Pharmacoepidemiology and Clinical Correlates of Lithium Treatment for Bipolar Disorder in Asia.

BACKGROUND: As clinical practices with lithium salts for patients diagnosed with bipolar disorder (BD) are poorly documented in Asia, we studied the prevalence and clinical correlates of lithium use there to support international comparisons. METHODS: We conducted a cross-sectional study of use and dosing of lithium salts for BD patients across 13 Asian sites and evaluated bivariate relationships of lithium treatment with clinical correlates followed by multivariate logistic regression modeling. RESULTS: In a total of 2139 BD participants (52.3% women) of mean age 42.4 years, lithium salts were prescribed in 27.3% of cases overall, varying among regions from 3.20% to 59.5%. Associated with lithium treatment were male sex, presence of euthymia or mild depression, and a history of seasonal mood change. Other mood stabilizers usually were given with lithium, often at relatively high doses. Lithium use was associated with newly emerging and dose-dependent risk of tremors as well as risk of hypothyroidism. We found no significant differences in rates of clinical remission or of suicidal behavior if treatment included lithium or not. CONCLUSIONS: Study findings clarify current prevalence, dosing, and clinical correlates of lithium treatment for BD in Asia. This information should support clinical decision-making regarding treatment of BD patients and international comparisons of therapeutic practices.

Clozapine Use for Bipolar Disorder: An Asian Psychotropic Prescription Patterns Consortium Study.

BACKGROUND: Pharmacoepidemiological studies of clozapine use to treat bipolar disorder (BD), especially in Asia, are rare, although they can provide insights into associated clinical characteristics and support international comparisons of indications and drug dosing. METHODS: We examined the prevalence and clinical correlates of clozapine treatment for BD in 13 Asian countries and regions (China, Hong Kong SAR, India, Indonesia, Japan, Korea, Malaysia, Myanmar, Pakistan, Singapore, Sri Lanka, Taiwan, and Thailand) within an Asian Prescription Patterns Research Consortium. We compared BD patients treated with clozapine or not in initial bivariate comparisons followed by multivariable logistic regression modeling. RESULTS: Clozapine was given to 2.13% of BD patients overall, at a mean daily dose of 275 (confidence interval, 267-282) chlorpromazine-equivalent mg/day. Patients receiving clozapine were older, more likely males, hospitalized, currently manic, and given greater numbers of mood-stabilizing and antipsychotic drugs in addition to clozapine. Logistic regression revealed that older age, male sex, current mania, and greater number of other antipsychotics remained significantly associated with clozapine treatment. Clozapine use was not associated with depressed mood, remission of illness, suicidal risk, or electroconvulsive treatment within the previous 12 months. CONCLUSIONS: The identified associations of clozapine use with particular clinical features call for vigilance in personalized clinical monitoring so as to optimize clinical outcomes of BD patients and to limit risks of adverse effects of polytherapy.

Minimum and optimal numbers of psychiatric beds: expert consensus using a Delphi process.

The required minimum number of psychiatric inpatient beds is highly debated and has substantial resource implications. The present study used the Delphi method to try to reach a global consensus on the minimum and optimal psychiatric bed numbers. An international board of scientific advisors nominated the Delphi panel members. In the first round, the expert panel provided responses exploring estimate ranges for a minimum to optimal numbers of psychiatric beds and three levels of shortage. In a second round, the panel reconsidered their responses using the input from the total group to achieve consensus. The Delphi panel comprised 65 experts (42% women, 54% based in low- and middle-income countries) from 40 countries in the six regions of the World Health Organization. Sixty psychiatric beds per 100 000 population were considered optimal and 30 the minimum, whilst 25-30 was regarded as mild, 15-25 as moderate, and less than 15 as severe shortage. This is the first expert consensus on minimum and optimal bed numbers involving experts from HICs and LMICs. Many high-income countries have psychiatric bed numbers that fall within the recommended range. In contrast, the number of beds in many LMIC is below the minimum recommended rate.

Data-mining analysis of media frame effects on social perception of schizophrenia renaming in Korea.

