Ming-Been Lee

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.

Associations Between Chronotypes, Psychopathology, and Personality Among Incoming College Students

Chronotye is associated with age, sex, personality, and parental monitoring during childhood. The evening type is associated with poor school performance, sleep problems, anxious/depressive symptoms, tobacco smoking, caffeine consumption, alcohol drinking, and suicidality in adolescents. The present study tested the relationships between chronotype and a wide range of psychopathology and personality traits among 2919 incoming undergraduate students. Each participant completed a self-administered questionnaire that included demographics, plus the Morningness-Eveningness (M-E) scale, Brief Symptom Rating Scale (BSRS), Tridimensional Personality Questionnaire, and Maudesley Personality Inventory. The t-score distribution of the M-E scale was used to form the morning (t-score >60, n = 419), evening (t-score <40, n = 371), and intermediate (40 ≤ t-score ≤ 60, n = 2129) groups. Multivariable regression was employed for data analysis. For males, the evening type scored higher on all subscales of the BSRS than the morning type, except phobic anxiety. For females, the evening type had higher scores than the other two types on all subscales, except in obsession/compulsion and phobic anxiety, where the evening type only scored higher than the intermediate type. The evening type of both sexes also scored higher than the morning type in novelty seeking, harm avoidance, and neurotic personality characteristics, but lower than the morning type in extraversion and social desirability. In reward dependence, the evening type scored lowest for males, but there was no difference for females. The findings of the evening type being associated with possible psychopathology and certain types of personality have public health implications, that is, chronotype needs to be taken into account in the development of mental health prevention programs and assessment of and intervention for mental problems in young adults. (Author correspondence: gaushufe@ntu.edu.tw)

Suicide by charcoal burning in Taiwan, 1995-2006.

BACKGROUND We sought to identify risk factors and trends that might underlie the greatly increased incidence of charcoal-burning suicide in Taiwan and to learn whether the increasing accessibility of a single suicide method can increase overall suicide rates. METHODS Data from a national mortality register for subjects who committed suicide during 2001 to 2006 and who were 15 years old or older when they died was analyzed. A review of available evidence and comparisons with historical cases were also performed. RESULTS From 1995 to 2006, 68% of suicides in Taiwan involved males, and suicide rates for men increased from 9.5 to 26.7 per 100,000 population; suicide rates for women rose from 5.6 to 11.7 per 100,000 population. The sex ratio (M:F) increased from 1.69:1 to 2.28:1. The greatest increase in suicide rates occurred among those 25-44 years of age. The incidence of charcoal-burning suicide was 0.22 per 100,000 in 1999 but reached 6.48 per 100,000 in 2006. Age, gender, marital status, and year of committing suicide were significant predictors for suicide by charcoal burning. This single suicide method accounted for 33.5% of suicide deaths in Taiwan in 2006. LIMITATIONS The number of suicides by charcoal burning may be under- or overestimated, and life events of the suicide subjects were not analyzed. CONCLUSIONS Romanticizing suicide by charcoal burning by the media and cultural influences may have contributed to the increased suicides. Prohibiting sale of charcoal in convenience stores, enforcing media guidelines, and setting up carbon monoxide detectors may help prevent suicide by charcoal burning.

Prevalence of Suicidal Ideation and Associated Risk Factors in the General Population

BACKGROUND/PURPOSE Suicide is an important public health problem and one of the leading causes of death worldwide. The present study investigated the prevalence of suicidal ideation (SI) and its associated risk factors in the general population. METHODS A nationwide community survey was conducted using a computer-aided telephone interview system with residents aged >or= 15 years, who were selected by a stratified, proportional randomization method. The questionnaire comprised demographic variables, five items of psychopathology selected from the Brief Symptom Rating Scale (BSRS-5) and questions about personal experience with suicide. In total, 2054 respondents, 1002 male (48.8%), and 1052 female (51.2%), completed the survey. RESULTS The weighted prevalence of SI was 2.84% in the past week, 5.50% in the past year, and 18.49% during a lifetime. Significant risk factors for SI in the last week included presence of SI over the past year [odds ratio (OR) =1763.6], SI during the lifetime (OR =267.6), psychiatric morbidity (OR = 30.3), depression (OR =26.1), inferiority (OR =11.2), hostility (OR = 10.9), anxiety (OR = 10.5), insomnia (OR =6.7), history of seeking help for psychological distress (OR = 7.9), divorce (OR =6.4), unemployment (OR = 5.0) and having suicidal behavior in relatives or friends (OR =3.8). Stepwise multiple regression analysis demonstrated that the five symptom items of BSRS-5 and unemployment significantly predicted 25.3% of the variance of SI. Using the BSRS-5 score 3 or 4 as a cut-off to predict SI, the rate of accurate classification was 85.88%, with sensitivity of 0.83 and specificity of 0.86. CONCLUSION A telephone interview survey containing the BSRS-5 items is an efficient way to identify determinants of SI in the general population.

