Differential item functioning of the Geriatric Depression Scale in an Asian population

BACKGROUND

The Geriatric Depression Scale (GDS) is widely used for screening and assessment of major depressive disorder (MDD). Screening scales are often culture-specific and should be evaluated for item response bias (synonymously differential item functioning, DIF) before use in clinical practice and research in a different population. In this study, we examined DIF associated with age, gender, ethnicity and chronic illness in a heterogeneous Asian population in Singapore.

METHODS

The GDS-15 and Structured Clinical Interview for DSM-IV diagnosis of MDD were independently administered by interviewers on 4253 non-institutionalized community living elderly subjects aged 60 years and above who were users of social service agencies. Multiple Indicator Multiple Cause latent variable modelling was used to identify DIF.

RESULTS

We found evidence of significant DIF associated with age, gender, ethnicity and chronic illness for 8 items: dropped many activities and interests, afraid something bad is going to happen, prefer staying home to going out, more problems with memory than most, think it is (not) wonderful to be alive, feel pretty worthless, feel (not) full of energy, feel that situation is hopeless.

LIMITATIONS

The smaller number of minority Indian and Malay subjects and the self-report of chronic medical illnesses.

CONCLUSIONS

In a heterogeneous mix of respondents in Singapore, eight items of the GDS-15 showed DIF for age, gender, ethnicity and chronic illness. The awareness and identification of DIF in the GDS-15 provides a rational basis for its use in diverse population groups and guiding the derivation of abbreviated scales.

Multidetector-row CT coronary angiographic finding of myocardial bridging

Myocardial bridging is caused by muscles overlying the intramyocardial course of an epicardial coronary artery. It is a congenital anomaly characterized by systolic compression of the tunnelled segment, commonly affecting the mid-portion of the left anterior descending coronary artery. The authors report two cases of myocardial bridging using electrocardiogram-gated multidetector-row CT coronary angiography as a reliable and non-invasive imaging technique.

Spontaneous rupture of the left common iliac vein associated with May–Thurner syndrome: successful management with surgery and placement of an endovascular stent

We report a case of spontaneous rupture of the left common iliac vein diagnosed pre-operatively with CT and successfully treated with surgery and placement of a stent. A 60-year-old woman was referred to our emergency room because of a sudden left lower abdominal pain and swelling of the left lower extremity. CT revealed a huge retroperitoneal haematoma and extrinsic compression of the left common iliac vein with acute thrombosis of deep veins of the left lower extremity. Venous patch angioplasty was performed at the site of spontaneous rupture. After thrombectomy with use of a Forgaty catheter, a stent was placed at the occluded segment of the left common iliac vein under the C-arm fluroscopic guidance. Follow-up CT 10 days and 8 months after initial examination demonstrated a venous stent with preserved luminal patency and striking resolution of deep vein thrombosis of the left lower extremity.

Calcified endobronchial leiomyoma

We report a case of calcified endobronchial leiomyoma in the left main bronchus. Leiomyoma of the airways is a rare benign tumour, usually described as a solitary lesion and located in the membranous portion of the lower third of the trachea and rarely in the bronchi. Chest CT showed a well-defined, calcified, polypoid endobronchial mass with a broad stalk in the left main bronchus.

Myocardial enhancement pattern in patients with acute myocardial infarction on two-phase contrast-enhanced ECG-gated multidetector-row computed tomography

AIM

To evaluate the myocardial enhancement pattern of the left ventricle on two-phase contrast-enhanced electrocardiogram (ECG)-gated multidetector computed tomography (MDCT) images in patients with acute myocardial infarction (AMI).

METHODS

Two-phase contrast-enhanced ECG-gated MDCT examinations were performed in 16 patients with AMI. The presence, location and pattern of myocardial enhancement were evaluated. MDCT findings were compared with the catheter angiographic results.

RESULTS

Subendocardial (n = 9) or transmural (n = 6) area of early perfusion defects of the myocardium was detected in 15 of 16 patients (94%) on early-phase CT images. Variable delayed myocardial enhancement patterns on late-phase CT images were observed in 12 patients (75%): (1) subendocardial residual perfusion defect and subepicardial late enhancement (n = 6); (2) transmural late enhancement (n = 1); (3) isolated subendocardial late enhancement (n=1); and (4) isolated subendocardial residual perfusion defect (n = 2). On catheter angiography, 14 of 15 corresponding coronary arteries showed significant stenosis.

CONCLUSION

Variable abnormal myocardial enhancement pattern was seen on two-phase, contrast-enhanced ECG-gated MDCT in patients with AMI. Assessment of myocardial attenuation on CT angiography gives additional information of the location and extent of infarction.