BACKGROUND: In 2011, Korean Neuropsychiatric Association renamed schizophrenia from 'mind split disorder' ('Jungshinbunyeolbyung' in Korean) to 'attunement disorder' ('Johyeonbyung' in Korean), in a strategic way to reduce social stigma toward people with schizophrenia. However, there remains an elusive consensus that how the renaming effort has contributed to changes in the social perception of schizophrenia in Korea. METHODS: With this regard, we explored whether media frames alter the social perception, in ways of respecting or disrespecting schizophrenia patients before and after the renaming. This study extensively investigated media keywords related to schizophrenia across the time by applying both language and epidemiologic analyses. RESULTS: In results, the media keywords have been negatively described for schizophrenia patients both before and after the renaming. Further, from an analysis using the regression model, a significant correlation was observed between the frequency of negative keywords and the hospitalization frequency of schizophrenia patients. CONCLUSIONS: These findings suggest that the social perception of schizophrenia has been scarcely changed, but rather remained negatively biased against schizophrenia patients, in spite of the renaming effort. Notably, the biased media frames have been demonstrated to negatively impact on the social perception, and even on the medical use patterns of general schizophrenia patients. In conclusion, we suggest that the unbiased media frames along with the renaming effort may collectively help reduce the negative social perception of schizophrenia. TRIAL REGISTRATION: This study was approved from the Institute of Review Board (IRB) of the Yoing-In Mental Hospital (IRB No. YIMH-IRB-2019-02).

The factor structure of extrapyramidal symptoms evaluated using the Drug-Induced Extrapyramidal Symptoms Scale in patients with schizophrenia: Results from the 2016 REAP AP-4 study.

INTRODUCTION: Drug-induced extrapyramidal syndrome (EPS) remains a major problem in clinical psychiatry. This study aimed to examine the factor structure of drug-induced extrapyramidal symptoms observed in patients with schizophrenia and assessed using the Drug-Induced Extrapyramidal Symptoms Scale (DIEPSS). METHODS: The participants were 1478 patients with a diagnosis of schizophrenia whose EPS was assessed using the DIEPSS in India, Indonesia, Japan, Malaysia, and Taiwan in the 2016 REAP AP-4 study. The records of the participants were randomly divided into two subgroups: the first for exploratory factor analysis of the eight DIEPSS items, and the second for confirmatory factor analysis. RESULTS: The factor analysis identified three factors: F1 (gait and bradykinesia), F2 (muscle rigidity and tremor), and F3 (sialorrhea, akathisia, dystonia, and dyskinesia). CONCLUSION: The results suggest that the eight individual items of the DIEPSS could be composed of three different mechanisms: acute parkinsonism observed during action (F1), acute parkinsonism observed at rest (F2), and central dopaminergic mechanisms with pathophysiology other than acute parkinsonism (F3).

Microbiota-Gut-Brain Axis in Major Depression: A New Therapeutic Approach.

Major depression is impacted by the disruption of gut microbiota. Defects in gut microbiota can lead to microbiota-gut-brain axis dysfunction and increased vulnerability to major depression. While traditional chemotherapeutic approaches, such as antidepressant use, produce an overall partial therapeutic effect on depression, the gut microbiome has emerged as an effective target for better therapeutic outcomes. Recent representative studies on the microbiota hypothesis to explore the association between gut pathophysiology and major depression have indicated that restoring gut microbiota and microbiota-gut-brain axis could alleviate depression. We reviewed studies that supported the gut microbiota hypothesis to better understand the pathophysiology of depression; we also explored reports suggesting that gut microbiota restoration is an effective approach for improving depression. These findings indicate that gut microbiota and microbiota-gut-brain axis are appropriate new therapeutic targets for major depression.

Dosing of Mood Stabilizers for Bipolar Disorder Patients in the Research on Asian Psychotropic Prescription Patterns Consortium Study.

