Evaluation of Methadone Treatment in Malaysia: Findings from the Malaysian Methadone Treatment Outcome Study (MyTOS).

BACKGROUND: Opioid misuse and dependence is a global issue with a huge negative impact. In Malaysia, heroin is still the main illicit drug used, and methadone maintenance treatment (MMT) has been used since 2005. OBJECTIVE: To evaluate the effectiveness of MMT. METHODS: This was a cross-sectional study conducted in 103 treatment centers between October and December 2014 using a set of standard questionnaires. Data were analyzed using SPSS Statistics 20. RESULTS: There were 3254 respondents (93.6% response rate); of these 17.5% (n = 570) transferred to another treatment center, 8.6% (n = 280) died, 29.2% (n = 950) defaulted, and 7.6% (n = 247) were terminated for various reasons. Hence, 1233 (37%) respondents' baseline and follow-up data were further analyzed. Respondents had a mean age of 39.2 years old and were mainly male, Malay, Muslim, married (51.1%, n = 617), and currently employed. Few showed viral seroconversion after they started MMT (HIV: 0.5%, n = 6; Hepatitis B: 0.3%, n = 4; Hepatitis C: 2.7%, n = 29). There were significant reductions in opioid use, HIV risk-taking score (p < 0.01), social functioning (p < 0.01), crime (p < 0.01), and health (p < 0.01). However, there were significant improvements in quality of life in the physical, psychological, social, and environmental domains. Factors associated with change were being married, employed, consuming alcohol, and high criminality at baseline. Lower methadone dosage was significantly associated with improvements in the physical, psychological, and environmental domains. Conclusion/Importance: The MMT program was found to be successful; hence, it should be expanded.

Risk factors of erectile dysfunction in patients receiving methadone maintenance therapy.

INTRODUCTION: While methadone effectively treats opiate dependence, the side effect of erectile dysfunction (ED) may interfere with treatment adherence and benefits. AIM: To determine the rate of ED and the associated factors which predict ED in male patients on methadone maintenance therapy (MMT) in a Malaysian population. MAIN OUTCOME MEASURES: The main outcome measures were the International Index of Erectile Function-15 (IIEF-15) and the Beck Depression Inventory (BDI). METHODS: A total of 108 participants diagnosed with heroin dependence were assessed. We used the Structured Clinical Interview for DSM-IV Axis-I Disorders (SCID-I) on subjects who received MMT, and they were assessed using the IIEF-15, the BDI, and measures of other clinical and sociodemographic variables. RESULTS: The rate of ED among men on MMT was 68.5% (mild ED, 36.1%; mild to moderate ED, 22.2%; severe ED, 3.7%). The mean age of the participants was 43.45 years. Older age (P = 0.002), concurrent illicit heroin use (P = 0.024), and having an older partner (P = 0.039) were significantly associated with ED. Following multivariate analysis, it was found that older age was the only significant predictor of ED, with an adjusted odds ratio of 1.07 (95% CI = 1.02-1.16). Methadone dose and duration of methadone treatment were not significantly associated with ED. CONCLUSION: ED was highly prevalent among male patients on MMT. This suggests that there is a need for routine assessment of sexual function in patients on methadone. Among the risk factors, age was the only factor that was significantly associated with ED. The current use of MMT in Malaysia in terms of dosage and duration did not pose a significant risk for ED.

Long-term Safety and Efficacy of Esketamine Nasal Spray Plus an Oral Antidepressant in Patients with Treatment-resistant Depression- an Asian Sub-group Analysis from the SUSTAIN-2 Study.

OBJECTIVE: To evaluate the long-term safety and efficacy of intranasal esketamine in patients with treatment-resistant depression from the Asian subgroup of the SUSTAIN-2 study. METHODS: SUSTAIN-2 was a phase 3, open-label, single-arm, multicenter study comprising a 4-week screening, 4-week induction, 48-week optimization/maintenance, and 4-week follow-up (upon esketamine discontinuation) phase. Patients with treatment-resistant depression received esketamine plus an oral antidepressant during the treatment period. RESULTS: The incidence of ≥ 1 serious treatment-emergent adverse event (TEAE) among the 78 subjects from the Asian subgroup (Taiwan: 33, Korea: 26, Malaysia: 19) was 11.5% (n = 9); with no fatal TEAE. 13 Asian patients (16.7%) discontinued esketamine due to TEAEs. The most common TEAEs were dizziness (37.2%), nausea (29.5%), dissociation (28.2%), and headache (21.8%). Most TEAEs were mild to moderate in severity, transient and resolved on the same day. Upon discontinuation of esketamine, no trend in withdrawal symptoms was observed to associate long-term use of esketamine with withdrawal syndrome. There were no reports of drug seeking, abuse, or overdose. Improvements in symptoms, functioning and quality of life, occurred during in the induction phase and were generally maintained through the optimization/maintenance phases of the study. CONCLUSION: The safety and efficacy of esketamine in the Asian subgroup was generally consistent with the total SUSTAIN-2 population. There was no new safety signal and no indication of a high potential for abuse with the long-term (up to one year) use of esketamine in the Asian subgroup. Most of the benefits of esketamine occurred early during the induction phase.

Factors Influencing Professional Help-Seeking Behavior During First Episode Psychosis in Schizophrenia: An Exploratory Study on Caregivers' Perspective.