Cloning of the Aspergillus niger pmrA gene, a homologue of yeast PMR1, and characterization of a pmrA null mutant

The pmrA gene, a yeast PMR1 homologue, was isolated from Aspergillus niger. Sequence analysis of the pmrA cDNA and the genomic DNA revealed that two introns exist in the coding region, and that an open reading frame in the cDNA encodes a polypeptide of 1056 amino acids containing all the conserved regions present in P-type Ca2+-ATPases. The predicted pmrA protein exhibited a high degree of sequence similarity to the Pmr1 proteins from yeasts and mammalians (50-59% identity). The expression of the pmrA cDNA partially restored the growth defect of Yarrowia lipolytica pmr1 null mutant on EGTA-containing medium. This indicates that the A. niger pmrA gene encodes a functional homologue of the yeast P-type Ca2+-ATPase involved in the secretory pathway. An A. niger pmrA null mutant exhibited growth retardation on EGTA-containing medium and the growth defect was overcome by adding Ca2+ or Mn2+ into the medium. This suggests an involvement of the pmrA protein in Ca2+ and Mn2+ homeostasis in A. niger.

Classification of metaphyseal change with magnetic resonance imaging in Legg-Calvé-Perthes disease

Seventy-eight patients (85 affected hips and 71 unaffected hips) with Legg-Calvé-Perthes disease were included in this study to evaluate the metaphyseal change in radiographs and magnetic resonance imaging (MRI) and to define the type of the metaphyseal cyst according to presence or absence of the epiphyseal involvement. The content of the metaphyseal cyst was evaluated by using T1,T2, proton, and gadolinium-enhanced T1-weighted MRI scans. Among 85 hips, there were no changes in 32 hips, marrow edema in 13 hips, false cyst with epiphyseal involvement in 28 hips, and true cyst without epiphyseal involvement in 12 hips. Granulation tissue was found in the false cysts and water-rich fibrotic tissue was found in the true cysts based on the MRI scans. The metaphyseal change in MRI scans was shown in 71% of groups 3 and 4 and in 35% of groups 1 and 2 according to the Catterall classification, and 52% of group A, 56% of group B, and 86% of group C according to the Herring classification. Of the 30 hips at the avascular stage, 33% showed metaphyseal cyst in MRI scans. Of the 53 hips at the fragmentation stage, 60% showed the metaphyseal cyst.

Proteolytic stability of recombinant human serum albumin secreted in the yeast Saccharomyces cerevisiae

In order to direct the persistent expression of recombinant human serum albumin (HSA) from the GAL10 promoter in the yeast Saccharomyces cerevisiae, we carried out periodic feeding of galactose during shake-flask cultures. Unexpectedly, the recombinant protein secreted was observed to undergo rapid degradation, which was apparently accelerated by carbon-source feeding. The extracellular degradation of HSA occurred even in the strain deficient in the major vacuolar proteases PrA and PrB, and in the strain lacking the acidic protease Yap3p (involved in the generation of HSA-truncated fragments). Interestingly, the degradation correlated closely with the acidification of extracellular pH and thus was significantly overcome either by buffering the culture medium above pH 5.0 or by adding amino acid-rich supplements to the culture medium, which could prevent the acidification of medium pH during cultivation. Addition of arginine or ammonium salt also substantially minimized the degradation of HSA, even without buffering. The extracellular degradation activity was not detected in the cell-free culture supernatant but was found to be associated with intact cells. The results of the present study strongly suggest that the HSA secreted in S. cerevisiae is highly susceptible to the pH-dependent proteolysis mediated by cell-bound protease(s) whose activity and expression are greatly affected by the composition of the medium.

The role of nitric oxide in experimental allergic conjunctivitis

PURPOSE

To evaluate the role of nitric oxide (NO) in the pathogenesis of allergic conjunctivitis and the effect of NO-synthase (NOS) inhibitors.

METHODS

The experimental allergic conjunctivitis was provoked in rabbits and healthy human volunteers by mast cell activators (codeine phosphate, 2.5 mg/mL; compound 48/80, 50 mg/mL; and lipopolysaccharide, 10 ng/eye). NOS inhibitors (aminoguanidine [AG], 1.5%, or N(G)-nitro-L-arginine methyl ester [L-NAME], 200 microg/eye) were applied as a pretreatment. In a rabbit model, concentrations of nitrite plus nitrate in the tear were measured colorimetrically using the Griess reaction after 0.5, 1.5, 3, 6, and 9 h. Immunohistochemical study for NOS was performed. The clinical scoring was performed in human volunteers. The vascular permeability was determined by measuring the albumin content in the tear of the challenged human eyes after 1 h.

RESULTS

After the instillation of mast cell activator, the NO level and clinical symptoms were markedly increased within 1.5 h. The NOS inhibitors suppressed the NO level. Vascular permeability was also increased in the activator-treated group. The NO-synthase immunoreactivity has been detected in the conjunctival subepithelial area and stroma for brain and endothelial isoform. L-NAME significantly reduces the immunoreactivity for NOS.

