Cross-cultural implementation of a Chinese version of the Schedules for Clinical Assessment in Neuropsychiatry (SCAN) in Taiwan

Validity of the Chinese Language Patient Health Questionnaire 2 and 9: A Systematic Review

Introduction

Chinese Americans with limited English proficiency have higher mental health needs than English speakers but are more likely to be undiagnosed and undertreated for depression. Increasing anti-Asian hate crimes during the COVID-19 pandemic has increased the urgency to accurately detect depressive symptoms in this community. This systematic review examines the validity of the Patient Health Questionnaire (PHQ)-2/9 for depression screening in Chinese-speaking populations.

Methods

We queried PubMed, Web of Science, Embase, and PsycINFO databases, examining studies through September 2021. Studies were included if they evaluated the Chinese language PHQ-2 or PHQ-9 and diagnosed depression using a clinical interview. Two investigators independently extracted study data and assessed quality using the QUADAS-2. Study sensitivities and specificities were combined in random effects meta-analyses.

Results

Of 513 articles, 20 met inclusion criteria. All examined the PHQ-9; seven also examined the PHQ-2. Studies were conducted in Mainland China (17), Hong Kong (1), Taiwan (1), and the United States (1). Fourteen studies were published in English; six in Chinese. Studies were diverse in setting, participant age, and comorbidities. For the Chinese language PHQ-9, Cronbach's alpha ranged from 0.765 to 0.938 for included studies (optimal cutoff scores ranged from 6 to 11). For the PHQ-2, Cronbach's alpha ranged from 0.727 to 0.785 (optimal cutoff scores 1-3). Overall, the PHQ-9 pooled sensitivity was 0.88 (95% CI 0.86-0.90), and pooled specificity was 0.87 (95% CI 0.83-0.91). Similarly, the pooled PHQ-2 sensitivity was 0.84 (95% CI 0.80-0.87), and pooled specificity was 0.87 (95% CI 0.78-0.93). The overall risk of bias was low (12 studies) or indeterminate (8 studies).

Discussion

While limited by missing study information, the Chinese language PHQ-9 appears to be a valid depression screening tool among Chinese-speaking populations across geographic and clinical settings. Further research should explore optimal cutoff scores for this population for routine depression screening and the validity of the tool to measure response to depression treatment.

Antidepressant Treatment and Manic Switch in Bipolar I Disorder: A Clinical and Molecular Genetic Study

Affective switch is an important clinical issue when treating bipolar disorder. Though commonly seen in clinical practice, the benefits of prescribing antidepressants for bipolar depression are still controversial. To date, there have been few genetic studies and no genome-wide association study (GWAS), focusing on manic switch following bipolar depression. This study aims to investigate the effects of individual genomics and antidepressant medication on the risk of manic switch in bipolar I disorder (BPI). A total of 1004 patients with BPI who had at least one depressive episode with complete data on antidepressant treatment and outcome were included. Clinical assessment of mania and depression was performed by trained psychiatric nurses and psychiatrists using the Chinese version of the Schedules for Clinical Assessment in Neuropsychiatry (SCAN), and the diagnosis of BPI was made according to DSM-IV criteria. Manic switch was defined as a manic episode occurring within eight weeks of remission from an acute depressive episode. The age at first depressive episode of the study patients was 30.7 years (SD 12.5) and 56% of all patients were female. GWAS was carried out in a discovery group of 746 patients, followed by replication in an independent group of 255 patients. The top SNP rs10262219 on chromosome 7 showed the strongest allelic association with manic switch (p = 2.21 × 10−7) in GWAS, which was however not significantly replicated. Antidepressant treatment significantly (odds ratio 1.7; 95% CI 1.3−2.2; p < 0.001) increased the risk of manic switch. In logistic regression analysis, the CC genotype of rs10262219 (odds ratio 3.0; 95% CI 1.7−5.2) and antidepressant treatment (odds ratio 2.3; 95% CI 1.4−3.7) significantly increased the risk of manic switch with a joint effect (odds ratio 5.9; 95% CI 3.7−9.4). In conclusion, antidepressant medication and rs10262219 variants jointly increased the risk of manic switch after bipolar depression.

Genome-Wide Association Study of Lithium-Induced Dry Mouth in Bipolar I Disorder

Dry mouth is a rather common unpleasant adverse drug reaction (ADR) to lithium treatment in bipolar disorders that often lead to poor adherence or early dropout. The aim of this study was to identify the genetic variants of dry mouth associated with lithium treatment in patients with bipolar I (BPI) disorder. In total, 1242 BPI patients who had ever received lithium treatment were identified by the Taiwan Bipolar Consortium for this study. The proportions of patients who experienced impaired drug compliance during lithium medication were comparable between those only with dry mouth and those with any other ADR (86% and 93%, respectively). Dry mouth appeared to be the most prevalent (47.3%) ADR induced by lithium treatment. From the study patients, 921 were included in a genome-wide association study (GWAS), and replication was conducted in the remaining 321 patients. The SNP rs10135918, located in the immunoglobulin heavy chain locus (IGH), showed the strongest associations in the GWAS (p = 2.12 × 10⁻³⁷) and replication groups (p = 6.36 × 10⁻¹³) (dominant model) for dry mouth with a sensitivity of 84.9% in predicting dry mouth induced by lithium. Our results may be translated into clinical recommendation to help identify at-risk individuals for early identification and management of dry mouth, which will improve medication adherence.

