Yu-Chen Kao

Beck Hopelessness Scale: Exploring its Dimensionality in Patients with Schizophrenia

Hopelessness is a pre-eminent risk factor for suicide and non-fatal self-harm. Although the Beck Hopelessness Scale is often used for schizophrenia, its factor structure has been given relatively little consideration in this context. This study aimed to examine the reliability and validity of the Taiwanese version of the Beck Hopelessness Scale (BHS-T) in a chronic schizophrenia out-patient sample. One hundred and two (102) outpatients were evaluated using the translated Taiwanese version of the BHS (BHS-T), as well as several Beck-related symptom rating scales and the Positive and Negative Syndrome Scale (PANSS) for psycho-pathology. The patients were also evaluated for suicidal intent using the critical items of the Scale for Suicide Ideation (SSI) and suicide attempts. The psychometric properties of the BHS-T were also evaluated, including construct validity, internal consistency, test–retest reliability, convergence, and discriminative validity. The BHS-T showed good overall reliability and stability over time. This translated scale comprised a two-factor solution corresponding negative expectation and loss of motivation dimensions. Differences in mean hopelessness scores between participants with and without suicidal intent were significant. The results also indicated that, among individuals with schizophrenia, “negative expectation in the future” is more closely linked to suicide intent than “loss of motivation for the future”. The BHS-T is a reliable and valid instrument for measuring the multi-dimensionality of hopelessness and may complement clinical suicidal risk assessments in individuals with schizophrenia.

Evidence for the indirect effects of perceived public stigma on psychosocial outcomes: The mediating role of self-stigma

This study examined the possible mediating role of self-stigma in the relationship between perceived public stigma and psychosocial outcomes and how this mechanism may be contingent on illness severity in a non-Western (Chinese) sample. A total of 251 participants, namely 151 psychiatric outpatients with psychotic disorders and 100 psychiatric outpatients without psychotic disorders, completed a questionnaire on stigma and psychosocial outcomes that covered topics such as self-esteem, depressive symptoms, and subjective quality of life (QoL). Using a cross-sectional design, ordinary least squares regression and bootstrapping mediation analyses were used to test whether self-stigma mediated the relationship between perceived public stigma and psychosocial outcomes and whether this mediating process was moderated by diagnostic status. The results indicated that self-stigma mediated the effect of perceived public stigma on psychosocial outcomes such as self-esteem, depressive symptoms, and subjective QoL among both patients with psychotic disorders and those without psychotic disorders after controlling for demographic and clinical characteristics. Further, moderated mediation analyses revealed that the indirect effect of perceived public stigma on psychosocial outcomes were not moderated by the status of psychotic diagnoses. Self-stigma might be an essential and tractable target for interventions aimed at breaking the vicious cycle of discrimination and stigmatization toward people with mental illness regardless of their diagnoses.

Relationships of perceived public stigma of mental illness and psychosis-like experiences in a non-clinical population sample

PurposeStudies on the association between psychopathology, perceived public stigma, and labeling in mental illness have focused primarily on severe but rare mental disorders, especially schizophrenia, or other clinically defined psychotic disorders. Although evidence is mounting that psychosis-like experiences show high prevalence in the general population and lead to an increased risk of psychotic disorders, little is known about how psychosis-like experiences independently affect perceived public stigma in the non-clinical population. The aim of the present study was to examine the relationship between psychosis-like experiences and perceived public stigma in a non-clinical sample.MethodsFor this cross-sectional study, we recruited 524 individuals (239 male, 285 female) who had no lifetime history of psychiatric disorder. Participants completed questionnaires that asked for sociodemographic and clinical information, a measure of perceived public stigma (Perceived Psychiatric Stigma Scale [PPSS]), and two measures of psychosis-like experiences (Peters et al. Delusions Inventory [PDI]; Cardiff Anomalous Perceptions Scale [CAPS]).ResultsOf the sociodemographic characteristics analyzed in this study—gender, age, education level, marital status, and religion—only age simultaneously influenced PPSS, PDI, and CAPS scores. As hypothesized, perceived public stigma was positively correlated with measures of psychosis-like experiences, even after controlling for age. Furthermore, the perceived stigma was more strongly associated with delusion proneness than with anomalous perceptual experiences.ConclusionThe association between psychopathology and perceived public stigma appears to extend beyond clinically defined psychosis to more common psychosis-like experiences in a sample drawn from the general Han Chinese population.

Risk of Dementia in Adults With ADHD: A Nationwide, Population-Based Cohort Study in Taiwan

Objective:This study aimed to investigate the association between adults with ADHD and the risk of developing dementia. Method: Utilizing National Health Insurance Research Database of Taiwan, ADHD patients were identified and compared with age- and gender-matched controls (1:3). Results: Of the study participants, 37 (5.48%) developed dementia compared with 81 (4.0%) in the control group. Cox proportional hazards regression analysis revealed that the study participants were more likely to develop dementia. The crude hazard ratio (HR) is 3.418 (95% confidence interval [CI] = [2.289, 5.106], p < .001), and adjusted HR is 4.008 (95% CI = [2.526, 6.361], p < .001) in risk of developing dementia after adjusted for age, gender, comorbidities, geographical area of residence, urbanization level of residence, and monthly income. Conclusion: Adults with ADHD have a 3.4-fold risk of developing dementia, and other large or national data sets should be explored to support the current findings.

