Yuan-Hwa Chou

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.

Levels of the potential biomarker p11 in peripheral blood cells distinguish patients with PTSD from those with other major psychiatric disorders

Posttraumatic stress disorder (PTSD) is a severely debilitating anxiety disorder. Over 80% of patients with PTSD also exhibit other psychiatric condition, such as bipolar disorder (BP) or major depression (MDD). Previously, it has been found that p11 mRNA expression was significantly changed in post mortem cortex of patients with PTSD and depression. We hypothesize that p11 mRNA levels in the peripheral blood cells will be a potential biomarker for PTSD with heterogeneity in terms of type of trauma, time since trauma and duration of illness. We examined the peripheral blood mononuclear cell (PBMC) P11 mRNA of patients with PTSD (n=13), major depressive disorder (MDD, n=16), bipolar disorder (BP, n=24), and schizophrenia (SCZ, n=12) or controls (n=14) using quantitative real-time PCR and the circulating levels of cortisol in blood plasma and saliva of PTSD using radioimmunoassay kit CORT-CT2. The Hamilton Rating Scale for Depression (HAMD) and Anxiety (HARS), the Chinese version of the Davidson Trauma Scale-Frequency (CDTS-F) and the Chinese version of the Davidson Trauma Scale-Severity (CDTS-S), and Impact of Event Scale-Revised (IES-R) were administered. We found that patients with PTSD had lower levels of p11 mRNA than control subjects, while those with MDD, BP and SCZ had significantly higher p11 levels than the controls. P11 mRNA levels were positively correlated with the scores of HAMD (r=0.62, p<0.05), CDTS-F (r=0.71, p<0.05) and CDTS-S (r=0.62, p<0.05), while they did not correlate with scores of HARS and IES-R. Basal levels of plasma and salivary cortisol of PTSD patients were not statistically different from those of controls. Our findings suggest that PBMC p11 mRNA expression levels may serve as a potential biomarker to distinguish PTSD from BP, MDD and SCZ.

White matter abnormalities in schizophrenia patients with tardive dyskinesia: a diffusion tensor image study.

OBJECTIVE Tardive dyskinesia (TD) is a severe side effect of antipsychotics. While increasing evidence suggests that damaged brain microcircuitry of white matter (WM) is responsible for the clinical symptoms in schizophrenia, no reports of WM abnormality associated with TD were noted. METHOD Brain white matter abnormalities were investigated among 20 schizophrenia patients with TD (Schizophrenia with TD group), 20 age-, gender-, and handedness-matched schizophrenic patients without TD (Schizophrenia without TD group), and 20 matched healthy subjects with magnetic resonance imaging and diffusion tensor imaging analysis. Voxel-wise analysis was used to compare fractional anisotropy (FA) maps of the white matter following intersubject registration to Talairach space. Clinical ratings included the Positive and Negative Symptoms Scale (PANSS), Abnormal Involuntary Movement Scale (AIMS), and the Simpson-Angus Scale (SAS). RESULTS The study subjects were 75% female with average of 40.1+/-9. 8 years. The Schizophrenia with TD group had significantly higher PANSS total scores (p=0.024), PANSS negative score (p=0.001), SAS (p<0.001) and AIMS (p<0.001) scores; and demonstrated more widespread FA decreases than the Schizophrenia without TD group, especially over the inferior frontal gyrus, temporal sublobar extranuclear WM (around the basal ganglion), parietal precuneus gyrus WM (around somatosensory cortex), and medial frontal gyrus WM (around dorsolateral prefrontal cortex). The AIMS (p<0.01) and SAS (p<0.01) score positively correlated with decreased FA over these areas, and PANSS negative score positively correlated with FA decrease over medial frontal gyrus WM (p<0.01). CONCLUSIONS More widespread abnormality of white matter was noted among schizophrenia patients than those without, especially involved cortico-basal ganglion circuits with clinical symptom correlation of involuntary movements and negative symptoms. Further studies with larger sample size are required to validate the findings.

Comorbidity of cardiovascular diseases with mood and anxiety disorder: a population based 4-year study.

Aims:  Accumulating evidence from Caucasian patients has shown that depression, bipolar and anxiety disorders are associated with an increased risk of cardiovascular diseases (CVD), but reports in the Asian population are limited, and age effect is rarely investigated. This population‐based study was carried out to examine and compare the CVD comorbidities among patients with mood and anxiety disorders in different age groups.