Genome-wide association study of early-onset bipolar I disorder in the Han Taiwanese population

The search for susceptibility genes underlying the heterogeneous bipolar disorder has been inconclusive, often with irreproducible results. There is a hope that narrowing the phenotypes will increase the power of genetic analysis. Early-onset bipolar disorder is thought to be a genetically homogeneous subtype with greater symptom severity. We conducted a genome-wide association study (GWAS) for this subtype in bipolar I (BPI) disorder. Study participants included 1779 patients of Han Chinese descent with BPI disorder recruited by the Taiwan Bipolar Consortium. We conducted phenotype assessment using the Chinese version of the Schedules for Clinical Assessment in Neuropsychiatry and prepared a life chart with graphic depiction of lifetime clinical course for each of the BPI patient recruited. The assessment of onset age was based on this life chart with early onset defined as ≤20 years of age. We performed GWAS in a discovery group of 516 early-onset and 790 non-early-onset BPI patients, followed by a replication study in an independent group of 153 early-onset and 320 non-early-onset BPI patients and a meta-analysis with these two groups. The SNP rs11127876, located in the intron of CADM2, showed association with early-onset BPI in the discovery cohort (P = 7.04 × 10^-8) and in the test of replication (P = 0.0354). After meta-analysis, this SNP was demonstrated to be a new genetic locus in CADM2 gene associated with early-onset BPI disorder (P = 5.19 × 10^-8).

PTSD with secondary psychotic features among trauma-affected refugees: The role of torture and depression

This cross-sectional study examined the prevalence of PTSD with secondary psychotic symptoms (PTSD-SP), its comorbidities, and its association with torture and depression in treatment-seeking refugees. Data were pooled from the Danish Database on Refugees with Trauma (DART). The sample represents approximately 90% of trauma-affected refugee-patients (N = 627) attending a Danish psychiatric outpatient clinic from 2008 to 2013. PTSD, secondary psychotic symptoms, and comorbidities were assessed with structured and routine clinical interviews. The association of PTSD-SP with torture and depression was investigated using hierarchical logistic regression. The prevalence of PTSD-SP in treatment-seeking refugees with PTSD was 30%. Among these, 44% fulfilled the criteria for Enduring Personality Change After Catastrophic Experience (EPCACE). Psychotic symptoms comprised hallucinations and persecutory delusions, often reflecting trauma-related themes. Comorbidity with depression was high (79%). Neither torture, nor other war-trauma (ex-combatant, imprisonment, civilian war trauma) predicted PTSD-SP, but comorbid depression did. Depression only explained a small amount of the total PTSD-SP variance. Results indicate that PTSD-SP is common in treatment-seeking refugees. However, its etiology is poorly understood. This highlights the need for further research to improve diagnosis and treatment for this patient group.

Using the Schedules for Clinical Assessment in Neuropsychiatry (SCAN 2.1) as a diagnostic interview providing dimensional measures: Cross-national findings on the psychometric properties of psychopathology scales

Background

The Schedules for Clinical Assessment in Neuropsychiatry (SCAN) is a set of clinical assessment instruments developed under the auspices of WHO. In contrast to other structured diagnostic interviews, SCAN also provides possibilities for dimensional assessment of psychopathology. This paper reports cross-national findings on the psychometric properties of psychopathology scales derived from SCAN 2.1.

Methods

Within a randomized controlled trial, SCAN 2.1 was used in Dresden (Germany), Michalovce (Slovak Republic), Prague (Czech Republic), and Wrocław (Poland). Forty-seven items from Part I of SCAN 2.1, identified as qualifying for constructing dimensional measures, were, on the one hand, grouped according to their allocation to five specific SCAN 2.1 sections. On the other hand, principal component analyses were used to group the items according to their statistical relationship. To estimate the reliability of the scales, Cronbach's α was computed. To assess factor similarity across sites, Tucker's congruence coefficients were calculated. To appraise concurrent validity, mean scale scores were compared across different diagnostic groups.

Results

Reliability was qualified as moderate to substantial for all generated scales. Factor-solutions differed across sites. Differences in mean scores supported the assumption that the scales might possess, in addition to face validity, concurrent validity.

Conclusions

This is the first cross-national study on the psychometric properties of psychopathology scales derived from SCAN 2.1, and findings are very encouraging concerning its use as a dimensional measure. However, further studies are needed to substantiate implementation of the scales established.

Immunophenotypes associated with bipolar disorder and lithium treatment

Immune dysfunction is implicated in the etiology of bipolar disorder. The single-nucleotide polymorphism rs17026688 in the gene encoding glutamate decarboxylase–like protein 1 (GADL1) has been found to be associated with lithium response in Han Chinese patients with bipolar I disorder (BDI). However, whether patients with GADL1 polymorphisms have different immunophenotypes is unknown. To address this issue, differences in the immune profiles based on analysis of peripheral blood mononuclear cells (PBMCs) were compared among BDI patients and healthy controls who lack or carry the T allele of rs17026688. BDI patients had significantly higher percentages of total T cells, CD4⁺ T cells, activated B cells, and monocytes than healthy controls, suggesting that immunologic imbalance might be involved in BDI development or progression. Treatment of BDI patients-derived PBMCs with lithium in vitro increased the percentage of CD14⁺ monocytes and dendritic cells, suggesting that lithium plays an immunomodulatory role in CD14⁺ monocytes and dendritic cells. Among BDI patients, non-T carriers had a significantly higher percentage of CD11b⁺/CD33^lo/HLA-DR⁻ myeloid-derived suppressor cells than T carriers. Moreover, only T carriers exhibited differential sensitivity to lithium therapeutic use with respect to the percentage of myeloid cells. These findings suggest that rs17026688 polymorphisms in GADL1 are associated with immune dysfunction in BDI patients.

