Swapna Verma

Metabolic risk factors in drug-naive patients with first-episode psychosis.

OBJECTIVE Metabolic risk factors, such as obesity, as well as abnormalities in glucose and lipid metabolism, have been shown to have an increased prevalence in patients with schizophrenia, especially in those treated with antipsychotic medication. However, studies looking at these abnormalities in drug-naive patients have been few in number and have yielded mixed results. The aim of our study was to look at the prevalence of some of the cardiovascular risk factors, such as obesity and lipid and glucose abnormalities, in drug-naive patients with first-episode psychosis compared to healthy controls matched for age, gender, and ethnicity. METHOD One hundred sixty patients aged between 18 and 40 years who presented to the Early Psychosis Intervention Programme in Singapore with a diagnosis of first-episode psychosis according to the Structured Clinical Interview for DSM-IV Axis I Disorders-Patient Edition were assessed for their body mass index (BMI) and plasma levels of fasting glucose and lipids. The results of this assessment were compared to similar data from 200 controls matched for age, gender, and ethnicity, collected as part of an annual workplace health screening. The study was conducted from June 2002 to March 2005. RESULTS There were significant differences in the mean baseline weight, BMI, and plasma levels of total and LDL cholesterol; all of these values were significantly higher in the controls compared to patients (p < .005 for all). Controls were significantly more likely to have high BMI (>or= 23 kg/m(2)) and high LDL cholesterol level (> 3.4 mmol/L) as compared to patients (p < .005 and p = .01, respectively). However, patients compared to controls were significantly more likely to have diabetes (p = .007). CONCLUSION The link between diabetes and psychotic illness previously reported in relatives of patients with schizophrenia and in medication-naive patients implies a possible genetic link between schizophrenia and abnormal glucose metabolism. However, the finding of low prevalence of obesity and dyslipidemia at the onset of illness suggests that the increased frequency of these abnormalities in patients is an effect of their antipsychotic medication.

Screening for Depressive Symptoms: Validation of the Center for Epidemiologic Studies Depression Scale (CES-D) in a Multiethnic Group of Patients With Diabetes in Singapore

OBJECTIVE—We determined the reliability and validity of the Center for Epidemiologic Studies Depression Scale (CES-D) against the DSM-IV–based diagnostic inventory, Schedule for Clinical Assessment in Neuropsychiatry (SCAN), in a multiethnic sample of adult subjects with diabetes attending a diabetes center in Singapore. RESEARCH DESIGN AND METHODS—A total of 522 subjects (74.7% Chinese, 11.1% Malay, and 14.2% Indian) completed culturally adapted versions of the CES-D; 291 subjects were administered the SCAN inventory. RESULTS—The CES-D (cutoff score 16) showed high negative predictive values of more than 90% in all three ethnic groups. The prevalence of depressive symptoms (CES-D) and depression (SCAN) was significantly different between the Chinese and Indian subjects (CES-D 27.4 vs. 43.2%, P = 0.006); (SCAN 15.0 vs. 31.1%, P = 0.01). CONCLUSIONS—The CES-D proved to be a reliable instrument for identifying patients with depressive symptoms in the multiethnic setting of this study.

Reducing the duration of untreated psychosis and changing help-seeking behaviour in Singapore

AimThis study was conducted to examine the impact of early detection strategies of an early psychosis intervention programme on the duration of untreated psychosis (DUP) and the pattern of help-seeking behaviour.MethodPatients with first-episode psychosis were compared before and after the initiation of a programme of public education and networking with primary health care providers. These two groups were compared on the DUP and the change in the pattern of help-seeking.ResultsThe DUP was significantly reduced from a median of 12 to median of 4 months (p=0.002, Mann–Whitney U-test). There was an increase in the proportion of self and family referrals, and a fall in the proportion of police referrals.ConclusionAwareness campaigns which target multiple groups and use various modes of communication are effective in influencing the DUP and patterns of help-seeking.

Substance abuse in schizophrenia: A Singapore perspective

Background Most of the information on the prevalence and patterns of substance abuse in patients with schizophrenia has been from studies conducted in North America and Europe and data from Asian countries are conspicuously lacking. This study was undertaken with the aim to identify the prevalence and patterns of substance abuse among patients with first-episode schizophrenia in the city-state of Singapore. Methods All new patients with a diagnosis of first-episode schizophrenia or schizophreniform disorder who were seen in one calendar year in the only state mental institute in Singapore and its affiliated outpatient clinics were evaluated for a lifetime history of substance use. Results In a sample of 272 patients, 201 (73.6 %) were abstainers, 43 (15.8 %) had “mild” substance use and 28 (10.3 %) had “heavy” use patterns. Alcohol was the most frequently abused substance. The substance users were more likely to be males and were more likely to have a criminal record than abstainers. Conclusions To our knowledge, this is the first study that examines the co-morbidity of substance abuse in schizophrenia in an Asian population. Our findings once again highlight the fact that patients with schizophrenia are at a high risk for substance abuse.

