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Benchalak Maneeton,1 Narong Maneeton,1 Surinporn Likhitsathian,1 Pakapan Woottiluk,2 Punjaree Wiriyacosol,1 Vudhichai Boonyanaruthee,1 Manit Srisurapanont1 1Department of Psychiatry, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand; 2Psychiatric Nursing Division, Faculty of Nursing, Chiang Mai University, Chiang Mai, Thailand Background: Previous evidence indicated that efficacy of escitalopram (Esc) and duloxetine (Dul) was comparable in the treatment of major depressive disorder (MDD). Since such studies had small sample sizes, this study purposefully applied a systematic review to determine the efficacy, acceptability, and tolerability those antidepressants in treatment of MDD. Participants and methods: The following primary databases were searched in July 2017: Scopus, PubMed, CINAHL, and Cochrane Controlled Trials Register. Any randomized controlled trials (RCTs) of Esc comparison with Dul in the treatment of MDD were included in this review. The primary efficacy of outcome was the pooled mean-changed scores of the rating scales for the standardized rating scales for depression. Results: A total of 1,120 randomized subjects from 3 RCTs were collected for synthesis in the present meta-analysis. The mean-changed scores of the Hamilton Depression Rating Scale (HAMD) and Clinical Global Impression – Severity, overall response rate by the HAMD, and remission rate by the HAMD and Montgomery–Asberg Depression Rating Scale (MADRS) in the Esc- and Dul-treated groups showed no significant differences. However, the mean-changed score of the MARDS, mean-end scores of Clinical Global Impression – Improvement, and overall response by the MADRS in the Esc-treated group were greater than that of the Dul-treated group. Although the overall discontinuation rate had no significant differences between the 2 groups, the discontinuation rate due to adverse events in the Esc-treated group was greater than that of the Dul-treated group. Limitations: This review had limited eligible studies. Conclusion: This review indicated the efficacy in the acute treatment of Esc vs Dul varied relying on measurements across the studies. However, the tolerability of Esc was superior to Dul in acute MDD treatment. Therefore, selection between the 2 antidepressants may depend on the tolerability of MDD patients. Due to limited included studies in this review, more large-scale and well-defined RCTs in such patients should be carried out to determine these outcomes. Keywords: Hamilton Depression Rating Scale, HAMD, Montgomery–Asberg Depression Rating Scale, MADRS, efficacy, acceptability, tolerability

Narong Maneeton,1 Benchalak Maneeton,1 Pakapan Woottiluk,2 Surinporn Likhitsathian,1 Sirijit Suttajit,1 Vudhichai Boonyanaruthee,1 Manit Srisurapanont1 1Department of Psychiatry, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand; 2Psychiatric Nursing Division, Faculty of Nursing, Chiang Mai University, Chiang Mai, Thailand Background: Some studies have indicated the efficacy of quetiapine in the treatment of generalized anxiety disorder (GAD).Objective: The purpose of this study was to systematically review the efficacy, acceptability, and tolerability of quetiapine in adult patients with GAD.Methods: The SCOPUS, MEDLINE, CINAHL, Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov databases were searched in April 2015. All randomized controlled trials (RCTs) of GAD were considered to be included in this meta-analysis. All RCTs of quetiapine in GAD patients providing endpoint outcomes relevant to severity of anxiety, response rate, remission rate, overall discontinuation rate, or discontinuation rate due to adverse events were included. The version reports from suitable clinical studies were explored, and the important data were extracted. Measurement for efficacy outcomes consisted of the mean-changed scores of the rating scales for anxiety, and response rate.Results: A total of 2,248 randomized participants in three RCTs were included. The pooled mean-changed score of the quetiapine-treated group was greater than that of the placebo-treated group and comparable to selective serotonin reuptake inhibitors (SSRIs). Unfortunately, the response and the remission rates in only 50 and 150 mg/day of quetiapine-XR (extended-release) were better than those of the placebo. Their response and remission rates were comparable to SSRIs. The rates of pooled overall discontinuation and discontinuation due to adverse events of quetiapine-XR were greater than placebo. Only the overall discontinuation rate of quetiapine-XR at 50 and 150 mg/day and the discontinuation rate due to adverse events of quetiapine-XR at 50 mg/day were comparable to SSRIs.Conclusion: Based on this meta-analysis, quetiapine-XR is efficacious in the treatment of GAD in adult patients. Despite its low acceptability and tolerability, the use of 50–150 mg/day quetiapine-XR for adult GAD patients may be considered as an alternative treatment. Further well-defined studies should be conducted to warrant these outcomes. Keywords: quetiapine, generalized anxiety disorder, efficacy, acceptability, tolerability

