Mei-Chih Tseng

Development and verification of validity and reliability of a short screening instrument to identify psychiatric morbidity.

BACKGROUND AND PURPOSE The accurate identification of minor mental disorders associated with depression and anxiety in non-psychiatric medical settings is an important component of mental health care. The present study aimed to develop a reliable and valid short screening tool to improve the identification of psychiatric morbidity. METHODS Data from the 50-item Brief Symptom Rating Scale (BSRS-50) obtained from 721 medical inpatients were used to develop a short screening tool (BSRS-5) to identify psychiatric morbidity. The BSRS-5 comprises 5 symptom items, selected from the BSRS-50, each of which has the highest correlation with the corresponding subscale score of Anxiety, Depression, Hostility, Interpersonal Sensitivity and Additional Symptoms in the BSRS-50. Various types of reliability and validity of the BSRS-5 were assessed in different populations, including 253 human immunodeficiency virus-1 infected outpatients, 257 psychiatric outpatients, 56 psychiatric inpatients, 100 rehabilitation outpatients with chronic low back pain, 2915 university freshmen, and 1090 community members. RESULTS Internal consistency (Cronbach alpha) coefficients of the BSRS-5 ranged from 0.77 to 0.90. The test-retest reliability coefficient was 0.82. Concurrent validity coefficients between the sum score of BSRS-5 and the General Severity Index of BSRS-50 ranged from 0.87 to 0.95. Choosing 6+ as the cut-off score for psychiatric cases, the rate of accurate classification of BSRS-5 was 76.3% (78.9% sensitivity, 74.3% specificity, 69.9% positive predictive value, 82.3% negative predictive value). The BSRS-5 could differentiate the severity of illness in psychiatric outpatients based on psychiatrists ratings using the Clinical Global Impression scale, severity of psychopathology of psychiatric inpatients between admission and discharge, levels of pain indicated by 4 dimensions of the Dallas Pain Questionnaire for outpatients with chronic low back pain, and the severity of psychopathology between university students and community members with and without suicidal ideation. CONCLUSION The BSRS-5 can be used to identify psychiatric morbidity in both medical practice and the community.

Brain Tumor Presenting as Anorexia Nervosa in a 19-Year-Old Man

Slow-growing brain tumors can produce disturbances of food intake and endocrine dysfunction. We report a case of slow-growing midline brain tumor in a patient with clinical presentation of anorexia nervosa (AN). A 19-year-old man was referred from a general practitioner to a psychiatric clinic due to illness behavior and psychopathological characteristics of AN. His body weight had decreased from 52 kg to 40 kg within 6 months. Laboratory tests showed hypernatremia (160 mmol/L), adrenal insufficiency (adrenocorticotrophic hormone, 11.4 pg/mL; 8 am cortisol, 1.4 microg/dL; 4 pm cortisol, 11.4 microg/dL) and hypogonadotropic hypogonadism (testosterone < 0.5 ng/mL, follicle-stimulating hormone < 0.1 mIU/mL, luteinizing hormone < 0.7 mIU/mL). Brain magnetic resonance imaging showed an extensive mass lesion at suprasellar, hypothalamic region, third ventricle, pineal region, lateral ventricle, and corpus callosum. Owing to central herniation during physical assessment, he died of unknown intracranial pathology. This case suggests that an intracranial tumor near the hypothalamus should be included in the differential diagnosis of AN. Any male adolescent with the clinical impression of AN should receive periodic re-evaluation, including neurological, endocrinological and, if necessary, neuroimaging study.

Response of Taiwanese obese binge eaters to a hospital-based weight reduction program

OBJECTIVE To investigate the characteristics and prevalence of binge eating among overweight Taiwanese and to determine the effect of binge eating on outcome of weight loss treatment. METHODS One hundred and eighty-nine participants in a 12-week traditional weight-reduction program were classified on the basis of the Bulimic Investigation Test, Edinburgh (BITE) scores into binge eaters (>/=20), subthreshold binge eaters (10-19), and nonbinge eaters (0-9). RESULTS This study found a 15.9% prevalence of binge eating. The binge-eating groups (binge eaters and subthreshold binge eaters) were younger, had an earlier onset of obesity, and more psychological distress than nonbinge eaters. Differences in obesity treatment weight loss among binge eaters, subthreshold binge eaters, or nonbingers by last observation carried forward (LOCF) method were not significant. At the end of treatment, the subthreshold binge eaters had the greatest weight loss. Although their binge eating and mood significantly improved, binge eaters and subthreshold binge eaters still had significant pathology in eating behaviors at completion of the program. CONCLUSION Alternative treatment strategies focusing on disordered eating behaviors are needed to supplement standard dietary management of overweight treatment-seeking binge eaters.

