model to estimate the hazard ratio (HR) and 95% confidence interval (95% CI). The major finding was the discovery of a higher incidence of subsequent OCD among patients with SADs (HR: 1.85; 95% CI 1.41–2.43) after adjusted for other demographic characteristics. Specifically, the risk of OCD was observed to be significant increase in systemic lupus erythematosus (1.65, 1.07–2.54) dermatomyositis (3.25, 1.04–10.17), and Sjogren’s syndrome (2.38, 1.53–3.72). Also, this study revealed some potential risk factors for developing OCD, including younger age (less than or equal to 50-year-old) and some comorbidities (alcohol use disorder, liver cirrhosis, and malignancies). Conversely, this study found that steroid use was a potential protective factor for the development of OCD. This study confirms that SADs are associated with higher incidence of OCD, suggesting that abnormal autoimmune process is associated with increased expression of psychiatric disturbances.

Background Obstructive sleep apnea involves repeated nocturnal desaturation and sleep fragmentation that leads to poor sleep quality, anxiety, and depression. This study aimed to investigate short- and long-term improvements in the anxiety and depression of patients with different obstructive sleep apnea treatments. Methods This is a prospective, non-randomized hospital-based study evaluated 55 patients (46 male, 9 female) with obstructive sleep apnea. The patients were divided into three groups based on different treatment: uvulopalatopharyngoplasty group, continuous positive airway pressure group, and no treatment group (by their own decision). They completed the Beck Depression Inventory II, Beck Anxiety Inventory, and Pittsburgh Sleep Quality Index before treatment and at one and six months after treatment. Results Compared to the no treatment group, the surgery and continuous positive airway pressure groups had higher body mass index, AHI, and Epworth sleepiness scale, but no difference in Pittsburgh Sleep Quality Index, Chinese Health Questionnaire-12, Beck Depression Inventory II, and Beck Anxiety Inventory. The continuous positive airway pressure and surgery groups still had no improvements in Pittsburgh Sleep Quality Index, Chinese Health Questionnaire-12, Beck Depression Inventory II, and Beck Anxiety Inventory scores one month after treatment. At six months after treatment, the continuous positive airway pressure group had significantly decreased Pittsburgh Sleep Quality Index, Chinese Health Questionnaire-12, Beck Depression Inventory II, and Beck Anxiety Inventory, whereas the surgery group had significant difference in Beck Anxiety Inventory only and the no treatment group still had no significant difference in any of the parameters. Conclusions Continuous positive airway pressure can improve the sleep quality, quality of life, depression, and anxiety of obstructive sleep apnea patients after six months of treatment. However, surgery can significantly improve anxiety only in the same period.

