Smoking and nicotine dependence in Singapore: findings from a cross-sectional epidemiological study

INTRODUCTION

Smoking is one of the leading preventable causes of death throughout the world and can lead to nicotine dependence, particularly when initiated at a young age. This paper describes the prevalence of smoking and nicotine dependence in the adult Singapore resident population, whilst also exploring rates among the major ethnic groups (Chinese, Malay and Indian), different education levels and those with chronic psychiatric and physical comorbidities.

MATERIAL AND METHODS

The Singapore Mental Health Study (SMHS) is a cross-sectional epidemiological study that was conducted between December 2009 and December 2010. Information on smoking status was assessed using the Composite International Diagnostic Interview version 3.0 (CIDI 3.0) and the Fagerstrom Test for Nicotine Dependence measured nicotine dependence. Socio-demographic information was also collected.

RESULTS

In total, 6616 respondents participated in the SMHS giving a response rate of 75.9%. We found that 16% of the population were current smokers and 4.5% had nicotine dependence. Current smokers were more likely to be younger (18 to 34 years old), males, Malay and have lower education, whilst males had a 4.6 times higher risk of nicotine dependence to that of females. The prevalence of nicotine dependence was also higher in those with alcohol abuse and those experiencing chronic pain.

CONCLUSION

The results from this study highlight the important differences in the prevalence of smoking and nicotine dependence among different age groups, gender and ethnicity in Singapore and are important for developing future health policies and targeted preventive strategies.

Prevalence and correlates of alcohol use disorders in the Singapore Mental Health Survey

AIMS

  To establish the prevalence, correlates, comorbidity and treatment gap of alcohol use disorders in the Singapore resident population.

DESIGN

  The Singapore Mental Health Study is a cross-sectional epidemiological survey.

SETTING

  A nationally representative survey of the resident (citizens and permanent residents) population in Singapore.

PARTICIPANTS

  A total of 6616 Singaporean adults aged 18 years and older.

MEASUREMENTS

  The diagnoses were established using the World Mental Health Composite International Diagnostic Interview (WMH-CIDI) diagnostic modules for life-time and 12-month prevalence of selected mental illnesses including alcohol use disorders.

FINDINGS

  The life-time prevalence of alcohol abuse and alcohol dependence was 3.1% and 0.5%, while the 12-month prevalence of alcohol abuse and alcohol dependence was 0.5% and 0.3%, respectively. The life-time and 12-month prevalence of alcohol use disorders was 3.6% and 0.8%, respectively. Those with alcohol use disorder had significantly higher odds of having major depressive disorder [odds ratio (OR) 3.1] and nicotine dependence (OR 4.5). Compared to the rest of the population, those with an alcohol use disorder had significantly higher odds of having gastric ulcers (OR 3.0), respiratory conditions (OR 2.1) and chronic pain (OR 2.1). Only one in five of those with alcohol use disorder had ever sought treatment.

CONCLUSIONS

  The prevalence of alcohol use disorders is relatively low in the Singapore adult population. Comorbidity with mental and physical disorders is significant, emphasizing the need to screen people with alcohol use disorders for these comorbidities.

Policy Implications of The Singapore Mental Health Study

This paper discusses the implications of the key findings of the Singapore Mental Health Study (SMHS) in the context of the first ever National Mental Health Policy and Blueprint (NMHPB). The SMHS was a cross-sectional epidemiological survey of the adult Singapore residents. The policy implications emanating from the findings of this study are discussed in this commentary. These pertain to initiatives to improve help-seeking behaviour, further developing the capability of the primary healthcare providers and the better integration of primary and specialist mental healthcare. Incorporation of mental health education and screening of mental disorders in the workforce should also be augmented with work practices that protect against discriminating those with mental disorders. Key words: Epidemiology, Mental disorders, Productivity, Unmet needs

The Singapore Mental Health Study: an overview of the methodology

The Singapore Mental Health Study (SMHS) is a population-based, cross-sectional, epidemiological study on the Singapore multi-ethnic adult population. This article provides an overview of the research design and methods used which took into consideration the unique characteristics of the country and its multi-ethnic population. A face-to-face household survey of Singapore residents aged 18 years and above was undertaken from 2009 to 2010. The nationally representative probability sample was derived using a disproportionate stratified sampling method. In order to increase precision for subgroup estimations the design was stratified with over-sampling of Malays, Indians and those aged 65 years and above. Respondents were assessed using the English, Chinese (computerized) and Malay (paper and pencil based) version of the Composite International Diagnostic Interview (CIDI) 3.0 to establish lifetime and 12-month prevalence of mental disorders, the current use of mental health services (both Western and traditional services), the treatment gaps and loss of role functioning.