Increased Risk of Psychiatric Disorders in Allergic Diseases: A Nationwide, Population-Based, Cohort Study

Background/objective Allergic diseases, such as bronchial asthma, allergic rhinitis, atopic dermatitis, and psychiatric disorders, are major health issues. There have been reports that allergic diseases were associated with depression or anxiety disorders. This study aimed to investigate the association between these allergic diseases and the risk of developing overall psychiatric disorders in patients from Taiwan. Methods This cohort study used the database of the Taiwan National Health Insurance Program. A total of 186,588 enrolled patients, with 46,647 study subjects who had suffered from allergic diseases, and 139,941 controls matched for sex and age, from the Longitudinal Health Insurance Dataset of 2000–2015, were selected from a sub-dataset of the National Health Insurance Research Database. Fine and Gray’s competing risk model analysis was used to explore the hazard ratio (HR), and 95% confidence interval, for the risk of allergic diseases being associated with the risk of developing psychiatric disorders during the 15 years of follow-up. Results Of the study subjects, 5,038 (10.8%) developed psychiatric disorders when compared to 9,376 (6.7%) in the control group, with significant difference (p < 0.001). Fine and Gray’s competing risk model analysis revealed that the adjusted HR was 1.659 (95% CI = 1.602–1.717, p < 0.001). In this study, we found that the groups of atopic dermatitis alone and the allergic rhinitis + atopic dermatitis were associated with a lower risk of psychiatric disorders, but all the other four groups, such as bronchial asthma alone, allergic rhinitis alone, bronchial asthma + allergic rhinitis, bronchial asthma + atopic dermatitis, and the combination of all these three allergic diseases, were associated with a higher risk of psychiatric disorders. Conclusion Allergic diseases are therefore associated with a 1.66-fold increased hazard of psychiatric disorders in Taiwan.

Chronic inflammatory demyelinating polyneuropathy associated with manic symptoms.

Chronic inflammatory demyelinating polyneuropathy (CIDP) is an autoimmune disease involving cellular and humoral immunity. It is characterized by progressive symmetrical weakness or sensory loss in both proximal and distal muscles developing over a more than 8-week period (Vallat et al., 2010). Neuropsychiatric disorders related to CIDP rarely occur. Here, we report a case of CIDP with manic symptoms. A 66-year-old man was referred to our hospital with progressive weakness and numbness in all limbs over the past 2 years. One year prior to presentation, he developed irritable and labile mood and manic symptoms, including exaggerated sense of self-confidence, talkativeness, spending sprees, insomnia and increased energy. Laboratory investigation showed increased erythrocyte sedimentation rate (ESR: 39 mm/h). The nerve conduction velocity showed prolonged distal latency, a slowing of the conduction velocity and prolonged F-wave latency of the median, ulnar and peroneal nerves. Although he refused lumbar puncture, cerebrospinal fluid (CSF) studies are not mandatory according to the Inflammatory Neuropathy Cause and Treatment criteria for CIDP. A clinical diagnosis of CIDP was made. Intravenous methylprednisolone was given for 4 days and then shifted to oral prednisolone. His muscle weakness gradually improved after 1 week of steroid therapy. The mood symptoms improved with the initial Young Mania Rating Scale (YMRS) 22 and decreased to 13 after 3 weeks of steroid treatment. To our knowledge, no cases of bipolar disorder associated with CIDP have been previously documented. In acute inflammatory demyelinating polyneuropathy (AIDP), brief reactive psychosis, anxiety, depressive episodes and rapid eye movement (REM) sleep abnormalities were observed (Chan and Gold, 2007). The possible mechanism includes potential central nervous system (CNS) targets of the disease shown by lower CSF hypocretin-1 levels, inflammation and microglial activation in CNS, and proinflammatory cytokine-induced neurotransmitter dysfunction (Chan and Gold, 2007). Several reports have shown subclinical involvement and demyelination of the central pathways (Chan and Gold, 2007; Vallat et al., 2010). This is similar to another chronic inflammatory demyelinating disorder, multiple sclerosis (MS), which affects the CNS and could increase rates of depression and bipolar disorder that might be related to oxidative stress, autoimmunity and demyelination (Carta et al., 2014). Immune-mediated inflammation and cytokines may influence brain circuits as observed in MS and AIDP, and steroid treatment was effective for both CIDP and mania-like episode in our patient, suggesting that his manic symptoms could relate to the immunopathogenesis of CIDP. In conclusion, we report the first case of mania-like episode associated with CIDP. More studies are needed to clarify the associations between CIDP and manic-like episode.

Self-Stigma Mediates the Impact of Insight on Current Suicide Ideation in Suicide Attempters with Schizophrenia: Results of a Moderated Mediation Approach

This study examined the relationships among insight, self-stigma, self-esteem, hope, quality of life, and suicidal behavior in individuals diagnosed as having schizophrenia. Hypotheses concerning mediating and moderating effects were examined. A total of 170 community-dwelling patients with schizophrenia participated in the study. The results revealed a negative association between insight and suicide ideation, which was partially mediated by self-stigma. Moreover, this indirect link was stronger among patients with suicide attempts than among those without attempts. We discuss the implications of these results for preventing or reducing the considerable risks of suicide in this population.