To the Editor: Delusional pregnancy is defined as the belief of being pregnant despite factual evidence to the contrary. The disorder can be triggered by a wide variety of organic brain syndromes and psychiatric illnesses as well as medication-induced hyperprolactinemia.1 Delusional pregnancy has been described in patients with bipolar disorder and is usually accompanied by antipsychotic agent–induced hyperprolactinemia.1,2 Here, we report the case of a delusion of triplet pregnancy in a drug-naive woman experiencing her first manic episode. The treatment strategy and the importance of psychological factors in the development of delusional pregnancy are discussed. Case report. Ms A is a 31-year-old woman with no history of psychiatric illness. She has been married for 8 years but has no children. She was admitted to the hospital because of a new-onset psychotic mania with presentation of labile mood, hypertalkativeness, decreased need for sleep, and flight of ideas accompanied by delusional pregnancy. She described some pregnancy signs such as cessation of menstrual periods, weight gain, frequency of urination, and abdominal distension. She firmly believed that she was pregnant with triplets, 2 females and 1 male, and said she could feel the babies moving. A series of examinations were arranged. The pregnancy test was negative. The results of blood count, serum chemistry, and prolactin levels were within normal limits. Her brain computed tomography scan was normal. After a full diagnostic workup, Ms A was administered lithium 900 mg/d combined with olanzapine 20 mg/d. On the 16th day of hospitalization, the delusional pregnancy resolved. Treatment with the same regimen resulted in gradual improvement of her manic symptoms. There is no specific treatment for delusional pregnancy outlined in the literature. Antipsychotic agents may play an important role along with the treatment of underlying medical and psychiatric comorbidities.3 Treatment of hyperprolactinemia is needed in patients with delusional pregnancy.4 Prolactin-sparing antipsychotic agents (such as aripiprazole and the “pines” [eg, clozapine, olanzapine, quetiapine, asenapine]) might be the first choice.4 In the case of Ms A, it would be important to take into account the possibility that olanzapine might induce hyperprolactinemia and weight gain that could mimic pregnancy and trigger her delusion. Three months after her hospitalization, lithium and olanzapine were gradually switched to aripiprazole 15 mg/d monotherapy in the outpatient clinic with no relapse of manic and psychotic symptoms. Delusional pregnancy might be explained by organic factors and an adaptation to stress induced by psychological factors.3 Very frequently, delusional pregnancy occurs when a married couple is infertile.4 The infertility is usually attributed to the woman, which results in experiencing substantial distress and discrimination. Neutral sensory perception is misidentified, such as weight gain, cessation of menstrual periods, abdominal distension, frequency of urination, or abdominal movement. The same sensory perception may have occurred many times before. But, as Ms A searched for what the sensory perception might mean in her manic episode, the delusional pregnancy formed. In psychodynamic view, Ms A’s psychotic mania may have resulted from her tyrannical superego against the long-term infertility. The infertility produced intolerable self-criticism that was then replaced by euphoric self-satisfaction and became a delusion of triplet pregnancy. In this point of view, the delusion of triplet pregnancy represents a kind of grandiose delusion in her manic episode. Our case adds to the limited literature on the phenomenon of delusional pregnancy in mania. Psychotropic drugs (lithium, olanzapine, and aripiprazole) demonstrate efficacy in treating delusional pregnancy, as was shown in our case.

ObjectiveaaThis paper aims to examine the association between painful physical symptoms (PPS) and major depressive disorder (MDD) in a naturalistic clinical practice setting within a Korean population. MethodsaaPatients with acute MDD that joined a multicountry, observational, three-month study in six Asian countries and regions were classified as PPS+ (mean score ≥2) and PPS(mean score

Depression is the predominant pole of disability in bipolar disorder and compared with mania/hypomania, has less systematic research guiding the development of treatment especially in its acute phase (acute bipolar depression). The deficiency in the management of the acute bipolar depression largely reflects the natural divergence of opinion resulting from significant knowledge gaps. At present, there are only 3 approved drug treatments for acute bipolar depression: olanzapine/fluoxetine combination, quetiapine (immediate or extended release), and lurasidone (monotherapy or adjunctive to lithium or valproate). Nonapproved agents and nonpharmacologic treatment such as lamotrigine, antidepressants, modafinil, pramipexole, ketamine, and electroconvulsive therapy are often prescribed to treat acute bipolar depression. This article discusses the challenges of diagnosing bipolar depression, and reviews above treatment options for acute bipolar depression.

Aripiprazole acts as a partial agonist at dopamine D2 and D3 and serotonin 1A receptors and as an antagonist at serotonin 2A receptors (HTR2A). Since aripiprazole acts as an antagonist at HTR2A, genetic variants of HTR2A may be important in explaining variability in response to aripiprazole. This study investigated whether the efficacy of aripiprazole can be predicted by functional HTR2A A-1438G/T102C polymorphisms (rs63311/rs6313) as modified by clinical factors in Han Chinese hospitalized patients with acutely exacerbated schizophrenia. After hospitalization, the patients (n = 128) were given a 4-week course of aripiprazole. Patients were genotyped for HTR2A A-1438G/T102C polymorphisms via the restriction fragment length polymorphism method. Clinical factors such as gender, age, duration of illness, education level, diagnostic subtype, and medication dosage were noted as well. The researchers measured psychopathology biweekly, using the Positive and Negative Syndrome Scale (PANSS). A mixed model regression approach (SAS Proc MIXED) was used to analyze the effects of genetic and clinical factors on PANSS performance after aripiprazole treatment. We found that the GG/CC genotype group of HTR2A A-1438G/T102C polymorphisms predicts poor aripiprazole response specifically for negative symptoms. In addition, the clinical factors, including dosage of aripiprazole, age, duration of illness, and diagnostic subtype, were found to influence PANSS performance after aripiprazole treatment. The data suggest HTR2A A-1438G/T102C polymorphisms may predict negative symptoms performance upon aripiprazole treatment in schizophrenic patients as modified by clinical factors.