Policy implications of the Singapore Mental Health Study

This paper discusses the implications of the key findings of the Singapore Mental Health Study (SMHS) in the context of the fi rst ever National Mental Health Policy and Blueprint (NMHPB). The SMHS was a cross-sectional epidemiological survey of the adult Singapore residents. The policy implications emanating from the findings of this study are discussed in this commentary. These pertain to initiatives to improve help-seeking behaviour, further developing the capability of the primary healthcare providers and the better integration of primary and specialist mental healthcare. Incorporation of mental health education and screening of mental disorders in the workforce should also be augmented with work practices that protect against discriminating those with mental disorders.

“How Much Can I Take?”: Predictors of Perceived Burden for Relatives of People with Chronic Illness

Introduction: Chronic illnesses are common and have detrimental effects not only on the affected individuals but also on their families. These negative consequences on the physical and psychological health of caregivers constitute the burden of care. We investigate the predictors of perceived burden of care among relatives of people with any chronic physical or mental illness using secondary data from a nationwide survey in Singapore. Materials and Methods: A cross-sectional household survey was conducted among adult residents of age 18 years and above and data were analysed to explore the predictors of high perceived burden of care. Two thousand four hundred and fifty-eight respondents having at least 1 close relative with any chronic physical and/or mental illness were included. Results: Majority of the respondents had at least 1 close family member with physical illness (88.3%)—the most common illnesses reported were memory problems (86.9%), physical disability (74.8%), heart problems (70.1%) and cancer (62.2%). About 30.9% (n = 723) perceived high burden resulting from their relatives’ health condition. Logistic analysis showed that women were more likely (OR 1.58, P = 0.0026) and Malays were less likely (OR 0.68, P = 0.0044) to perceive burden. Those who were able to open up to their family or friends (OR 1.65, P = 0.0162) and those who had dysthymia had higher odds (OR 4.91, respectively, P =0.0364) of perceiving burden. Conclusion: Our results suggest that regardless of the nature of the chronic illnesses, gender or ethnicity, the capacity to open up to family or friends and the mental health status of caregivers can predict their perceived burden. The results provide valuable preliminary information for planning social policies and interventions for improving the well-being of caregivers. Key words: Mental illness, Social support, Subjective burden

"How much can I take?": predictors of perceived burden for relatives of people with chronic illness

INTRODUCTION

Chronic illnesses are common and have detrimental effects not only on the affected individuals but also on their families. These negative consequences on the physical and psychological health of caregivers constitute the burden of care. We investigate the predictors of perceived burden of care among relatives of people with any chronic physical or mental illness using secondary data from a nationwide survey in Singapore.

MATERIALS AND METHODS

A cross-sectional household survey was conducted among adult residents of age 18 years and above and data were analysed to explore the predictors of high perceived burden of care. Two thousand four hundred and fifty-eight respondents having at least 1 close relative with any chronic physical and/or mental illness were included.

RESULTS

Majority of the respondents had at least 1 close family member with physical illness (88.3%)--the most common illnesses reported were memory problems (86.9%), physical disability (74.8%), heart problems (70.1%) and cancer (62.2%). About 30.9% (n = 723) perceived high burden resulting from their relatives' health condition. Logistic analysis showed that women were more likely (OR 1.58, P = 0.0026) and Malays were less likely (OR 0.68, P = 0.0044) to perceive burden. Those who were able to open up to their family or friends (OR 1.65, P = 0.0162) and those who had dysthymia had higher odds (OR 4.91, respectively, P =0.0364) of perceiving burden.

CONCLUSION

Our results suggest that regardless of the nature of the chronic illnesses, gender or ethnicity, the capacity to open up to family or friends and the mental health status of caregivers can predict their perceived burden. The results provide valuable preliminary information for planning social policies and interventions for improving the well-being of caregivers.