BACKGROUND: Because use and dosing of mood stabilizers (MSs) to treat bipolar disorder (BD) patients in Asia are not well documented, we examined prevalence and clinical correlates of treatment of Asian BD patients with relatively high doses of MSs. METHODS: We conducted a pharmacoepidemiological survey across 13 Asian countries and territory in the Research on Asian Psychotropic Prescription Patterns Consortium. Mood stabilizer doses were converted to lithium carbonate equivalents (Li-eq milligrams per day). We compared relatively high (>900 Li-eq mg/day) versus lower MS doses by bivariate comparisons, followed by multivariable linear regression to identify factors associated with higher MS doses. RESULTS: Among 1647 participants, MS dose averaged 584 (confidence interval, 565-603 Li-eq mg/d). Preliminarily, the 13.1% of the subjects given greater than 900 mg/d versus those given lower doses were younger, male, currently hospitalized, not currently depressed, and reported lifetime suicidal ideation; they also received relatively high doses of antipsychotics, received electroconvulsive treatment within the previous 12 months, and had greater ratings of tremors and sedation. By linear regression modeling, the mean proportion given high doses of MS was associated significantly and independently with higher doses of antipsychotics, younger age, male sex, hospitalized, more years of illness, country, higher body mass index, recent electroconvulsive treatment, and being in illness remission. CONCLUSIONS: Relatively high doses of MSs for BD are prevalent, but vary markedly among Asian countries, and are particularly likely among young males, ill for many years, and given high doses of antipsychotics or ECT. These characteristics allow better identification of patient profiles that can guide treatment of BD patients.

Risks of complicated acute appendicitis in patients with psychiatric disorders.

BACKGROUND: Acute appendicitis often presents with vague abdominal pain, which fosters diagnostic challenges to clinicians regarding early detection and proper intervention. This is even more problematic with individuals with severe psychiatric disorders who have reduced sensitivity to pain due to long-term or excessive medication use or disturbed bodily sensation perceptions. This study aimed to determine whether psychiatric disorder, psychotropic prescription, and treatment compliance increase the risks of complicated acute appendicitis. METHODS: The diagnosis records of acute appendicitis from four university hospitals in Korea were investigated from 2002 to 2020. A total of 47,500 acute appendicitis-affected participants were divided into groups with complicated and uncomplicated appendicitis to determine whether any of the groups had more cases of psychiatric disorder diagnoses. Further, the ratio of complicated compared to uncomplicated appendicitis in the mentally ill group was calculated regarding psychotropic dose, prescription duration, and treatment compliance. RESULTS: After adjusting for age and sex, presence of psychotic disorder (odds ratio [OR]: 1.951; 95% confidence interval [CI]: 1.218-3.125), and bipolar disorder (OR: 2.323; 95% CI: 1.194-4.520) was associated with a higher risk of having complicated appendicitis compared with absence of psychiatric disorders. Patients who are taking high-daily-dose antipsychotics, regardless of prescription duration, show high complicated appendicitis risks; High-dose antipsychotics for < 1 year (OR: 1.896, 95% CI: 1.077-3.338), high-dose antipsychotics for 1-5 years (OR: 1.930, 95% CI: 1.144-3.256). Poor psychiatric outpatient compliance was associated with a high risk of complicated appendicitis (OR: 1.664, 95% CI: 1.014-2.732). CONCLUSIONS: This study revealed a close relationship in the possibility of complicated appendicitis in patients with severe psychiatric disorders, including psychotic and bipolar disorders. The effect on complicated appendicitis was more remarkable by the psychiatric disease entity itself than by psychotropic prescription patterns. Good treatment compliance and regular visit may reduce the morbidity of complicated appendicitis in patients with psychiatric disorders.

Use of a Wearable Biosensor to Study Heart Rate Variability in Chronic Obstructive Pulmonary Disease and Its Relationship to Disease Severity.

The purpose of this study was to explore the relationships between heart rate variability (HRV) and various phenotypic measures that relate to health and functional status in chronic obstructive pulmonary disease (COPD), and secondly, to demonstrate the feasibility of ascertaining HRV via a chest-worn wearable biosensor in COPD patients. HRV analysis was performed using SDNN (standard deviation of the mean of all normal R-R intervals), low frequency (LF), high frequency (HF), and LF/HF ratio. We evaluated the associations between HRV and COPD severity, class of bronchodilator therapy prescribed, and patient reported outcomes. Seventy-nine participants with COPD were enrolled. There were no differences in SDNN, HF, and LF/HF ratio according to COPD severity. The SDNN in participants treated with concurrent beta-agonists and muscarinic antagonists was lower than that in other participants after adjusting heart rate (beta coefficient -3.980, p = 0.019). The SDNN was positively correlated with Veterans Specific Activity Questionnaire (VSAQ) score (r = 0.308, p = 0.006) and handgrip strength (r = 0.285, p = 0.011), and negatively correlated with dyspnea by modified Medical Research Council (mMRC) questionnaire (r = -0.234, p = 0.039), health status by Saint George's Respiratory Questionnaire (SGRQ) (r = -0.298, p = 0.008), symptoms by COPD Assessment Test (CAT) (r = -0.280, p = 0.012), and BODE index (r = -0.269, p = 0.020). When measured by a chest-worn wearable device, reduced HRV was observed in COPD participants receiving inhaled beta-sympathomimetic agonist and muscarinic antagonists. HRV was also correlated with various health status and performance measures.