Objectives Aripiprazole, a novel antipsychotic agent, acts as a partial agonist at dopamine D2 receptors (DRD2). We investigate whether its efficacy is predictable by DRD2/ANKK1 gene polymorphisms and clinical factors in Han Chinese hospitalized patients with acutely exacerbated schizophrenia. Method After hospitalization, the patients (n = 128) were given aripiprazole for up to 4 weeks. They were genotyped for four functional DRD2/ANKK1 polymorphisms: −141 Ins/Del, Ser311Cys, C957T, and TaqIA. Clinical factors such as gender, age, illness duration, education level, diagnostic subtype, and medication dosage were also recorded. Psychopathology was measured biweekly with the positive and negative syndrome scale (PANSS). The effects of genetic and clinical factors on PANSS performance upon aripiprazole treatment were analyzed by a mixed modeling approach (SAS Proc MIXED). Results Compared to the patients with TaqI A2/A2 genotype, A1 carriers are associated with superior therapeutic response on positive symptoms after 4-week aripiprazole treatment. Regarding the C957T polymorphism, patients with C/C genotype were associated with poor aripiprazole response for excitement symptoms when compared with T/T patients. The other two polymorphisms, −141 Ins/Del, and Ser311Cys, have no significant effects on PANSS performance. The clinical factors including medication dosage, illness duration, and diagnostic subtype could influence PANSS performance upon aripiprazole treatment. Conclusion This study suggests that DRD2/ANKK1 gene variations and some clinical factors may predict individual response to aripiprazole.

To investigate the effects of antidepressants on glucose-insulin homeostasis, we provided homogenous situation and performed standard procedures to assess the interactions of antidepressants and glucose regulation during hospitalization.Twenty-three non-diabetic depressed males were recruited and assigned to two groups based on the antidepressants received (maprotiline n=11, fluoxetine n=12). The severity of depression was evaluated using a 21-item Hamilton depression rating scale (HAM-D). Before and after the 4-week treatment, participants underwent 75-g oral glucose tolerance test (OGTT) and frequently sampled intravenous glucose tolerance test (FSIGT). Insulin sensitivity (SI), glucose effectiveness (SG), acute insulin response (AIR), and disposition index (DI) were estimated using minimal model method.The HAM-D scores were reduced significantly (P0.005) after antidepressant treatment. Following maprotiline treatment, the body weight and BMI were significantly increased (P=0.02). Individuals treated with maprotiline displayed a significantly increased AIR (3239+/-682 vs. 4698+/-597 pmol; P=0.04) during the FSIGT.The sample size was limited. Furthermore, the study was conducted in the early phase of depression-treated course.The results suggest that the beta-cell function is hyperbolic in order to offset the insulin resistance following maprotiline treatment. Our findings imply that norepinephrine reuptake inhibitor (NRI) antidepressants might attenuate insulin sensitivity.