Where do People with Mental Disorders in Singapore go to for Help?

Introduction: This study aims to examine the pattern of services utilisation and the factors associated with help-seeking behaviour among those with mental disorders in the multi-ethnic Asian population of Singapore. Materials and Methods: A household survey was carried out on a nationally representative sample of the adult (18 years and above) resident population. The main instrument used to establish the diagnosis of mental disorders and the services sought was the Composite International Diagnostic Interview version 3.0 (CIDI 3.0). The ‘services’ component of the instrument contains questions, which examine service utilisation for mental health problems. Results: A total number of 6616 completed respondents constituted a representative sample of the adult resident population in Singapore. Only 31.7% of those with mental disorders had sought help: 15.7% from mental health providers, 8.4% from general practitioners, and 7.6% from religious/spiritual advisors or other healers. Among respondents with severe disability across any disorder assessed in our survey, 50.1% had sought help from some service in the past 12 months. Individuals with moderate or mild levels had lower rates of consultation, i.e. 35.4% and 30.6% respectively. The rate of using the Internet as a source of help was low in this population. Conclusion: There is a need to engage and work collaboratively with healthcare providers (including religious and spiritual healers) in the community to detect, assess and treat those with mental illness. More general practitioners need to be involved, and the role of the Internet also requires further consideration as a source for help. Key words: Disability, Help-seeking, Mental health, Religious healers, Service use

Exploratory and confirmatory factor analyses of the Multidimensional Scale of Perceived Social Support in patients with schizophrenia

INTRODUCTION

Social support promotes community adaptation of patients with mental illness by facilitating coping and competence. The Multidimensional Scale of Perceived Social Support (MSPSS) is a widely used measure of perceived social support that investigates 3 domains of support, from significant other, family, and friends. This study was conducted to provide evidence of the reliability and construct validity of the MSPSS in an adult Asian population with schizophrenia.

METHODS

The MSPSS was self-rated by patients with schizophrenia. Reliability was determined using Cronbach α for internal consistency, and preliminary construct was examined using exploratory factor analysis (using principal component with varimax rotation). Four a priori hypothesized models were tested via confirmatory factor analysis: first-order 2-factor (2 models), and first-order and higher order 3-factor models, using 5 goodness-of-fit indices.

RESULTS

Internal reliability was high (Cronbach α of .90, .90, and .91 for support from significant others, family and friends, respectively) for the MSPSS. Exploratory factor analysis on the 12-item measure indicated 3-factor solution that supported the 3 theoretical dimensions of the MSPSS. The indices of goodness of fit confirmed the first-order and higher-order 3-factor confirmatory models of MSPSS by providing the best fit in this sample.

CONCLUSION

Our findings demonstrate high internal consistency and construct validity of MSPSS in outpatients with schizophrenia, making it appropriate for assessing the perceived social support in this population.

Where do people with mental disorders in Singapore go to for help?

INTRODUCTION

This study aims to examine the pattern of services utilisation and the factors associated with help-seeking behaviour among those with mental disorders in the multi-ethnic Asian population of Singapore.

MATERIALS AND METHODS

A household survey was carried out on a nationally representative sample of the adult (18 years and above) resident population. The main instrument used to establish the diagnosis of mental disorders and the services sought was the Composite International Diagnostic Interview version 3.0 (CIDI 3.0). The 'services' component of the instrument contains questions, which examine service utilisation for mental health problems.

RESULTS

A total number of 6616 completed respondents constituted a representative sample of the adult resident population in Singapore. Only 31.7% of those with mental disorders had sought help: 15.7% from mental health providers, 8.4% from general practitioners, and 7.6% from religious/ spiritual advisors or other healers. Among respondents with severe disability across any disorder assessed in our survey, 50.1% had sought help from some service in the past 12 months. Individuals with moderate or mild levels had lower rates of consultation, i.e. 35.4% and 30.6% respectively. The rate of using the Internet as a source of help was low in this population.

CONCLUSION

There is a need to engage and work collaboratively with healthcare providers (including religious and spiritual healers) in the community to detect, assess and treat those with mental illness. More general practitioners need to be involved, and the role of the Internet also requires further consideration as a source for help.

