Suicidal ideation in systemic lupus erythematosus: NR2A gene polymorphism, clinical and psychosocial factors.

Background Systemic lupus erythematosus (SLE) patients are a high-risk population for suicide. Glutamatergic neurosystem genes have been implicated in the neurobiology of depression in SLE and suicidal behaviour in general. However, the role of glutamate receptor gene polymorphisms in suicidal behaviour among SLE patients remains unclear in the context of established clinical and psychosocial factors. We aimed to investigate the association of NR2A gene polymorphism with suicidal ideation in SLE while accounting for the interaction between clinical and psychosocial factors. Methods A total of 130 SLE patients were assessed for mood disorders (MINI International Neuropsychiatric Interview), severity of depression (Patient Health Questionnaire-9), suicidal behaviour (Columbia-Suicide Severity Rating Scale), socio-occupational functioning (Work and Social Adjustment Scale), recent life events (Social Readjustment Rating Scale) and lupus disease activity (SELENA-SLE Disease Activity Index). Eighty-six out of the 130 study participants consented for NR2A genotyping. Results Multivariable logistic regression showed nominal significance for the interaction effect between the NR2A rs2072450 AC genotype and higher severity of socio-occupational impairment with lifetime suicidal ideation in SLE patients ( p = 0.038, odds ratio = 1.364, 95% confidence interval = 1.018-1.827). However, only the association between lifetime mood disorder and lifetime suicidal ideation remained significant after Bonferroni correction ( p < 0.001, odds ratio = 33.834, 95% confidence interval = 7.624-150.138). Conclusions Lifetime mood disorder emerged as a more significant factor for suicidal ideation in SLE compared with NR2A gene polymorphism main and interaction effects. Clinical implications include identification and treatment of mood disorders as an early intervention for suicidal behaviour in SLE. More adequately-powered gene-environment interaction studies are required in the future to clarify the role of glutamate receptor gene polymorphisms in the risk stratification of suicidal behaviour among SLE patients.

Suicide ideation and intent in Malaysia: a review of the literature.

The aim of this paper was to review the literature on suicide ideation and intent in Malaysia. PsyINFO, PubMed, Medline databases from 1845 to 2012 and detailed manual search of local official reports from Ministry of Health, Malaysian Psychiatric Association and unpublished dissertations from 3 local universities providing postgraduate psychiatric training, were included in the current review. A total of 13 studies on suicide ideation and intent in Malaysia were found and reviewed. The review showed that research on suicide ideation and intent in Malaysia was fragmented and limited, at best. Approximately 50% of existing research on suicide ideation and intent simply focused on sociodemographic data. Fifty-four percent of the data were obtained from hospitals. No study has been conducted on treatment and interventions for suicide ideation and intent. None of the studies used validated suicide scales. The impact of culture was rarely considered. It was clear from the review that for researchers, clinicians and public health policy makers to gain a better understanding of suicide behavior especially suicide ideation and intent in Malaysia, more systematic and empirically stringent methodologies and research frameworks need to be used.

Psychometric properties and validation of the Reasons for Living Inventory in an outpatient clinical population in Malaysia.

The Reasons For Living Inventory has been shown to have good psychometric properties in Western populations for the past three decades. The present study examined the psychometric properties and factor structure of English and Malay version of the Reasons For Living (RFL) Inventory in a sample of clinical outpatients in Malaysia. The RFL is designed to assess an individual's various reasons for not committing suicide. A total of 483 participants (283 with psychiatric illnesses and 200 with non-psychiatric medical illnesses) completed the RFL and other self-report instruments. Results of the EFA (exploratory factor analysis) and CFA (confirmatory factor analysis) supported the fit for the six-factor oblique model as the best-fitting model. The internal consistency of the RFL was α=.94 and it was found to be high with good concurrent, criterion and discriminative validities. Thus, the RFL is a reliable and valid instrument to measure the various reasons for not committing suicide among psychiatry and medical outpatients in Malaysia.

Risk factors for suicidal ideation, plans and attempts in Malaysia--results of an epidemiological survey.

