Pathological personality explains individual differences in global emotion dysregulation within the pathway between child maltreatment and severe depressive symptoms

OBJECTIVE

Global emotion dysregulation mediates the relationship between child maltreatment and severe depressive symptoms; however, there is a lack of research on maladaptive personality traits and their contribution to individual differences in global emotion dysregulation within this conceptual model. The present study tested a preliminary serial mediation model where maladaptive personality traits and global emotion dysregulation mediate the relationship between child maltreatment and severe depressive symptoms.

METHOD

A total of 200 patients with mood disorders (Mage = 36.5 years; 54% females) were assessed for maladaptive personality traits (Personality Inventory for Diagnostic and Statistical Manual of Mental Disorders [5th ed.] Brief Form), global emotion dysregulation (Difficulties in Emotion Regulation Scale-Short), childhood trauma (Childhood Trauma Questionnaire), and depressive symptoms (Patient Health Questionnaire-9).

RESULTS

Ordinary least squares regression and partial least squares-structural equation modeling revealed a consistent and significant indirect effect of child maltreatment on severe depressive symptoms through negative affectivity, detachment, psychoticism, and global emotion dysregulation. Among child maltreatment types, only emotional abuse had a significant indirect effect on severe depressive symptoms through maladaptive personality traits and global emotion dysregulation, b = 0.50, SE = 0.09, 95% confidence intervals [0.326, 0.694] after controlling for age, gender, and remaining types of child maltreatment.

CONCLUSIONS

Findings support the view that maladaptive personality traits shed important insights on individual differences in global emotion dysregulation, and this information could aid clinical formulation and treatment of childhood adversity-related psychopathology. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Efficacy of Using Intermittent Theta Burst Stimulation to Treat Negative Symptoms in Patients with Schizophrenia-A Systematic Review and Meta-Analysis

Negative symptoms in schizophrenia impose a significant burden with limited effective pharmacological treatment options. Recent trials have shown preliminary evidence for the efficacy of using intermittent theta burst stimulation (iTBS) in treating negative symptoms in schizophrenia. We aim to systematically review the current evidence of iTBS in the treatment of the negative symptoms of schizophrenia as an augmentation therapy. The study protocol was developed and registered on Prospero (registration ID: 323381). MEDLINE, EMBASE, Web of Science (Scopus), PsycINFO and Wan Fang databases were searched for sham-controlled, randomized trials of iTBS among patients with schizophrenia. The mean difference in major outcome assessments for negative symptoms was calculated. The quality of evidence was assessed using the Cochrane Risk of Bias Tool (version 1) and the GRADE system. Moreover, 12 studies including a total of 637 participants were included. Compared to sham treatment, the pooled analysis was in favor of iTBS treatment for negative symptoms (mean weight effect size: 0.59, p = 0.03) but not for positive symptoms (mean weight effect size: 0.01, p = 0.91) and depressive symptoms (mean weight effect size: 0.35, p = 0.16). A significant treatment effect was also observed on the iTBS target site left dorsal prefrontal cortex (mean weight effect size: 0.86, p = 0.007) and for stimulation with 80% motor threshold (mean weight effect size: 0.86, p = 0.02). Thus, our synthesized data support iTBS as a potential treatment for negative symptoms among patients with schizophrenia. However, the long-term efficacy and safety issues of iTBS in a larger population have yet to be examined.

The impact of the number of previous illness episodes on early response to electroconvulsive therapy (ECT) in psychosis, mania, depression, psychotic depression, and catatonia: A naturalistic transdiagnostic analysis

Electroconvulsive Therapy (ECT) is an effective treatment for mood and psychotic disorders but there is growing evidence of treatment resistant to ECT. Our study aimed to investigate the relationship between the number of previous illness episodes and the symptomatic improvement after acute ECT treatment. We conducted a retrospective naturalistic cohort analysis of patients' ECT registry data from March 2017 to February 2023. We categorized the number of previous illness episodes into "0-3″ and ">3 episodes", paired T-tests were used to compare the changes in scores of clinical assessments, generalized linear models were used to analyze the association between the number of previous illness episodes and change in symptomatic scores. A total of 1137 patients were included for analysis. There was a significant global improvement in psychiatric symptoms (CGI) after 6 ECT treatments across five indications. We observed that compared to patients with less previous illness episodes, patients with more than 3 previous illness episodes had 30% lower chance of response to acute ECT treatment. Thus, our study suggests that use ECT earlier in the course of illness is associated with greater response and support offering ECT earlier in the disease course.

Effect of early electroconvulsive therapy on length of stay in patients with bipolar, depressive and psychotic disorders

OBJECTIVE

There is limited literature examining the effect of early electroconvulsive therapy(ECT) on the length of stay(LOS), especially for psychotic disorders. This study aimed to evaluate the association between early ECT and LOS in three main groups of patients with bipolar, depressive and primary psychotic disorders.

METHOD

A retrospective descriptive analysis of 464 patients who received inpatient ECT from May 2017 to March 2021 in a large tertiary psychiatric institution was conducted. Early ECT was defined as ECT done before the mean number of days from admission to initiation of ECT by diagnosis. The main outcome measure was LOS, which was examined by diagnosis between the early and late ECT groups, using a linear regression model with adjustment factors chosen based on univariate analysis.

