Clinical practice guidelines for depression.

The Ministry of Health Clinical Practice Guidelines for Depression were prepared and distributed to all doctors in Singapore in early 2004. This article highlights salient points and discusses pharmacotherapy, psychotherapy and psychoeducation in managing cases of depression. Assessment of suicide risk is elaborated upon, although this was not discussed in the guidelines. The learning points will be enhanced if this article is reviewed together with the Ministry of Health Clinical Practice Guidelines.

Assessment of suicide risk.

Suicide is preventable and the first step in prevention is to identify those who are at risk. The psychiatrically ill are at high risk of suicide. The majority who commit suicide have given clear indications of suicidal intent shortly before the act. In the assessment of suicide risk the precipitating factor, the intensity of suicidal intentions, the patient's motivation for suicide and the lethality of the attempt have to be taken into consideration. Patients with significant suicide risk need to be hospitalized.

Management of obsessive compulsive disorder.

The treatment of obsessive compulsive disorder was characterised by therapeutic pessimism until 25 years ago when effective treatments using behaviour therapy and the serotonin reuptake inhibitors were developed. At present the best available treatment is a combination of behaviour therapy and pharmacotherapy with a serotonin reuptake inhibitor. Psychosurgery is only indicated for patients who fail to respond to pharmacologic and behavioural treatments and who suffer from disabling symptoms.

Suicide in Singapore: a changing sex ratio over the last decade.

AIM OF STUDY: To examine for any change in the sex ratio of suicides in Singapore over the last decade. METHODS: Data on suicides in Singapore for the decade 1989-98 were examined, both as an overall set and as four age-based sub-groups. RESULTS: The male to female ratio increased significantly over the decade, contributed to most distinctly by changed rates in young adults (ie a group defined as 29-40 years). The changed sex ratio appeared limited to Chinese subjects, where the suicide rate/100,000 population was consistently higher than for the non-Chinese. The changed ratio appeared more to reflect an absolute decrease in female suicides rather than any distinct absolute increase in male suicides. CONCLUSIONS: The previous distinct male preponderance in suicide,which had progressively diminished by the early eighties, has become distinct again, but is now seemingly more driven by a disproportionate decline in the absolute rate of suicides in younger females. We speculate on possible social determinants of this intriguing epidemiological trend.

Psychiatric survey of offenders under criminal commitment in Singapore.

AIM OF STUDY: The study examined the demographic characteristic, pattern of psychiatric morbidity in offenders committed by Singapore courts and the effects of psychiatric recommendations on the disposal of these offenders. METHODS: A retrospective case-note study was done on all offenders committed by the courts from January 1987 to December 1988 to Woodbridge Hospital. A 23-item questionnaire was used to collect data from the offenders. RESULTS: There were 187 offenders in the study, 165 males and 22 females. The typical offender was Chinese, male, unemployed and suffered from schizophrenia. 63.1% of the offenders required treatment after commitment. 13.9% had no psychiatric disorder. At the end of commitment, charges were dropped in 25% of cases. Theft was the most common offense and this was followed by sexual offences (molestation, outrage of modesty, exhibitionism). Offenders with schizophrenia were more likely than the others to have committed violent offences. CONCLUSION: A large proportion of offenders were unwell at the time of the offence, the majority were suffering from schizophrenia. 13.9% had no psychiatric illness and charges were dropped in 25% indicating that the legal process could be further improved by providing additional psychiatric input to the courts so that offenders who exhibit abnormal or deviant behaviour may be appropriately dealt with.

Risperidone in the treatment of first episode psychosis.