OBJECTIVE: This is an epidemiological study to determine the prevalence of suicidal behavior and its association with generalised anxiety disorder (GAD) and major depressive disorder (MDD) in a nationally representative sample. METHOD: Suicidal ideation, plans and attempts were assessed in face-to-face interviews of respondents selected by a multistage probability sampling using items on suicidality from the WHO SUPRE-MISS questionnaire. The Mini International Neuropsychiatric Interview (MINI) was used to generate DSM-IV diagnoses of GAD and MDD. A total of 19309 subjects were studied. Multivariate regression analysis was conducted controlling for demographic characteristics such as age, gender and ethnicity. RESULTS: The prevalence estimates for suicide ideation, plans and attempts were 1.7% (95% CI: 1.4-1.9), 0.9% (CI: 0.7-1.1) and 0.5% (CI: 0.4-0.7) respectively. Younger people (16-24 years) had higher risk of suicidal behavior (OR: 2.6, CI: 1.08-6.2). Females (OR: 1.6, CI: 1.2-2.1) and Indians (OR: 3.3, CI: 2.2-4.9) also had higher risk. CONCLUSION: The prevalence of suicidal behavior in Malaysia is low, but it broadly corresponds to the pattern described in other countries. This national study confirms that Malaysians of Indian descent have much higher rates of suicidal behavior than other groups. The younger age group, females and the Indian ethnic group would need focused preventive efforts.

Suicide attempts in Malaysia from the year 1969 to 2011.

The aim of this paper is to review the literature on suicide attempts in Malaysia. PsycINFO, PubMed, and Medline databases from 1845 to 2012 and detailed manual search of local official reports from the Ministry of Health and the Malaysian Psychiatric Association and unpublished dissertations from 3 local universities providing postgraduate psychiatric training were included in the current review. A total of 38 studies on suicide attempts in Malaysia were found and reviewed. Twenty-seven (76%) of the studies on suicide attempts were descriptive studies looking at sociodemographic data, psychiatric illnesses, and methods and reasons for suicide attempts. No study has been conducted on treatment and interventions for suicide attempts and the impact of culture was rarely considered. The review showed that in order for researchers, clinicians, and public health policy makers to obtain a better understanding of suicide attempts in Malaysia, more systematic and empirically stringent methodologies and research frameworks need to be used.

Suicide prevention program for at-risk groups: pointers from an epidemiological study.

OBJECTIVES: The aim of this paper is to identify at-risk groups for a focused suicide prevention program for Malaysia. METHODS: Data from 20,552 persons aged 16 years and above (males 45.9%), was obtained using stratified, random sampling in a national survey of psychiatric morbidity using locally validated General Health Questionnaire (GHQ-28) which included questions on suicidal ideation. RESULTS: The overall prevalence of suicidal ideation (SI) was 6.3%, CI 6.1-6.8 (n=1288). Logistic regression analysis was performed with age, ethnicity, gender, urban/rural residence, age group, marital status, household income, type of household, presence of chronic pain, social dysfunction, somatic, anxiety or depressive symptoms, obesity, and chronic medical illnesses as independent variables. Only Insomnia, Religion, Marital Status, Depression, Social Dysfunction and Anxiety were seen to be significant predictors. Prevalence of SI was significantly higher among Indians (11.0%, CI 9.5-12.5), especially those of the Hindu faith (12.2%, CI 10.5-14.0), Chinese (9.7%, CI 8.8-10.7) and those having depressive symptoms. CONCLUSION: In a developing country with competing priorities, prudent allocation of resources requires focusing suicide prevention efforts on treating depression in vulnerable groups.

Psychological distress, quality of life and coping in cancer patients: a prospective study.

We present the results and conclusions of an observational prospective cohort design study using self-administered questionnaires to determine correlation between psychosocial factors and cancer outcome among 80 consecutive newly diagnosed treatment naïve cancer subjects who were being referred to the Oncology Clinic, Hospital Universiti Kebangsaan Malaysia. Subjects were recruited over a period of 43 weeks from October 2000 till July 2001. Follow-up assessments were carried out at 6-months and 12 to 26 months later. The prediction of survival time was performed by the Cox Regression Analysis method with adjustments for biological and psychosocial risk factors. It was noted that depression (p = 0.001), stage 4 cancer disease (p = 0.016), neurological (p = 0.032), gastrointestinal tract (p = 0.04), head and neck (p = 0.011), gynaecological (p = 0.005) and bone and soft tissue (p = 0.030) malignancies were independent and statistically significant prognostic factor of survival during the study period. It was further shown than depressed patients were found to have almost four fold greater risk of dying than non-depressed patients and patients with stage 4 cancer illness have a five fold greater risk of dying than patients with stage 1 disease. Furthermore, based on tumour types subjects with neurological, gynaecological, head and neck, bone and soft tissue and gastro intestinal tract malignancies were found to have approximately thirty-six, twenty-five, twenty-two, sixteen and seven fold greater risk of dying respectively when compared to subjects with genitourinary cancers. This study further affirms the need for health care providers to be aware of the psychological aspects of the cancer patient and provide appropriate therapy so as to ensure that this group of individuals would have enhanced survival rates.