RESULTS

A strong, significant association was found between early ECT and a shorter LOS (β -28.3, 95 % CI -33.6 to -23.0, p < 0.001), even after accounting for adjustment factors. This association was consistent in all three diagnosis groups: bipolar disorders (β -14.5, 95 % CI -20.1 to -9.0, p < 0.001), major depressive disorder (β -18.2, 95 % CI -27.1 to -9.3, p < 0.001) and psychotic disorders (β -39.0, 95 % CI -46.8 to -31.2, p < 0.001). There was no significant difference in the 30-day readmission rates between the early and late ECT groups trans-diagnostically.

CONCLUSION

Early ECT is strongly associated with a shorter LOS across a range of diagnostic indications including major depressive disorder, bipolar disorder and schizophrenia. ECT can be considered earlier in treatment-decision algorithms and may offer a reduction in LOS.

The association between outpatient continuation/maintenance electroconvulsive therapy, readmission risk and total direct cost in patients with depressive, bipolar and psychotic disorders: A naturalistic retrospective cohort study

BACKGROUND

The transdiagnostic effect of continuation/maintenance ECT (CM-ECT) across mood and psychotic disorders on hospital psychiatric readmission risk and total direct cost remains unclear.

METHODS

A naturalistic retrospective analysis of 540 patients who received inpatient acute ECT treatment from May 2017 to Mar 2021 in a tertiary psychiatric institution. Patients were assessed with validated clinical rating scales pre-ECT and after the first 6 treatments of a course of inpatient acute ECT. After discharge, patients who continued with CM-ECT were compared with those not receiving CM-ECT using survival analysis of hospital readmission. Total direct cost (hospitalisation and ECT treatment cost) was also analysed. All patients were subjected to a standard post-discharge monitoring program with case managers checking in on the patients regularly after discharge and ensuring they were given an outpatient appointment within a month of discharge.

RESULTS

Both cohorts had significant improvement in their rating scales scores after their first six 6 sessions of inpatient acute ECT. Patients who continued with CM-ECT after completing their inpatient acute ECT (mean number of acute ECT: N = 9.9, SD 5.3), had a significantly lower risk of readmission [adjusted hazard ratio of 0.68 (95 % CI: 0.49-0.94, p = 0.020)]. Patients who received CM-ECT also had a significantly lower average total direct cost compared to those who did not (SGD$35,259 vs SGD$61,337). For patients with mood disorders, the CM-ECT group had a significantly lower inpatient ECT cost, hospitalisation cost and total direct costs compared to those without CM-ECT.

LIMITATIONS

The naturalistic study cannot prove a causal relationship between CM-ECT and reduced readmission and lower healthcare costs.

CONCLUSION

CM-ECT is associated with lower readmission risks and lower total direct healthcare costs for the treatment of mood and psychotic disorders, especially for mood disorders.

The utility of the Sydney Melancholia Prototype Index (SMPI) for predicting response to electroconvulsive therapy in depression: A CARE Network study

An enhanced understanding of clinical predictors of positive ECT outcome could assist with the decision to prescribe ECT for select patients. Reliable predictors of ECT response such as psychotic symptoms and age have been identified, however, studies of melancholia and ECT response have been inconsistent. The Sydney Melancholia Prototype Index (SMPI) is a clinical measure designed to differentiate melancholic and non-melancholic depression. This study aimed to investigate whether melancholic depression (as measured by the clinician rated version of the SMPI) predicted a better response to ECT than non-melancholic depression. The study included data collated from four participating sites in the Clinical Alliance for ECT and Related treatments (CARE) network. The primary outcome was response (>50% improvement) on the Montgomery Asberg Depression Rating Scale (MADRS) and the secondary outcome was raw change in MADRS score. Of the 329 depressed patients included in the study, 81% had melancholic features and 76% met criteria for clinical response. SMPI defined melancholia was associated with older age, higher pre-treatment mood scores and presence of psychosis. Melancholia as defined by the SMPI, however, did not significantly predict either clinical response or overall mood improvement with ECT in multivariate analyses. Instead, older age, greater pre-treatment depression severity and the use of bifrontal compared to right unilateral ultrabrief ECT were significant predictors of mood improvement. Path analysis showed that higher pre-treatment mood score and older age were independently associated with mood improvement with ECT.

Effects of electroconvulsive therapy on cognition and quality of life in schizophrenia

INTRODUCTION

The effects of electroconvulsive therapy (ECT) on quality of life (QoL), and its relationship with symptom and cognitive change remains unclear. We aim to examine the association of QoL changes with psychiatric symptom and cognitive changes among patients with schizophrenia who underwent ECT.

METHODS

This is a retrospective cohort study of 132 patients who received ECT from July 2017 to December 2019. Sociodemographic and clinical characteristics were obtained from medical records. Changes in QoL, psychiatric symptoms and cognition function were examined after 6 sessions of ECT. Generalised linear regression was used to examine the associations of Brief Psychiatric Rating Scale (BPRS) scores and Montreal Cognitive Assessment (MoCA) scores with QoL as measured by EQ-5D scores.