OBJECTIVE: To evaluate the efficacy and safety of risperidone in Singapore patients with first-episode psychosis in an eight-week open label prospective study. METHOD: Previously untreated male and female patients aged 18 - 65 with DSM IV schizophreniform disorder or DSM IV schizophrenia for no longer than 12 months were recruited from Woodbridge Hospital and Geylang Psychiatric Outpatient Clinic. Patients were treated with risperidone for 56 days. Outcome was assessed with the Positive and Negative Syndrome Scale (PANSS), the Clinical Global Impression scale (CGI). Safety was assessed by monitoring of vital signs and by comparing the frequency of adverse events (AEs) before and after treatment. RESULTS: 24 patients with a mean age of 33.29+/-9.12 years and a mean duration of illness of 166.5+/-111.4 days (median 180 days) were included. The mean risperidone dosage was 2.7 mg +/- 1.0 at day 56. Mean PANSS total scores reduced by 50.21% from 88.29+/-21.55 at baseline to 43.96+/-7.5 at endpoint (p < 0.001). The responder rate (> or = 20% reduction in the total PANSS score) was 87.5%. 13 patients (54.2%) exhibited a 50% or greater reduction in total PANSS score. Except for item G5 (mannerisms and posturing) all single PANSS items were reduced significantly. The CGI scores of all patients improved at endpoint. No serious adverse events were reported. CONCLUSIONS: Overall the therapy of first-episode psychosis patients with risperidone was effective and safe.

Clinical evaluation of risperidone in Asian patients with schizophrenia in Singapore.

OBJECTIVE: To evaluate the short-term efficacy and safety of risperidone in a group of Asian patients with schizophrenia in an 8-week open-label, prospective study. METHODS: Patients with DSM-IV schizophrenia were recruited from Woodbridge Hospital. After a washout period, they were started on a 56-day trial of risperidone. Outcome was assessed with the positive and negative syndrome scale (PANSS), the clinical global impression scale (CGI) and the extrapyramidal symptom rating scale (ESRS). RESULTS: The mean daily risperidone dose at end point was 5.6 mg (range, 3 to 8 md/day). Mean PANSS scores were reduced significantly from 78 +/- 15.1 at baseline to 56.6 +/- 10.9 at end point. Seventeen patients (85%) who were treatment responders, showed at least a 20% reduction in total PANSS scores at end point while nine patients (45%) had a greater than 50% reduction in the total PANSS scores. According to the CGI scale, 85% improved at end point. The severity of extrapyramidal symptoms (mean ESRS scores) were significantly lower at end point than at baseline. CONCLUSIONS: Risperidone was effective in the treatment of positive and negative symptoms of schizophrenia.

Mental disorders and public safety of the community at large--does the Tarasoff principle apply in Singapore?

The Tarasoff Principle is a legal ruling arising out of the Tarasoff case in California, in which 2 therapists were found by a court to be negligent for not warning an intended victim of a threat to her by their mentally disordered patient, and she was subsequently killed. The 2 therapists were deemed to have an obligation to protect an intended victim of a patient who presented a serious danger of violence. The question is whether this would apply under Singapore law, and whether an act of disclosure to protect a victim would be a breach of confidentiality and the doctor-patient relationship.

Early psychosis intervention.

Early psychosis intervention programmes have been around for 20 years. The duration of psychosis has been hypothesised to be neurotoxic, and there is a critical period, postulated to be up to five years from the onset of psychosis for intervention before the psychosis becomes established. Early intervention is expected to change the course of psychosis and hence, the outcome. However, despite the proliferation of early intervention services, research has shown that improvement in outcome is at best modest, lasting only for the duration of the intervention, and these benefits are not sustained after five years. Evidence for the cost-effectiveness of these services is accumulating and indicates that the reduction in costs is due to reduced inpatient stays.

Mental health literacy survey of psychiatrically and generally trained nurses employed in a Singapore psychiatric hospital.

Mental health literacy studies consider the capacity of respondents to recognize certain psychiatric disorders, judge the comparative utility of a range of interventions, and make estimates about outcome and prognostic issues. We report such a study involving a sample of nursing staff employed at a large psychiatric institution in Singapore, and who were provided with separate brief vignettes of mania, schizophrenia and depression. Subjects were highly accurate in 'diagnosing' schizophrenia, less accurate for depression and even less accurate in diagnosing mania. Depression was alternately diagnosed as stress, mania was most commonly misdiagnosed as schizophrenia, and for both psychotic conditions, a percentage returned non-psychotic diagnoses. In terms of treatment options, staff distinctly favoured a 'medical model' and viewed traditional and alternative healing options as distinctly harmful. Analyses contrasted psychiatrically trained and generally trained nurses, but identified few significant differences. Such information has the potential to shape the education and training of mental health professional staff, as well as provide important insights about how nurses may diagnose, view and favour alternative treatments and strategies to assist those with common psychiatric disorders.