Prevalence of insulin resistance in schizophrenia in HUKM.

This is a cross-sectional study to determine the prevalence of insulin resistance and its associated factors in Hospital UKM patients with schizophrenia using the Homeostatic Model Assessment (HOMA) model. Fasting glucose and insulin from 85 patients were obtained. Fasting glucose revealed 15% of the patients were diabetic, while another 15% had impaired fasting glucose. Using the HOMA model, 68% of the patients had insulin resistance. Univariate analyses found BMI (p < 0.001) and waist circumference (p < 0.001) to be associated with insulin resistance. The statistical significance disappeared after multivariate analyses. All patients with schizophrenia should be screened and managed as a group at high risk for development of diabetes with emphasis on body weight management.

Positive effects of Individual Cognitive Behavior Therapy for patients with unipolar mood disorders with suicidal ideation in Malaysia: A randomised controlled trial.

The aim of this study was to investigate the effectiveness of Individual Cognitive Behavior Therapy (ICBT) in treating patients with mood disorders with suicidal ideation. A total of 69 patients (48 females, 21 males) with the diagnoses above were randomly allocated to either the group of Treatment As Usual (TAU)+ICBT (n=33) or the TAU group (n=36). All participants completed the Beck Depression Inventory (BDI), Beck Scale for Suicide Ideation (BSS), Positive and Negative Suicide Ideation Inventory (PANSI), Beck Hopelessness Scale (BHS), and Depression Anxiety Stress Scale-21 (DASS-21). These questionnaires were administered at pre-treatment, midway through treatment (week 4), post-treatment (week 8), and at follow-ups after three months (week 20) and six months (week 32). Factorial ANOVA results showed that the TAU+ICBT patients improved significantly and at faster rate as compared to the TAU group, which showed improvement only from pre to mid treatment on DASS-D and BHS-T measures. The effect size (Cohen's d), for the TAU+ICBT group showed large effect (1.47) for depressive symptoms and suicidal ideation (1.00). These findings suggest that ICBT used in addition to the TAU, was effective in enhancing treatment outcome of patients with unipolar mood disorders as well as, reducing risk for suicide behavior.

The effect of a clinical posting in psychiatry on the attitudes of medical students towards psychiatry and mental illness in a Malaysian medical school.

INTRODUCTION: The stigma attached to mental illness and the mentally ill is a universal phenomenon and a major barrier to the provision of mental health services. Stigmatising attitudes among doctors themselves can result in compromised patient care. The aim of this research project is to study the impact of a clinical posting in psychiatry on the attitudes of medical students to mental illness and to psychiatry. This paper reports the results of the first phase of a longitudinal study. MATERIALS AND METHODS: A total of 122 year 4 medical students responded to this study. The Attitudes Towards Mental Illness (AMI) and Attitudes Towards Psychiatry (ATP) questionnaires were administered before and after an 8-week attachment in psychiatry. RESULTS: We found that students had somewhat favourable attitudes towards psychiatry and mental illness at the start of their attachment, with a mean score of 108.34 on ATP (neutral score, 90) and 68.24 on AMI (neutral score, 60). There was a significant increase in the mean scores of both scales following the psychiatric attachment for female students (ATP: P = 0.003; AMI: P <0.0005), but not male students (ATP: P = 0.435; AMI: P = 0.283). CONCLUSIONS: An 8-week clinical posting of fourth-year medical students in psychiatry was associated with an increase in positive attitudes to mental illness and to psychiatry among female students but not among male students.

Does clinical exposure to patients in medical school affect trainee doctors' attitudes towards mental disorders and patients?--A pilot study.