RESULTS

The mean (standard error) improvements after ECT were statistically significant for the assessment scales of EQ-5D utility score: 0.77 (0.02) to 0.89 (0.02), P<0.001; EuroQol-5-Dimension (EQ-5D) visual analogue scale score: 66.82 (2.61) to 73.05 (1.93), P=0.012; and EQ-5D subdomain scores. Both improvement in BPRS (adjusted β coefficient -0.446, 95% confidence interval [CI] -0.840 to -0.052) and MoCA (adjusted β 12.068, 95% CI 0.865 to 12.271) scores were significantly associated with improvement in EQ-5D utility scores after adjustment for sociodemographic and clinical characteristics. Improvement of BPRS scores (psychiatric symptoms) was significantly associated with improvement of the patients' mental health that was assessed by EQ-5D subdomain scores of pain (adjusted β coefficient 0.012, 95% CI 0.004 to 0.021) and anxiety (adjusted β coefficient 0.013, 95% CI 0.002 to 0.024). Improvement of MoCA scores (cognitive function) was significantly associated with patients' physical health as assessed by EQ-5D subdomain score of usual activity (adjusted β coefficient -0.349, 95% CI -0.607 to -0.09).

CONCLUSION

ECT was associated with an overall improvement of QoL among patients with schizophrenia. The improvement of psychiatric symptoms was found to be significantly associated with better mental health while the improvement of cognitive function was associated with better physical health.

The Impact of Electroconvulsive Therapy on Negative Symptoms in Schizophrenia and Their Association with Clinical Outcomes

OBJECTIVE

The treatment efficacy of electroconvulsive therapy (ECT) for negative symptoms amongst patients with schizophrenia remains unclear. In this study, we aim to examine the effects of ECT on negative symptoms in schizophrenia and their association with other clinical outcomes, including cognition and function.

METHODS

This is a retrospective data analysis of patients with schizophrenia/schizoaffective disorder treated with ECT at the Institute of Mental Health (IMH), Singapore, between January 2016 and December 2019. Clinical outcomes were assessed by the Brief Psychiatric Rating Scale (BPRS), the Montreal Cognitive Assessment (MoCA), and Global Assessment of Function (GAF). Changes in scores were compared with repeated measures analysis of variance. Sequential structural modelling was utilized to examine the pathway relationships between changes in negative symptoms, global functioning, and cognition functioning after ECT.

RESULTS

A total of 340 patients were analysed. Hence, 196 (57.6%), 53 (15.5%), and 91 (26.7%) showed improvements, no change, and deterioration in negative symptoms, respectively. ECT-induced improvement of negative symptoms was significantly associated with improvement of global functioning (direct effect correlation coefficient (r): -0.496; se: 0.152; p = 0.001) and cognition function (indirect effect r: -0.077; se: 0.037; p = 0.035). Moreover, having capacity to consent, more severe baseline negative symptoms, lithium prescription, and an indirect effect of voluntary admission status via consent capacity predicted ECT associated negative symptoms improvement.

CONCLUSION

ECT is generally associated with improvements of negative symptoms in people with schizophrenia, which correlate with improvements of overall function. Possible novel clinical predictors of negative symptom improvement have been identified and will require further research and validation.

Association of cardiovascular metabolic risk factor measurements with psychiatric readmission among in-hospital patients with severe mental illness: a retrospective study

BACKGROUND

Patients with severe mental illness (SMI) and comorbid physical conditions were often associated with higher risks of mortality and hospital readmission. In this study, we aim to examine the association of cardiovascular metabolic risk factor measurements with risks of psychiatric readmissions among in-hospital patients with severe mental illness (SMI).

METHODS

We collected the longitudinal information of laboratory investigations, blood pressure and body mass index (BMI) among in-hospital patients who had been diagnosed with schizophrenia, major depression disorder or bipolar disorder and with comorbid diagnosis of hypertension, hyperlipidemia or diabetes from Jan 2014 to Jan 2019. The primary outcome was time to first psychiatric readmission. Cox proportional hazard model was utilized to calculate the hazard risks (HR) of cardiovascular metabolic risk factors with psychiatric readmission.

RESULTS

A total of 5,256 patients were included in the analysis. Compared to patients with normal blood parameters, patients with aberrant tests of high-density dyslipidemia (HDL) and diastolic blood pressure (DBP) during in-hospitalization period were associated with higher risks to first psychiatric readmission [ HR (Hazard Ratio), 1.37 95% Confidence interval (CI), 1.03-1.83 for HDL and HR, 1.32 (95% CI, 1.04-1.67])for DBP]. Compared to patients with optimal monitoring, patients with suboptimal monitoring of blood lipids and blood pressure during in-hospitalization period or recommended window period of cardiovascular disease (CVD) risk management were associated with higher risks to first psychiatric readmission.

