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Background— Antipsychotic medications have been increasingly and more widely prescribed despite continued uncertainty about their association with the incidence of acute myocardial infarction (AMI). Methods and Results— We investigated the risk of AMI associated with antipsychotic treatment in 56 910 patients with schizophrenia, mood disorders, or dementia first hospitalized or visiting an emergency room for AMI in 1999 to 2009. A case-crossover design was used to compare the distributions of antipsychotic exposure for the same patient across 1 to 30 and 91 to 120 days just before the AMI event. Adjustments were made for comedications and outpatient visits. The adjusted odds ratio of AMI risk was 2.52 (95% confidence interval, 2.37–2.68) for any antipsychotics, 2.32 (95% confidence interval, 2.17–2.47) for first-generation antipsychotics, and 2.74 (95% confidence interval, 2.49–3.02) for second-generation antipsychotics. The risk significantly increased ( P P P P P Conclusions— Antipsychotic use may be associated with a transient increase in risk for AMI, possibly mediated by dopamine type 3 receptor blockades. Further education on drug safety and research into the underlying biological mechanisms are needed.

BACKGROUND: Acupressure, a noninvasive form of acupuncture, may be used as a low-cost and noninvasive means of improving sleep quality. Although it has been evaluated to improve self-reported sleep quality, it has not been assessed with regard to effectiveness in improving perceived and objective measures of sleep quality outcomes. OBJECTIVES: The aim of this study was to investigate the effectiveness of acupressure in improving sleep quality of psychogeriatric inpatients. METHODS: Using a convenience sample, 60 psychogeriatric inpatients with affective disorders from southern Taiwan were recruited. They were assigned randomly to an experimental or control group. Although both groups received standard medical care, those in the experimental group received 9-minute acupressure treatment daily for 4 consecutive weeks. Acupressure was applied to three acupoints: shenmen, yangchuan, and neiguan. Outcomes were measured using the Pittsburgh Sleep Quality Index and actigraphy. Data were collected at baseline and after 4 weeks of intervention. RESULTS: Participants in the experimental group improved significantly in subjective sleep quality as measured by the Pittsburgh Sleep Quality Index and in objective sleep quality as measured by actigraphy (p

Numerous studies have shown that doctors, nurses or other hospital staff may suffer from tremendous stress at work. A high level of work-related stress might increase vulnerability to mental illness and result in a poor quality of clinical care. This study was conducted in a Taiwanese regional general hospital. Minor psychiatric disorder, depressive disorder and quality of life were assessed for all staff, using self-rating questionnaires including the Chinese Health Questionnaire 12-item version, the Center for Epidemiologic Studies Depression Scale and World Health Organization Quality of Life Scale brief version. Nearly half of the staff had either a minor psychiatric disorder or depressive disorder. Nurses and pharmacists had the highest prevalence. The risk factors included single/divorced and being a nurse or pharmacist. Quality of life for hospital staff was poor, as compared with the Taiwanese norms, and was even worse for the nurses and pharmacists. In conclusion, the management teams of hospitals should pay more attention to the mental condition of all hospital staff, especially nurses and pharmacists. Adequate staffing, support, counselling or psychological intervention are required for further management, and may logically result in better mental health on the part of the staff and a better quality of care. Copyright © 2009 John Wiley & Sons, Ltd.

This study contrasted the relative importance between the number of physiological diseases and activities of daily living (ADLs) to the mental health of elderly adults after controlling for mini-mental state exam (MMSE) scores and depression. Participants were 1342 elderly people with a mean age of 73.22 years and living in three communities in southern Taiwan. Age, gender, years of education duration, marital status, and MMSE and hamilton depression rating scale (HAMD) scores were control variables. The ability of the ADLs scale scores and number of physiological diseases to predict mental health, as measured by the 12-item Chinese health questionnaire, was compared using hierarchical regression analyses. The final hierarchical model indicated that only HAMD and the number of physiological diseases scores were significant and that the former was much more predictive than the latter. The results imply that the number of physiological diseases is more predictive of mental health than ADLs scores and that depression is a dangerous risk factor for elderly people.