Intermediate-term Outcome of Psychiatric Inpatients with Major Depression

BACKGROUND/PURPOSE A wide range of recovery rates has been reported during the 1st year of follow-up inpatients with depression, and there is a lack of consensus regarding which clinical and psychosocial variables are associated with prognosis. This study investigated the outcome of inpatients with a major depressive episode at 10-22 months (mean +/- SD = 14.0 +/- 3.4 months) of follow-up and the associated psychosocial and clinical variables. METHODS The demographic and clinical characteristics of 67 inpatients with a DSM-IV major depressive episode were assessed at admission, discharge and 1 year after the initial assessment. A logistic regression model was used to examine the predictive factors of depressive status at follow-up. RESULTS At the 1-year follow-up, 12 patients could not be located, one refused further interview and one had committed suicide 1 month after discharge. Eighty percent of patients had follow-up examinations. Out of 67 patients, 31 (47%) underwent a DSM-IV diagnosis (29 with major depression and two with minor depression) and 22 (33%) recovered. Low socioeconomic status (p = 0.05), long duration of illness before admission (p = 0.03) and number of previous hospitalizations (p = 0.04) were predictive factors for a depressive morbidity at 10-22 months. CONCLUSION At follow-up, almost half of the discharged depressive patients were still depressed. Screening for predictive factors of chronic depressive morbidity facilitates better outcome by considering the heterogeneity of psychopathology that can lead to failure in the treatment plan.

Long-term outcome of bulimia nervosa in Taiwanese.

BACKGROUND AND PURPOSE Patients with bulimia nervosa (BN) often experience many associated psychiatric symptoms and behaviors other than disordered eating and body image disturbance. Follow-up studies showed a broad range of remission rates and few prognostic factors were consistently identified. This study examined the outcome of BN in Taiwanese patients using a broad scope of assessment methods. METHODS From January 1985 to August 1999, a total of 68 consecutive patients with BN who visited the Department of Psychiatry at National Taiwan University Hospital were identified by chart review and invited to participate. Forty five patients (66.2%) agreed to participate in the study and were invited back for a follow-up assessment. The follow-up assessments used both semi-structured interview and self-rating questionnaires. RESULTS The mean duration of follow-up was 4.7 +/- 2.9 (2 to 15) years. One patient died of gradual weight loss and malnutrition during the follow-up period. Forty four percent of the patients (n = 20) had no signs of eating disorder at follow-up, while 56% of the patients (n = 25) still met the criteria for diagnosis of an eating disorder (anorexia nervosa, BN, and eating disorders not otherwise specified). The rate of crossover from BN to anorexia nervosa was 6.6% (n = 3). The illness persisted for more than 2 years in most of the patients (84.5%). Purging subtype of BN was the only predictor of the presence of an eating disorder diagnosis at follow-up. CONCLUSIONS This study found a high percentage of Taiwanese patients with BN failed to recover from eating disorders on long-term follow-up. The need for attention to the chronic nature of BN should be emphasized by medical professionals managing these patients.

Medically Unexplained Physical Symptoms with Masked Depression: A Case of Intractable Low Back Pain

We present a patient who suffered from intractableand medically unexplained low back pain whowas successfully treated.The patient was a 53-year-old woman who hadcompleted elementary school in childhood andwho became a housewife. Diabetes mellitus wasdiagnosed at the age of 39; it was not managed,but she was generally healthy in those years.In 2002, the patient’s husband became involvedin an extramarital affair. Severe conflict betweenthem occurred in February 2003, and her low backpain emerged. Unfortunately, her husband fellinto debt and committed suicide in June 2003.The patient’s low back pain became remarkablyaggravated, she groaned day and night, and herdaily function was seriously affected. All treatmentsthat she was given in different hospitals over aperiod of more than 1 year were in vain, and nodefinite physical reason could be found to explainthe pain. She was at last brought to our clinic inNovember 2004 for help.After admission, she showed great sufferingin appearance, and complained about severe lowback pain. Her cognitive function remained intactand there was no evidence of a psychotic disorder.However, the patient felt hopeless and frequentlythought about death. She almost ignored all ac-tivities and spent most of her time crying loudly.The diagnosis of major depressive disorder wasestablished, and a comorbid pain disorder wasalso specified due to her extraordinary distress.Thus, we started pharmacologic treatment withmirtazapine (45mg/day). Quetiapine (graduallytitrated up to 400mg/day) was prescribed as anaugmentation of the antidepressant

Outcome of short-term hospitalization in a psychosomatic ward.