Prevalence and Impact of Mental and Physical Comorbidity in the Adult Singapore Population

Introduction: This study aims to assess the prevalence rates of mental disorders and chronic medical conditions in the Singapore resident population, and examine their association and respective impact on the quality of life. Materials and Methods: A household survey was carried out on a nationally representative sample of the adult (18 years and above) resident population. The main instrument used to establish the diagnosis of mental disorders is the World Mental Health Composite International Diagnostic Interview (WMH-CIDI). The mental disorders included in study were major depressive disorder, bipolar disorder, generalised anxiety disorder, obsessive compulsive disorder, alcohol abuse and alcohol dependence. Respondents were asked if they had any of the chronic medical conditions from a list of 15 conditions. Health-related quality of life was assessed with the EQ-5D. Results: Of the 6616 respondents, the lifetime prevalence of mental disorders was 12.0%, and that of chronic medical disorders were 42.6% and those with comorbid mental and medical disorders was 6.1%. The prevalence of any physical disorder in this population was high (42.6%). Among those with chronic physical disorders, 14.3% also had a mental disorder, and among those with mental disorders, more than half (50.6%) had a medical disorder. Most of the mental disorders were not treated. Males, Indians, older people, and those who were separated or divorced were more likely to have comorbidity. The health-related quality of life was significant worse in those with both mental and medical disorders compared to those with either mental or medical disorder. Conclusion: Our study re-emphasised the common occurrence of mental and medical disorders and the importance for an integrated care system with the capability to screen and treat both types of disorders. It also identified certain subpopulations which are more likely to have comorbidity for which a more targeted intervention could be planned. Key words: Chronic conditions, Ethnicity, Health-related quality of life, Marital status

ARVCF genetic influences on neurocognitive and neuroanatomical intermediate phenotypes in Chinese patients with schizophrenia

OBJECTIVE

There are notable similarities between velocardiofacial syndrome and schizophrenia in terms of neurocognitive deficits and brain structural abnormalities. These similarities have supported the role of the armadillo repeat gene deleted in velocardiofacial syndrome (ARVCF) as a susceptibility gene in schizophrenia. This study investigated the relationships between haplotypes of the ARVCF gene and specific intermediate phenotypes in schizophrenia. We hypothesized that ARVCF gene haplotypes influence caudate nucleus volume, fractional anisotropy, and neurocognitive functioning in schizophrenia.

METHOD

Between May 2006 and November 2009, 200 Chinese participants (125 patients with DSM-IV diagnosis of schizophrenia and 75 controls) were genotyped using blood samples, and a subset of 166 participants (99 patients with DSM-IV diagnosis of schizophrenia and 67 controls) underwent structural magnetic resonance imaging, diffusion tensor imaging, and completed neuropsychological testing.

RESULTS

The haplotype T-G-A-T-T-G-G-C-T-G-T (ARVCF-Hap1) was significantly associated with fractional anisotropy of the caudate nucleus and executive functioning in patients. Specifically, patients with more copies of ARVCF-Hap1 have lower white matter integrity in caudate nucleus (P = .0008) and greater perseverative errors (P = .00003) on the Wisconsin Card Sorting Test. A trend of lower caudate volume (P = .015) in patients with more copies of ARVCF-Hap1 was also observed.

CONCLUSIONS

These findings are consistent with known ARVCF gene effects on neurodevelopment in terms of cellular arrangement, migration, and intracellular signaling involving the striatum and may involve interactions with other brain networks such as prefrontal cortex, and they underscore the importance of imaging-genetic studies to elucidate the genetic influences underlying intermediate phenotypes in complex neurobehavioral disorders.

Prevalence and impact of mental and physical comorbidity in the adult Singapore population

INTRODUCTION

This study aims to assess the prevalence rates of mental disorders and chronic medical conditions in the Singapore resident population, and examine their association and respective impact on the quality of life.

MATERIALS AND METHODS

A household survey was carried out on a nationally representative sample of the adult (18 years and above) resident population. The main instrument used to establish the diagnosis of mental disorders is the World Mental Health Composite International Diagnostic Interview (WMH-CIDI). The mental disorders included in study were major depressive disorder, bipolar disorder, generalised anxiety disorder, obsessive compulsive disorder, alcohol abuse and alcohol dependence. Respondents were asked if they had any of the chronic medical conditions from a list of 15 conditions. Health-related quality of life was assessed with the EQ-5D.