Effect of ω-3 Polyunsaturated Fatty Acids in Young People at Ultrahigh Risk for Psychotic Disorders: The NEURAPRO Randomized Clinical Trial

Importance A promising treatment to prevent onset and improve outcomes in patients at ultrahigh risk for psychosis is dietary supplementation with long-chain &ohgr;-3 polyunsaturated fatty acids (PUFAs). Objective To determine whether treatment with &ohgr;-3 PUFAs in combination with a high-quality psychosocial intervention (cognitive behavioral case management [CBCM]) is more effective than placebo plus CBCM. Design, Setting, and Participants NEURAPRO, a double-blind, placebo-controlled, randomized clinical trial, was conducted from March 1, 2010, to September 30, 2014, in 10 specialized early psychosis treatment services in Australia, Asia, and Europe. The primary analysis used the intention-to-treat approach. Interventions A daily dose of 1.4 g of &ohgr;-3 PUFAs or placebo (paraffin oil), plus 20 or fewer sessions of CBCM over the 6-month study period. Main Outcomes and Measures The primary outcome was transition to psychosis status at 6 months. The secondary outcomes were general levels of psychopathology and functioning, as assessed by the Brief Psychiatric Rating Scale (BPRS) (range, 24-168), Scale for the Assessment of Negative Symptoms (SANS) (range, 0-125), Montgomery-Åsberg Depression Rating Scale (MADRS) (range, 0-60), Young Mania Rating Scale (YMRS) (range, 0-44), Social and Occupational Functioning Assessment Scale (SOFAS) (range, 0-100), and the Global Functioning: Social and Role scale (range, 0-10). For SOFAS and Global Functioning: Social and Role scale, higher scores were better; for other measures, lower scores were better. Results In this study of 304 adults at ultrahigh risk for psychotic disorders, 153 (50.3%) received &ohgr;-3 PUFAs and 151 (49.7%) received placebo. In all, 139 (45.7%) were male; mean (SD) age was 19.1 (4.6) years. The Kaplan-Meier–estimated 6-month transition rates were 5.1% (95% CI, 1.3%-8.7%) in the control group and 6.7% (95% CI, 2.3%-10.8%) in the &ohgr;-3 PUFA group. At 12 months, the rates were 11.2% (95% CI, 5.5%-16.7%) in the control group and 11.5% (95% CI, 5.8%-16.9%) in the &ohgr;-3 PUFA group. No significant difference was observed between the transition rates of both groups (hazard ratio, 1.1; 95% CI, 0.55-2.23; P = .76, stratified log-rank test). Conclusions and Relevance This trial clearly failed to replicate the findings of the original single-center trial. The most likely explanation is that &ohgr;-3 PUFAs lack efficacy under these conditions. However, the lower-than-expected transition rate may have prevented a test of the main hypothesis. Given the substantial symptomatic and functional improvement in both groups, the other treatments received (ie, CBCM and antidepressants) likely produced a ceiling effect beyond which &ohgr;-3 PUFAs, even if effective, could not be shown to confer additional benefits. Nevertheless, the main conclusion is that &ohgr;-3 PUFAs are not effective under conditions where good quality, evidence-based psychosocial treatment is available. Trial Registration anzctr.org.au Identifier: 12608000475347

Aggression in Asian Patients with First-Episode Psychosis.

Aims: The aims of this study were to examine the prevalence and severity of aggression in patients with first-episode psychosis and to identify the association between aggression and sociodemographic and clinical factors. Methods: Consecutive patients with first-episode psychosis admitted to the Early Psychosis Intervention Programme, Singapore, were assessed for a history of aggressive acts. Diagnosis was confirmed using the Structured Clinical Interview for DSM-IV and psychopathology was assessed using PANSS. Results: Of the 146 patients, 63.0% had no history of aggressive acts, 13.7% demonstrated severe aggression (defined as weapon use, sexual assault or victim injury) and 23.3% had lesser aggression (all other acts of aggression). Patients with aggression had a significantly longer duration of untreated psychosis (DUP) than those with no history of aggression (p 1/4 .01). The mean total PANSS scores did not differ significantly among the three groups. However, the General Psychopathology scores and the scores for ‘hostility’, ‘poor impulse control’, ‘lack of insight and judgement’ and ‘somatic concern’ were all significantly elevated in patients with aggression (p < .05). Conclusion: The significant association between aggression and longer DUP once again reiterates the need for early detection and effective management of first-episode psychosis.