Association of the MAOA promoter uVNTR polymorphism with suicide attempts in patients with major depressive disorder

BackgroundThe MAOA uVNTR polymorphism has been documented to affect the MAOA gene at the transcriptional level and is associated with aggressive impulsive behaviors, depression associated with suicide (depressed suicide), and major depressive disorder (MDD). We hypothesized that the uVNTR polymorphism confers vulnerability to MDD, suicide or both. The aim of this study was to explore the association between the MAOA uVNTR and depressed suicide, using multiple controls.MethodsFour different groups were included: 432 community controls, 385 patients with MDD who had not attempted suicide, 96 community subjects without mental disorders who had attempted suicide, and 109 patients with MDD who had attempted suicide. The MAOA uVNTR polymorphism was genotyped by a PCR technique. The symptom profiles and personal characteristics in each group were also compared.ResultsThe MAOA 4R allele was more frequent in males with MDD than in male community controls (χ2 = 4.182, p = 0.041). Logistic regression analysis showed that, among the depressed subjects, those younger in age, more neurotic or who smoked had an increased risk of suicide (β = -0.04, p = 0.002; β = 0.15, p = 0.017; β = 0.79, p = 0.031, respectively). Moreover, among those who had attempted suicide, those younger in age, with more paternal overprotection, and more somatic symptoms were more likely to be in the MDD group than in the community group (β = -0.11, p < 0.001; β = 0.15, p = 0.026; β = 1.11, p < 0.001). Structural equation modeling (SEM) showed that nongenetic factors, such as age, paternal overprotection, and somatic symptoms, were associated with MDD, whereas depressed suicide were associated with severity of depression, personality traits, age, marital status, and inversely associated with anxiety symptoms. However, depression did not affect suicidal behavior in the community group.ConclusionThe MAOA 4R allele is associated with enhanced vulnerability to suicide in depressed males, but not in community subjects. The MAOA 4R allele affects vulnerability to suicide through the mediating factor of depressive symptoms. Further large-scale studies are needed to verify the psychopathology of the relationships among MAOA uVNTR polymorphism, symptom profiles, and suicidal behavior.

Low prevalence of major depressive disorder in Taiwanese adults: possible explanations and implications

BACKGROUND This study examined the prevalence of major depressive disorder (MDD), and the correlations and co-morbid conditions associated with MDD, in the adult Taiwanese population, which a previous estimate in the 1980s had found to be at the lower end of the spectrum worldwide. Possible explanations for the reported low prevalence of MDD were evaluated. METHOD As part of a survey of common psychiatric disorders in a nationally representative sample of individuals aged ≥ 18 years who were non-institutionalized civilians in Taiwan, a face-to-face interview using the paper version of the World Mental Health Survey of the World Health Organization (WHO) Composite International Diagnostic Interview (WMH-CIDI) was conducted between 2003 and 2005. Functional impairment and help-seeking behaviors were compared between Taiwanese subjects with MDD and their counterparts in the USA. RESULTS Among the 10 135 respondents, the lifetime prevalence of MDD was 1.20% [standard error (S.E.)=0.2%]. Individuals who were divorced or widowed, aged ≤ 40 years, and female were at increased risk, whereas rural residents were at lower risk for MDD. The proportion of MDD cases co-morbid with other psychiatric disorders in this study was much lower than in the US study. Only one-third of Taiwanese individuals with MDD sought help despite having twice the number of lost workdays compared with the US sample. CONCLUSIONS Despite the low prevalence of MDD in Taiwanese adults, the pattern of low help-seeking behavior and profound functional impairment indicates much room for improvement in the early detection of and intervention in major depression in this population.

Why do people choose charcoal burning as a method of suicide? An interview based study of survivors in Taiwan

BACKGROUND Marked increases in the incidence of charcoal burning suicide have contributed to Taiwans rising suicide rate in the past decade. To assess possible opportunities for intervention, we have compared survivors of suicide attempts by charcoal burning with people who ingested poisons. METHODS We interviewed a consecutive series of suicide attempters by charcoal burning (n=37) and self-poisoning (n=38) admitted to Taipei Veterans General Hospital (TVGH) between January 2009 and March 2010. Interviews included the Structured Clinical Interview of DSMIV (SCID) and Beck Suicide Intent Scale. RESULTS Compared to people who ingested medicines/poisons, charcoal burning suicide attempters were less likely to have a pre-existing physical illness or contact with psychiatric services prior to the attempt and more likely to be employed. Charcoal burning suicide attempters had higher levels of suicide intent (mean score 20.1) compared to people ingesting poisons (mean score 13.5) (p<0.001) and were considerably more likely to report that their choice of method was influenced by the media (87% vs. 8%), particularly the portrayal of the method as a peaceful way of dying. Charcoal burning suicides were less impulsive. LIMITATIONS The study sample was limited to a single hospital. CONCLUSIONS Survivors of suicide attempts by charcoal burning have high levels of intent and low levels of psychiatric contact indicating they may be more difficult to prevent than suicides by self-poisoning. Encouraging responsible media reporting of suicide and restricting the availability of charcoal may be the most promising approaches to preventing these deaths.