Lithium and GADL1 regulate glycogen synthase kinase-3 activity to modulate KCTD12 expression

Potassium channel tetramerization domain containing 12 (KCTD12), the auxiliary GABA_B receptor subunit, is identified as a susceptibility gene for bipolar I (BPI) disorder in the Han Chinese population. Moreover, the single-nucleotide polymorphism (SNP) rs17026688 in glutamate decarboxylase–like protein 1 (GADL1) is shown to be associated with lithium response in Han Chinese BPI patients. In this study, we demonstrated for the first time the relationship among lithium, GADL1, and KCTD12. In circulating CD11b⁺ macrophage cells, BPI patients showed a significantly higher percentage of KCTD12 expression than healthy controls. Among BPI patients, carriers of the ‘T’ allele (i.e., CT or TT) at site rs17026688 were found to secrete lower amounts of GADL1 but higher amounts of GABA b receptor 2 (GABBR2) in the plasma. In human SH-SY5Y neuroblastoma cells, lithium treatment increased the percentage of KCTD12 expression. Through inhibition of glycogen synthase kinase-3 (GSK-3), lithium induced cyclic AMP-response element binding protein (CREB)–mediated KCTD12 promoter activation. On the other hand, GADL1 overexpression enhanced GSK-3 activation and inhibited KCTD12 expression. We found that lithium induced, whereas GADL1 inhibited, KCTD12 expression. These findings suggested that KCTD12 may be an important gene with respect to neuron excitability and lithium response in BPI patients. Therefore, targeting GSK-3 activity and/or KCTD12 expression may constitute a possible therapeutic strategy for treating patients with BPI disorder.

Diagnostic validity of the Patient Health Questionnaire-2 (PHQ-2) among Ethiopian adults

BACKGROUND

The Patient Health Questionnaire-2 (PHQ-2) is an ultra-brief questionnaire widely used by researchers and clinicians to detect major depressive disorder (MDD). Despite its individual and societal impact, MDD is often undetected and untreated particularly among sub-Saharan Africans. We conducted this study to evaluate the reliability and validity of using the PHQ-2 as a screen for MDD among Ethiopian adults.

METHODS

A total of 926 adults attending outpatient departments in a major referral hospital in Addis Ababa, Ethiopia participated in this study. Construct validity was assessed by examining associations of PHQ-2 scores with World Health Organization Quality of Life (WHO-QOL) domains. We assessed criterion validity and performance characteristics against an independent, blinded, and psychiatrist administered semi-structured Schedules for Clinical Assessment in Neuropsychiatry (SCAN) interview using measures of sensitivity, specificity and receiver operating characteristics (ROC) curves.

RESULTS

The PHQ-2 items showed good reliability (intraclass correlation coefficient=0.92). Quality of life, as reflected by subscale scores for four WHO-QOL domains, was significantly lower among patients with increasing PHQ-2 scores demonstrating good construct validity. ROC analysis and Youden Index showed that a PHQ-2 threshold score of 3 offered optimal discriminatory power with respect to the diagnosis of MDD via the clinical interview (sensitivity=74% and specificity=60%).

CONCLUSION

The Amharic language version of the PHQ-2 had good sensitivity and fair specificity for detecting MDD compared against a psychiatrist administered SCAN diagnosis. This study provides evidence for the PHQ-2 as a reliable and valid ultra-brief screening tool for initial identification of MDD.

GADL1 variant and medication adherence in predicting response to lithium maintenance treatment in bipolar I disorder

BACKGROUND

Genetic variants and medication adherence have been identified to be the main factors contributing to lithium treatment response in bipolar disorders.

AIMS

To simultaneously examine effects of variant glutamate decarboxylase-like protein 1 (GADL1) and medication adherence on response to lithium maintenance treatment in Han Chinese patients with bipolar I (BPI) disorder.

METHOD

Frequencies of manic and depressive episodes between carriers and non-carriers of the effective GADL1 rs17026688 T allele during the cumulative periods of off-lithium, poor adherence to lithium treatment and good adherence to lithium treatment were compared in Han Chinese patients with BPI disorder (n=215).

RESULTS

GADL1 rs17026688 T carriers had significantly lower frequencies of recurrent affective episodes than non-T carriers during the cumulative period of good adherence, but not during those of poor adherence.

CONCLUSIONS

GADL1 rs17026688 and medication adherence jointly predict response to lithium maintenance treatment in Han Chinese BPI patients.

DECLARATION OF INTEREST

None.

COPYRIGHT AND USAGE

© The Royal College of Psychiatrists 2016. This is an open access article distributed under the terms of the Creative Commons Non-Commercial, No Derivatives (CC BY-NC-ND) license.

Variant GADL1 and response to lithium therapy in bipolar I disorder

BACKGROUND

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.

METHODS

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.

RESULTS

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.

CONCLUSIONS

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.).

Validity of the Patient Health Questionnaire-9 for depression screening and diagnosis in East Africa

Depression is often underdiagnosed and undertreated in primary care settings, particularly in developing countries. This is, in part, due to challenges resulting from lack of skilled mental health workers, stigma associated with mental illness, and lack of cross-culturally validated screening instruments. We conducted this study to evaluate the reliability and validity of the Patient Health Questionnaire-9 (PHQ-9) as a screen for diagnosing major depressive disorder among adults in Ethiopia, the second most populous country in sub-Saharan Africa. A total of 926 adults attending outpatient departments in a major referral hospital in Ethiopia participated in this study. We assessed criterion validity and performance characteristics against an independent, blinded, and psychiatrist administered semi-structured Schedules for Clinical Assessment in Neuropsychiatry (SCAN) interview. Overall, the PHQ-9 items showed good internal (Cronbach's alpha=0.81) and test re-test reliability (intraclass correlation coefficient=0.92). A factor analysis confirmed a one-factor structure. Receiver Operating Characteristics (ROC) analysis showed that a PHQ-9 threshold score of 10 offered optimal discriminatory power with respect to diagnosis of major depressive disorder via the clinical interview (sensitivity=86% and specificity=67%). The PHQ-9 appears to be a reliable and valid instrument that may be used to diagnose major depressive disorders among Ethiopian adults.

Validity and reliability of the Chinese version of the Short Form of Quality of Life Enjoyment and Satisfaction Questionnaire (Q-LES-Q-SF)

PURPOSE

The Short Form version of the Quality of Life Enjoyment and Satisfaction Questionnaire (Q-LES-Q-SF) was designed to measure patients' subjective experience of enjoyment and satisfaction. However, it had not yet been validated for Chinese societies. This paper reports on the validation of the Chinese version of the Q-LES-Q-SF among primary care patients in Taiwan.