RESULTS

Of the 6616 respondents, the lifetime prevalence of mental disorders was 12.0%, and that of chronic medical disorders were 42.6% and those with comorbid mental and medical disorders was 6.1%. The prevalence of any physical disorder in this population was high (42.6%). Among those with chronic physical disorders, 14.3% also had a mental disorder, and among those with mental disorders, more than half (50.6%) had a medical disorder. Most of the mental disorders were not treated. Males, Indians, older people, and those who were separated or divorced were more likely to have comorbidity. The health-related quality of life was significant worse in those with both mental and medical disorders compared to those with either mental or medical disorder.

CONCLUSION

Our study re-emphasised the common occurrence of mental and medical disorders and the importance for an integrated care system with the capability to screen and treat both types of disorders. It also identified certain subpopulations which are more likely to have comorbidity for which a more targeted intervention could be planned.

A Population-based Survey of Mental Disorders in Singapore

Introduction: Mental illnesses are not only a growing public health concern but also a major social and economic issue affecting individuals and families throughout the world. The prevalence of mental disorders, the extent of disability caused by these disorders, and services utilisation of these patients has been well studied in developed countries. The aim of this study was to establish the prevalence of select mental disorders and their associated sociodemographic correlates in the adult Singapore resident population. Materials and Methods: This was a cross-sectional, population-based, epidemiological study of adult Singapore residents aged 18 years and above. The subjects were randomly selected using a disproportionate stratified sampling method. The diagnoses of selected mental disorders including major depressive disorder (MDD), dysthymia, bipolar (bipolar I & II) disorders, generalised anxiety disorder (GAD), obsessive compulsive disorder (OCD), alcohol abuse and alcohol dependence were established using the Composite International Diagnostic Interview, which is a fully structured diagnostic instrument that assesses lifetime and 12-month prevalence of mental disorders. Results: Among the 6616 respondents (response rate of 75.9%), 12.0% had at least one lifetime affective, anxiety, or alcohol use disorders. The lifetime prevalence of MDD was 5.8% and that of bipolar disorder was 1.2%. The combined lifetime prevalence of the 2 anxiety disorders, GAD and OCD was 3.6%, with the latter being more common than GAD (0.9% and 3.0% respectively). The lifetime prevalence of alcohol abuse and dependence were found to be 3.1% and 0.5% respectively. Age, gender, ethnicity, marital status and chronic physical illnesses were all significant correlates of mental disorders. Conclusion: The identified associated factors would help guide resource allocation, policy formulation and programme development in Singapore. Key words: Affective disorders, Alcohol, Anxiety disorders, Population-based survey

A population-based survey of mental disorders in Singapore

INTRODUCTION

Mental illnesses are not only a growing public health concern but also a major social and economic issue affecting individuals and families throughout the world. The prevalence of mental disorders, the extent of disability caused by these disorders, and services utilisation of these patients has been well studied in developed countries. The aim of this study was to establish the prevalence of select mental disorders and their associated sociodemographic correlates in the adult Singapore resident population.

MATERIALS AND METHODS

This was a cross-sectional, populationbased, epidemiological study of adult Singapore residents aged 18 years and above. The subjects were randomly selected using a disproportionate stratified sampling method. The diagnoses of selected mental disorders including major depressive disorder (MDD), dysthymia, bipolar (bipolar I & II) disorders, generalised anxiety disorder (GAD), obsessive compulsive disorder (OCD), alcohol abuse and alcohol dependence were established using the Composite International Diagnostic Interview, which is a fully structured diagnostic instrument that assesses lifetime and 12-month prevalence of mental disorders.

RESULTS

Among the 6616 respondents (response rate of 75.9%), 12.0% had at least one lifetime affective, anxiety, or alcohol use disorders. The lifetime prevalence of MDD was 5.8% and that of bipolar disorder was 1.2%. The combined lifetime prevalence of the 2 anxiety disorders, GAD and OCD was 3.6%, with the latter being more common than GAD (0.9% and 3.0% respectively). The lifetime prevalence of alcohol abuse and dependence were found to be 3.1% and 0.5% respectively. Age, gender, ethnicity, marital status and chronic physical illnesses were all significant correlates of mental disorders.