CONCLUSIONS

Aberrant cardiovascular metabolic blood test and blood pressure and missing measurements among in-hospital patients with SMI were associated with increased risks of psychiatric readmissions. This calls for more active screening and monitoring of CVD risk factors for those in-hospital patients in need.

A Southeast Asia Consensus on the Definition and Management of Treatment-Resistant Depression

INTRODUCTION

Despite the abundance of literature on treatment-resistant depression (TRD), there is no universally accepted definition of TRD and available treatment pathways for the management of TRD vary across the Southeast Asia (SEA) region, highlighting the need for a uniform definition and treatment principles to optimize the management TRD in SEA.

METHODS

Following a thematic literature review and pre-meeting survey, a SEA expert panel comprising 13 psychiatrists with clinical experience in managing patients with TRD convened and utilized the RAND/UCLA Appropriateness Method to develop consensus-based recommendations on the appropriate definition of TRD and principles for its management.

RESULTS

The expert panel agreed that "pharmacotherapy-resistant depression" (PRD) is a more suitable term for TRD and defined it as "failure of two drug treatments of adequate doses, for 4-8 weeks duration with adequate adherence, during a major depressive episode". A stepwise treatment approach should be employed for the management of PRD - treatment strategies can include maximizing dose, switching to a different class, and augmenting or combining treatments. Non-pharmacological treatments, such as electroconvulsive therapy and repetitive transcranial magnetic stimulation, are also appropriate options for patients with PRD.

CONCLUSION

These consensus recommendations on the operational definition of PRD and treatment principles for its management can be adapted to local contexts in the SEA countries but should not replace clinical judgement. Individual circumstances and benefit-risk balance should be carefully considered while determining the most appropriate treatment option for patients with PRD.

The utility of the brief ECT cognitive screen (BECS) for early prediction of cognitive adverse effects from ECT: A CARE network study

Although highly effective, electroconvulsive therapy (ECT) often produces cognitive side effects which can be a barrier for patients. Monitoring cognitive side effects during the acute course is therefore recommended to identify patients at increased risk for adverse outcomes. The Brief ECT Cognitive Screen (BECS) is a brief instrument designed to measure emerging cognitive side effects from ECT. The aim of this study was to examine the clinical utility of the BECS for predicting adverse cognitive outcomes in real world clinic settings. The study included data collated from four participating sites in the Clinical Alliance for ECT and Related treatments (CARE) network. The BECS was administered at pre ECT and post 3 or 4 ECT. The primary outcome was a ≥4 point decrease on the Montreal Cognitive Assessment (MoCA) from pretreatment to post ECT. Logistic multiple regression analyses examined the BECS and other relevant clinical and demographic and treatment factors as predictors. The final analysis included 623 patients with diverse indications for ECT including 53.6% with major depression and 33.7% with schizophrenia or schizoaffective disorder. A higher total score on the BECS significantly predicted decline in Total Scores on the MoCA [B = 0.25 (0.08), p = 0.003], though not decline in MoCA Delayed Recall scores (p > 0.1). Other significant predictors included higher pretreatment MoCA Total Scores and female gender for verbal anterograde memory decline. This study confirmed that the BECS has clinical utility for identifying patients with both reduced and increased risk for adverse cognitive outcomes from ECT.

Neurostimulation therapies in major depressive disorder: A decision-analytic model

AIM

Neurostimulation techniques are effective treatments for major depressive disorders (MDD). However, the optimal sequence of electroconvulsive therapy (ECT) and transcranial magnetic stimulation (TMS) as part of antidepressant treatment algorithm is unclear. We examined the cost-effectiveness of ECT and TMS in MDD.

METHODS

A decision-analytic model was developed to determine total costs, quality-adjusted life-years (QALYs) and incremental cost-effectiveness ratios (ICERs) for 10 strategies. Each strategy comprised four treatment lines with ECT and TMS incorporated as second, third, or fourth line. A scenario analysis that explored the cost-effectiveness of maintenance approach by continuing ECT and TMS after acute treatment was performed.

RESULTS

In the base case, fourth-line TMS after three preceding trials of antidepressants was least costly at US$ 5523 yielding 1.424 QALYs. Compared with this strategy, fourth-line ECT and third-line TMS followed by ECT were cost-effective with ICERs of US$ 7601 per QALY gained and US$ 11 388 per QALY gained, respectively. In the scenario analysis where continuation treatments of ECT and TMS were provided, third-line TMS followed by ECT was cost-effective, with an ICER of US$ 17 198 per QALY gained. Effectiveness of ECT and cost of managing severe depression were influential parameters affecting the cost-effectiveness results.

CONCLUSIONS

In acute treatment of MDD, fourth-line ECT was the most cost-effective strategy. In maintenance treatment, the strategy that incorporated third-line TMS and fourth-line ECT was cost-effective. The overall findings confirmed the value of neurostimulation therapies which should be offered early in the process of managing depression.