METHODS

The study included adult patients in primary care clinics. The participants completed the Q-LES-Q-SF, the Patient Health Questionnaire, and the Short Form Health Survey. After that, the trained researchers interviewed the patients using the mood module of the Schedules for Clinical Assessment in Neuropsychiatry and the 17-item Hamilton Rating Scale for Depression. A subsample of participants was reassessed with Q-LES-Q-SF within a 2-week interval.

RESULTS

A total of 1,482 patients completed the Q-LES-Q-SF. The content validity was good, with no significant floor/ceiling effect. The internal consistency of the Q-LES-Q-SF proved to be substantial as well as the test-retest reliability. The factor structure was examined by exploratory factor analysis (EFA) and confirmatory factor analysis (CFA). The EFA yielded a 2-factor structure, which was confirmed by a CFA with acceptable fit indices. Known-group validity of the Q-LES-Q-SF was satisfactory in distinguishing patients with and without depression, according to hierarchical regression analyses. Evidence of concurrent validity was provided for the Q-LES-Q-SF, and its two subscales identified significant correlations with other measures.

CONCLUSION

The Chinese Q-LES-Q-SF was shown to have adequate validity and reliability. It may be a useful tool to measure patients' quality of life in Chinese societies.

Incidence of first onset alcohol use disorder: a 16-year follow-up in the Taiwanese aborigines

PURPOSE

To investigate the incidence and cumulative risk of first onset alcohol use disorder (AUD) in a 16-year follow-up among Taiwanese aboriginal populations.

METHODS

Participants included in this study were cohort subjects free from any AUD at phase 1 survey (n = 428 for DSM-3-R and 451 for DSM-4) of the Taiwan aboriginal study project conducted in 1986-1988. They were reassessed approximately 16 years later, with a response rate of 98.8 %. A Chinese version of the WHO schedules for clinical assessment in neuropsychiatry was employed to assess the lifetime drinking history and AUD.

RESULTS

Age-standardized annual incidence rates of AUD in all groups were 2.26 and 1.75 % according to DSM-3-R and DSM-4, respectively. The overall incidence rates of AUD were comparable to most of other studies in Caucasian populations, but the sex ratios of women to men were higher in this study (1:2-3) than in the latter (1:6). The incidence of AUD was higher with DSM-3-R than with DSM-4 criteria in this study, attributable to the exclusion of physical/psychological harm in DSM-4 alcohol abuse. The cumulative risks of DSM-4 AUD in this study were very high, being 72.2 ± 19.8 for men and 48.7 ± 8.2 for women up to the age of 65 years.

CONCLUSIONS

High incidence rates and cumulative risks of AUD in Taiwanese aborigines demand effective prevention strategy.

Convergent evidence from mouse and human studies suggests the involvement of zinc finger protein 326 gene in antidepressant treatment response

Objectives

The forced swim test (FST) is a commonly used model to predict antidepressant efficacy. Uncovering the genetic basis of the model may unravel the mechanism of antidepressant treatment.

Methods

FVB/NJ (FVB) and C57BL/6J (B6) were first identified as the response and non-response strains to fluoxetine (a serotonin-specific reuptake inhibitor antidepressant) treatment in the mouse FST. Simple-interval (SIM) and composite-interval (CIM) mappings were applied to map the quantitative trait loci (QTLs) of the anti-immobility effect of fluoxetine in FST (FST_FLX) in 865 male B6×FVB-F2 mice. The brain mRNA expressions of the gene with the maximum QTL-linkage signal for FST_FLX after the FST were compared between B6 and FVB mice and also compared between fluoxetine and saline treatment. The association of the variants in the human homologue of the mouse FST_FLX-QTL gene with major depressive disorder (MDD) and antidepressant response were investigated in 1080 human subjects (MDD/control = 582/498).

Results

One linkage signal for FST_FLX-QTL was detected at an intronic SNP (rs6215396) of the mouse Zfp326 gene (maximal CIM-LOD = 9.36). The Zfp326 mRNA expression in the FVB thalamus was significantly down-regulated by fluoxetine in the FST, and the higher FVB-to-B6 Zfp326 mRNA expressions in the frontal cortex, striatum and hypothalamus diminished after fluoxetine treatment. Two coding-synonymous SNPs (rs2816881 and rs10922744) in the human homologue of Zfp326, ZNF326, were significantly associated with the 8-week antidepressant treatment response in the MDD patients (Bonferroni-corrected p = 0.004–0.028).

Conclusions

The findings suggest the involvement of the Zfp326 and ZNF326 genes in antidepressant treatment response.

Evidence of involvement of the human Par-4 (PAWR) gene in major depressive disorder

QBJECTIVES: The aim of the study was to examine the associations between genetic variations in the human PAWR gene and major depressive disorder (MDD) as well as the response to antidepressant treatment.

METHODS

Six-hundred and two patients with MDD and 543 controls were included in the study; among the MDD patients, 268 were followed-up for a further 8 weeks in order to assess their response to treatment with selective serotonin reuptake inhibitors (SSRIs). Six polymorphisms (rs17005769, rs4842318, rs7305141, rs2307223, rs8176874 and rs2307220) of the PAWR gene were investigated with regard to their association with MDD and antidepressant treatment efficacy.

RESULTS

One polymorphism, rs8176874, was in genotypic (uncorrected P=0.005) and allelic (uncorrected P=0.0015) association with MDD. Several haplotypes spanning rs7305141-rs2307223-rs8176874 were also significantly associated with MDD after correction for multiple testing (corrected P<0.05). However, neither single-marker nor haplotype-based analyses suggested an association between the studied markers and SSRI treatment response.