To the Editor: In the current Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), catatonia is not recognized as a separate disorder but is associated with many psychiatric and medical conditions.1 Psychiatric causes of catatonia range from 70% to 80%, and organic causes of catatonia range from 20% to 30%.2 Among the psychiatric causes of catatonia, around 30% are related to mood disorders, and approximately 10% to 15% are associated with schizophrenia.2 Catatonia is a rare condition for someone to experience with a major depressive episode with psychotic features. There is only 1 report describing a young woman with this rare phenomenon during the postpartum period.3 Otherwise, catatonia associated with bereavement has rarely been described. There are only 2 reports describing terminal cancer patients who developed brief psychotic disorder with catatonic syndromes after bereavement.4,5 Here, we report the case of a patient who developed an emergent catatonia in a major depressive episode with psychotic features associated with bereavement. The catatonia was improved by injectable diazepam and olanzapine. The psychotic depression was successively treated with mirtazapine and olanzapine. Case report. Ms A is a 42-year-old woman without psychiatric illness history. Her fiance’s sudden death during a gastric operation was a terrible shock to her. After he died, Ms A was sad and anhedonic, with guilty delusion and suicidal ideation. She presented with intense negativism about herself and severe psychomotor retardation. She was unable to carry out daily activities without help at home and was admitted to the hospital. During hospitalization, she was mute, presented extreme loss of motor skill, held rigid poses for hours, and was not responding to any external stimuli. She required intensive nursing care and administration of intravenous fluids for nutrition and carried a urethral catheter for bladder distention. A series of examinations were arranged. The results of blood counts and serum chemistry were within normal limits. Her brain computerized tomography was normal. Drug screening tests were negative for central nervous system suppressants. After full diagnostic workup, Ms A was administered injectable diazepam 20 mg/d combined with olanzapine 10 mg/d. On the 10th day of hospitalization, the catatonia resolved gradually. While recovering from catatonia, Ms A presented with severe depression and guilty delusion (according to DSM-5 criteria). Treatment with tablet mirtazapine 60 mg/d and olanzapine 10 mg/d resulted in gradual improvement of her psychotic depression. According to the DSM-5,1 Ms A experienced a major depressive episode with psychotic features just after her fiance died. A period of catatonia developed insidiously during this psychotic depressive episode. A previous report described catatonia that developed during a major depressive episode with psychotic features in the postpartum period.3 The case of Ms A suggests that patients may develop catatonia in psychotic depression when they experience loss of close relatives. Based on clinical evidence, the 2 main treatment options for catatonic depression are benzodiazepines and electroconvulsive therapy.6 Atypical antipsychotics are also utilized in certain cases, as they are thought to help manage psychotic symptoms or to be an augmentation strategy for depression.6 As in our case, injectable diazepam and olanzapine demonstrate their efficacy in treating this condition. Psychotic depression affects approximately 25% of patients who are admitted to the hospital for depression.7 Usually, combinations of antidepressants and antipsychotic medications are needed to treat this condition.8 In the case of Ms A, mirtazapine combined with olanzapine demonstrated efficacy in treating catatonia. To our knowledge, no hypotheses have been made linking the neurobiology of psychotic depression and that of catatonic syndromes. Our case, as well as the case reported during the postpartum period,3 highlight the need for clinicians to watch for the emergence of catatonia in cases of psychotic depression, especially during the postpartum and bereavement periods.

Huntington's disease (HD) is an autosomal dominant neurodegenerative disorder characterized by midlife onset, progressive course and a combination of motor, cognitive and psychiatric symptoms. Since dysregulation of the glutamate/calcium signalling pathway is beginning to emerge as a potential cause of neuron degeneration, antagonists of glutamate pathways such as lamotrigine, may have beneficial value for treatment of HD. We describe the use of lamotrigine in the treatment of an HD patient with motor abnormality (choreoathetoidic movements) complicated by psychiatric abnormalities (depression, severe mood swing and recurrent high risk of suicidal attempts). The patient's depression, severe mood swing and choreoathetoidic movements significantly improved with 300 mg/day of lamotrigine. Experience from our patient suggests that lamotrigine might be effective in treating HD patients with motor and mood symptoms. Further controlled studies are warranted to confirm its efficacy in patients of this type.

