Yue-Joe 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.

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.

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.

Sleep disorders in Chinese culture : Experiences from a study of insomnia in Taiwan

Abstract Traditional Chinese culture‐constituted health beliefs continue to influence the Taiwanese people after more than one hundred years of contact with Western medicine. Medicine for sleep disorders, as well as psychiatric medicine, meets some specific difficulties in the professional development. A study of insomnia in Taiwan showed that patients might seek help from a traditional physician and visit a modern hospital at the same stage of medication. General internists and neurologists help to differentiate organic conditions underlying sleep problems but may generalize insomnia to a psychogenic illness. The culture‐conditioned attribution of insomnia could also exert certain effects upon pharmacotherapeutic response.

The counterbalance between leptin and cortisol may be associated with comorbid depression and anxiety.

Details of the psychopathologic relationship that exists between major depression and leptin are uncertain. However, the comorbidity which is known to occur between major depression and anxiety disorders may help elucidate this controversy. In addition to their comments on the heterogeneity of obsessive-compulsive disorder (OCD), Atmaca and colleagues have also provided important insight regarding the heterogeneity of major depression. 1 In theory, hyperactivity of the hypothalamo–pituitary–adrenal (HPA) axis, yielding an elevated level of cortisol, is an important pathogenic factor for major depression. From a dynamic perspective, previous neuroendocrinological studies have established that the HPA axis responds quickly to acute stress. The HPA axis also has the capacity to adapt to chronic stress so that further responsiveness is maintained. 2 Leptin, a neuropeptide derived primarily from peripheral adipose tissue, may provide negative feedback inhibition to the HPA axis which is crucial for adapting to chronic stress. 2 Psychopathology would be the result if such a mechanism of counterbalance was impaired. Hence, compromised suppression of cortisol secretion by a reduced level of leptin could precipitate major depression. It is thus feasible that the role of leptin to a hyperfunctioning HPA axis, as occurs in major depression, may be influenced by a psychiatric comorbidity. Many community-based epidemiological studies have shown that major depression is often accompanied by anxiety disorders. Hypoleptinemic subjects with both major depression and OCD may in fact have an impaired feedback loop involving the HPA axis, which in turn may contribute to hyperactivity of the HPA axis. In a study involving the victims of a giant earthquake, hyperleptinemia was demonstrated in the subjects exhibiting persistent partial posttraumatic stress disorder (PTSD), yet during an 18-month followup did not meet the diagnostic criteria of major depression. 3 Hypothetically, hyperleptinemia may correlate with excessive inhibition of the HPA axis, manifesting as a lower cortisol level in PTSD. The activity of the HPA axis differs between PTSD and major depression. 4 However, dysfunction of the counterbalance between leptin and cortisol in the opposing direction, irrespective of the cause (i.e. PTSD or major depression with comorbid OCD), is plausible. Future research which investigates the relationship between major depression and leptin should consider psychiatric comorbidities. Such a possibility has not been addressed by previous studies. Structured diagnostic algorithms may be required to identify an anxiety syndrome. Those with pure major depressive episodes and with comorbid anxiety disorders may have a different etiology in the pattern or impact of the leptin–cortisol interaction.

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.