Smoking and the Risk of Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) Infection.

INTRODUCTION: It is unclear whether smokers are more vulnerable to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. This study aimed to evaluate the association between smoking and the risk of SARS-CoV-2 infection. METHODS: A matched case-control study was conducted using a large nationwide database. The case group included patients with SARS-CoV-2 infection confirmed by the Korea Centers for Disease Control and Prevention, and the control group was randomly sampled from the general Korean population in the National Health Insurance Service database by matching sex, age, and region of residence. Conditional logistic regression models were used to investigate whether the risk of infection with SARS-CoV-2 was affected by smoking status. RESULTS: A total of 4167 patients with SARS-CoV-2 infection and 20 937 matched controls were enrolled. The proportion of ex-smokers and current smokers was 26.6% of the total participants. In multivariate analysis, smoking was not associated with an increased risk of SARS-CoV-2 infection (odds ratio [OR] = 0.56, confidence interval [CI] = 0.50-0.62). When ex-smokers and current smokers were analyzed separately, similar results were obtained (current smoker OR = 0.33, CI = 0.28-0.38; ex-smoker OR = 0.81, CI = 0.72-0.91). CONCLUSIONS: This study showed that smoking may not be associated with an increased risk of SARS-CoV-2 infection. Smoking tends to lower the risk of SARS-CoV-2 infection; however, these findings should be interpreted with caution. IMPLICATIONS: It is unclear whether smokers are more vulnerable to coronavirus disease 2019. In this large nationwide study in South Korea, smoking tended to lower the risk of infection with severe acute respiratory syndrome coronavirus 2. However, these findings should be interpreted with caution, and further confirmatory studies are required.

Challenges and Strategies for Current Classifications of Depressive Disorders: Proposal for Future Diagnostic Standards.

The Diagnostic and Statistical Manual of Mental Disorder, Fourth Edition (DSM-IV) was revised based on a combination of a categorical and a dimensional approach such that in the DSM, Fifth Edition (DSM-5), depressive disorders have been separated as a distinctive disease entity from bipolar disorders, consistent with the deconstruction of Kraepelinian dualism. Additionally, the diagnostic thresholds of depressive disorders may be reduced due to the addition of "hopelessness" to the subjective descriptors of depressed mood and the removal of the "bereavement exclusion." Manic/hypomanic, psychotic, and anxious symptoms in major depressive disorder (MDD) and other depressive disorders are described using the transdiagnostic specifiers of "with mixed features," "with psychotic features," and "with anxious distress," respectively. Additionally, due to the polythetic and operational characteristics of the DSM-5 diagnostic criteria, the heterogeneity of MDD is inevitable. Thus, 227 different symptom combinations fulfill the DSM-5 diagnostic criteria for MDD. This heterogeneity of MDD is criticized in view of the Wittgensteinian analogy of language game. Depression subtypes determined by disturbances in monoamine levels and the severity of the disease have been identified in the literature. According to a review of the Gottesman and Gould criteria, neuroticism, morning cortisol, cortisol awakening response, asymmetry in frontal cortical activity on electroencephalography (EEG), and probabilistic reward learning, among other variables, are evidenced as endophenotypes for depressive disorders. Network analysis has been proposed as a potential method to compliment the limitations of current diagnostic criteria and to explore the pathways between depressive symptoms, as well as to identify novel and interesting relationships between depressive symptoms. Based on the literature on network analysis in this field, no differences in the centrality index of the DSM and non-DSM symptoms were repeatedly present among patients with MDD. Furthermore, MDD and other depressive syndromes include two of the Research Domain Criteria (RDoC), including the Loss construct within the Negative Valence Systems domains and various Reward constructs within the Positive Valence Systems domain.

Dyskinesia is most centrally situated in an estimated network of extrapyramidal syndrome in Asian patients with schizophrenia: findings from research on Asian psychotropic prescription patterns for antipsychotics.