The five-item Brief-Symptom Rating Scale as a suicide ideation screening instrument for psychiatric inpatients and community residents

BackgroundAn efficient screening instrument which can be used in diverse settings to predict suicide in different populations is vital. The aim of this study was to use the five-item Brief Symptom Rating Scale (BSRS-5) as a screening instrument for the prediction of suicide ideation in psychiatric, community and general medical settings.MethodsFive hundred and one psychiatric, 1,040 community and 969 general medical participants were recruited. The community participants completed a structured telephone interview, and the other two groups completed the self-report BSRS-5 questionnaire.ResultsThe logistic regression analysis showed that the predictors of suicide ideation for the psychiatric group were depression, hostility and inferiority (p < 0.001, p = 0.016, p = 0.011), for the community group, inferiority, hostility and insomnia (p < 0.001, p < 0.001, p = 0.003), and for the general medical group, inferiority, hostility, depression and insomnia (p < 0.001, p = 0.001, p = 0.020, p = 0.008). The structural equation model showed the same symptom domains that predicted suicide ideation for all three groups. The receiver operating characteristic curve using the significant symptom domains from logistic regression showed that for the psychiatric group, the optimal cut-off point was 4/5 for the total of the significant dimensions (positive predictive value [PPV] = 78.01%, negative predictive value [NPV] = 79.05%), for the community group, 7/8 (PPV = 68.75%, NPV = 96.09%), and for the general medical group, 12/13 (PPV = 92.86%, NPV = 88.48%).ConclusionThe BSRS-5 is an efficient tool for the screening of suicide ideation-prone psychiatric inpatients, general medical patients, and community residents. Understanding the discriminative symptom domains for different groups and the relationship between them can help health care professionals in their preventative programs and clinical treatment.

Validity of the five-item brief symptom rating scale among subjects admitted for general health screening

BACKGROUND AND PURPOSE Hospital-based general health screening plays an important role in the early detection of mental disorders. The present study examined the validity of the 5-item Brief Symptom Rating Scale (BSRS-5) in subjects admitted for a 2-day general health screening program. METHODS A cross-sectional survey with a modified 2-phase design was conducted at a medical center in Taipei. A total of 283 consecutive subjects who received health screening in a 1-month period completed the BSRS-5 in the first phase. There were 172 (60.8%) males and 111 (39.2%) females with a mean age of 54.4+/-12.0 years. 115 subjects received a standard psychiatric interview with the Mini International Neuropsychiatric Interview-Plus in the second phase. RESULTS In this hospital-based sample, the internal consistency (Cronbach alpha) coefficient for the BSRS-5 was 0.84 and the area under the receiver-operating characteristic curve was 0.91 [95% confidence interval (CI), 0.86-0.95]. The optimal cut-off point was 5/6. The rate of accurate classification was 82.2% (82.6% sensitivity, 81.8% specificity, 81.9% positive predictive value, 82.5% negative predictive value). The estimated prevalence of minor psychiatric morbidity in this sample was 27.2% (95% CI, 22.2-32.4%). CONCLUSION The BSRS-5 is an effective screening instrument for the identification of psychiatric morbidity in hospital-based health screening settings.

Risk factors for suicide in Taiwanese college students

Objective: The authors investigated the personality characteristics, psychopathology, parenting style, and family function among Taiwanese college students with high, moderate, and low suicidal risks. Participants: The sample included 2,919 first-year college students (1,414 men, 1,505 women) from a university in Taipei, Taiwan. Methods: A self-administered questionnaire assessed domains covering demographics, personality, psychopathology, frequency of substance use, parenting style, family functioning, and suicidal behaviors. The authors used mixed models for data analysis. Results: The authors observed a positive linear trend between increased suicidal tendency and levels of neuroticism, harm avoidance, novelty seeking, psychopathology, and parenting styles of low affection, overprotection, and authoritarian controlling. Use of tobacco and alcohol and impaired family adaptation and cohesion were associated with high and moderate suicidal risks. Conclusions: Personality, psychopathology, substance use, and familial factors are important correlates of suicidal risks among college students in Taiwan. Optimal suicide prevention strategies in the college setting should incorporate the multiple facets of suicidal risks.