Aripiprazole-related hyponatremia and consequent valproic acid–related hyperammonemia in one patient:

Australian & New Zealand Journal of Psychiatry, 51(3) patients with schizophrenia, but these blood levels also significantly increased side-effect burden. Therefore, when psychiatrists are faced with clozapine non-responsive patients with schizophrenia, the first suggested step would be to measure clozapine serum levels, aiming for between 350 and 400 μg/mL (Spina et al., 2000), if clozapine side effects can be tolerated. This would be a recommended strategy before adding a second antipsychotic medication. TDM is particularly important in differentiating between psychotic symptoms due to either breakthrough psychosis or non-compliance with clozapine. Break-through psychosis due to non-response at maintenance clozapine doses will possibly require an increased dose of clozapine, while non-compliance to clozapine will generally require reinitiation of the usual maintenance clozapine dose. At this stage, beyond clozapine, there is only limited evidence for regular TDM for other second-generation antipsychotic medication (Lopez and Kane, 2013).

Dilemma of prescribing aripiprazole under the Taiwan health insurance program: a descriptive study

Objectives Refractory major depressive disorder (MDD) is a serious problem leading to a heavy economic burden. Antipsychotic augmentation treatment with aripiprazole and quetiapine is approved for MDD patients and can achieve a high remission rate. This study aimed to examine how psychiatrists in Taiwan choose medications and how that choice is influenced by health insurance payments and administrative policy. Design Descriptive study. Outcome measures Eight questions about the choice of treatment strategy and atypical antipsychotics, and the reason to choose aripiprazole. Intervention We designed an augmentation strategy questionnaire for psychiatrists whose patients had a poor response to antidepressants, and handed it out during the annual meeting of the Taiwanese Society of Psychiatry in October 2012. It included eight questions addressing the choice of treatment strategy and atypical antipsychotics, and the reason whether or not to choose aripiprazole as the augmentation antipsychotic. Results Choosing antipsychotic augmentation therapy or switching to other antidepressant strategies for MDD patients with an inadequate response to antidepressants was common with a similar probability (76.1% vs 76.4%). The most frequently used antipsychotics were aripiprazole and quetiapine, however a substantial number of psychiatrists chose olanzapine, risperidone, and sulpiride. The major reason for not choosing aripiprazole was cost (52.1%), followed by insurance official policy audit and deletion in the claims review system (30.1%). Conclusion The prescribing behavior of Taiwanese psychiatrists for augmentation antipsy-chotics is affected by health insurance policy.

Duloxetine may enhance control of pain related to bladder trauma.

Duloxetine is a serotonin-norepinephrine reuptake inhibitor antidepressant (Bymaster et al., 2001), which also plays a significant role in the treatment of diabetic neuropathic pain (Bymaster et al., 2005). Here we report a patient with severe pain secondary to bladder trauma who responded to duloxetine as an adjunctive treatment. A 23 year-old single male involved in a car accident two years previously experienced persistent severe pelvic injury, even after successive operations, including urinary bladder repair, urethral reconstruction, suprapubic cystostomy and malecot catheter placement. During the following two years the intermittent pain, lasting about 15 minutes per bladder contraction, with intervals of 30 minutes to two hours, responded poorly to oral gabapentin 100mg tid and solifenacin 5mg QD, even with adjunctive nalbuphine 10mg intravenously 3-4 times a day and ranged from 9 to 10 on self-rating as ‘severe and unable to endure’ using a visual analgesic scale (VAS). A psychiatric consultation was requested because of a depressed mood for nearly two months, related to the unremitting pain. Loss of interest, difficulty initiating sleep, decreased energy, worthlessness and suicidal ideation were also present. A diagnosis of major depressive disorder was made, and duloxetine 30-60mg/day was commenced. On days two to three of duloxetine use, although the pain frequency and depression remained unchanged, the severity decreased from VAS 9-10 to 4-5. Ability to move from the bed was regained. Light activities outside the ward room were attempted, while his depressive mood, as well as his pain, improved during the following eight weeks. In this case, there is little response when the pain management begins with gabapentin, nalbuphine and solifenacin, but prominent improvement after duloxetine administration. The observation that the pain preceded the depressive episode, and rapidly reduced after the administration of duloxetine, suggests that duloxetine possibly relieved the pain via analgesic pathways, rather than an antidepressant effect, which usually takes many weeks. We hypothesise that duloxetine alleviates pain through simultaneous modulation of norepinephrine and serotonin in the descending analgesic pathway, from the supraspinal or spinal levels. Indeed, a recent study shows that duloxetine may block the NMDA receptor involved in pain perception in mice (Zomkowski et al., 2012). To our knowledge, this is the first report of duloxetine use in the management of refractory pain from bladder trauma. Further studies are warranted to investigate the use of duloxetine in the management of pain from bladder or other pelvic trauma.