BACKGROUND: Network analysis provides a new viewpoint that explicates intertwined and interrelated symptoms into dynamic causal architectures of symptom clusters. This is a process called 'symptomics' and is concurrently applied to various areas of symptomatology. AIMS: Using the data from Research on Asian Psychotropic Prescription Patterns for Antipsychotics (REAP-AP), we aimed to estimate a network model of extrapyramidal syndrome in patients with schizophrenia. METHODS: Using data from REAP-AP, extrapyramidal symptoms of 1046 Asian patients with schizophrenia were evaluated using the nine items of the Drug-Induced Extrapyramidal Symptoms Scale (DIEPSS). The estimated network of the ordered-categorical DIEPSS items consisted of nodes (symptoms) and edges (interconnections). A community detection algorithm was also used to identify distinctive symptom clusters, and correlation stability coefficients were used to evaluate the centrality stability. RESULTS: An interpretable level of node strength centrality was ensured with a correlation coefficient. An estimated network of extrapyramidal syndrome showed that 26 (72.2%) of all possible 35 edges were estimated to be greater than zero. Dyskinesia was most centrally situated within the estimated network. In addition, earlier antipsychotic-induced extrapyramidal symptoms were divided into three distinctive clusters - extrapyramidal syndrome without parkinsonism, postural instability and gait difficulty-dominant parkinsonism, and tremor-dominant parkinsonism. CONCLUSIONS: Our findings showed that dyskinesia is the most central domain in an estimated network structure of extrapyramidal syndrome in Asian patients with schizophrenia. These findings are consistent with the speculation that acute dystonia, akathisia, and parkinsonism could be the risk factors of tardive dyskinesia.

Neural Circuitry-Neurogenesis Coupling Model of Depression.

Depression is characterized by the disruption of both neural circuitry and neurogenesis. Defects in hippocampal activity and volume, indicative of reduced neurogenesis, are associated with depression-related behaviors in both humans and animals. Neurogenesis in adulthood is considered an activity-dependent process; therefore, hippocampal neurogenesis defects in depression can be a result of defective neural circuitry activity. However, the mechanistic understanding of how defective neural circuitry can induce neurogenesis defects in depression remains unclear. This review highlights the current findings supporting the neural circuitry-regulated neurogenesis, especially focusing on hippocampal neurogenesis regulated by the entorhinal cortex, with regard to memory, pattern separation, and mood. Taken together, these findings may pave the way for future progress in neural circuitry-neurogenesis coupling studies of depression.

The Entorhinal Cortex and Adult Neurogenesis in Major Depression.

Depression is characterized by impairments in adult neurogenesis. Reduced hippocampal function, which is suggestive of neurogenesis impairments, is associated with depression-related phenotypes. As adult neurogenesis operates in an activity-dependent manner, disruption of hippocampal neurogenesis in depression may be a consequence of neural circuitry impairments. In particular, the entorhinal cortex is known to have a regulatory effect on the neural circuitry related to hippocampal function and adult neurogenesis. However, a comprehensive understanding of how disruption of the neural circuitry can lead to neurogenesis impairments in depression remains unclear with respect to the regulatory role of the entorhinal cortex. This review highlights recent findings suggesting neural circuitry-regulated neurogenesis, with a focus on the potential role of the entorhinal cortex in hippocampal neurogenesis in depression-related cognitive and emotional phenotypes. Taken together, these findings may provide a better understanding of the entorhinal cortex-regulated hippocampal neurogenesis model of depression.

Coprescription of mood stabilizers in schizophrenia, dosing, and clinical correlates: An international study.

OBJECTIVE: Studies examining coprescription and dosages of mood stabilizers (MSs) with antipsychotics for psychotic disorders are infrequent. Based on sparse extant data and clinical experience, we hypothesized that adjunctive MS use would be associated with certain demographic (e.g., younger age), clinical factors (e.g., longer illness duration), and characteristics of antipsychotic treatment (e.g., multiple or high antipsychotic doses). METHODS: Within an Asian research consortium focusing on pharmaco-epidemiological factors in schizophrenia, we evaluated rates of MS coprescription, including high doses (>1000 mg/day lithium-equivalents) and clinical correlates. RESULTS: Among 3557 subjects diagnosed with schizophrenia in 14 Asian countries, MSs were coprescribed with antipsychotics in 13.6% (n = 485) of the sample, with 10.9% (n = 53) on a high dose. Adjunctive MS treatment was associated (all p < 0.005) with demographic (female sex and younger age), setting (country and hospitalization), illness (longer duration, more hospitalizations, non-remission of illness, behavioral disorganization, aggression, affective symptoms, and social-occupational dysfunction), and treatment-related factors (higher antipsychotic dose, multiple antipsychotics, higher body mass index, and greater sedation). Patients given high doses of MSs had a less favorable illness course, more behavioral disorganization, poorer functioning, and higher antipsychotic doses. CONCLUSIONS: Schizophrenia patients receiving adjunctive MS treatment in Asian psychiatric centers are more severely ill and less responsive to simpler treatment regimens.