CONCLUSION

These results suggest that the expression of NOS mainly contributes to the allergic symptoms. Therefore, NO is an important factor in the induction and progress of the allergic reaction to ocular surface. The NOS inhibitors may have a beneficial effect for allergic conjunctivitis.

Stress and the undergraduates

OBJECTIVES

To assess the psychological health of undergraduates during their initial entry to the University, and to identify common sources of stress in their lives.

METHOD

All first year law and medical undergraduates were administered a series of questionnaires.

RESULTS

Of the 135 medical and 128 law first year undergraduates surveyed using the General Health Questionnaire (GHQ) to measure psycho-emotional distress, 77 medical students (57%) and 69 law students (47.3%) scored above the traditional cut-off of 4/5 points. Law students had significantly lower (p < 0.05) Life-Events Scores (mean 40.62, SD 29.30) than medical students (mean 55.62, SD 31.70). There was no statistical significant difference between medical (mean 89.32, SD 18.36) and law (mean 93.39, SD +/- 19.76) students (p = 0.88) in Type A Behavioural Pattern (TAPB). Hostelites (n = 67) reported significantly higher (p < 0.05) LES (mean 56.22, SD +/- 28.17) than non-hostelites (n = 196, mean 45.40, SD +/- 32.04). The commonest life events experienced in the past twelve months by the students were: (1) Difficulty keeping up with reading (84.4%), (2) Increased amount of academic work (82.5%), (3) Difficulty in tutorials (66.5%), (4) Little time for personal activities (61.6%) and (5) Difficulties in lectures as well as (6) peer competition (each 46.8%). Law students cited more relationship problems, while medical students were more troubled by academic work. When faced with a problem, more than seven out of ten students would turn to friends and classmates for help. The other common avenues of support were the family, and religion. A substantial proportion of law (37.5%) and medical (31.1%) students preferred to keep their problems to themselves; significantly (p < 0.00001) more of them (72.2%) were high GHQ scorers than other students (high GHQ scorers 47.4%). Interestingly 27.8% of these students turn to religion for emotional support.

CONCLUSION

Health education programmes, mentorship and a reduction in information overload in the curriculum can be important strategies to enable undergraduates cope better with the demands of tertiary education.

Under-diagnosed psychiatric syndrome. II: Pathologic skin picking

Pathologic skin picking (PSP), previously known as neurotic excoriation, is characterised by habitual and repetitive self-excoriation of skin. Affecting mainly women with onset in the 20s and 30s, it can lead to significant distress, dysfunction and disfigurement. The extent and degree of self-excoriation is reported to be proportional to the distortion of the underlying personality. Because of the close similarity to obsessive compulsive disorder in phenomenology and pharmacological response to the serotonin re-uptake inhibitor (e.g. clomipramine, fluoxetine and sertraline), PSP has been considered as an obsessive compulsive spectrum disorder.

Under-diagnosed psychiatric syndrome. I: Trichotillomania

Trichotillomania is a chronic psychiatric condition characterised by uncontrollable, self-inflicted, hair pulling, resulting in noticeable hair loss. The hair pulling may occur anywhere on the body; with the scalp and eyelashes most commonly affected. Onset is often during childhood or early adolescence. Once presumed to be an obscure condition, the estimated lifetime prevalence is 1.5% for male and 3.4% for female college students. In very young patients, a more equal sex ratio is observed. On the whole, women show 5 to 10 times higher prevalence rates than men. Majority of the sufferers disguise their hair loss very well. Because of the secrecy and shame about their behaviour, many remain silent sufferers, and treatment is often delayed. Serotonin reuptake inhibitors currently are the pharmacological treatment of choice, although other drugs like naltrexone and antipsychotics like pimozide and haloperidol have varying responses. Behaviour therapy includes habit reversal coupled with exposure therapy and response prevention.

Telephone counselling in psychiatry

AIM OF STUDY

To study the description of callers using a telephone helpline to improve support to patients in between appointments.

METHOD

This includes creating a helpline in the department and getting psychiatrists, medical officers, psychologists and social workers trained to man this line during office hours. Information from callers were recorded and analysed using SPSS for MS Windows version 6.0.

RESULTS

The callers were mainly females calling about personal problems, namely psychiatric symptoms and sleep difficulties. Half were given specialist appointments and one-fifth were discharged after telephone counselling.

CONCLUSIONS

Telephone counselling is useful in clarifying medical instructions and supporting psychiatric patients in between outpatient appointments.

Cloning and characterization of the Hansenula polymorpha homologue of the Saccharomyces cerevisiae PMR1 gene

A gene homologous to Saccharomyces cerevisiae PMR1 has been cloned in the methylotrophic yeast Hansenula polymorpha. The partial DNA fragment of the H. polymorpha homologue was initially obtained by a polymerase chain reaction and used to isolate the entire gene which encodes a protein of 918 amino acids. The putative gene product contains all ten of the conserved regions observed in P-type ATPase. The cloned gene product exhibits 60.3% amino acid identity to the S. cerevisiae PMR1 gene product and complemented the growth defect of a S. cerevisiae pmr1 null mutant in the EGTA-containing medium. The results demonstrate that the H. polymorpha gene encodes the functional homologue of the S. cerevesiae PMR1 gene product, a P-type Ca(2+)-ATPase.