Effect of treatment on weight gain and metabolic abnormalities in patients with first-episode psychosis

Objective: The aim of the present prospective and naturalistic study was to examine the effects of antipsychotic medication on weight and serum levels of lipids, glucose and insulin in first-episode psychosis patients. Method: Fifty-six patients admitted to the Singapore Early Psychosis Intervention Programme participated in this study. They were assessed at baseline (i.e. within 72 h of starting antipsychotics), and 6 months later. Weight (kg) and height (m) were measured and body mass index (BMI) was calculated. Blood samples were taken after a 12 h overnight fast. Choice of antipsychotics was based on the treating physicians clinical decision. Total cumulative Chlorpromazine (CPZ) equivalent of antipsychotic exposure during the 6 months was calculated. Statistical analyses were carried out for comparisons between baseline and 6 months, and for the two outcome event groups of ≥7% versus <7% weight gain. Where appropriate, confounders were controlled. Results and conclusion: There were significant increases in BMI, serum levels of triglyceride, low-density lipoprotein and total cholesterol from baseline to 6 months. Mean increase in weight was 6.2±7.0 kg (p < 0.05) and 65% of the patients had clinically significant weight gain (i.e. ≥7% increase from baseline). On logistic regression lower baseline BMI, female gender, and younger age, were associated with clinically significant weight gain.

Comorbid depression and increased health care utilisation in individuals with diabetes

OBJECTIVE The objective of this study was to examine the extent of health care utilisation (excluding costs) of diabetic patients with and without depressive symptoms attending a specialist clinic in Singapore. METHODS A total of 537 Asian outpatients (aged 21 years and above) who were attending a Diabetes Centre were recruited on a consecutive basis between August 2006 and February 2007. Sociodemographic data, clinical and health care utilisation data were collected from the participants. Depressive symptoms were assessed using the Center for Epidemiologic Studies Depression Scale. RESULTS Individuals with depressive symptoms, on average, had more hospitalizations and hospitalization days. Those with depression reported losing significantly more working days as compared to the nondepressed individuals (1.9 vs. 1.4, P=.001). CONCLUSIONS Our findings in this population suggest that the presence of depressive symptoms has an independent effect on the greater utilization of medical services.

Diagnostic Stability 2 Years After Treatment Initiation in the Early Psychosis Intervention Programme in Singapore

Objective: To evaluate the diagnostic stability of psychotic disorders over a 2 year period in patients presenting with first-episode psychosis. Methods: One hundred and fifty-four patients were recruited from an early psychosis intervention programme (EPIP). They were diagnosed by the attending psychiatrist using the Structured Clinical Interview for DSM-IV Axis I at first contact (baseline) and after 24 months. The diagnoses were classified into the following categories: schizophrenia spectrum disorders (schizophrenia, schizophreniform disorder and schizoaffective disorder), affective psychosis (bipolar and major depressive disorders with psychotic symptoms), and other non-affective psychosis (delusional disorder, psychosis not otherwise specified and brief psychotic disorder). Two measueres of stability, the prospective and the retrospective consistency were determined for each diagnosis. Results: The diagnoses with the best prospective consistency were schizophrenia (87.0%) and affective psychosis (54.5%). The shift into schizophrenia spectrum disorder was the most frequent diagnostic change. Duration of untreated psychosis was found to be the only significant predictor of shift. Conclusion: It is difficult to make a definitive diagnosis at first contact. The clinical need to review the diagnosis throughout the period of follow up is emphasized.

Validity of a brief screening instrument-CRAFFT in a multiethnic Asian population.

AIM To validate the CRAFFT screening test, against the DSM IV Axis 1-based diagnostic inventory in a population of adolescents and young adult males in Singapore. METHODS The 23,248 participants belonged to a cohort of males who had undergone a medical examination prior to enlistment for military service. This study took place between August 2004 and August 2005. Subjects underwent a two-stage assessment and were administered the CRAFFT questionnaire and the Composite International Diagnostic Interview (CIDI). RESULTS The mean age of the subjects was 19 years (range, 16 to 26 years). The CRAFFT showed moderately high levels of internal consistency (Cronbachs α=0.73). The optimum cutoff point for drug-related disorder either abuse or dependence and alcohol-related disorder either abuse or dependence criterions were found at CRAFFT score of 1 or higher. CONCLUSION The CRAFFT test is a valid means of screening adolescents for substance-related disorders in a multiethnic population of adolescent and young adult males.