Comparative outcomes in electroconvulsive therapy (ECT): A naturalistic comparison between outcomes in psychosis, mania, depression, psychotic depression and catatonia

Electroconvulsive Therapy's (ECT) use and place in treatment guidelines varies worldwide with a primary indication of depression in Western countries and acute psychosis in Asian countries. There is sparse evidence about the relative effectiveness of ECT among different indications that may account for this discrepancy. We aimed to compare the clinical global impression of disease severity, cognitive change, subjective quality of life (QoL) and global functioning after ECT given for treatment of the indications of acute psychosis, mania, depression, psychotic depression and catatonia. We conducted a retrospective naturalistic cohort study with post-hoc analyses of patients' ECT registry data from 2017 to 2019. 691 patients were assessed before and after 6 sessions of ECT treatment, using the Clinical Global Impression-Improvement and Severity (CGI-I and CGI-S) scale, Montreal Cognitive Assessment (MoCA), Quality of Life Enjoyment and Satisfaction Questionnaire Short Form (Q-LES-Q-SF), EQ-5D utility score and Global Assessment of Functioning (GAF) scale. The pre-ECT vs post-ECT clinical assessment change scores were compared within and across the five indications. For each indication, there were large improvements in clinical global impression of disease severity, QoL and global functioning. There were no significant changes in MoCA score for most indications except for an improvement in patients with schizophrenia. ECT is a rapidly acting and effective acute treatment across several severe mental illnesses with large improvements in symptoms, QoL and global functioning.

Comparison of mental-physical comorbidity, risk of death and mortality among patients with mental disorders - A retrospective cohort study

AIM

To compare the risk of death, the prevalence of comorbid chronic physical illness and mortality among an Asian population of patients with mental disorders.

METHODS

This was a retrospective data analysing of medical records of patients with schizophrenia, depression, anxiety, bipolar disorder, alcohol use disorder (AUD) or substance use disorder and the comorbid chronic physical illnesses. The hazard risk of death was calculated with Cox regression and compared between patients with and without comorbid chronic physical illness(es). Odds ratios of specific comorbid chronic physical illness were calculated with logistic regression and mean crude death rate was calculated for patients with different mental disorders.

RESULTS

A total of 56,447 patients with mental disorders were included in the analysis. Compared to patients without comorbid physical illness, patients with mental-physical comorbidity were associated with a higher risk of death [2.36 (2.22-2.52); hazard ratio (95% CI)] and less estimated survival days [2157 (2142-2172) vs 2508 (2504-2513)]. Compared to other mental disorders, those with AUD had the highest prevalence of two or more comorbid chronic physical illnesses and associated with the highest odds of comorbid hypertension, diabetes mellitus, stroke, nephritis, chronic kidney disease, and cancer. The highest one-year crude death rate was similarly observed in patients with AUD.

CONCLUSIONS

Mental-physical comorbidity was associated with a higher risk of death compared to patients with mental disorders only. The highest prevalence of mental-physical comorbidity and mortality were observed in patients with AUD. More attention and resources may be needed to tackle the burden of AUD.

A Pilot Study of Switching Electroconvulsive Therapy for Patients With Treatment Resistant Schizophrenia or Mood Disorder

OBJECTIVES

Switching of ECT electrode modality is commonly done in clinical practice but outcomes are unclear. We aimed to compare the clinical outcomes between ECT modality switchers and nonswitchers in a large tertiary psychiatric institution over 1 year.

METHODS

Brief Psychiatric Rating Scale (BPRS), Montgomery-Åsberg Depression Rating Scale (MADRS) and Montreal Cognitive Assessment (MoCA) were used to assess symptoms and cognition. General linear regression was utilized to compare the change of BPRS or MADRS and MoCA score among switchers vs nonswitchers.

RESULTS

21.5% of 209 patients switched ECT. Baseline BPRS scores were lower among nonswitchers. Response rate in schizophrenia, depression and mania were higher for nonswitchers (69.6%, 81.35% and 84.8% respectively / 9.2 (SD 3.3) sessions) compared to switchers (53.8%, 0% and 66.7% respectively / 10.6 (SD 4.5) sessions). Most common ECT switches were Bifrontal (BF) to Bitemporal (BT) (schizophrenia), UB RUL (ultrabrief right unilateral) to BT (depression), and UB RUL to BT / BF (mania). There was no significant difference in the change of BPRS and MoCA scores between nonswitchers and switchers. However, there was significantly more improvement of MADRS scores among nonswitchers [adjusted mean ± SE: (-26.4 ± 2.8)] compared with switchers (-10.6) ±6.6).

CONCLUSIONS

ECT switching was commonly done and may result in better or worse outcomes than not switching depending on diagnosis. Controlled trials are required to address this urgent clinical issue.

Accelerated transcranial magnetic stimulation (aTMS) to treat depression with treatment switching: study protocol of a pilot, randomized, delayed-start trial

Background

Repetitive transcranial magnetic stimulation (rTMS) is a technique for stimulating brain activity using a transient magnetic field to induce an electrical current in the brain producing depolarization of focal groups of brain cells. TMS is a protocol approved by the U.S. Food and Drug Administration in routine clinical practice as a treatment for depression. A major limitation of rTMS is the large amount of time taken for a standard protocol (38 min a day for 20–30 working days). The optimal type and duration of TMS are still uncertain, as is the optimal strategy for continuing or changing the type of rTMS if there is a poor initial response.