Studying the mental health of a nation: a preliminary report on a population survey in Singapore

AIM

A Singapore Mental Health Survey was designed to study the prevalence and pattern of psychiatric morbidity of the general population. Community surveys reveal the true pattern of mental disorders, free from any self-selection into, or referral within the health care system.

METHODS

A cross-sectional survey design was used to estimate the point prevalence of minor psychiatric morbidity (MPM) in an area-probability sample drawn from different regions. Disproportionate quota sampling yielded approximately equal numbers of Chinese, Malays and Indians for inter-ethnic comparison. The General Health Questionnaire, 28-item version (GHQ-28) measured psychoemotional symptoms in 3,020 subjects aged between 13-65 years. The GHQ-28 was validated against ICD-10 psychiatric diagnoses derived from structured psychiatric interview with the Composite International Diagnostic Interview (CIDI).

RESULTS

The optimal cut-off point for the GHQ-28 was determined to be 4/5 for Chinese, and 5/6 for Malays and Indians. Using the validated ethnic-specific cut-offs, MPM rate for Chinese was 17.4%, Malays 15.1% and Indians 17.8%. The population MPM prevalence rate was estimated to be 16.6% after standardisation with population census data. Specific types of ICD-10 psychiatric disorders which give rise to MPM were mainly anxiety and depressive disorders. Twelve percent of individuals with MPM had at least one ICD-10 disorder in the previous year.

CONCLUSION

Two-staged methodology is an efficient, cost-effective approach to study population prevalence of mental illness. Screening instruments utilised should be validated specifically for the culture and setting. Information from population surveys of psychiatric morbidity are important for the planning of mental health services for the country.

Depression of young and elderly patients

OBJECTIVE

To compare the presentation and outcome of depression between young and elderly patients.

DESIGN

The clinical presentation, treatment and outcome of 47 young patients (21 to 64 years) were compared with 58 elderly (65 years and older) patients admitted to a general hospital psychiatric ward for the treatment of depressive disorders (based on ICD-10).

SUBJECTS

There was no significant difference between the sexes in each age group. The majority of the elderly were either widowed (36%) or married (53%) while 45% of the young were single and 51% married. Seventy per cent of the elderly had retired while 64% of the young were in full-time employment. Most patients lived with their families (87% young and 96% elderly). All but one elderly suffered at least one physical disorder with two-thirds having two or more physical disorders; this contrasts greatly to young patients who were physically healthier (p < 0.001).

RESULTS

In clinical presentation and symptomatology, the young patients had significantly more suicide ideation (p < 0.003) and psychomotor retardation (p < 0.001) but there was no difference in suicidal attempt, delusion, hallucination or agitation. More young patients (36%) had a past psychiatric illness (often depressive disorders) than elderly patients (8%) (p < 0.001), more elderly patients (88%) were treated with antidepressants than the young patients (62%) (p < 0.002). At one year follow-up, more elderly patients (46%) recovered compared with the young patients (23%) (p < 0.05).

CONCLUSION

There were some differences in the symptomatology of depression between young and elderly patients, but the prognosis was better for elderly patients.

Obsessive compulsive disorder following head injury

Although researchers continue to report neurological abnormalities and neuropsychiatric associations in patients with obsessive compulsive disorders, there is a paucity of published reports on this condition following head injury. Such a case is described here, including the efficacy of behavioural intervention in ameliorating the symptoms.

The NUH Memory Clinic. National University Hospital, Singapore

OBJECTIVE

To assess the cognitive performance of elderly patients referred to the memory clinic.

DESIGN

The patients were interviewed using the computerised mental state programme, GMS-AGECAT, and assessed on the Cognitive Assessment Scale (CAS) which includes the Elderly Cognitive Assessment Questionnaire (ECAQ) and the Cambridge Memory Test (CMT), modified for Chinese elderly.

SUBJECTS

There were 72 Chinese elderly subjects aged 65 years and above, referred to the NUH Memory Clinic in the first year.

RESULTS

Only 45 (62.5%) of the 72 subjects were diagnosed to have dementia using DSM III R criteria. There were 25 cases of Alzheimer's Disease and 20 multi-infarct dementia. In the non-demented group, 15 (20.8%) had depression or anxiety disorders and 12 (16.7%), had no mental disorders but had physical illness which could affect memory. There was a highly significant difference in the ECAQ, CMT and CAS scores of demented and non-demented elderly. There was also a significant difference in the cognitive performance of elderly with mild dementia and those with no mental disorder.