CONCLUSIONS

Genetic variations in the PAWR gene are related to susceptibility to MDD but not to SSRI treatment response.

Genome-wide association study of bipolar I disorder in the Han Chinese population

We report the first genome-wide association study in 1000 bipolar I patients and 1000 controls, with a replication of the top hits in another 409 cases and 1000 controls in the Han Chinese population. Four regions with most strongly associated single-nucleotide polymorphisms (SNPs) were detected, of which three were not found in previous GWA studies in the Caucasian populations. Among them, SNPs close to specificity protein 8 (SP8) and ST8 α-N-acetyl- neuraminide α-2,8-sialyltransferase (ST8SIA2) are associated with Bipolar I, with P-values of 4.87 × 10(-7) (rs2709736) and 6.05 × 10(-6) (rs8040009), respectively. We have also identified SNPs in potassium channel tetramerization domain containing 12 gene (KCTD12) (rs2073831, P=9.74 × 10(-6)) and in CACNB2 (Calcium channel, voltage-dependent, β-2 subunit) gene (rs11013860, P=5.15 × 10(-5)), One SNP nearby the rs1938526 SNP of ANK3 gene and another SNP nearby the SNP rs11720452 in chromosome 3 reported in previous GWA studies also showed suggestive association in this study (P=6.55 × 10(-5) and P=1.48 × 10(-5), respectively). This may suggest that there are common and population-specific susceptibility genes for bipolar I disorder.

Randomized controlled trial of a brief intervention for unhealthy alcohol use in hospitalized Taiwanese men

AIMS

To evaluate the effectiveness of a brief intervention in hospitalized Taiwanese men to reduce unhealthy alcohol consumption.

DESIGN

Randomized controlled trial.

SETTING

Medical/surgical wards of a medical centre in Taipei, Taiwan.

PARTICIPANTS

Of 3669 consecutive adult male in-patients, 616 were identified as unhealthy alcohol users (>14 drinks/week) and assigned randomly to either usual care (n = 308) or a brief intervention (n = 308).

MEASUREMENTS

Primary outcomes were changes in alcohol consumption at 4, 9 and 12 months, including self-reported weekly alcohol consumption, drinking days and heavy drinking episodes assessed by 7-day time-line follow-back. Secondary outcomes were (i) self-reported alcohol problems, (ii) health-care utilization (hospital days and emergency department visits), (iii) self-reported seeking of speciality treatment for alcohol problems and (iv) 3-month Quick Drinking Screen.

FINDINGS

Based on intention-to-treat analyses, the intervention group consumed significantly less alcohol than the control group among both unhealthy drinkers and the subgroup of alcohol-dependent participants over 12 months, on both 7-day and 3-month assessments. Adjunctive analyses of only those who completed all assessments found that total drinks consumed did not remain significant. Significantly more participants with alcohol use disorders in the intervention than in the control group (8.3%, 19 of 230 versus 2.1%, four of 189) consulted specialists by 12 months (P = 0.01). However, alcohol-related problems and health-care utilization did not differ significantly in the two groups during follow-up.

CONCLUSIONS

Data from Taiwan confirm that brief in-hospital intervention can result in a reduction in alcohol intake by men who drink heavily or are diagnosed with an alcohol use disorder.

Validation of Patient Health Questionnaire for depression screening among primary care patients in Taiwan

PURPOSE

The aim of this study was to determine the reliability and validity of a Chinese version of the Patient Health Questionnaire (PHQ-9) for the purpose of screening major depressive disorder (MDD) among primary care patients in Taiwan.

METHOD

A total of 1954 primary care patients completed the PHQ-9. Patients (n = 1532) were interviewed using the Schedule for Clinical Assessments in Neuropsychiatry and 17-item of Hamilton Rating Scale. Subsample cases were retested within 2 weeks.

RESULTS

The PHQ-9 had a good internal consistency (α = .80) and test-retest reliability (intraclass correlation coefficient = 0.87). A principal component factor analysis yielded 1-factor structure, which accounted for a total of 42.0% of the variance. The PHQ-9 was significantly correlated with the external validators such as the 17-item of Hamilton Rating Scale and the Short Form of the Quality of Life Enjoyment and Satisfaction Questionnaire (P < .001). Using the Schedule for Clinical Assessments in Neuropsychiatry interview as the criterion standard, a PHQ-9 score of 10 or higher had a sensitivity of 0.86 and a specificity of 0.94 for recognizing MDD. The screening accuracy of the 2 items version, PHQ-2, was also satisfactory (scores ≥ 2: sensitivity 0.88; specificity 0.82). The single-question screen, PHQ-1 (depressed mood), was 78% sensitive and 93% specific for detecting MDD (score ≥ 2).

CONCLUSION

The PHQ-9 and its 2 subscales, PHQ-2 and PHQ-1, seem reliable and valid for detecting MDD among Chinese primary care patients.

Stigma associated with schizophrenia: cultural comparison of social distance in Japan and China

AIMS

The aim of the present study was to investigate social attitudes toward schizophrenia in Japan and China in view of social distance and knowledge of psychiatry, as well as sociocultural aspects.

METHODS

Two self-rating scales were used to compare social distance and knowledge regarding schizophrenia in 352 Japanese subjects and 347 Chinese subjects. The Social Distance Scale-Japanese version was used to measure social distance from schizophrenia subjects in Japan. This scale consists of eight questions graded using a 4-point Likert scale (0-3 points), with higher scores representing increased social distance. A translation of the SDSJ into Chinese was used to assess social distance in China. The Knowledge of Illness and Drugs Inventory was used to determine participant knowledge of mental illness and its treatment (medication) through 20 questions (responses are graded as correct or incorrect, with higher scores indicating greater knowledge). A Chinese version of this questionnaire was also created.

RESULTS

Total scores of both scales were significantly higher in Japanese subjects than in Chinese subjects.