Stigmatising attitudes towards mental illness may improve with clinical exposure during medical school training. Attitudes of 48 fourth year medical students in Universiti Kebangsaan Malaysia were assessed before and after their compulsory attachment in Psychiatry, using the Attitude Towards Psychiatry-30 (ATP) and the Attitude towards Mental Illness (AMI) questionnaires. ATP scores improved significantly with training (104.8 and 114.4, pre- and post-attachment respectively) as did AMI scores (63.4 and 68.1 respectively). Both improvements were statistically significant. (ATP: z = 4.55, p < 0.0005) (AMI: z = 3.75, p < 0.0005). Attitudes towards mental illness appeared to have become more favourable with clinical training in psychiatry.

Psychometric Properties and Validation of the Positive and Negative Suicide Ideation (PANSI) Inventory in an Outpatient Clinical Population in Malaysia.

The PANSI is a measure designed to assess the risk and protective factors related to suicidal behaviors. The present study evaluated the psychometric properties and factor structure of the Positive and Negative Suicide Ideation (PANSI) Inventory in a sample of clinical outpatients at a major hospital in Malaysia. In this study, 283 psychiatric patients and 200 medical (non-psychiatric) patients participated. All the patients completed the PANSI and seven other self-report instruments. Confirmative factor analysis supported the 2-factor oblique model. The internal consistency of the two subscales of PANSI-Negative and the PANSI-Positive were 0.93 and 0.84, respectively. In testing construct validity, PANSI showed sizable correlation with the other seven scales. Criterion validity was supported by scores on PANSI which differentiated psychiatric patients from medical patients. Logistic regression analyses showed PANSI can be used to classify the patients into suicidal or non-suicidal. The PANSI is a reliable and valid instrument to measure the severity of suicidal ideation among clinical outpatients in Malaysia.

Suicide and undetermined violent deaths in Malaysia, 1966-1990: evidence for the misclassification of suicide statistics.

Suicide statistics are generally recognised to be unreliable. This study of the reported rates of suicide in West Malaysia between 1966-1990 shows that the mean crude suicide rate between 1966-1974 was 6.1 per 100,000, but had dropped drastically between 1975-1990 to a mean of 1.6 per 100,000. Three lines of evidence are presented to show that this reduction in the suicide rate is due to a systematic misclassification of medically certified suicides as deaths due to undetermined violent deaths (which refers to violent deaths not known to be accidentally or deliberately inflicted). Firstly, the large drop in reported suicide rates corresponds closely to an increase in the rate of deaths due to undetermined violent deaths. There is a highly positive negative correlation between the two rates (coefficient of correlation, r = -0.9). Secondly, the misclassification appears to be mainly a problem with the medically certified deaths which follow the ICD classification. The mean ratio of uncertified to certified suicides before 1975 was 0.8, but from 1975 onwards the mean was 3.1. This is in contrast to the corresponding ratio for deaths due to all accidents which has remained fairly constant throughout these years. Thirdly, the race and sex differences for the rates of undetermined violent deaths are identical to those of suicide. Taking the misclassification into account the corrected suicide rate for West Malaysia is estimated to be between 8-13 per 100,000 since 1982.

Suicide in Fiji: a review of the literature.

Clinical experience, public perceptions and research have indicated that the Indian community have been overrepresented in suicide statistics in Fiji. A computerised Medline search of the literature back to 1966 on suicide and ethnicity in Fiji using the search words SUICIDE and FIJI was performed supplemented by other relevant research and published material. A consistent pattern of higher suicide rates for the Indian population in Fiji compared to the indigenous Fijian population was found. Factors including religious and cultural beliefs, higher suicide risk in rural areas, use of toxic biocides as a method of suicide and relatively high suicide rates in young Indian women are discussed. Evidence for Indian vulnerability to suicide in Fiji has to date been based upon uncontrolled, descriptive observations. Helpful directions for future research include studying postulated vulnerability variables for suicide in the Indian community.

Drinking habits of Malaysians in general practice.

Five hundred and sixty-two consecutive attenders at an urban general practice were studied using the Consumption Index which has been successfully used in a general hospital sample. Seventy per cent of Chinese, 11% of Malays and 42% of Indians have used or are currently using alcohol-a vast majority of them were social drinkers. Among those who ever drank, 6% of Chinese and 22% of Malays drank more than 14 units per week. The hypotheses that more Indians used alcohol and used it more heavily were not supported in this urban sample. Possible explanations for these findings and the limitations of this study are discussed.