Objective The aim of this study was to investigate the 1-month prevalence, symptom profiles and demographic correlates in late-life clinically significant non-major depression (CSNMD) among a community-dwelling elderly population. Methods One thousand five hundred subjects aged 65 years and older, who were randomly selected from three communities in Taiwan, received comprehensive psychiatric assessment by trained psychiatrists. Two categorical diagnoses of depressive disorder, including major depression and CSNMD, were made. The 1-month prevalence was calculated. Frequencies of depressive symptoms across CSNMD and major depression were compared. The risks of CSNMD based on demographic characteristics were estimated using multinominal logistic regression. Results The 1-month prevalence of CSNMD among the community-dwelling elderly was 8.8%. Symptoms of diminished interest, appetite changes, sleep disturbance, worthlessness or inappropriate guilt, trouble in concentrating or indecisiveness, and suicidal thoughts or acts were less frequent in CSNMD than in major depression, but symptoms of depressed mood, psychomotor changes, and fatigue or loss of energy were as frequent in both categories of illness. CSNMD shares similar demographic risks, such as living in an urban area, female gender and low educational status, with major depression. Conclusions CSNMD is common among community-dwelling elders in Taiwan, and with its identical demographic characteristics, but qualitatively different presentation, we suggest CSNMD may be considered part of a spectrum of severe late life depressions with a distinct manifestation. Major depression and CSNMD may share common demographic characteristics with different manifestation. We conclude that late-life depression is a dimensional disease. Copyright © 2006 John Wiley & Sons, Ltd.

This study examines the differences in explicit and implicit stigma between medical and non-medical undergraduate students at baseline; the changes of explicit and implicit stigma in medical undergraduate and non-medical undergraduate students after a 1-month psychiatric clerkship and 1-month follow-up period; and the differences in the changes of explicit and implicit stigma between medical and non-medical undergraduate students. Seventy-two medical undergraduate students and 64 non-medical undergraduate students were enrolled. All participants were interviewed at intake and after 1 month. The Taiwanese version of the Stigma Assessment Scale and the Implicit Association Test were used to measure the participants’ explicit and implicit stigma. Neither explicit nor implicit stigma differed between two groups at baseline. The medical, but not the non-medical, undergraduate students had a significant decrease in explicit stigma during the 1-month period of follow-up. Neither the medical nor the non-medical undergraduate students exhibited a significant change in implicit stigma during the one-month of follow-up, however. There was an interactive effect between group and time on explicit stigma but not on implicit stigma. Explicit but not implicit stigma toward mental illness decreased in the medical undergraduate students after a psychiatric clerkship. Further study is needed to examine how to improve implicit stigma toward mental illness.

Objective: Epidemiological studies suggest that elevated plasma homocysteine is associated with an increased risk of depression and cerebrovascular disease. There are no published reports of homocysteine levels and methylenetetrahydrofolate reductase (MTHFR) C677T genotype in clinical samples of patients with late-onset major depressive disorder (MDD). The purpose of this study was to examine the association of homocysteine levels or MTHFR C677T genotype and late-onset MDD and assess whether this may be affected by brain magnetic resonance imaging (MRI) hyperintensities. Methods: Authors recruited 39 elderly patients with MDD with first episode occurring after age 50 and 20 comparison subjects and assessed total plasma homocysteine levels, MTHFR genotype, and brain MRIs. Results: Plasma total homocysteine levels were higher in elderly patients with late-onset MDD versus comparison subjects. The association did not change after controlling for MRI hyperintensities, and the distribution of MTHFR C677T genotype was not different between the groups. Conclusions: In this exploratory study, elevated homocysteine levels were associated with late-onset MDD, and the association did not appear to be mediated by vascular pathology as identified by brain MRI hyperintensities. (Am J Geriatr Psychiatry 2005