CONCLUSIONS

Social distance associated with schizophrenia is large in both Beijing and Fukuoka, but the features of social distance differ between countries. It is important to determine the features of stigma associated with schizophrenia and develop anti-stigma programs based on trans-cultural considerations.

Acculturation, psychiatric comorbidity and posttraumatic stress disorder in a Taiwanese aboriginal population

BACKGROUND

This study investigates acculturation and other antecedent psychiatric and socio-environmental risk factors for posttraumatic stress disorder (PTSD) in one aboriginal group (the Bunun) exposed to an earthquake disaster in Taiwan.

METHOD

Respondents (n = 196) were assessed 5 months after the disaster, using a Chinese version of the Schedules for Clinical Assessment in Neuropsychiatry and the Taiwan Aboriginal Acculturation Scale.

RESULT

Four risk factors exerted independent effect on the risk of PTSD, including magnitude of the earthquake, subsequent traumas, antecedent major depressive disorder and acculturation status.

CONCLUSION

Public mental health programs need to consider the liability to PTSD in populations with different ethnicity and socio-cultural environments.

Validation and comparison of alcohol-screening instruments for identifying hazardous drinking in hospitalized patients in Taiwan

AIM

The aim of this study was to validate the Mandarin Chinese version of different screening instruments and compare their performances for identifying hazardous drinkers in Taiwan.

METHODS

We compared the performance of the Mandarin Chinese versions of AUDIT, AUDIT-C (AUDIT items 1, 2 and 3), AUDIT-4 (AUDIT items 1, 2, 3 and 10), AUDIT-3 (AUDIT item 3), TWEAK, SMAST and CAGE to detect hazardous drinking in hospitalized patients in Taiwan. The results of the test instruments were blindly compared with the reference standard Schedule for Clinical Assessments in Neuropsychiatry (SCAN).

RESULTS

Of 404 patients evaluated, 100 were identified as having a hazardous drinking pattern. All screening instruments showed acceptable sensitivities (ranging from 85 to 93%) and specificities (ranging from 72 to 92%), but AUDIT and its short forms performed consistently better than the other instruments.

CONCLUSIONS

The Mandarin Chinese versions of AUDIT and its derivatives perform well in screening hospitalized Taiwanese patients for hazardous drinking.

The influence of media reporting of a celebrity suicide on suicidal behavior in patients with a history of depressive disorder

BACKGROUND

Few studies have directly assessed the impact of a specific media report in vulnerable people. This study investigates possible influences of media reporting of a celebrity suicide on subsequent suicidal behaviors and associated risk factors among depressive patients.

METHODS

Depressive patients (N=461) were assessed through a structured interview soon after extensive media reporting of a celebrity suicide.

RESULTS

Among 438 depressive patients exposed to the media report, 38.8% reported an influence on subsequent suicidal behaviors, including 24 (5.5%) with a suicide attempt. The risk of such influence was highest among patients in a severe depressive state just prior to the media report (adjusted OR 7.81, 95% CI 3.28-18.59). Such influence on a subsequent suicide attempt was highest in patients with a most recent suicide attempt within one month prior to the media reports (adjusted hazard ratio 11.91, 95% CI 3.76-37.72).

LIMITATIONS

Our finding of the significant media influence may reflect adverse thoughts among more suicidal and depressed individuals. The possible influence of other factors on the findings cannot be ruled out.

CONCLUSIONS

This study has provided more convincing evidence suggesting negative influences of media reporting of a celebrity suicide on subsequent suicidal behaviors among depressive patients. Particular attention in terms of potential negative media influences should be paid to patients who are younger and currently depressed and have made a recent suicide attempt.

[Psychometric properties of dimensional measures derived from the latest German version of the Schedules for Clinical Assessment in Neuropsychiatry 2.1]

BACKGROUND

The Schedules for Clinical Assessment in Neuropsychiatry (SCAN) is a comprehensive set of clinical assessment instruments developed by the World Health Organisation. This is the first study to report psychometric properties of dimensional measures derived from the latest German version SCAN 2.1.

METHODS

Within a randomized controlled trial comparing psychiatric day-hospital treatment to inpatient treatment, 202 acute mentally ill patients were interviewed by clinically experienced interviewers. Forty-seven items of Part I of SCAN 2.1 were selected for constructing dimensional measures. Six scales were generated using principal component analyses (PCA). They were compared to five scales constructed according to the items' affiliation to specific sections of SCAN 2.1.

RESULTS AND CONCLUSIONS

Cronbach's alpha coefficients qualify the reliability of most scales as moderate (0.50<alpha<0.70) or substantial (alpha>0.70). With respect to high correlations between the scales generated using PCA and the section-specific scales, using the latter is recommended. Research into psychotic disorders, however, is missing, given that the present analyses are based on items from Part I of SCAN 2.1 only.

Cross-cultural validation of the DMI-10 measure of state depression: the development of a Chinese language version

Depression measurement tools in cross-cultural research require careful design and thorough validation to ensure that cognitive concepts in one culture can be appropriately translated and applied to a differing culture. The aim of this study was to validate the Chinese version of a screening measure of state depression, the 10-item Depression in Medically Ill (DMI-10), and we report three interdependent studies. An initial bilingual test-retest study identified four (of the 10) items as having poor cross-cultural validity. A second study involved focus groups participants exploring the meaning of translated items with Chinese speakers. The third study repeated the bilingual test-retest analyses on the modified DMI-10 form and demonstrated improved correlation coefficients on all items and an excellent overall correlation (r=0.87) between the Chinese and English versions. The Chinese DMI-10 should prove useful as a tool in cross-cultural research to understand the Chinese experience of depression. The findings of this study have methodological implications for cross-cultural research on depression.

Glutamate Decarboxylase Genes and Alcoholism in Han Taiwanese Men

OBJECTIVE

Glutamate decarboxylase (GAD), the rate-limiting enzyme in the synthesis of gamma-aminobutyric acid (GABA), may be involved in the development of alcoholism. This study examined the possible roles of the genes that code for 2 forms of GAD (GAD1 and GAD2) in the development of alcoholism.