Schizophrenia is a severe mental illness that leads to significant productivity loss and is listed in the top 15 global burdens of disease. One important contributor to the high disease burden is duration of untreated psychosis (DUP) which can be shortened with promotion of professional help-seeking behavior. This study explored caregivers' perspective on factors influencing professional help-seeking behavior during first episode psychosis (FEP) in schizophrenia in Malaysia. The results of this study would inform the development of intervention strategies targeted at promoting professional help-seeking behavior in caregivers of individuals experiencing first episode psychosis (FEP). This is a thematic exploratory study which employed purposive sampling using focus group discussion (FGD). These interviews were audio recorded and transcribed verbatim. Basic thematic approach was used in analyzing the transcribed interviews. Two main themes identified were adequacy of knowledge and stigma. These two factors were found to co-influence each other. Stigma undermined the impact of knowledge on professional help-seeking; likewise, the reverse was also observed. Intervention strategies for promoting help-seeking behavior during FEP should simultaneously focus on improving knowledge about schizophrenia and reducing the stigma attached to it.

Metabolic Syndrome in First Episode Schizophrenia, Based on the National Mental Health Registry of Schizophrenia (NMHR) in a General Hospital in Malaysia: A 10-Year Retrospective Cohort Study.

Schizophrenia has been linked with various medical comorbidities, particularly metabolic syndrome. The number of studies on this aspect is lacking in Malaysia. (1) Objective: To investigate metabolic syndrome rates and its associated factors. (2) Method: This is the first 10-year retrospective-outcome study of patients with first episode schizophrenia in Malaysia. Out of 394 patients diagnosed with first episode schizophrenia and registered with the National Mental Health Registry of Schizophrenia (NMHR) in the General Hospital Kuala Lumpur (GHKL) in 2004⁻2005, 174 patients consented to participate in the study. They were interviewed using a Schizophrenia outcome questionnaire and the International Physical Activity Questionnaire (IPAQ). The diagnosis of metabolic syndrome was made using the National Cholesterol Education Program—Third Adult Treatment Panel (NCEP ATP III). (3) Results: All patients’ weight, body mass index, fasting blood sugar, and blood pressure are significantly increased. Sixty-three subjects (36.2%) developed metabolic syndrome while 36 (23.2%) were hypertensive, and 41 (28.1%) were diabetic. Use of fluphenthixol depot (CI = 1.05⁻5.09, OR: 0.84, p = 0.039), reduced physical activity (CI = 0.13⁻1.00, OR: −1.04, p = 0.049), and substance use disorder (CI = 1.40, 13.89, OR: 1.48, p = 0.012) were significantly associated with metabolic syndrome based on univariate analysis. In further multivariate analysis, comorbid substance abuse was the only significant factor associated with metabolic syndrome after adjusting for physical activity and intramuscular depot. (4) Conclusion: Patients with schizophrenia are at high risk of metabolic syndrome. It is important to address substance use problems as an important risk factor of this comorbidity.

The economic burden of schizophrenia in Malaysia.

INTRODUCTION: Schizophrenia (SCZ) is a highly debilitating disease despite its low prevalence. The economic burden associated with SCZ is substantial and mainly attributed to productivity loss. To improve the understanding of economic burden of SCZ in the low- and middle-income country regions, we aimed to determine the economic burden of SCZ in Malaysia. METHODS: A retrospective study was conducted using a prevalence-based approach from a societal perspective in Malaysia with a 1 year period from 2013. We used micro-costing technique with bottom-up method and included direct medical cost, direct non-medical cost, and indirect cost. The main data source was medical chart review which was conducted in Hospital Kuala Lumpur (HKL). The medical charts were identified electronically by matching the unique patient's identification number registered under the National Mental Health Schizophrenia Registry and the list of patients in HKL in 2013. Other data sources were government documents, literatures, and local websites. To ensure robustness of result, probabilistic sensitivity analysis was conducted. RESULTS: The total estimated number of treated SCZ cases in Malaysia in 2015 was 15,104 with the total economic burden of USD 100 million (M) which was equivalent to 0.04% of the national gross domestic product. On average, the mean cost per patient was USD 6,594. Of the total economic burden of SCZ, 72% was attributed to indirect cost, costing at USD 72M, followed by direct medical cost (26%), costing at USD 26M, and direct non-medical cost (2%), costing at USD 1.7M. CONCLUSION: This study highlights the magnitude of economic burden of SCZ and informs the policy-makers that there is an inadequate support for SCZ patients. More resources should be allocated to improve the condition of SCZ patients and to reduce the economic burden.

Serotonin transporter polymorphisms and clinical response to sertraline across ethnicities.

The aim of this pilot study was to examine the relationship between clinical response, adverse effects, sertraline (SERT) plasma concentrations and the genetic polymorphism of the serotonin transporter gene-linked polymorphic region (5HTTLPR) in 2 ethnic patient groups. The study involved 45 patients in a clinical trial who received a fixed dose regimen of 50 mg SERT for one week, then a variable-dose regimen for a further 6 weeks for major depressive disorder. At weeks 1 and 6, the following assessments were completed: Hamilton Depression Rating Scale (HDRS), Clinical Global Impression (CGI), drug adverse reaction scale and measurement of plasma SERT levels. Genomic analysis for the long and short allele variants of the 5HTTLPR polymorphism was also carried out. Caucasian subjects had a higher rate of l/l genotype while Chinese subjects had higher frequencies of l/s and s/s genotypes. Comparison of the subjects with the 5HTTLPR s/s genotype and those with the l/l and l/s genotypes found no significant differences in the HDRS scores, CGI scores, response rates, adverse effects and SERT plasma concentrations at week 6.