Nahathai Wongpakaran, Tinakon Wongpakaran, Vudhichai Boonyanaruthee, Manee Pinyopornpanish, Suthi Intaprasert Department of Psychiatry, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand Purpose: To investigate the personality disorders (PDs) diagnosed in patients with depressive disorders.Material and methods: This study included a cross-sectional analysis, and was an extension of the Thai Study of Affective Disorder (THAISAD) project. Eighty-five outpatients with depressive disorders were interviewed using the Mini International Neuropsychiatric Inventory to assess for depression, in accordance with the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision and using the Thai version of the Structured Clinical Interview for PDs to assess for PD.Results: Seventy-seven percent of the patients had at least one PD, 40% had one PD and 60% had two or more PDs (mixed cluster). The most common PDs found were borderline PD (20%) and obsessive–compulsive PD (10.6%), while the occurrence of avoidant PD was low when compared to the findings of previous, related studies. Among the mixed cluster, cluster A combined with cluster C was the common mix. Both dysthymic disorder and double depression were found to have a higher proportion of PDs than major depressive disorder (85.7% versus 76.1%). Dependent PD was found to be less common in this study than in previous studies, including those carried out in Asia.Conclusion: The prevalence of PDs among those with depressive disorder varied, and only borderline PD seems to be consistently high within and across cultures. Mixed cluster plays a prominent role in depression, so more attention should be paid to patients in this category. Keywords: personality disorders, depressive disorder, prevalence, Asian, mixed cluster, SCID-II

Tinakon Wongpakaran, Nahathai Wongpakaran, Vudhichai Boonyanaruthee, Manee Pinyopornpanish, Suthi Intaprasert Department of Psychiatry, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand Purpose: The impact of personality disorders on the treatment of and recovery from depression is still a controversial topic. The aim of this paper is to provide more information on what has led to this disagreement.Materials and methods: Clinician-rated Hamilton Depression Rating Scale (HAMD) scores were assessed among 82 depressed outpatients who were receiving a routine treatment combination of antidepressant medication and psychosocial intervention. The participants were followed up over five visits at 3-month intervals: at the baseline, at 3, 6, 9 and 12 months. Personality disorders were assessed after the last visit in accordance with Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. These repeated measures were used to explore the impact of personality disorders on HAMD scores by using a linear mixed model.Results: Among the four personality clusters that were used (A, B, C, and mixed), only those in cluster B and in the mixed cluster were found to take significantly longer than those without personality disorders, for reduction in HAMD scores over the course of treatment.Conclusion: In this study, the impact of personality disorders on treatment outcomes varied with the way that the personality disorder variables were described and used as independent predictors. This is because the outcomes were influenced by the impact weight of each personality disorder, even within the same cluster. Keywords: depressive disorder, mixed linear model, impact, multilevel analysis