Anxiety Disorders in the DSM-5: Changes, Controversies, and Future Directions.

Under the partial influences of paradigm shift form category to dimension, the Diagnostic and Statistical Manual of Mental Disorder (DSM) was revised to the fifth edition (DSM-5); however, due to the lack of consistent biological makers and processes and the restricted availability of dimensional meta-structure, the revisions for the DSM-5 were based on a combination of categorical and dimensional approaches. Anxiety disorders were more clearly and consistently defined in the DSM-5 with the removal of obsessive compulsive, acute stress, and post-traumatic stress disorders. Differences between the childhood and adulthood categories of anxiety disorders were decreased, and overall, the symmetrical classification of anxiety subtypes was increased, since separation anxiety disorder and selective mutism were considered anxiety disorders, not neurodevelopmental disorders. Additionally, based on growing evidence, agoraphobia is distinct from panic disorder. Next, considering cultural syndromes including taijin kyofusho, khyal cap, trung gio attacks, and ataque de nervios, cultural influences are considered a significant factor for definitions and presentations of anxiety disorders. Controversies in the DSM-5 criteria for anxiety disorders are lowering the diagnostic thresholds of anxiety disorders and limiting the dichotomous view of anxiety and depression when defining generalized anxiety disorder. Further studies of alternative approaches to the restrictions of the DSM-5 criteria of anxiety disorders, including transdiagnostic specifiers and dimensional assessment tools, may be required.

Network analysis of the depressive symptom profiles in Asian patients with depressive disorders: Findings from the Research on Asian Psychotropic Prescription Patterns for Antidepressants (REAP-AD).

AIM: We aimed to estimate the network structures of depressive symptoms using network analysis and evaluated the geographic regional differences in theses network structures among Asian patients with depressive disorders. METHODS: Using data from the Research on Asian Psychotropic Prescription Patterns for Antidepressants (REAP-AD), the network of the ICD-10 diagnostic criteria for depressive episode was estimated from 1174 Asian patients with depressive disorders. The node strength centrality of all ICD-10 diagnostic criteria for a depressive episode was estimated using a community-detection algorithm. In addition, networks of depressive symptoms were estimated separately among East Asian patients and South or Southeast Asian patients. Moreover, networks were estimated separately among Asian patients from high-income countries and those from middle-income countries. RESULTS: Persistent sadness, fatigue, and loss of interest were the most centrally situated within the network of depressive symptoms in Asian patients with depressive disorders overall. A community-detection algorithm estimated that when excluding psychomotor disturbance as an outlier, the other nine symptoms formed the largest clinically meaningful cluster. Geographic and economic variations in networks of depressive symptoms were evaluated. CONCLUSION: Our findings demonstrated that the typical symptoms of the ICD-10 diagnostic criteria for depressive episode are the most centrally situated within the network of depressive symptoms. Furthermore, our findings suggested that cultural influences related to geographic and economic distributions of participants could influence the estimated depressive symptom network in Asian patients with depressive disorders.

Reduced awareness of surroundings is the most central domain in the network structure of posttraumatic stress disorder symptoms.