Objectives

The trial aims to assess whether a 1-week compressed course of left dorsolateral prefrontal (L DLPFC) 5 Hz accelerated rTMS (aTMS) treatment is as effective as an established 4-week course of non-accelerated rTMS and if additional 5 Hz L DLPFC aTMS treatments will be efficacious in non-responders as compared to 1 Hz right DLPFC aTMS treatment.

Methods

A randomized, single-blind, delayed-start trial was planned to commence in Jan 2020. A total of 60 patients will be enrolled from the Institute of Mental Health Singapore within a 2-year period and randomized into the early or delayed-start phase of the trial. The primary outcome of the trial is the improvement of Montgomery-Asberg Depression Rating scale at the end of the active treatment phase.

Discussion

If this study protocol proves to be effective, the findings of this trial will be updated to the College of Psychiatrists, Academy of Medicine Singapore, as well as published in a peer-reviewed journal to enhance local and international TMS treatment guidelines.

Trial registration

ClinicalTrials.gov ID: NCT03941106

Association of Anaesthesia-ECT time interval with ECT clinical outcomes: A retrospective cohort study

AIM

To examine the association of the anaesthesia to ECT stimulus TI (anaesthesia-ECT TI) with efficacy and cognitive outcomes after ECT treatment.

METHODS

Retrospective cohort study of 690 patients who received ECT from July 2017 till December 2019. Generalized linear regression was utilized to analyse the association of mean anaesthesia-ECT TI (from session 2 to session 6 ECT treatment) with Clinical Global Impression-Severity scale (CGI-S) scores and Montreal Cognitive Assessment (MoCA) score after 6 ECT treatments, and with EEG quality during the treatments (post ictal suppression scores).

RESULTS

The averaged TI was 106.6±20.2 (mean±SD) seconds. There was significant improvement of overall CGI-S score after ECT treatment (3.3±1.0) vs pre-ECT treatment (5.0±0.8, p<0.001) while there was no significant change of MoCA score over the course of 6 ECT (p>0.05). The anaesthesia-ECT TI had no association with post-ECT CGI-S while longer anaesthesia-ECT TI was associated with poorer post-ECT MoCA scores [adjusted β, -0.056; 95% CI (-0.099, -0.013), p=0.011] and better EEG quality score [adjusted β (0.001), 95% CI (0, 0.002), p=0.011].

CONCLUSION

Longer TI between anaesthesia and ECT stimulus administration resulted in higher seizure quality, suggesting more effective stimulation. This was associated with more cognitive impairment but not higher efficacy. The assessment of outcomes after only 6 ECT limited the ability to fully explore associations between the TI and clinical outcomes. This was a retrospective analysis of clinical data from a real-world treatment setting. A controlled study would provide greater potential to fully explore the association between TI and clinical outcomes.

A cross-sectional study of burnout and its associations with learning environment and learner factors among psychiatry residents within a National Psychiatry Residency Programme

BACKGROUND

Multiple studies have reported high burnout rates among residents, including psychiatry. There is a paucity of studies examining the relationship between burnout and learning context, stress levels, resilience, stigma in healthcare providers and coping methods concurrently within the same cohort.

OBJECTIVE

We examined the rate of burnout among our psychiatry residents in a cross-sectional study and hypothesised that burnout is associated with poorer perception of learning environment, greater perceived stress, stigma levels, lower resilience and specific coping strategies during training.

METHODS

Ninety-three out of 104 psychiatry residents (89.4%) within our National Psychiatry Residency Programme participated in the study from June 2016 to June 2018. Relevant scales were administered to assess the perception of learning environment, burnout, stress, resilience, stigma levels and coping methods, respectively. We performed comparisons of the above measures between groups (burnout vs no burnout) and within-group correlations for these same measures.

RESULTS

Overall, 54.8% of the sample met criteria for burnout. Residents with burnout had poorer perception of the learning environment, greater stress levels (both p<0.001), were less willing to disclose/seek help and employed greater active-avoidance coping strategies. Within the burnout group, greater perceived stress was correlated with poorer perception of learning environment (r_s=-0.549) and greater use of active-avoidance coping (r_s=0.450) versus additional use of problem-focussed coping within the non-burnout group.

CONCLUSIONS

Burnout was related to both environment and learner factors. These findings viewed within the transactional, sequential and imbalance models of burnout suggest the need to address stressors, beef up coping, provide continual support and develop resilience among our learners.

Clinical effectiveness and speed of response of electroconvulsive therapy in treatment-resistant schizophrenia

AIM

Although electroconvulsive therapy (ECT) has been shown to be efficacious for patients with treatment-resistant schizophrenia, there has been limited evidence on the rate of response, cognition, and quality-of-life outcomes. The primary aims of the present study were thus to examine the effectiveness and speed of response to ECT in a naturalistic retrospective cohort in patients with treatment-resistant schizophrenia.