Chawanun Charnsil, Sirijit Suttajit, Vudhichai Boonyanaruthee, Samornsri LeelarphatDepartment of Psychiatry, Chiang Mai University, Sriphum, Amphur Muang, Chiang Mai, ThailandBackground: The purpose of this study was to evaluate the long-term effect of repetitive transcranial magnetic stimulation (rTMS) as adjunctive treatment in patients with partial remission of major depressive disorder.Methods: This was a 12-month, prospective, open-label study in patients meeting the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision criteria for nonpsychotic major depressive disorder who responded to 8 weeks of medication treatment but did not reach remission. All patients were assigned to receive 10 sessions of rTMS applied at the left dorsolateral prefrontal cortex. During the course of rTMS, the patients were still taking their usual medication. Patients were followed up for 12 months to determine the long-term antidepressant effect.Results: There were nine patients (seven women and two men) who met the inclusion criteria and agreed to receive rTMS. The mean Hamilton rating scale for depression (HAM-D) score prior to treatment with rTMS was 12.89 ± 2.15. At 12 months after treatment, the mean HAM-D score was 6.45 ± 1.67 using a Friedman test, and in patients with partial remission of major depressive disorder, the HAM-D score significantly decreased after treatment with rTMS at 12 months (P = 0.001). Seven patients (77.78%) had reached the stage of remission (HAM-D < 8) after treating with rTMS at 12 months. There were no serious adverse events. One patient had vertigo after the first session of treatment and one patient felt scalp contractions during treatment, and both fully recovered within half an hour with no medical intervention.Conclusion: For patients with major depressive disorder in partial remission, high frequency rTMS at the left dorsolateral prefrontal cortex may provide benefits in adjunctive treatment with well tolerability. Also, follow-up findings show a long duration of benefit.Keywords: depression, remission, magnetic stimulation, adjunctive, long term

Abstract Background Not only the prevalence, but also the progress of metabolic abnormalities in schizophrenic patients is of importance for treatment planning and policy making. However, there have been very few prospective studies of metabolic disturbance in schizophrenic patients. This study aimed to assess the progress of metabolic abnormalities in Thai individuals with schizophrenia by estimating their one-year incidence rate of metabolic syndrome (MetS). Methods We screened all schizophrenic patients who visited our psychiatric clinic. After the exclusion of participants with MetS at baseline, each subject was reassessed at 6 and 12 months to determine the occurrence of MetS. The definition of MetS, as proposed by the International Diabetes Federation (IDF), was applied. Results Fifty-seven participants (24 males and 33 females) had a mean of age and duration of antipsychotic treatment of 37.5 years old and 8.4 years, respectively. At baseline, 13 subjects met the MetS definition. Of 44 subjects who had no MetS at baseline, 35 could be followed up. Seven of these 35 subjects (20.0%) had developed MetS at the 6- or 12-month visit, after already having 2 MetS components at baseline. The demographic data and characteristics of those developing and not developing MetS were not different in any respect. Conclusion Thai schizophrenic patients are likely to develop MetS. Their metabolic abnormalities may progress rapidly and fulfill the MetS definition within a year of follow-up. These findings support the importance of assessing and monitoring metabolic syndrome in schizophrenic patients.

Objective: This study aimed to evaluate the effect of adjunctive treatment with rTMS in patients with partial remission major depressive disorder., Method: Subjects were patients meeting DSM-IV-TR criteria for non-psychotic major depressive disorder who responded to 8 weeks of medication treatment but still had residual symptoms (HAM-D score between 7 and 18). All patients were assigned to receive 10 daily sessions (total of 12,500 magnetic pulses) of rTMS applied at the left dorsolateral prefrontal cortex as adjunctive treatment. The antidepressant effect was measured repeatedly at 6 days, and at 4 and 8 weeks after treatment with the Thai version of HAM-D scale as a primary outcome scale., Results: Seven of nine patients (78%) reached the stage of remission (HAM-D < 8) after being treated with adjunctive rTMS. There was a statistically significant difference in decreasing of the HAM-D score during the treatment, χ(2) (df 3) = 17.929, P < 0.001. There was no severe adverse event. One patient had vertigo after the first session of treatment and one patient had a scalp contraction feeling during treatment but full recovered in half an hour with no medical intervention., Conclusion: For patients with a major depressive disorder in partial remission, high frequency rTMS may provide benefits in adjunctive treatment which are tolerated well. However, the long term effects should be observed.