Psychiatric morbidity in an urban general practice.

Two hundred and six patients attending an urban general practice were surveyed using a self-rating questionnaire, the 30-item version of the General Health Questionnaire. At a cut-off score of 6/7, 34.5% of the respondents were found to be high-scorers which gives a corrected estimate of psychiatric morbidity of 29.9% in this clinic. Among those who presented with general complaints, such as aches and pains for which no organic cause was found, a significant proportion (70%) were high-scorers. There were no significant differences in the sex and age distribution of the high-scorers. However the mean score of Malays was significantly higher than that of Chinese.

Family characteristics of suicides in Cameron Highlands: a controlled study.

Cameron Highlands has one of the highest suicide rates in the world, especially among Indians. Forty Indian families (19 suicides; 21 controls) were studied to compare family characteristics such as income, overcrowding, birth order of index cases of suicide, family history of suicidal behaviour or mental illness, marital disharmony, presence of alcohol abuse, availability of, and knowledge about, weedicides/insecticides, talk/threat of suicide among family members and experience of significant losses in the past year. Controls were matched for age, sex and educational level with the index cases of suicide. A significant difference was only found for one of the above factors, namely increased experience of significant losses in the past year in the family of index cases of suicide. More than 75% in both groups had alcohol related problems. About equal proportions in each group had a family history of suicidal behaviour and mental illness. There was more marital disharmony in families of suicides but this failed to reach significance. These results and methodological limitations of this study are discussed.

The prescription of psychotropic medication in general practice--a descriptive study.

The prescriptions of all patients who attended an urban general practice from September 1987 to December 1987 were studied. Of the 111 patients (60 females and 51 males) who received a psychotropic prescription the commonest presenting complaint was insomnia (56 patients or 50.5%). This was followed by tension, headache and unexplained aches and pains (19 patients or 17.1%), and anxiety (nine patients or 8.1%). Consistent with these presentations a vast majority (92.8%) received a benzodiazepine. The commonest drugs prescribed were Lorazepam and Bromazepam whereas the longer acting benzodiazepines were rarely used. Polypharmacy was rare.

All elevated creatine kinase is not neuroleptic malignant syndrome.

Creatine kinase (CK) is an enzyme that is found widely in muscle tissues. Raised levels would occur when there is muscle damage. Raised levels are used as one of the diagnostic criteria for Neuroleptic Malignant Syndrome (NMS). This study looks at CK levels in 30 psychotic inpatients without NMS and compares them with 10 patients with NMS. It was found that 67% of the patients without NMS had raised CK levels, 20% of whom had levels in excess of 1000 IU/L. The rest had a two to five-fold increase over normal limits. Raised levels were associated with the use of intramuscular injections and physical restraints, situations which are well known to result in muscle injury. All the NMS patients had raised CK levels but 40% had levels below 1000 IU/L. Our findings support the idea that CK levels, though helpful, should be interpreted with care as raised levels are nonspecific.

Hospital-based community psychiatric service for patients with schizophrenia in Kuala Lumpur: a 1-year follow-up study of re-hospitalization.

INTRODUCTION: Hospital-based community psychiatric service (HCPS) is a developing intervention in Malaysia targeted for patients with severe mental illnesses (SMIs). Its effectiveness had not been systematically measured. This study aimed to assess the outcome of HCPS with respect to re-hospitalization and factors associated with low re-hospitalization among patients with schizophrenia in the metropolitan city of Kuala Lumpur. METHODS: A naturalistic and retrospective cohort study was conducted using within-subject pre-post design on 155 patients with schizophrenia who received HCPS in Hospital Kuala Lumpur (HKL). The selection was made by simple random sampling. The hospital admission profiles were obtained from clinical records. The socio-demographic and relevant clinical data were also assessed through clinical interviews. RESULTS: One hundred and forty (90%) of 155 respondents had low rate of hospital admission with significant reduction of being hospitalized within 1 year after receiving HCPS (p < 0.001). Having good social support was significantly associated with lower rate of rehospitalization (p = 0.001). DISCUSSION: The study revealed the effectiveness of HCPS in terms of reducing rates of hospital admission among patients with schizophrenia in Malaysia. The finding may be used as an evidence to develop the service further in other hospitals. However, the finding needs to be replicated through studies with better design involving more psychiatric centres.