Aims Few studies have examined the use of depot antipsychotics in East Asian patients with schizophrenia. This study examined the prevalence of depot antipsychotic use and its clinical correlates. Methods Across six East Asian countries and territories, 2399 patients with schizophrenia were surveyed using a standardized protocol. Results Depot antipsychotic medications were prescribed in 15.3% (n=368) of the patients, being the most common in Singapore, followed by Taiwan, Japan and China. Being on depot antipsychotic drugs was significantly associated with male gender (particularly in Taiwan and Japan), delusions in Japan, aggression, higher daily CPZ equivalent dose and co-prescription of anticholinergic drugs but less likely with disorganized speech (particularly in China) and negative symptoms (particularly in Japan and Singapore). On multivariate analysis, the significant associated factors were treatment setting, younger age, longer duration of illness, aggression and the lack of use of an oral, atypical antipsychotic. Conclusion There was a wide variation in the prevalence of depot antipsychotic prescription, suggesting that it may not be guided by any recognizable principles and is more likely determined by local traditions and prescription culture. There is a need to re-examine the risk–benefit profile of each patient before deciding on the initiation or continuation of depot antipsychotic medication. Copyright © 2004 John Wiley & Sons, Ltd.

Systemic lupus erythematosus (SLE) patients may have psychiatric manifestations during the illness course. Psychotropic agents are indicated in treating these symptoms. Second-generation antipsychotics, such as risperidone, olanzapine and quetiapine, have been thought to be safer than clozapine with regard to the side effect of neutropenia or agranulocytosis. We report a case of SLE who developed agranulocytosis during the treatment with olanzapine for the SLE-related psychiatric symptoms.

Lithium has been a first-line choice for maintenance treatment of bipolar disorders to prevent relapse of mania and depression, but many patients do not have a response to lithium treatment.We selected subgroups from a sample of 1761 patients of Han Chinese descent with bipolar I disorder who were recruited by the Taiwan Bipolar Consortium. We assessed their response to lithium treatment using the Alda scale and performed a genomewide association study on samples from one subgroup of 294 patients with bipolar I disorder who were receiving lithium treatment. We then tested the single-nucleotide polymorphisms (SNPs) that showed the strongest association with a response to lithium for association in a replication sample of 100 patients and tested them further in a follow-up sample of 24 patients. We sequenced the exons, exon-intron boundaries, and part of the promoter of the gene encoding glutamate decarboxylase-like protein 1 (GADL1) in 94 patients who had a response to lithium and in 94 patients who did not have a response in the genomewide association sample.Two SNPs in high linkage disequilibrium, rs17026688 and rs17026651, that are located in the introns of GADL1 showed the strongest associations in the genomewide association study (P=5.50×10(-37) and P=2.52×10(-37), respectively) and in the replication sample of 100 patients (P=9.19×10(-15) for each SNP). These two SNPs had a sensitivity of 93% for predicting a response to lithium and differentiated between patients with a good response and those with a poor response in the follow-up cohort. Resequencing of GADL1 revealed a novel variant, IVS8+48delG, which lies in intron 8 of the gene, is in complete linkage disequilibrium with rs17026688 and is predicted to affect splicing.Genetic variations in GADL1 are associated with the response to lithium maintenance treatment for bipolar I disorder in patients of Han Chinese descent. (Funded by Academia Sinica and others.).

Background Cognitive impairment in remitted late-life depression varies and might be associated with greater risk of dementia in some individuals. This study aimed to classify the subtypes of mild cognitive impairment (MCI) in late-life major depressive disorder in remission and to examine their clinical correlates and structural magnetic resonance imaging (MRI) features. Methods Elderly patients with major depressive disorder in remission and elderly comparisons were examined by a comprehensive battery of cognitive tasks. Proposed diagnostic criteria were used for MCI classification, and the degree of brain atrophy and white matter hyperintensity on MRI were evaluated. Results We found information-processing speed and memory were independent cognitive domains associated with late-life remitted major depressive disorder. Of the study cohort, 52.3% met the definition of MCI, including 28.5% with amnestic MCI (aMCI) and 23.8% with nonamnestic MCI (naMCI). A clinical correlate of aMCI was the late-onset of disorder (OR = 4.76; 95% CI=1.57, 14.40) and of naMCI was a higher score on the Framingham stroke risk scale (OR = 1.39; 95% CI=1.12, 1.72). The odds ratio of highest quartile of ventricular atrophy for aMCI compared to the comparisons was 3.65 (95% CI=1.22, 10.96). Conclusions The central cognitive impairments among the elderly with major depressive disorder in remission were memory and information-processing speed, and over half of the subjects met the MCI diagnostic criteria. Different risk factors existed for the subtypes of aMCI and naMCI. Later-age onset of first episode and ventricular atrophy were associated with aMCI, whereas vascular risk factor were associated with naMCI. We suggest there were different pathogeneses between aMCI and naMCI in late-life major depressive disorder.