Predictors of carbon monoxide poisoning-induced delayed neuropsychological sequelae

OBJECTIVE Carbon monoxide poisoning (COP) commonly results in delayed neuropsychological sequelae (DNS). The aim of the article is to demonstrate the clinical characteristics and potential predictors of COP-induced DNS later. METHOD Retrospective medical record review was performed for patients who had COP in the past year at a National Medical Center in Taiwan. Sixty patients with COP were registered during a one-year period. Fifty-six of them (93.3%) were COP because of suicide attempt. Patients with COP who have a complete medical record of carboxyhemoglobin (COHb) and Glasgow Coma Scale (GCS) and Mini-Mental Status Examination (MMSE) scores were recruited. Multiple regression analysis was performed to search for the predictive factors of DNS. RESULTS Forty-three patients were recruited. Most had attempted suicide (93.0%) using CO, and thirteen developed DNS later. A longer duration of admission, more sessions of hyperbaric oxygen therapy, and positive findings in brain computed tomography (CT) scans were more often found in patients with DNS than those without DNS. The GCS and MMSE scores and positive findings in brain CT scans were associated with the development of DNS but COHb was not. CONCLUSIONS Our results identified several potential predictors of DNS. This finding may help clinicians understand and treat COP patients efficiently.

Imaging the serotonin transporter using 123I-ADAM in the human brain

The aim of this study was to examine the feasibility of (123)I-ADAM to image the serotonin transporter (SERT) in Asian (Taiwanese) subjects. Single photon emission computed tomography (SPECT) scans were performed on nine healthy volunteers who were s-allele carriers at the polymorphism within the serotonin transporter promoter region (SERTPR) after intravenous bolus injection of (123)I-ADAM. Quantification of (123)I-ADAM binding was performed using the ratio equilibrium method (REM) with specific uptake ratio (SUR) and a simplified reference tissue model (SRTM). Curve-fitting techniques were used to obtain the peak equilibrium point from 241 to 301 min (average 264+/-20 min) after injection of (123)I-ADAM for the midbrain and from 215 to 270 min (average 235+/-18 min) after injection of (123)I-ADAM for the striatum. Two sets of SUR were obtained by either curve fitting (estimated values) or integrated period from 240 to 270 min (observed values). The estimated values of SUR were 2.11+/-0.51 for the midbrain and 1.50+/-0.44 for the striatum, whereas the observed values were 2.11+/-0.83 for the midbrain and 1.24+/-0.31 for the striatum. The SRTM showed that the binding potential (BP) was 2.10+/-0.66 for the midbrain and 1.35+/-0.25 for the striatum. There was a good correlation between estimated SUR, observed SUR and SRTM in the midbrain but not in the striatum. The optimal scanning duration for both the midbrain and the striatum should be 220 to 280 min similar to that suggested by previous studies in Caucasians. However, due to the low signal-to-noise ratio in the striatum, (123)I-ADAM could be an ideal tracer for imaging SERT in the midbrain but not in the striatum.

Medically Unexplained Symptoms and Somatoform Disorders: Diagnostic Challenges to Psychiatrists

Background: Clinical limitations of the criteria of somatoform disorders (SDs) have been criticized. However, little objective evidence supports this notion. We aimed to examine the prevalence of SDs in a population with medically unexplained symptoms (MUS), which was expected to have higher probabilities meriting such diagnoses, and to evaluate factors that may influence the clinical judgment of psychiatrists. Methods: Data of subjects with MUS (n = 101, 9.5%) as their chief consulting problems, of 1,068 consecutive ethnic Chinese adult medical inpatients referred for consultation‐liaison psychiatry services, were reviewed. Psychiatric diagnoses including SDs and clinical variables were collected. Those with SDs were followed‐up 1 year later, and structured interviews were applied. Results: Patients with MUS had a high level of psychiatric comorbidity, especially depression (35.6%) and anxiety disorder (29.7%), rather than SDs (9.9%). Most diagnosed with SDs suffered from persistent MUS at the 1‐year follow‐up. Pain was the most common presentation of MUS. Most of the subjects diagnosed with SDs were female and younger, with multiple painful sites at presentation, no past psychiatric diagnosis and no comorbid organic diagnoses. The diagnosis of SDs was seldom given in those with simultaneous MUS and mood symptoms. Conclusion: A significant proportion (9.5%) of patients in psychiatric consultation suffered from MUS, and most were comorbid with depression and anxiety. The identification of SDs was made in only 9.9%. Because MUS are associated with a high rate of mental comorbidities, psychiatric consultations while facing such clinical conditions are encouraged.

Short term vs. long term test–retest reproducibility of 123I-ADAM for the binding of serotonin transporters in the human brain

Previous brain imaging studies have demonstrated a seasonal difference of serotonin transporter (SERT) binding in the human brain. However, the results were somewhat contradictory. We conducted test-retest study with single photon emission computed tomography (SPECT) with ¹²³I-ADAM as ligand in 28 healthy subjects. Ten of the subjects were studied within 1 month, whereas 18 were randomly assigned to be studied over a period of up to 1 year. The primary measure was the specific uptake ratio (SUR). Regions of interest included the midbrain, thalamus, putamen and caudate. The intra-class correlation coefficient (ICC) was 0.52-0.94 across different brain regions over 1 month, whereas the ICC was -0.24-0.63 over a 1-year period. The 1-month variability ranged from 6.5 ± 5.1% to 12.5 ± 10.6% across different brain regions, and the 1-year variability ranged from 16.5 ± 9.6% to 41.9 ± 35.5%. The Kruskal-Wallis test revealed a significant difference of variability across months. The Wilcoxon Signed Ranks Test showed the SUR between test-retest scans was of borderline significance. Curve fitting, using a 4th degree polynomial model, revealed a significant circadian correlation between the variability and interval of test-retest measurements. Our findings demonstrate the test-retest reproducibility of ¹²³I-ADAM in different time periods and suggest that circadian variation of SERT levels in the human brain might exist.