CONCLUSION

The memory clinic is a useful facility for the diagnosis and management of dementia. The Cognitive Assessment Scale provides a valid and reliable battery of tests for dementia.

The preparation of norfloxacin-loaded liposomes and their in-vitro evaluation in pig's eye

The effectiveness of norfloxacin as an antibacterial agent in ophthalmology is limited by poor drug delivery and limited ocular bioavailability. Liposomes containing norfloxacin have been prepared from different phospholipids using a novel technique with an encapsulation efficiency sixteen times greater than that of a conventional film method. The in-vitro release of the norfloxacin and the transcorneal characteristics of the liposomes have been evaluated. Differential scanning calorimetry was used to determine the interaction occurring between liposomes and cornea. The release of liposome-entrapped norfloxacin was affected by the pH of the environment. In the in-vitro corneal perfusion studies, norfloxacin-loaded liposome was transferred through the cornea at a slower rate than was the free drug. Norfloxacin-loaded liposomes were accumulated primarily in the cornea. The drug corneal retention of the lipids increased in the order dimyristoyl-L-alpha-phosphatidylcholine < dipalmitoyl-L-alpha -phosphatidylcholine < distearoyl-L-alpha-phosphatidylcholine. In the corneal drug-elimination study, liposomal norfloxacin increased the loading of the drug in cornea; the maximum value of the loading occurred 5 h after dosing. The drainage of liposomes from the cornea was somewhat slower than the solution form. Accumulation of norfloxacin in the cornea was greater for the liposome-entrapped drug. The results suggest that norfloxacin-loaded liposomes are absorbed by the cornea via endocytosis.

Obsessive compulsive disorder--a neuropsychiatric illness

Until recently, obsessive compulsive disorder (OCD) was thought to be a rare condition. Once viewed predominantly as a manifestation of psychodynamic conflict, OCD is now considered a model neuropsychiatric disorder. While clear differences exist between OCD patients and normal controls, there are more similarities between OCD and Tourette's Syndrome than most other neurotic disorders in neurological signs, electrophysiology and neuropsychology. These include a lack of laterality, bilateral or dominant (left) frontal lobe dysfunction, shortened REM latency in sleep electroencephalogram, shortened latency of N200 and P300 components in visual evoked potentials, abnormal glucose metabolism in the caudate nucleus, and greater ventricle to brain ratios in OCD patients. Neuropharmacological and neuroendocrinological researches have increasingly shown that serotonin plays an important role in the complex aetiology in OCD. Finally, psychopharmacological trials have consistently demonstrated the effectiveness of the selective serotonin reuptake inhibitors in the treatment of OCD.

Behaviour therapy in psychiatric outpatients

In a prospective study of fifty consecutive outpatients (30 men and 20 women) attending the Behaviour Therapy Clinic at a general hospital, the commonest conditions were obsessive compulsive disorders (n = 16), phobic disorders (n = 11) and generalised anxiety disorders (n = 9). Three-quarters of the referrals were from psychiatrists and family physicians. The patients received between 2 to 10 sessions of behaviour treatment; most had 4 to 6 sessions with a mean of 4.7, SD 1.82. The commonest behavioural techniques administered were exposure therapy with response prevention and relaxation therapy. Initially, treatment was therapist-aided, but subsequently self-help was encouraged with regular reviews of the patient's homework. After one month, 42 patients (84%) were assessed to have improved somewhat, with 20 (40%) showing moderate improvement. After three months, 41 (82%) continued to improve, with 33 (66%) showing moderate to great improvement. Nine patients were considered to have failed in therapy-six defaulted and three were non-responders. The reasons for defaulting treatment were unwillingness to bear with the discomfort involved in exposure therapy, lack of motivation or returning to own hometown in Malaysia. Sixteen patients (n = 32%) were treated solely with behavioural techniques while the rest had a combination of behaviour therapy and drugs, especially anxiolytics and antidepressants. However, at the end of treatment, the dosages of most medications were reduced or else discontinued completely.

Chinese psychogeriatric patients in a general hospital

A retrospective study of 100 consecutive elderly Chinese patients (29 males, 71 females) aged 65 years and above admitted to a general hospital psychiatric unit, showed a predominance of depressive disorders (n = 36) and dementia (n = 26). Depressed patients (mean age = 72.0; SD = 5.8) were significantly younger than demented patients (mean age = 75.6; SD = 6.7) (p < 0.03). Patients with depressive disorders presented with low mood, sleep disturbance, attempted suicide as well as vague somatic symptoms in the absence of organic causes. Those suffering from dementia presented with cognitive dysfunctions (especially memory impairment), confusional state, deteriorated self care and sleep disturbance. More than three quarters of the depressed patients were prescribed antidepressants, and five had required electroconvulsive therapy. Almost nine out of every ten patients had co-existing physical disorders, with one in two being afflicted by two or more physical disorders; the average number of physical disorders was 1.55 per patient. The commonest were cardiovascular disorders such as hypertension (37%) and ischaemic heart diseases (12%). Endocrine disorders like diabetes mellitus, constituted 21%. The mean duration of admission of all patients was 16.3 days (SD = 12.6 days.)