No single assessment method can successfully evaluate the clinical ability of medical students in psychiatric clerkships; however, few studies have examined the efficacy of multiple assessments, especially in psychiatry. The aim of this study was to examine the relationship among different types of assessments of medical students’ clinical ability in psychiatric clerkships and whether it is reasonable to use multiple assessments. A group of 196 students were enrolled during their psychiatric clerkship between September 2008 and May 2009 in Kaohsiung, Taiwan. The mini-clinical evaluation exercise (mini-CEX) and standardized patient (SP)-based test were used to evaluate “does” and “show how” in psychiatric clinical ability. A multiple-choice examination was used to evaluate knowledge of psychiatry. There were statistically significant but weak correlations among the scores on the multiple-choice examination, SP-based test, and overall clinical competence domain on the mini-CEX. A blended assessment composed of a multiple-choice examination, mini-CEX, and SP-based test can evaluate different dimensions of clinical ability. It is reasonable to use multiple methods to assess medical students’ competency in psychiatric clerkships.

Poststroke depression (PSD) is one of the most frequent neuropsychiatric consequences of stroke. It has been shown to be associated with both impaired recovery and increased mortality. The purpose of this study is to investigate the prophylactic effect of milnacipran in PSD. Ninety-two patients were enrolled in the 12 months of this double-blind randomized placebo-controlled trial. The assessment was performed at baseline, and at the first, third, sixth, ninth and 12th month after enrollment. The definition of PSD was in accordance with the diagnostic criteria of major depressive episode based on the Diagnostic and Statistical Manual, fourth edition. Forty-six patients were randomized to the treatment group with milnacipran and another 46 patients to the placebo group. No significant differences were found between the two groups in terms of sex (P=0.83), age (P=0.08), marital status (P=0.66), occupation (P=0.22), educational level (P=0.29), and drug side-effects (P=0.73). The incidence of depression in the two groups was 2.22% and 15.22%, respectively. Milnacipran was proved to have a statistically significant advantage in preventing PSD (P

Epidemiological studies suggest that elevated plasma homocysteine is associated with an increased risk of depression and cerebrovascular disease. There are no published reports of homocysteine levels and methylenetetrahydrofolate reductase (MTHFR) C677T genotype in clinical samples of patients with late-onset major depressive disorder (MDD). The purpose of this study was to examine the association of homocysteine levels or MTHFR C677T genotype and late-onset MDD and assess whether this may be affected by brain magnetic resonance imaging (MRI) hyperintensities.Authors recruited 39 elderly patients with MDD with first episode occurring after age 50 and 20 comparison subjects and assessed total plasma homocysteine levels, MTHFR genotype, and brain MRIs.Plasma total homocysteine levels were higher in elderly patients with late-onset MDD versus comparison subjects. The association did not change after controlling for MRI hyperintensities, and the distribution of MTHFR C677T genotype was not different between the groups.In this exploratory study, elevated homocysteine levels were associated with late-onset MDD, and the association did not appear to be mediated by vascular pathology as identified by brain MRI hyperintensities.

Previous studies of the prescription patterns of psychotropic medications in patients with schizophrenia have highlighted a high rate of antipsychotic polypharmacy, but data in Asia are sparse. This study seeks to examine the prevalence of antipsychotic polypharmacy in patients with schizophrenia and compare the differences between patients receiving one vs. those receiving more than one antipsychotic.Antipsychotic prescription for a sample of 2399 patients with schizophrenia from six countries and territories was evaluated. Daily doses of antipsychotic medications were converted to standard chlorpromazine equivalents (CPZ).Antipsychotic polypharmacy was found in 45.7% (n = 1097) of the patients with wide intercountry variations. Polypharmacy was associated with male gender [odds ratio (OR) 1.24, 95% confidence interval (CI) 1.06, 1.46, P0.01], advanced age (t = -7.81, d.f. = 2396, P0.001), psychiatric hospital setting (OR 1.34, 95% CI 1.11, 1.62) as well as higher daily CPZeq doses (411.47 vs. 983.10 CPZeq day(-1), z = -25.94, P0.001), anticholinergic use (OR 3.17, 95% CI 2.65, 3.79, P0.001) and less use of an atypical antipsychotic drug (OR 0.83, 95% CI 0.71, 0.98, P0.05). On multivariate analysis, country, age and duration of illness were significantly associated with antipsychotic polypharmacy.This study highlighted the wide intercountry variations of antipsychotic polypharmacy which are likely to be influenced by a complex combination of clinical, setting, cultural and personal practice factors, requiring more research.