Inhalants encompass a wide range of pharmacologically diverse substances that readily vaporize. They are widely available and frequently misused. The type, frequency, and method of inhalant abuse vary widely in relation to the age of the abuser, the geographic region, and availability. Inhalant abuse causes psychosocial as well as organic morbidity. The chief organic morbidity is dementia and cerebellar dysfunction. Death due to inhalant abuse can occur by several mechanisms, including asphyxia, suffocation, risky behaviors, aspiration, and sudden sniffing death syndrome. The Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision provides two categories of inhalant-related disorders. The first category is inhalant use disorders (inhalant abuse and dependence), which are characterized by a maladaptive pattern of inhalant use. The second category is inhalant-induced disorders (intoxication delirium, persisting dementia, psychotic disorder, anxiety disorder, and mood disorder), which result from the toxic effects of inhalants. This chapter reviews important aspects of inhalant addiction and makes several recommendations involving prevention and education strategies to address this problem.

Summary Aims: Reports from non-Asian populations indicate that painful physical symptoms (PPS) are associated with poorer clinical and functional outcomes in major depressive disorder (MDD). The purpose of this study is to report comparative changes in disease severity, treatment patterns and quality of life observed in East Asian patients with MDD, with and without PPS, as assessed prospectively over a 3-month observation period. Methods: This observational study enrolled 909 patients with MDD in psychiatric care settings in China, Hong Kong, Korea, Malaysia, Singapore and Taiwan. Patients were classified as PPS positive (PPS+) or negative (PPS−) based on mean modified Somatic Symptom Inventory scores of ≥ 2 or

Aripiprazole, a novel antipsychotic agent, has a unique pharmacological action (partial agonist) on the dopamine neurotransmission system. Aripiprazole has high affinity for dopamine D2 and D3 receptors (DRD2 and DRD3). We investigated whether the efficacy of aripiprazole can be predicted by a functional DRD3 gene polymorphism Ser9Gly (rs6280) as modified by clinical factors in Han Chinese hospitalized patients with acutely exacerbated schizophrenia. After hospitalization, the patients (n=128) were given aripiprazole for up to four weeks. Patients were genotyped for DRD3 Ser9Gly polymorphism by Restriction Fragment Length Polymorphism (RFLP) method. Clinical factors such as gender, age, duration of illness, education level, diagnostic subtype and medication dosage were recorded. Psychopathology was measured biweekly with the Positive and Negative Syndrome Scale (PANSS). The effects of genetic and clinical factors on PANSS performance after aripiprazole treatment were analyzed by a mixed model regression approach (SAS Proc MIXED). We found that, although the Ser carriers have numerically larger score reductions when compared with non-carriers in almost all PANSS dimensions, the difference of their effects are statically not significant. However, the clinical factors, including dosage of aripiprazole, age, duration of illness, and diagnostic subtype could influence PANSS performance after aripiprazole treatment. This study suggests that DRD3 Ser9Gly polymorphism may not contribute significantly to inter-individual differences in therapeutic efficacy of aripiprazole, but some clinical factors may predict treatment efficacy.

Stevens-Johnson syndrome is a severe and potentially life-threatening cutaneous reaction associated with lamotrigine. The incidence of developing Stevens-Johnson syndrome during lamotrigine therapy is low. On the basis of the glutamate and dopamine neuron dysregulation hypothesis in schizophrenia, we propose new strategies for the treatment of schizophrenic patients using a glutamate system stabilizer lamotrigine as an adjunctive treatment for the poor responders of a dopamine system stabilizer, aripiprazole. The finding of Stevens-Johnson syndrome in two cases out of three treated with lamotrigine plus aripiprazole, however, has a much higher index of suspicion and it is correct to warn of its possible raised risk. As lamotrigine is currently licensed for the prophylactic treatment of bipolar depression, many of these patients have psychotic features where it would be considered reasonable to add an antimanic atypical antipsychotic such as aripriprazole. The two case reports raised the question about the possible increased risk of Stevens-Johnson syndrome with the combination therapy.

Aripiprazole is a novel atypical antipsychotic agent with unique pharmacological profiles as a partial dopamine receptor agonist. Few extrapyramidal signs have been reported previously following the use of aripiprazole. In the present study, we report on an 84-year-old female patient who suffered from vascular dementia with psychotic symptoms. She was treated with aripiprazole and acute dystonia was noted. This case report highlights the importance of slow titration of aripiprazole and close monitoring for extrapyramidal signs in elderly psychotic patients with vascular dementia.