METHODS

We performed a retrospective database analysis. The primary effectiveness outcome was defined as an improvement of ≥40% from pretreatment scores based on the Brief Psychiatric Rating Scale (BPRS) Psychotic Symptom subscale. Data were included for analysis for all patients with a primary DSM-5 diagnosis of schizophrenia that was treatment-resistant and who had had an acute course of ECT initiated for the treatment of schizophrenia between 1 July 2016 and 1 December 2016.

RESULTS

A total of 50 inpatients were included for analysis. The present study revealed that 50% of patients showed at least a 40% reduction in BPRS Psychotic Symptom subscale scores after completion of ECT and that 16.7% of patients responded after the first three sessions, 39.3% after six sessions, 46.4% after nine sessions, and 50% after 12 sessions. The greatest improvement in BPRS scores was between the third and sixth ECT sessions. BPRS scores, Clinical Global Impression, Montreal Cognitive Assessment, and Global Assessment of Functioning showed significant improvement. There was no significant difference in quality-of-life outcomes.

CONCLUSION

Utilizing modern techniques in treatment-resistant schizophrenia, this study demonstrates the real-world effectiveness and rate of response of patients receiving ECT.

Cost-Effectiveness Modeling of Repetitive Transcranial Magnetic Stimulation Compared to Electroconvulsive Therapy for Treatment-Resistant Depression in Singapore

BACKGROUND

Compared to electroconvulsive therapy (ECT), the cost-effectiveness of repetitive transcranial magnetic stimulation (rTMS) in the management of treatment-resistant depression (TRD) remains unclear.

OBJECTIVE/HYPOTHESIS

This study evaluated the cost-effectiveness of rTMS vs. ECT for TRD from Singapore societal perspective.

METHODS

We constructed a Markov model to project the cost and benefit of rTMS compared with ECT over one year in patients with TRD. The relative treatment effects between rTMS and ECT were obtained from meta-analyses of published trials. The effectiveness and quality of life data for patients using ECT, resource use for TRD and their associated costs were derived from the national tertiary mental institution in Singapore.

RESULTS

At one year, rTMS was cost-effective relative to ECT. The incremental cost-effectiveness ratio (ICER) associated with ECT was Singapore dollars (SGD) 311,024 per quality-adjusted life-year (QALY) gained. This exceeded the willingness-to-pay threshold of SGD 70,000 per QALY gained. A similar trend was observed for ICER per remission achieved (i.e., SGD 143,811 per remission achieved with ECT). In the subgroup analysis, rTMS was found to be less costly and more effective than ECT in nonpsychotic depressive patients. In the scenario analysis, ECT employed as an ambulatory service yielded a much smaller ICER (i.e., SGD 78,819 per QALY gained) compared to the standard inpatient setting.

CONCLUSIONS

rTMS was a cost-effective treatment compared to ECT in TRD over one year. The cost-effectiveness of rTMS was attenuated when ECT was used in the outpatient setting.

Comparison of Attitudes of Psychiatrists vs Primary Healthcare Physicians in Singapore Towards At Risk Mental States (ARMS)

Aims: It is possible to define at risk mental states (ARMS) that predict conversion to schizophrenia in up to 40% of help seeking individuals within a year of screening. Treatment of ARMS is controversial due to difficulties with diagnosis and uncertainties of treatment effective- ness. This survey was conducted to assess and compare attitudes of Singapore psychiatrists vs primary healthcare physicians towards ARMS. Materials and Methods: An anonymous survey containing a clinical vignette and questions related to the diagnosis and management of ARMS was sent out to all registered psychiatrists/ psychiatry trainees and all doctors in a public primary healthcare group in Singapore. Results: The response rate was 62.1% (87/140) and 72.3% (107/ 148) for psychiatrists and primary healthcare physicians respectively. The proportion of psychiatrists diagnosing ARMS vs psychosis was 44.8% vs 43.7% respectively. Among primary care physicians, the corresponding proportion was 54.2% vs 40.2%. The difference between the 2 groups did not reach statistical significance. Among psychiatrists who diagnosed ARMS, 74.4% (29/39) would treat the patient with active management. Of the total number of psychiatrists surveryed, 49.4% would advocate population screening of high risk groups compared to 30.8% of primary healthcare physicians. And 64.4% of psychiatrists felt that there was no consensus regarding the management of ARMS. Conclusions: There is currently clinical equipoise with regards to both diagnosis and management of ARMS in Singapore. Primary care physicians may be more likely to diagnose psychosis vs ARMS when compared to psychiatrists. Psychiatrists were more likely than primary healthcare physicians to advocate population screening of ARMS in high-risk groups. Most psychiatrists would manage ARMS actively. Key words: Prodrome, Schizophrenia

Comparison of attitudes of psychiatrists vs primary healthcare physicians in Singapore towards at risk mental states (ARMS)

AIMS

It is possible to define at risk mental states (ARMS) that predict conversion to schizophrenia in up to 40% of help seeking individuals within a year of screening. Treatment of ARMS is controversial due to difficulties with diagnosis and uncertainties of treatment effectiveness. This survey was conducted to assess and compare attitudes of Singapore psychiatrists vs primary healthcare physicians towards ARMS.