The purpose of this international collaborative study was to investigate the prescription patterns of antipsychotic drugs for schizophrenia in East Asia and to analyze factors that affect these patterns. Prescription patterns for patients admitted for treatment of schizophrenia were surveyed using a standardized protocol from six East-Asian region/countries: China, Hong Kong, Japan, Korea, Singapore and Taiwan. Patients' social and clinical characteristics, psychiatric symptoms, course of illness, and adverse effects of medications were systematically assessed and recorded. Prescriptions of the first- and second-generation antipsychotic drugs were compared. A total of 2399 patients were recruited. The second-generation drugs comprised 28.1% of all prescribed antipsychotics, and 46% of the antipsychotic prescriptions were in the context of polypharmacy. The mean dosage of antipsychotics for the whole sample was 675.3 + 645.1 mg chlorpromazine equivalents. Japan had a high frequency of prescribing high doses and polypharmacy; Singapore had a high utilization of depot injections while China had a higher prescription of clozapine. Using multiple logistic regression analysis, distinctions in the prescription patterns of antipsychotic drugs were found: first-generation drugs were mainly for controlling aggressive behavior, while second-generation drugs were targeted at the alleviation of positive, negative psychotic symptoms as well as disruptive behavior in schizophrenia. The present collaborative study highlighted differences in the prescription patterns, especially the under-utilization of second-generation antipsychotic drugs in East Asia. The pattern of antipsychotic medication use varied from country to country and is likely to be influenced by the prevailing health-care system, the availability and cost of the drugs.

Objective: To test the validity and reliability of the Chinese Geriatric Mental State Schedule (CGMS) in Taiwanese elders. Methods: The CGMS has gone through a standardized two-way translation, a pretest phase, and consensus focus group meetings in order to modify relevant culture-related terms of the original English version. The interrater reliability of the CGMS among eight psychiatrists was conducted after a training course was given to them. Diagnoses generated by the CGMS-AGECAT (Automated Geriatric Examination for Computer Assisted Taxonomy) were compared with psychiatric diagnoses according to the DSM-III-R criteria. The sample subjects were aged 65 and over and recruited from a community (n = 36) and an “old age home” (n = 56). Results: Four of the eight diagnostic categories generated by the CGMS-AGECAT had a generalized kappa value of 1.0, and the figures for the remaining four categories were acceptable: .8 for depressive neurosis, .6 for anxiety disorder, .5 for schizophrenia, and .5 for depressive psychosis (generalized kappa = .5). The overall agreement between the CGMS-AGECAT and independent psychiatric diagnosis (based on the DSM-III-R criteria) was satisfactory. Conclusion: The CGMS has been found to be a crossculturally valid and reliable instrument for use in Taiwan.

BackgroundPublished studies of prevalence of depression in old age in Taiwan have yielded equivocal results.AimsTo study the prevalence of depressive disorders among community-dwelling elderly; further, to assess socio-demographic correlates and life events in relation to depression.MethodA randomised sample of 1500 subjects aged 65 and over was selected from three communities. Research psychiatrists conducted all assessments using the Geriatric Mental State Schedule. The diagnosis of depression was made with the GMS–AGECAT (Automated Geriatric Examination for Computerised Assisted Taxonomy); data on life events were collected with the Taiwanese version of the Life Events and Difficulties Schedule.ResultsOne-month prevalence of psychiatric disorders was 37.7%, with 15.3% depressive neurosis and 5.9% major depression. A high risk of depressive disorders was found among widows with a low educational level living in the urban community, and among those with physical illnesses.ConclusionsContrary to most previous reports, we found that the prevalence of depressive disorders among the elderly in the community in Taiwan is high and comparable to rates reported in some studies of UK samples.