Acute renal failure after paliperidone overdose: a case report.

CASE REPORT A 34-year-old Chinese man with schizophrenia had received paliperidone 12 mg/d for the previous year and maintained a stable condition. He was satisfied with paliperidone and felt it improved his cognitive function. In September 2010, the patient wanted to improve his thinking ability more, so he took 16 tablets of paliperidone (3 mg each) within 2 days and also took his mother’s medications, including 1 tablet of atenolol 50 mg and 2 tablets of simvastatin 20 mg to relieve his headache. His mother worried about the possible sequelae and brought him to the emergency department. On arrival, the patient had clear consciousness with good orientation and was cooperative. He denied suicidal ideation and any use of illicit drugs, herbal medicine, or alcohol. No significant extrapyramidal adverse effects were observed. All vital signs (body temperature, 36.8-C [orally obtained]; blood pressure, 115/60 mm Hg; respiration, 18 breaths per minute) and physical examination, electrocardiography, and chest x-ray results were unremarkable. Gastric lavage and activated charcoal were withheld. To our surprise, the blood laboratory tests showed serum creatinine level of 7.19 mg/dL and serum urea nitrogen of 56 mg/dL, and the arterial blood gas demonstrated metabolic acidosis (pH 7.345; HCO3 , 17.4 mM; PCO2, 32.7 mm Hg). Therefore, he was admitted to the medical ward under the diagnosis of ARF. After admission, a thorough workup was performed to rule out other causes of ARF. All data were unremarkable, including abdominal ultrasound; urinalysis; serum creatine phosphokinase; serum levels of IgG, IgA, IgM, C3, and C4; and virological screening for anti-HAV IgM, HbsAg, anti-HCV, anti-HIV, ANA, anti-dsDNA antibody, and anti-GBM antibody, SSA, SSB, and ANCA. The patient’s renal function improved gradually with intravenous hydration and sodium bicarbonate treatment. The serum creatinine level decreased to 2.80, 2.08, and 1.50 mg/dL on days 5, 6, and 9, respectively. The patient was discharged in a stable condition. He insisted on continuing paliperidone, and 12 mg/d was prescribed from the 10th day. In a subsequent clinical follow-up, the patient’s condition was stable, and the serum creatinine level was still within reference limits (1.14 mg/dL) 3 months after discharge.

Faster onset of antidepressant effects of citalopram compared with sertraline in drug-naïve first-episode major depressive disorder in a Chinese population: a 6-week double-blind, randomized comparative study.

Several previous studies, including a meta-analysis, reported no significant differences between various selective serotonin reuptake inhibitors (SSRIs) in the treatment of major depressive disorder. However, because of the different chemical structure of SSRIs and the difference in the frequency of serotonin transporter polymorphisms between ethnic groups, a head-to-head comparative study between SSRIs in different populations may be enlightening. We compared the efficacy and adverse effect profiles of citalopram and sertraline in a double-blinded randomized clinical trial in a Chinese population of drug-naïve patients with first-episode major depressive disorder. Fifty-one patients were randomly assigned to citalopram or sertraline treatment. The Montgomery-Åsberg Depression Rating Scale (MADRS) was used as the primary outcome. Efficacy and adverse effects were analyzed in an intent-to-treat population. Efficacy was analyzed using a last-observation-carried-forward method for early terminators. There were no significant differences in demographic characteristics at baseline. No significant differences were found in MADRS scores between citalopram and sertraline at baseline (36.6 ± 5.5 vs 38.2 ± 4.9; P = 0.322) or at the end of treatment (week 6; 10.8 ± 10.0 vs 16.7 ± 11.3; P = 0.082). However, MADRS scores in the citalopram group were significantly lower at week 1 (25.2 ± 8.5 vs 30.4 ± 6.1; P = 0.029) and week 3 (15.9 ± 10.0 vs 22.1 ± 8.7; P = 0.037). Overall, treatment-emergent adverse effects were reported by 14.3% and 28.6% of patients in the citalopram and sertraline groups, respectively. In conclusion, citalopram and sertraline were both efficacious and well tolerated. However, citalopram exhibited a significantly faster onset than sertraline during the early weeks of treatment and tended to have a better efficacy in overall treatment, although the statistic was not significant.