MATERIALS AND METHODS

An anonymous survey containing a clinical vignette and questions related to the diagnosis and management of ARMS was sent out to all registered psychiatrists/ psychiatry trainees and all doctors in a public primary healthcare group in Singapore.

RESULTS

The response rate was 62.1% (87/140) and 72.3% (107/ 148) for psychiatrists and primary healthcare physicians respectively. The proportion of psychiatrists diagnosing ARMS vs psychosis was 44.8% vs 43.7% respectively. Among primary care physicians, the corresponding proportion was 54.2% vs 40.2%. The difference between the 2 groups did not reach statistical significance. Among psychiatrists who diagnosed ARMS, 74.4% (29/39) would treat the patient with active management. Of the total number of psychiatrists surveyed, 49.4% would advocate population screening of high risk groups compared to 30.8% of primary healthcare physicians. And 64.4% of psychiatrists felt that there was no consensus regarding the management of ARMS.

CONCLUSIONS

There is currently clinical equipoise with regards to both diagnosis and management of ARMS in Singapore. Primary care physicians may be more likely to diagnose psychosis vs ARMS when compared to psychiatrists. Psychiatrists were more likely than primary healthcare physicians to advocate population screening of ARMS in high-risk groups. Most psychiatrists would manage ARMS actively.

Treatment emergent mania responding to valproate in a Chinese female adolescent population with eating disorders: a case series

Eating disorders are commonly associated with depressive symptoms. In an adolescent and binge eating population fluoxetine is commonly used to treat co-morbid depression associated with eating disorders. In some patients this may precipitate treatment emergent mania (TEM). Risk factors in the adolescent population include being older, female, having a longer duration of illness, more previous mood episodes, a higher prevalence of subclinical hypothyroidism, early-onset anxiety and recent exposure to a mood-elevating agent. Diagnosis and management of these co-morbid conditions is challenging due to the overlapping symptomatology and the adverse effects of both conditions complicating pharmacological management. This is illustrated with three cases in a Chinese female adolescent population that experienced TEM while on fluoxetine and responded to valproate.

The Media and Suicide

Suicide is a common and preventable event that is often reported by the media when there are sensationalistic elements or if the suicide involves a celebrity. Media reports of suicide can induce a copycat or “Werther effect”. There is increasing evidence that sensationalistic reporting of suicides has a direct effect on increasing suicide rates. Responsible reporting guidelines drawn up in consultation with media professionals have been shown to improve reporting of suicides. Local reporting on suicides tends to be sensationalistic but also has a strong educational slant. The media should educate both the public and the medical professional about their role in suicide prevention. Key words: Singapore, Suicide prevention, Werther effect

The media and suicide

Suicide is a common and preventable event that is often reported by the media when there are sensationalistic elements or if the suicide involves a celebrity. Media reports of suicide can induce a copycat or "Werther effect". There is increasing evidence that sensationalistic reporting of suicides has a direct effect on increasing suicide rates. Responsible reporting guidelines drawn up in consultation with media professionals have been shown to improve reporting of suicides. Local reporting on suicides tends to be sensationalistic but also has a strong educational slant. The media should educate both the public and the medical professional about their role in suicide prevention.

Survey of attitudes of mental health professionals in Singapore towards at-risk mental states

INTRODUCTION

Schizophrenia is a severe, chronic mental illness with a worldwide prevalence of about one percent. It is possible to define at-risk mental states (ARMS) that predict conversion to schizophrenia in up to 40 percent of help-seeking individuals within a year of screening. Treatment of ARMS is controversial due to difficulties with diagnosis and uncertainties of treatment effectiveness. There is currently no consensus among psychiatrists in Singapore or internationally, regarding the diagnosis of ARMS, or its treatment. This survey was conducted to assess current attitudes of Singaporean psychiatrists towards ARMS.

METHODS

An anonymous survey containing a clinical vignette and questions related to the diagnosis and management of ARMS was sent out to all registered psychiatrists and psychiatric trainees in Singapore.

RESULTS

There was a response rate of 62.1 percent (87/140). 60.9 percent of respondents were fully-trained psychiatrists. 44.8 percent versus 43.7 percent of respondents diagnosed ARMS versus psychosis, respectively. 74.4 percent (29/39) of respondents who diagnosed ARMS would treat the patient with active management rather than watchful waiting. 64.4 percent felt that there was no consensus regarding the management of ARMS. There was no significant relationship between responses and age, gender, training or place of practice.

CONCLUSION

There is currently clinical equipoise with regard to both diagnosis and management of ARMS in Singapore. Most psychiatrists would manage ARMS actively rather than with watchful waiting.

Late-onset mania with psychosis associated with hypothyroidism in an elderly Chinese lady

Late-onset bipolar disorder is rare and can be precipitated by organic brain disorders. While the association between hyperthyroidism and mania is well described, mania or hypomania precipitated by hypothyroidism is rare. The authors present late-onset bipolar disorder in a 72-year-old woman presenting with mania and psychosis, which appear to have been precipitated by autoimmune hypothyroidism. This case shows the importance of ascertaining the thyroid status in patients with mood and psychotic disorders, especially in elderly patients and in patients lacking prominent signs of thyroid disease.