Backgroud: Network models suggest that co-occurring symptoms are conceptualized as a syndrome due to interactions, rather than a categorical entity with an underlying common cause.Aim: Our study aimed to examine the network structure and centrality of Diagnostic and Statistical Manual of Mental Disorders (DSM)-IV posttraumatic stress disorder (PTSD) symptoms, including essential and associated features.Methods: We constructed a network structure of 21 intertwined symptoms, evaluated with the Clinician-Administered PTSD Scale (CAPS), in 249 PTSD patients who have been exposed to various types of traumatic events (73% being traffic or other accidents) and were beginning psychiatric treatment. In addition, we estimated the centrality of the 21 symptoms through network analysis. Each of the symptoms was defined as ordered-categorical variables.Results: The network, with 21 symptoms, demonstrated a strong correlation among difficulty concentrating, reduced awareness of surroundings, and derealization. In addition, reduced awareness of surroundings was estimated as the most central symptom, whereas inability to recall important aspects of trauma was estimated as the least central symptom in the subjects. A community-detection analysis estimated that the 21 PTSD symptoms were organized into three clinically meaning clusters.Conclusion: Although dissociative features have been defined as associative symptoms rather than essential symptoms for the DSM diagnostic criteria, reduced awareness of surroundings may be regarded as the most central symptom in patients in the early phase of PTSD. Thus, evaluation and intervention for dissociative features may be needed in clinical practice and studies on PTSD.

Treatment Rate of Schizophrenia in China: a Meta-Analysis of Epidemiological Studies.

Effective and prompt medication treatment is essential for schizophrenia patients to alleviate psychotic symptoms and improve prognosis. The treatment rate of schizophrenia usually varies greatly across studies. This is a meta-analysis that examined the overall treatment rate of schizophrenia in China. Both international (PubMed, EMBASE, PsycINFO, Web of Science) and Chinese (CNKI, WanFang and Sinomed) databases were searched. The random effects model was used to analyze the data. Fifteen studies with 1,219,472 patients were included. This meta-analysis found that 73% (95%CI: 66%, 80%) of schizophrenia patients received treatment in any type of medical institutions, while 31.0% (95%CI = 21.0%, 41.0%) received treatment in psychiatric institutions. Studies conducted in middle region of China (76.8% for any type of medical institutions; 42.6% for psychiatric institutions) and those published before 2007 (74.6% for any type of medical institutions; 31.3% for psychiatric institutions) reported significantly higher treatment rates. Studies using combined diagnostic instruments had a higher treatment rate of schizophrenia (72.0%) in any type of medical institutions, while using the Chinese classification of Mental Disorders (47.7%) and including both rural and urban areas (35.7%) had higher treatment rates of schizophrenia in psychiatric institutions. The treatment rate of schizophrenia was relatively high in China, but most treatments were delivered in non-psychiatric medical institutions. Greater efforts should be made to improve the provision of accessible mental health services for schizophrenia patients in this part of the world.

Relationship Between Body Mass Index and Extrapyramidal Symptoms in Asian Patients with Schizophrenia: The Research on Asian Psychotropic Prescription Patterns for Antipsychotics (REAP-AP).

BACKGROUND: Although an inverse relationship between body mass index (BMI) and Parkinson disease (PD) has been repeatedly reported, to our knowledge, the relationship between BMI and antipsychotic-induced extrapyramidal symptoms (EPS) has rarely been studied in patients with schizophrenia. Our study aimed to evaluate the relationship between BMI and EPS in patients with schizophrenia. SUBJECTS AND METHODS: Using data from the Research on Asian Psychotropic Prescription Patterns for Antipsychotics (REAP-AP) study, we compared the prevalence of EPS in 1448 schizophrenia patients stratified as underweight, normal range, overweight pre-obese, overweight obese I, overweight obese II, and overweight obese III according to the World Health Organization (WHO) classification system for body weight status, and with underweight, normal range, overweight at risk, overweight obese I, and overweight obese II according to the Asia-Pacific obesity classification. RESULTS: In the first step of the WHO classification system for body weight status, adjusting for the potential effects of confounding factors, the multinomial logistic regression model revealed that underweight was significantly associated with greater rates of bradykinesia and muscle rigidity, and a lower rate of gait disturbance. In the second step of the Asia-Pacific obesity classification, adjusting for the potential effects of confounding factors, the multinomial logistic regression model revealed that underweight was significantly associated with a higher rate of muscle rigidity. CONCLUSION: Findings of the present study consistently revealed that underweight was associated with a greater rate of muscle rigidity in a stepwise pattern among Asian patients with schizophrenia. Although the mechanism underlying the inverse relationship between BMI and muscle rigidity cannot be sufficiently explained, it is speculated that low BMI may contribute to the development of muscle rigidity regardless of antipsychotic "typicality" and dose in patients with schizophrenia.