CONCLUSION

The identified associated factors would help guide resource allocation, policy formulation and programme development in Singapore.

Prevalence and correlates of psychotic symptoms among Asian males

PURPOSE

Psychotic symptoms have been reported at varying rates in the general population in the West. We studied the association of psychotic symptoms with educational attainment and other psychiatric disorders in 23,248 male pre-enlistees for National Service in Singapore.

METHODS

In a 2-stage assessment, these enlistees were first screened with the Self-Reporting Questionnaire (SRQ-24) and the CRAFFT. Those screened positive were then assessed by the Composite International Diagnostic Interview (CIDI) to establish the presence of psychiatric disorders based on the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV).

RESULTS

The rate of psychotic symptoms (after excluding those with psychotic disorders) was 8.2% (n = 1,909). A multinomial logistic regression using the controls as the reference group revealed that younger age, lower PSLE scores, and mood and anxiety disorder remained significantly associated with both the diagnoses of psychotic disorders and the presence of psychotic symptoms.

CONCLUSIONS

A combination of categorical and dimensional representation of psychopathology for the diagnosis of psychotic disorders would better inform treatment and prognosis as there is a considerable overlap in the presentation of psychotic symptoms and psychotic disorders.

Validity of the Personality Diagnostic Questionnaire-4 (PDQ-4+) among mentally ill prison inmates in Singapore

We examined the validity of the Personality Diagnostic Questionnaire--4+ (PDQ-4+) as a screening instrument for personality disorders among mentally ill prison inmates in Singapore. A total of 313 prison inmates completed the PDQ-4+ and the Structured Clinical Interview for DSM-IV Axis II Disorders (SCID-II). The subjects were 303 (96.8%) males and 10 (3.2%) females with a mean (SD) age of 40.7 (8.8) years. Kappa agreement between PDQ-4+ and SCID-II for the presence at least one personality disorder was moderate with high sensitivity and low specificity. For specific personality disorders and clusters, we found that the PDQ-4+ diagnosed more subjects as having each of the personality disorders than SCID-II with high negative predictive values. The area under the curve indicated moderate discriminatory capabilities. Our results suggest that the PDQ-4+ could be used as a potential screening instrument for personality disorders in prison inmates.

The positive mental health instrument: development and validation of a culturally relevant scale in a multi-ethnic Asian population

Background

Instruments to measure mental health and well-being are largely developed and often used within Western populations and this compromises their validity in other cultures. A previous qualitative study in Singapore demonstrated the relevance of spiritual and religious practices to mental health, a dimension currently not included in exiting multi-dimensional measures. The objective of this study was to develop a self-administered measure that covers all key and culturally appropriate domains of mental health, which can be applied to compare levels of mental health across different age, gender and ethnic groups. We present the item reduction and validation of the Positive Mental Health (PMH) instrument in a community-based adult sample in Singapore.

Methods

Surveys were conducted among adult (21-65 years) residents belonging to Chinese, Malay and Indian ethnicities. Exploratory and confirmatory factor analysis (EFA, CFA) were conducted and items were reduced using item response theory tests (IRT). The final version of the PMH instrument was tested for internal consistency and criterion validity. Items were tested for differential item functioning (DIF) to check if items functioned in the same way across all subgroups. Results: EFA and CFA identified six first-order factor structure (General coping, Personal growth and autonomy, Spirituality, Interpersonal skills, Emotional support, and Global affect) under one higher-order dimension of Positive Mental Health (RMSEA = 0.05, CFI = 0.96, TLI = 0.96). A 47-item self-administered multi-dimensional instrument with a six-point Likert response scale was constructed. The slope estimates and strength of the relation to the theta for all items in each six PMH subscales were high (range:1.39 to 5.69), suggesting good discrimination properties. The threshold estimates for the instrument ranged from -3.45 to 1.61 indicating that the instrument covers entire spectrums for the six dimensions. The instrument demonstrated high internal consistency and had significant and expected correlations with other well-being measures. Results confirmed absence of DIF.