BACKGROUND AND PURPOSE This study investigated the short-term outcome of patients with common mental disorders (CMDs) admitted to a psychosomatic ward. Multidimensional outcome measurements were used, including psychological symptoms, global functioning, and service satisfaction. METHODS A total of 56 consecutive patients with CMDs admitted to a 33-bed psychosomatic ward for crisis intervention or due to refractory conditions unresponsive to treatment at outpatient clinics were enrolled. Structured measurements including psychological symptoms, personality traits, family functioning and global functioning, at admission and discharge, were used to assess outcome. Baseline social functioning was measured at admission. Perspective on life satisfaction and satisfaction with therapy were assessed at discharge. Univariate analysis and multiple regression models that employed the stepwise method were used to determine the predictors of outcome. RESULTS Psychological symptoms, global functioning and family function demonstrated significant improvement after hospitalization (p<0.05). Personality traits remained stable during hospitalization. Baseline social functioning, educational level, marital status, comorbid mental disorder, length of hospital stay, and neuroticism were significantly associated with psychological stress at discharge (adjusted R2=0.51). Higher educational level and male gender were significantly correlated with better global functioning at discharge (adjusted R2=0.18). Perspective on life satisfaction and improvement of family functioning predicted satisfaction with therapy during the index hospitalization (adjusted R2=0.19). CONCLUSIONS This study demonstrated a significant improvement after short-term hospitalization in a psychosomatic ward. Demographic and clinical variables were able to predict the outcome measurement of symptoms, functioning and service satisfaction. This study also suggested that individual psychotherapy is a useful approach to the treatment of hospitalized patients with CMDs.

Prevalence and Psychiatric Referrals of Mental Disorders in Hospitalized Cancer Patients

Background: Cancer has become the leading cause of death in many countries, and its co-morbid psychologic problems present a challenge to medical professionals. In Taiwan, little research has been conducted on these psychologic problems. Objectives: To examine the prevalence of mental disorders and the frequency of psychiatric referral in hospitalized cancer patients. Methods: The present study was a cross-sectional epidemiologic survey of psychiatric comorbidity in 759 medical inpatients. Psychiatrists conducted in-depth interviews to make a psychiatric diagnosis, and standardized self-report scales were used to assess the subjects’ psychologic distress (Brief Symptom Rating Scale, BSRS-50), personality traits (Maudsley Personality lnventory, MPI), and family function (Family APGAR lndex). We compared 142 subjects with cancer to 617 subjects who had other medical diagnoses. Results: Off the cancer patients, 23.9% had a DSM III-R defined psychiatric diagnosis, which included adjustment disorders (53%), major depression (14.7%), and organic mental disorders (9%). Approximately 80% of those subjects with a psychiatric diagnosis suffered from depression, anxiety, or both. The prevalence of psychiatric disorders and the severity of the psychologic distress in the cancer patients were not statistically different than those in the non-cancer patients. However, the psychiatric referral rate of the cancer patients (12.7%) was significantly higher than the rate of the non-cancer patients (5%). The referral rate was not significantly related to the severity of psychopathology. The cancer patients with a positive psychiatric diagnosis scored significantly higher in neuroticism and significantly lower in extroversion on the MPI. Conclusion: The psychopathology of the cancer inpatients was similar to that of the non-cancer inpatients; however, the rate of psychiatric referral in the cancer patients was significantly higher. Addressing the psychologic needs of the cancer patients may have been more difficult for the non-psychiatric physicians; thus, the rate of referral was higher for these patients.

Psychiatric Morbidity and Associated Psychosocial Features in Heart Transplant Recipients

Background and purpose: The present study aimed to investigate psychiatric morbidity and associated psychosocial features in heart transplant recipients. Methods: The subjects comprised prior to the study. Experienced psychiatrists conducted an in-depth interview of each patient and psychiatric diagnoses were made in accordance with DSM-IV. In addition, a series of standardized reliable self-rating scales were used to assess the severity of psychopathology (Brief Symptom Rating Scale, BSRS), personality traits (modified Maudsley Personality Inventory MPI), family function (Family APGAR Index) and coping strategies. Results: the subjects were interviewed at a mean of 48.3 months (48.3 ± 12.9 months) after transplantation. They were all with good cardiac function condition (New York Heart Association (NYHA) class I). The employment rate was higher than in the pretransplant period (22.4% vs. 48.7%). Psychiatric illness was diagnosed in 12% of subjects based on the findings of the psychiatric interview. Comparison of the results of the general severity index (GSI) of BSRS in heart transplant recipients with normative GSI data obtained from medically ill inpatients without a formal diagnosis of psychiatric disorder revealed no significant difference. In total, 11.8% of the subjects manifested significant psychiatric morbidity based on GSI scores. The prevalence of marked psychiatric symptoms as measured by the BSRS included: phobia (21.1%), hostility (17.1%), depression (14.5%) and obsession (13.2%). Four psychosocial features, namely, “neuroticism”, “avoidance-withdrawal”, “fatalism-resignation” and “attention-shifting” accounted for 62% of the total variance in the severity of psychopathology based on GSI of BSRS. Conclusion: In this study, 88% of the survivors of heat transplantation were free from psychiatric morbidity. However, subjects with a higher score of neuroticism and those who more frequently used immature coping had a significantly increased risk of developing psychiatric morbidity.