Psychiatric referrals from an accident and emergency department in Singapore

A total of 500 consecutive psychiatric referrals from the Accident and Emergency (A&D) Department of the National University Hospital of Singapore were studied with regard to their demographic characteristics, diagnoses, presenting problems and management. There were 314 females (62.8%) and 186 males (37.2%), and the mean age of subjects was 35.5 years. The three main diagnoses were anxiety disorders (25.6%), depression (19.4%) and schizophrenia (17.6%). About 41% were admitted, of whom two-fifths were initially admitted to the medical ward because of drug overdose or alcohol intoxication. A further 34% were treated as out-patients, and 21% were discharged.

Calcium, magnesium, and psychotic symptoms in a girl with idiopathic hypoparathyroidism

A case of psychosis due to idiopathic hypoparathyroidism (IHP) has been followed for over 9 years. The optimal treatment for IHP psychosis was found to be a combination of ergocalciferol and fairly large doses of antipsychotic medication. In general, psychotic episodes occurred when there was hypocalcemia, hypercalcemia, or hypomagnesemia. Antipsychotic medication was not efficacious unless serum calcium and magnesium levels were both normal. It is suggested that psychiatric disturbances in hypoparathyroidism and treatment resistance to antipsychotic medication in other functional psychoses may also be related to hypomagnesemia.

Pharmacotherapy of obsessive-compulsive disorder

Previously thought of as merely an interesting syndrome, obsessive-compulsive disorder is now estimated to afflict 1%-2% of the world's population. Over the past decade extensive research into the epidemiology, aetiology, pathophysiology and pharmacological treatment of this condition has greatly improved its prognosis. This is largely due to the development of the serotonergic group of antidepressants, the selective serotonin reuptake inhibitors (SSRIs), which have consistently demonstrated antiobsessional properties. Monoamine oxidase inhibitors (MAOIs) and lithium have also contributed to the amelioration of symptoms in some patients. Other pharmacological treatment, often prescribed in combination with the SSRIs, include the antipsychotic drugs, benzodiazepines, and anticonvulsants.

Prevalence of dementia among elderly Chinese and Malay residents of Singapore

This is a comparative study of the prevalence of dementia among elderly Chinese and Malay persons living in the community in Singapore. The subjects, aged 65 years and over, were all living in public housing estates. Two hundred elderly Chinese and 149 elderly Malay persons were interviewed. They were first screened for any cognitive deficit with the Elderly Cognitive Assessment Questionnaire (ECAQ). All those who scored 5 or fewer points on the ECAQ were then assessed with the Geriatric Mental State schedule. The results showed an overall dementia prevalence of 4.0% among the Malay elderly and 2.5% among the Chinese elderly. The rate of dementia of the Alzheimer's type was 1.8% for Chinese women and 1.5% for Malay women; for multi-infarct dementia the rate for Malay women was 4.4% and for Chinese women 0.9%. For Chinese and Malay men, the prevalence of Alzheimer's disease and multi-infarct dementia was quite similar (1.1% and 1.2%).

Ethnicity and elderly suicide in Singapore

In the cosmopolitan city of Singapore the annual suicide rates in the general population from 1985 to 1991 remained fairly constant, with a mean of 15.3 per 100,000. It was highest among Indians (19.5 per 100,000), followed by Chinese (16.2 per 100,000) and Malays (2.3 per 100,000). The suicide rates were higher in elderly people (aged 65 years and over) than in younger age groups (10 to 64 years) and in males than in females. For the elderly, the mean annual suicide rate for this period was 52.0 per 100,000. However, it was highest among Chinese, with 59.3 per 100,000, followed by Indians at 33.9 per 100,000, and, again, lowest among Malays, with 3.0 per 100,000. Possible sociocultural factors are proposed to account for differences in suicide rates among these ethnic groups.

The ageing of elderly people

OBJECTIVE

To assess the performance of activities of daily living, social resources and incidence of dementia in a cohort of elderly Chinese.

DESIGN

This was a longitudinal study which measured changes in a five-year interval.

SETTING

The study was conducted in the Henderson district of Singapore at the subjects' homes and at a day centre.

SUBJECTS

A random sample of elderly Chinese was selected in 1985 from the electoral roll of the Henderson constituency and reassessed after 5 years.

OUTCOME MEASURES

A semi-structured questionnaire adapted from the Older American Resources and Services, and the computerised mental state programme, GMS-AGECAT.

RESULTS

There was no apparent change in social resources after 5 years and the majority of the elderly (80.3%) were still living with their families. On activities of daily living, there was a significant decline especially after the age of 75. The incidence of dementia was 2.01%--the rate of Alzheimer's disease was 0.67% and multi-infarct dementia 1.34%.