Conclusions

The PMH instrument is a reliable and valid instrument that can be used to measure and compare level of mental health across different age, gender and ethnic groups in Singapore.

Cross-ethnic differences in severity of symptomatology of individuals with first-episode schizophrenia spectrum disorder

AIMS

The aims of this study were to describe the relationship between ethnicity and severity of baseline symptomatology in a sample of Asian individuals with first-episode schizophrenia spectrum disorder, and to determine if ethnicity predicts severity of symptomatology independent of gender, duration of untreated illness, premorbid functioning, and age of illness onset.

METHODS

This descriptive study included all Chinese, Malay and Indian individuals consecutively admitted into an early intervention programme for treatment of first-episode schizophrenia spectrum disorder. Comparisons of mean scores among the three ethnic groups were performed using analysis of variance, while chi-squared tests were used to compare proportions. Subsequent pair-wise comparisons were performed with Bonferroni corrected statistic to examine specific ethnic group differences. Multivariate regression analyses were conducted to identify factors significantly associated with the severity of different clinical dimensions of schizophrenia measured using the Positive and Negative Syndrome Scale (PANSS).

RESULTS

The analyses involved 503 individuals. The mean PANSS scores were significantly different between the ethnic groups across the PANSS subscales. A post-hoc analysis showed that Malays scored significantly higher than Chinese did across the PANSS subscales. Malays also scored significantly higher than Indians did on the negative scale and the general psychopathology scale. Being Malay compared with Chinese consistently predicted more severe positive, negative and general psychopathology symptoms.

DISCUSSION

The results indicated that the severity of baseline symptomatology of individuals with first-episode schizophrenia spectrum disorders differed by ethnicity. Premorbid functioning appears to act as a potential mediator of the effects of ethnicity on the severity of psychotic symptoms.

Ministry of Health clinical practice guidelines: schizophrenia

The Ministry of Health (MOH) has updated the clinical practice guidelines on Schizophrenia to provide doctors and patients in Singapore with evidence-based treatment for schizophrenia. This article reproduces the introduction and executive summary (with recommendations from the guidelines) from the MOH clinical practice guidelines on Schizophrenia, for the information of readers of the Singapore Medical Journal. Chapters and page numbers mentioned in the reproduced extract refer to the full text of the guidelines, which are available from the Ministry of Health website: http://www.moh.gov. sg/mohcorp/publications.aspx?id=26138. The recommendations should be used with reference to the full text of the guidelines. Following this article are multiple choice questions based on the full text of the guidelines.

Integrated genetic and genomic approach in the SingaporeTranslational and Clinical Research in Psychosis Study: an overview

AIMS

Schizophrenia is a severe mental disorder with onset frequently in adolescence and followed by a chronic and disabling course. Although the exact pathophysiology of this devastating disorder has not been clearly elucidated, a large part of it has been attributed to genetic influences. This article seeks to provide an overview on what our group has embarked on--to elucidate genetic risk factors for schizophrenia within the Chinese ethnic group.

METHODS

We plan to conduct an integrated approach to interrogate comprehensively the genome from different angles and in stages. The first stage involves a genome-wide association study of 1000 cases of schizophrenia-control pairs, with a follow-up replication study in another 1000 cases of schizophrenia and in 1000 controls, and combination analyses with groups from other places including China and Hong Kong. Other than the genome-wide association study, gene sequencing for purported candidate genes and copy number variation analysis will be performed. Neurocognitive intermediate phenotypes will be employed to deconstruct the complex schizophrenia phenotype in a bid to improve association findings. Promising leads from longitudinal gene and protein expression in ultra-high-risk subjects who develop psychosis and schizophrenia (in a parallel study) will be followed up as candidate genes and sequenced in the genetic analysis. Functional analysis forms the last stage of this integrated approach.

CONCLUSION

This integrated genetic and genomic approach will hopefully help in further characterizing and deepening our understanding of molecular pathophysiological mechanisms underlying schizophrenia.