Objective: Explore the interrater reliability of Thai version of Structured Clinical Interview for DSM-IV Personality Disorders (T-SCID-II)., Material and Method: Fifty-four psychiatric patients were assessed by seven psychiatrists. Each patient was interviewed independently and separately by two psychiatrists using T-SCID-II, with the second interview held within one to six weeks of the first., Results: The Kappa value between the first and second raters with regard to the diagnosis of each personality disorder ranged from 0.70 for Depressive Personality Disorder to 0.90 for Obsessive-compulsive Personality Disorder with a mean of 0.81 for all the personality disorders. The mean trait intraclass correlation coefficient score was 0.90 and the summed score was 0.83. The overall interrater reliability was shown to be good across all the studies., Conclusion: Overall, Thai version of Structured Clinical Interview for DSM-IV Personality Disorders (T-SCID-II) showed between good and excellent reliability. Limitation of the present study and its generalizability was discussed.

Background: Not only the prevalence, but also the progress of metabolic abnormalities in schizophrenic patients is of importance for treatment planning and policy making. However, there have been very few prospective studies of metabolic disturbance in schizophrenic patients. This study aimed to assess the progress of metabolic abnormalities in Thai individuals with schizophrenia by estimating their one-year incidence rate of metabolic syndrome (MetS)., Methods: We screened all schizophrenic patients who visited our psychiatric clinic. After the exclusion of participants with MetS at baseline, each subject was reassessed at 6 and 12 months to determine the occurrence of MetS. The definition of MetS, as proposed by the International Diabetes Federation (IDF), was applied., Results: Fifty-seven participants (24 males and 33 females) had a mean of age and duration of antipsychotic treatment of 37.5 years old and 8.4 years, respectively. At baseline, 13 subjects met the MetS definition. Of 44 subjects who had no MetS at baseline, 35 could be followed up. Seven of these 35 subjects (20.0%) had developed MetS at the 6- or 12-month visit, after already having 2 MetS components at baseline. The demographic data and characteristics of those developing and not developing MetS were not different in any respect., Conclusion: Thai schizophrenic patients are likely to develop MetS. Their metabolic abnormalities may progress rapidly and fulfill the MetS definition within a year of follow-up. These findings support the importance of assessing and monitoring metabolic syndrome in schizophrenic patients.

Unlabelled: This study aimed to find the good and bad attributes of a doctor from people besides doctors themselves., Material and Method: One thousand, one hundred people were asked to complete a 120 item questionnaire on the good and bad attributes of doctors in Maharaj Nakorn Chiang Mai Hospital. The sample groups comprised of patients, patients' relatives, and hospital personnel., Results: Forty-four per cent of them responded. The top three good attributes were; to have good knowledge, to have a good rapport and to deal with a patient carefully. The top three bad attributes were; to be immodest in handling a female patients, being deceptive, and neurotic or having a psychiatric problem. Some good and bad attributes were different among different groups., Discussion: Comparison with other studies was discussed including the limitation and application of this study.

Unlabelled: The purpose of this study was to determine how birth position i.e. first-born, middle-born, lastborn, and only child, correlates with personality., Material and Method: One hundred and eighty from 186 (97%) 1st year medical students of Chiang Mai Medical School were asked to complete a questionnaire and take a personality test. The data obtained included age, sex, Grade Point Average (GPA), and family background i.e. birth order and the students' personality profiles, which were assessed by the California Psychological Inventory (CPI)., Results: The results showed that only children and lastborn had more positive personality factors than other groups. They had more ambition, breadth of interests, versatility, self confidence, clear-thinking, intelligence, and independence than first-born and middle-born (Cs and Ai scale on CPI). In addition, the students whose parents had died, separated, or divorced had some personality profiles that differed from the others. The findings both supported and contradicted other papers.

This study was a case report of an amphetamine abuser who came to see doctor because of amphetamine withdrawal syndrome three days after stopping prolonged use of amphetamine. The patient was treated him with a slow-release bupropion at the dose of 150 mg per day. After taking bupropion, his withdrawal symptoms i.e. dysphoric mood, fatigue, somnolence, and psychomotor retardation gradually disappeared within two to three days. Moreover, his craving for amphetamines was absent. The authors discussed the possible application for the clinical use for amphetamine abusers or dependence.