METHOD

An association study was conducted among 140 male alcoholic subjects meeting the DSM-III-R criteria for alcohol dependence and 146 controls recruited from the Han Taiwanese in community and clinical settings. Psychiatric assessment of drinking conditions was conducted using a Chinese version of the Schedules for Clinical Assessment in Neuropsychiatry. The SHEsis and Haploview programs were used in statistical analyses.

RESULTS

Nine single-nucleotide polymorphisms (SNPs) at the GAD1 gene were valid for further statistics. Between alcoholic subjects and controls, significant differences were found in genotype distributions of SNP1 (p=0.000), SNP2 (p=0.015), SNP4 (p=0.015), SNP5 (p=0.031), SNP6 (p=0.012), and SNP8 (p=0.004) and in allele distributions of SNP1 (p=0.001), SNP2 (p=0.009), and SNP8 (p=0.009). Permutation tests of SNP1, SNP2, and SNP8 demonstrated significant differences in allele frequencies but not in 2 major haplotype blocks. Three valid SNPs at the GAD2 gene demonstrated no associations with alcoholism. Further permutation tests in the only 1 haplotype block or individual SNPs demonstrated no significant differences.

CONCLUSIONS

This is the first report indicating a possible significant role of the GAD1 gene in the development of alcohol dependence and/or the course of alcohol withdrawal and outcome of alcoholism.

Development of a Chinese Version of the Yale-Brown Obsessive Compulsive Scale for Heavy Drinking

BACKGROUND

Measurement of craving is an important component in the investigation of the etiology and clinical pictures of alcoholism and dependence of other substances in different cultures. The aim of this study was to develop a Chinese version of the Yale-Brown Obsessive Compulsive Scale for heavy drinking (YBOCS-hd-C), the instrument most frequently used in assessing the severity of alcohol craving in Taiwan.

METHODS

Four hundred twenty Han Chinese (220 with alcohol use disorders) and 218 Bunun aborigines (150 with alcohol use disorders) in Taiwan were interviewed by mental health professionals with the YBOCS-hd-C and a Chinese version of the World Health Organization Schedules for Clinical Assessment in Neuropsychiatry to establish the psychiatric diagnosis. Validity and reliability of the YBOCS-hd-C were examined.

RESULTS

The YBOCS-hd-C was found to have acceptable interrater reliability (intraclass correlation, 0.89-0.96), internal consistency (Cronbach's alpha = 0.99), construct validity, concurrent validity, and cross-cultural validity. The correlations between 10 items of the YBOCS-hd-C and 11 items of the World Health Organization Schedules for Clinical Assessment in Neuropsychiatry adjusted for age, gender, and ethnicity ranged from 0.39 to 1.00. The YBOCS-hd-C also discriminated effectively among individuals with alcohol dependence, alcohol abusers, and normal drinkers.

CONCLUSIONS

This study demonstrated that the YBOCS-hd-C is a reliable and valid instrument for assessing the extent of craving for alcohol in Taiwanese Han and Bunun individuals.

New approach to the validity of the alcohol use disorders identification test: stratum-specific likelihood ratios analysis

BACKGROUND

Previous validation studies of the Alcohol Use Disorders Identification Test (AUDIT) used either the fixed-threshold approach or receiver operating characteristic (ROC) analyses. This study was aimed to conduct a stratum-specific likelihood ratio (SSLR) analysis on the validity of the AUDIT for detecting alcohol use disorders.

METHODS

A two-phase validation study was conducted among nonpsychiatric inpatients at a general hospital, using the AUDIT for phase 1 screening and the Schedules for Clinical Assessment in Neuropsychiatry for the phase 2 interview. All of the patients with positive screening results and a subsample of the patients with negative screening results were interviewed in the second phase. The validity of the AUDIT for current alcohol use disorders was estimated using the ROC first, and an SSLR analysis was performed subsequently.

RESULTS

In 422 inpatients who completed the screening, 193 had a negative result with a zero score, 103 had a negative result with a nonzero score, and 126 had a positive result. Twenty screened patients with a negative result and a nonzero score and 107 patients with a positive result were interviewed in the second phase, in which 59 patients were found to have current alcohol use disorders according to DSM-IV criteria. The area under the ROC curve of the AUDIT for current alcohol use disorders was 0.98. The sensitivity and specificity of the AUDIT at the optimal cutoff of 8 were 0.97 and 0.90, respectively. Three strata of the AUDIT scores (0-7, 8-13, and > or = 14) were derived for alcohol use disorders, with the SSLRs being 0.04, 3.67, and 49.72, and the corresponding posttest probabilities being 0.01, 0.42, and 0.91, respectively.

CONCLUSIONS

The AUDIT is a valid screening tool for alcohol use disorders, and the three strata derived from the SSLR analysis are informative and readily applicable in clinical practice.

A functional polymorphism in the promoter region of the tryptophan hydroxylase gene is associated with alcohol dependence in one aboriginal group in Taiwan

BACKGROUND

Polymorphisms within intron 7 of the tryptophan hydroxylase (TPH1) gene were found to be associated with alcohol dependence in different ethnic groups, including the aboriginal Bunun group in Taiwan. This study aimed to identify genetic variants at the TPH1 locus and to examine their associations with alcoholism. We hypothesized that the polymorphism of TPH1 gene is functional and influences the human circadian rhythm to contribute to the pathophysiology of alcohol dependence.

METHODS

DNA from the Taiwanese Han and Bunun was subjected to sequence for screening genetic variation in the coding and promoter regions of the TPH1 locus. Polymorphisms among individuals with alcohol dependence and control subjects in two ethnic groups in Taiwan were investigated.