Authorizing psychiatric research: principles, practices and problems

Psychiatric research is advancing rapidly, with studies revealing new investigative tools and technologies that are aimed at improving the treatment and care of patients with psychiatric disorders. However, the ethical framework in which such research is conducted is not as well developed as we might expect. In this paper we argue that more thought needs to be given to the principles that underpin research in psychiatry and to the problems associated with putting those principles into practice. In particular, we comment on some of the difficulties posed by the twin imperatives of ensuring that we respect the autonomy and interests of the research subject and, at the same time, enable potentially beneficial psychiatric research to flourish. We do not purport to offer a blueprint for the future; we do, however, seek to advance the debate by identifying some of the key questions to which better answers are required.

Impact of Depression on Health Related Quality of Life in Patients with Diabetes

Introduction: Diabetes mellitus (DM) is a serious chronic illness that has a major impact on the quality of life of the individuals. Our aim was to examine the determinants of health-related quality of life (HRQOL) in patients with DM. Materials and Methods: Adult outpatients attending a Diabetes Centre were recruited on consecutive basis between August 2006 and February 2007. Clinical data were collected from interviews with the subjects and from medical records. Assessment of depressive symptoms was done using the Center for Epidemiologic Studies Depression Scale (CES-D) and HRQOL using the Short Form 36 Health Survey (SF-36). A two-step regression analysis was conducted for identifying factors affecting patients’ quality of life. Results: Five hundred and thirty-seven patients participated in the study. The mean (SD) age of the participants was 54.7 (13.3) years and 315 (58.7%) were males. The prevalence of depressive symptoms was 31.1% (n = 167). After adjusting for other variables, the effects of depressive symptoms persisted for all the 8 domains of SF-36 (P <0.001 for all). The medical factors that were negatively associated with HRQOL were a diagnosis of Type 1 DM, duration of the illness of more than 10 years, HbA1c levels of ≥7%, and comorbidity of stroke and retinopathy. Being male and a regular exerciser had a positive effect on HRQOL. Conclusion: These findings highlight the importance of detecting and treating comorbid depression in DM. Key words: CES-D, Diabetes mellitus, SF-36

Validity of a brief screening instrument-CRAFFT in a multiethnic Asian population

AIM

To validate the CRAFFT screening test, against the DSM IV Axis 1-based diagnostic inventory in a population of adolescents and young adult males in Singapore.

METHODS

The 23,248 participants belonged to a cohort of males who had undergone a medical examination prior to enlistment for military service. This study took place between August 2004 and August 2005. Subjects underwent a two-stage assessment and were administered the CRAFFT questionnaire and the Composite International Diagnostic Interview (CIDI).

RESULTS

The mean age of the subjects was 19 years (range, 16 to 26 years). The CRAFFT showed moderately high levels of internal consistency (Cronbach's α=0.73). The optimum cutoff point for drug-related disorder either abuse or dependence and alcohol-related disorder either abuse or dependence criterions were found at CRAFFT score of 1 or higher.

CONCLUSION

The CRAFFT test is a valid means of screening adolescents for substance-related disorders in a multiethnic population of adolescent and young adult males.

Impact of depression on health related quality of life in patients with diabetes

INTRODUCTION

Diabetes mellitus (DM) is a serious chronic illness that has a major impact on the quality of life of the individuals. Our aim was to examine the determinants of health-related quality of life (HRQOL) in patients with DM.

MATERIALS AND METHODS

Adult outpatients attending a Diabetes Centre were recruited on consecutive basis between August 2006 and February 2007. Clinical data were collected from interviews with the subjects and from medical records. Assessment of depressive symptoms was done using the Center for Epidemiologic Studies Depression Scale (CES-D) and HRQOL using the Short Form 36 Health Survey (SF-36). A two-step regression analysis was conducted for identifying factors affecting patients' quality of life.

RESULTS

Five hundred and thirty-seven patients participated in the study. The mean (SD) age of the participants was 54.7 (13.3) years and 315 (58.7%) were males. The prevalence of depressive symptoms was 31.1% (n = 167). After adjusting for other variables, the effects of depressive symptoms persisted for all the 8 domains of SF-36 (P <0.001 for all). The medical factors that were negatively associated with HRQOL were a diagnosis of Type 1 DM, duration of the illness of more than 10 years, HbA1c levels of ≥7%, and comorbidity of stroke and retinopathy. Being male and a regular exerciser had a positive effect on HRQOL.

CONCLUSION

These findings highlight the importance of detecting and treating comorbid depression in DM.