Unlabelled: Tic disorders happen in nearly 20 per cent of children. There is no "best drug" to treat this illness. Potent antipsychotics e.g. haloperidol and pimozide, are the most effective drugs but their limitations are their extrapyramidal side effects (EPS). Risperidone has been proved on efficacy for tic disorders but EPS still remain, even though it was claimed to be less. Thus, quetiapine, a newer atypical neuroleptic with the same action as risperidone and produces fewer EPS, was included in this study., Objective: To study the efficacy and side effects of quetiapine in tic disorders., Method: A case report of a 19-year-old female patient with tic disorder who had taken haloperidol 2 mg/d with benzhexol HCl 2-4 mg/d, then switched to risperidone 1.5 mg/d with benzhexol HCl 4 mg/d because of acute dystonia and oculogyric. She was then prescribed quetiapine, 50 mg/d as a starting dose without benzhexol HCI, because of the remaining symptoms and EPS. The severity of the symptoms was assessed monthly using the Behavior Rating Scale. The dose was increased by 50 mg/d weekly for a better outcome., Results: The tic was improved after the first week and disappeared for three weeks with 150 mg/d of quetiapine. However, the tic returned again, but less frequently (20%). Thus, the dose was stepped up to 200 mg/d. One week later, the patient reported that the tic has disappeared., Conclusion: Quetiapine showed the efficacy and fewest EPS in this patient. However, a further clinically controlled trial must be carried out before quetiapine can become the first-line treatment for tic disorders.

Objective: This study aimed to find the medical students' attitude to Behavioral Science after completing the course., Method: Second and third year Chiang Mai medical students were asked to complete a 25-item questionnaire regarding their attitude to Behavioral Science at the end of their final examination., Results: Both mean scores of attitude were quite high. There was no difference in mean scores for both years, but some items were answered differently., Conclusion: Even though Behavioral Science was regarded as a crucial matter for medical application and the results were satisfactory, many factors involving this subject, such as the teaching system could be changed. The author suggested a possible way to make Behavioral Science more acceptable and understandable.

This study analysed the correlation between contemplation and psychosis from three cases of patients presenting psychotic symptoms subsequent to practising meditation. Sleep loss following a wrong doing in meditation was found to be the main cause in the first two cases, and drug withdrawal was found to be the principal factor in causing a psychotic eruption in the third case. In this last case, sleep deprivation subsequent to meditation was only a minor influence. Discussion regarding the correlation between meditation and psychosis is presented in this study.

Sixty-five from a total of 160 medical students were administered the California Psychological Inventory (CPI) to identify which of all 18 scales can be used as a predictor for academic performance. The entrance examination scores of six subjects were also combined with the CPI variables for the purpose of the study. Students' performances were determined by Grade Point Average (GPA) collected between 1993-1997 (year 1 to year 5). Data was analyzed by descriptive and stepwise method of multiple linear regression analysis. The results showed that mathematics, biology and English language were positively correlated with all year GPAs-r2 value was 10-18 per cent. Scales of "dominance", "flexibility" and "socialization" were positively correlated to the GPA, while "sociability" and "sense of well-being" were negatively correlated. R2 value was increased to 16-59 per cent as prediction of GPA when the CPI variables were combined with scores of entrance examination. A comparison of this finding with other studies was conducted.

Alprazolam differs from other benzodiazepines by the incorporation of a triazolo ring in the basic chemical structure. Several lines of evidence have supported that alprazolam and standard antidepressants have some similar actions, such as beta-adrenergic receptor down-regulation, antipanic effect. Because of the difference in opinions pertaining to the antidepressant effect of alprazolam, this issue could not reach a firm conclusion. In the present analysis, we carried out a meta-analysis of 11 random controlled studies that compared the antidepressant effect of alprazolam and standard antidepressants in depressed patients. The results showed that the weighted mean effect size d (dw) is equal to 0.06. In conclusion, the antidepressant effect of alprazolam is comparable to that of low-dose tricyclic antidepressants. Very few studies have investigated severely depressed patients. Also, in long-term administration, the lack of a long-term treatment study makes the issue of alprazolam's benefits and disadvantages still undetermined.