CONCLUSION

The change in performance of activities of daily living after the age of 75 and the low incidence of dementia were similar to studies in Europe and the United States.

Neurotic depression in the elderly

Depression is a common condition in the geriatric population. A retrospective study of 30 elderly patients suffering from neurotic depression, who were admitted consecutively to a general hospital psychiatric ward, showed a predominance of females (n = 21) over males (n = 9) and young-old (65 to 74 years, n = 22) more than old-old (75 years or over, n = 8). Their ages ranged from 65 to 85 years with a mean of 71.6 years, SD 5.5 years. Co-existing physical disorders were present in every patient, the average being 1.8 per patient, and half (n = 15) had two or more physical disorders. Cardiovascular diseases (e.g. ischaemic heart disease and hypertension) and diabetes mellitus were present in about seven-eighths of the patients. The two commonest symptoms were low mood (n = 18, 60%) and vague somatic complaints inexplicable by any physical pathology (n = 19, 63%). Sleep disturbance bothered 12 patients (40%), while nine (30%) had attempted suicide. Twenty patients (67%) were prescribed antidepressants and 13 (43%) received benzodiazepines in low dosages, mainly as hypnotics. Electroconvulsive therapy was necessary for two patients with high suicidal risk. The mean duration of admission was 15.3 days, SD 12.9 days.

Blood-injury phobia

Blood-injury phobia is a unique and peculiar phobia. It is different from other phobias in that it evokes a diphasic cardiovascular response; it has a propensity to induce fainting and nausea more than fear and anxiety; and often there is a family history of a similar phobia. Although it may cause no great difficulty or social handicap in everyday life compared to social phobia, agoraphobia or other simple phobias, it can have grave implications and may even become life-threatening when it prevents essential medical procedures. Unfortunately, not many of its sufferers come for treatment until circumstances require urgent attention. Yet, it can be effectively treated behaviourally by modeling and exposure therapy. Two cases of this fascinating condition are described.

Spirit possession and healing among Chinese psychiatric patients

This is a study of the illness behaviour of 100 Chinese psychiatric patients referred consecutively to the psychiatric unit of a general hospital in Singapore. More women than men felt that their illness was due to spirit possession; but belief in possession was not related to educational status. Thirty-six patients or their relatives had consulted a traditional healer before going to the hospital. Duration of illness, sex and educational status were not associated with the tendency to seek help from the traditional healer; there was also no significant difference between psychotic or neurotic patients. The majority of depressed patients (72%) presented with somatic complaints of chest discomfort, headache and abdominal discomfort. Somatization was not related to the educational level or sex of the patients.

A cross-cultural study of suicide among the elderly in Singapore

In the general population of Singapore the mean annual suicide rate over 1985-88 was highest in the Indians (20.4 per 100,000), followed by Chinese (15.8 per 100,000), and the Malays (2.4 per 100,000). However, in the elderly population (65 years and over) the rate was highest in the Chinese (61.2 per 100,000) with Indians second (30.5 per 100,000), and Malays still the lowest (3.2 per 100,000). Among elderly Chinese, women had a higher suicide rate than men.

A questionnaire to screen for cognitive impairment among elderly people in developing countries

Most questionnaires designed to assess cognitive impairment among elderly people are constructed in the West, where literacy is high. However, such questionnaires may not be applicable in developing countries because of cultural differences or low literacy. The Elderly Cognitive Assessment Questionnaire (ECAQ) is derived from items in the Mini-Mental State Examination and Geriatric Mental State Schedule. It is a satisfactory scale for quantitative assessment of cognitive impairment among elderly people living in developing countries. This 10-item questionnaire shows a sensitivity of 85.3%, specificity 91.5%, positive predictive value 82.8% and overall miscalculation rate 10.5%. In a sample of 105 elderly subjects from 2 day centres and a psychiatric outpatient clinic in Singapore, the ECAQ was compared with Kahn's Mental Status Questionnaire. The sensitivity of the scales was found to be similar but the ECAQ had a higher specificity and positive predictive value, and lower overall miscalculation rate.

Psychiatric syndromes in pernicious anaemia--a case report

Surveys of psychiatric population had previously shown a high incidence of patients with low serum vitamin B12. A variety of psychiatric syndromes have been described, ranging from mild disturbance in mood state like depression to maniacal excitement; psychotic conditions like paranoid states and schizophrenia; and cognitive dysfunctions such as memory defect, delirium and dementia. A case of a 67-year-old Chinese lady suffering from pernicious anaemia, but presenting with prominent paranoid delusions is reported. Treatment with cyanocobalamine and anti-psychotic medication led to prompt resolution of her psychotic experience. Subsequently she developed a transient depressive syndrome which also responded well to a short course of antidepressant.