RESULTS

Three variants in the TPH1 promoter region were identified, and the markers are in complete linkage disequilibrium in both populations. Positive associations at both allelic and genotypic levels were obtained between case and control groups in the Bunun. Expression studies demonstrated that the variants indeed affected reporter gene activity in human choriocarcinoma and colon adenocarcinoma cell lines.

CONCLUSIONS

Polymorphisms in the promoter region may influence the function of the TPH1 gene and further influence the proclivity of alcohol dependence in one ethnic group in Taiwan. The associations between TPH1 genotypes and alcoholism may deserve further investigation.

Prevalence and identification of alcohol use disorders among nonpsychiatric inpatients in one general hospital

Alcohol use disorders (AUDs) are common among inpatients in general hospitals and often cause excess mortality. This study investigates the prevalence of AUDs among nonpsychiatric inpatients in one general hospital and evaluates the ability of medical staff to identify such morbidity. A two-phase case-identification strategy was employed utilizing the Alcohol Use Disorders Identification Test as the first-phase screening tool and the Schedules for Clinical Assessment in Neuropsychiatry as the second-phase diagnostic interview. Among 538 eligible patients, a total of 422 (78.4%) completed the first-phase screening. A subsample (20%) of those screened negative and 90% of those screened positive were interviewed at the second phase. The weighted 1-year prevalence rates of alcohol abuse and alcohol dependence were 3.9% and 12.6%, respectively. The overall identification rate of AUDs by medical staff was 25.4% (0% for alcohol abuse and 30% for alcohol dependence). In conclusion, approximately one sixth of nonpsychiatric inpatients in a general hospital have AUDs and have been neglected substantially by medical staff. Implications of the findings for the prevention of AUDs and their physical complications are discussed.

Endogenous Opioid Receptor Genes and Alcohol Dependence Among Taiwanese Han

BACKGROUND

Nonselective opioid antagonists reduce alcohol consumption under various experimental situations, and several association studies have examined possible roles of opioid receptor mu (OPRM), delta (OPRD), and kappa (OPRK) genes in the development of alcohol dependence.

METHODS

We examined 20 single nucleotide polymorphisms (SNPs) across the OPRM, OPRD, and OPRK genes in 158 alcohol-dependent subjects and 149 controls. Differences in allele frequency and genotype distribution between case subjects and controls, as well as the deviation from Hardy-Weinberg equilibrium, were examined using Fisher's exact tests.

RESULTS

No significant difference in either allele or genotype frequency was found between case subjects and controls for each of the SNPs.

CONCLUSIONS

Our findings do not support a possible role of the opioid receptor genes for the proclivity to alcohol dependence in the Taiwanese Han.

Cultural adaptation of mental health measures: improving the quality of clinical practice and research

The need for accurate information about the mental health problems of multicultural communities requires valid measures of mental health for use in a number of languages and cultural contexts. Measures of psychopathological symptoms leading to a diagnosis have been especially criticised for their universal application, without attention to their limitations across cultures. Yet, measures are crucial to assess recovery and the performance of services, and to take account of carer and user views. We summarise the main challenges in the cultural adaptation of such measures in our work with adults and adolescents of South Asian, African and Caribbean origin.

Association study of novel human serotonin 5-HT(1B) polymorphisms with alcohol dependence in Taiwanese Han

BACKGROUND

Abnormal serotonergic pathways are implicated in numerous neuropsychiatric disorders, such as depression, anxiety, migraine, substance abuse, and alcoholism. The human serotonin receptor 1B, encoded by the HTR1B gene, is a presynaptic serotonin autoreceptor that plays a role in regulating serotonin synthesis and release. Because the linkage of antisocial alcoholism to the HTR1B gene was recently reported in two populations, it was of interest to identify genetic variants at the HTR1B locus and study their association with alcoholism in the Taiwanese Han population.

METHODS

We sequenced DNA from Taiwanese Han to screen for genetic variation in the coding, promoter, and partial 3' untranslated regions of the HTR1B locus of 158 alcohol-dependent cases with withdrawal symptoms and 149 control subjects, who either never drank or drank only occasionally and in low quantities.

RESULTS

Seven variants were identified. Positive associations were found between variant A-161T and alcohol dependence at both the allelic and genotypic level. In addition, an expression study showed that the A-161T variant affected reporter gene activity.

CONCLUSIONS

Our results support an association between HTR1B and alcohol dependence. The HTR1B A-161T polymorphism may be valuable both as a functional and as an anonymous genetic marker for HTR1B.

Genetic polymorphisms of the promoter region of dopamine D2 receptor and dopamine transporter genes and alcoholism among four aboriginal groups and Han Chinese in Taiwan

This study aims to examine the relationship between the functional polymorphism at the promoter region of the dopamine D2 receptor (DRD2) gene (i.e. -141C Ins/Del) and variable number of tandem repeat polymorphism at the 3' untranslated region of the dopamine transporter (DAT) gene (SLC6A3) with alcoholism in a case-control study. The cases (n = 203) were alcohol dependents with withdrawal symptoms, and the controls (n = 213) were sex- and ethnicity-matched individuals who were screened to exclude those with alcohol problems among four aboriginal groups (Atayal, Ami, Bunun, and Paiwan) and Han Chinese in Taiwan. To control for potential confounding factors, we excluded tobacco abusers from control subjects in part of the analysis and compared the distribution of the genetic polymorphisms in alcoholics with severe medical complications versus those with less severe medical complications. There were no differences in allele and genotype frequencies of these two distinct genetic markers between alcoholics and control subjects in these five different ethnic groups. There was no significant linkage disequilibrium between the -141C polymorphism and two other DRD2 polymorphisms (TaqI A and NcoI). The results remained unchanged when cases were limited to alcoholics with more severe medical complications or when tobacco abusers were excluded from control subjects. The results suggest that both the DRD2 promoter region and the DAT gene do not play a significant role in conferring vulnerability to alcoholism.