Family violence and Asian drinkers

This is a study of 70 consecutive referrals to the Department of Psychological Medicine, National University Hospital, for treatment of drinking problems. There were 31 Chinese and 39 Indian drinkers, with 63 males and 7 females. Family violence with physical abuse occurred in 21 cases (30%). One of three wives of drinkers had been physically abused, but no children were victims. Drinkers with family violence were generally younger and more severely dependent on alcohol than the non-violent drinkers. There was no relationship between family violence and the ethnicity or marital status of the drinkers.

New admissions to a psychiatric ward in a general hospital

A study of 343 new patients in the first psychiatric department in a general hospital in Singapore revealed a large proportion (40%, n = 137) of neurotic patients, especially neurotic depressives (n = 76). The next largest group is the non-organic psychoses 35% (n = 120), most of which were schizophrenic psychoses (n = 73). The other major diagnostic groups were adjustment or acute stress reactions, alcohol or drug dependence and personality disorders. The neurotic patients were generally older than the psychotic patients at the time of admission (p less than 0.02). More of them were married (62.7%) compared with the psychotics of whom 51.5% remained unmarried (p less than 0.02). Comparison between neurotic depressives and manic-depressive psychotics should have no difference in sex ratio and marital status. However, the duration of admission for the latter was longer.

Drinking problems

This is a study of 54 patients referred for treatment of drinking problems. They were from two age groups--20 to 39 years and 40 to 59 years. More of the younger patients were referred by their families and older patients by their doctors or other health professionals. The younger patients had a mean duration of 8.2 years of drinking and were more severely dependent on alcohol (higher mean SADQ score). The older patients' mean duration of drinking was 14.1 years and had a lower mean SADQ score. More younger patients had work and family problems, but did not differ significantly from the older patients in alcohol-related physical or mental disabilities.

A comparative study of new cases seen at the Child Psychiatric Clinic in 1975 and 1985

A comparative analysis of new cases seen at the Child Psychiatric Clinic in 1975 and 1985 is made in this study. There was a three and a half fold increase in the number of patients seen from 245 to 893. There was no significant change in sex ratio or ethnic groups. However, in 1985 more younger children (aged less than 6 years) were seen at the Clinic. The waiting time remained short with half the number of cases seen within one week of appointment. The commonest conditions besides Normal Variation were Adjustment Reaction, Mental Retardation, Conduct Disorder and Neurosis. Three-fifths of cases were discharged from follow-up within three months of therapy. Most cases (90%) did not require pharmacological therapy whilst family therapy was prescribed for a fifth of cases seen in 1985.

Work stress and mental distress

In a study of 14 managers and 25 workers who were referred for psychiatric treatment, the majority suffered from depressive illness (60%) or anxiety neurosis (28%). The main work problem of the managers was conflict with the employers (or directors), but for the workers the main problem was difficulty with fellow workers. The patients' scores on the Work Environment Scale (WES) indicated that the managers felt they had little supervisor support and work pressure was great. However the workers complained of poor peer cohesion but could get on well with the employers, and their work was not too taxing.

Cerebral tumours presenting with psychiatric symptoms

Four cases of cerebral tumours presenting with psychiatric symptoms were referred to the psychiatrist for management. They displayed some degree of cognitive impairment, notably impaired memory for recent events, and nominal aphasia. Clinical neurological examinations were generally unremarkable with no evidence of focal signs or features of raised intracranial pressure. CT scan demonstrated parietal lobe lesions in all four patients with two showing involvement of the frontal lobe, one the temporal lobe and another the occipital lobe as well. Only one patient was operated, two died and the last continued treatment elsewhere. Factors contributing to the psychiatric symptomatology of cerebral tumours are raised intracranial pressure, location of the tumour, nature of the tumour and the individual constitution and response of the patient.

Cotard's syndrome--two case reports

Two cases of Cotard's Syndrome are described--one in a 33-year-old housewife suffering from paranoid schizophrenia and another in a 43-year-old housewife with acute psychotic depression. This rare syndrome is characterized by an extreme form of nihilistic delusion in which the patient, more frequently a woman, denies her own existence and that of the external world. Its onset is often sudden with no previous psychiatric history. Treatment of the condition depends on the underlying psychiatric illness. Both cases responded well to treatment.

A retrospective study of the profile of ESN children seen at the Child Psychiatric Clinic

A retrospective study of 50 cases of educationally subnormal children seen at the Child Psychiatric Clinic was done. Almost half of the referrals were initiated by schools, the majority being picked up at Primary 1. Forty-six percent of fathers and sixty percent of mothers had no more than primary education. Eighty-two percent of fathers had unskilled or semi-skilled jobs. Besides being below average in academic performance in school, these children also showed some behavioural problems like restlessness, disobedience, bullying, quarrelling or fighting with other children. They tended to be solitary, unresponsive, inert or apathetic, and were not much liked by others. Although all the children were referred and registered for special education, only half the number of parents accepted the offer for their children.