Development of mental health care in Sri Lanka: Lessons learned Samudra T Kathriarachchi, V Lakmi Seneviratne, Luckshika Amarakoon,  Taiwanese Journal of Psychiatry 2019 33(2):55-65 Background: Sri Lanka is a multi-ethnic country with a rich cultural heritage and biodiversity. Sri Lanka has a population of 21 million with an annual population growth rate of 0.76%. Methods: The authors explored the evolution of mental health care, life-cycle approach to psychiatric disorders, addressing resource limitations in a developing country, and the dilemma of reducing the treatment gap while maintaining standards and quality of care. This review was based on the analysis of related literature, as well as through work experience. Results: As a result of continuous effort, Sri Lanka has more than 110 psychiatrists, practicing in all districts of the country. Academic psychiatry has flourished over the years. Measures to improve mental health literacy, training of allied disciplines, and targeted approaches to improve services for vulnerable groups are taking place at a reasonable rate. The psychiatrists employed throughout Sri Lanka, the Sri Lanka College of Psychiatrists, the Board of Study in Psychiatry, and Postgraduate Institute of Medicine, have taken initiative to improve quality of care, by joining hands with the Ministry of Health and other stakeholders. Conclusion: Sri Lanka has achieved quality mental health-care outcomes despite having considerable limitations in resource allocation. Mental health services need to be consistently revamped, giving priority to face ongoing challenges to provide quality as well as equitable and efficient service to all the citizens in this beautiful country.

Treatment-resistant attention-deficit hyperactivity disorder: Clinical significance, concept, and management Mu-Hong Chen, Kai-Lin Huang, Ju-Wei Hsu, Shih-Jen Tsai Taiwanese Journal of Psychiatry 2019 33(2):66-75 Background: Attention-deficit hyperactivity disorder (ADHD) is the most commonly diagnosed neurodevelopmental disorder known to cause impairment across the lifespan. ADHD was ranked as approximately the 50th leading cause of global years lived with disability for children, coming in ahead of diabetes, meningitis, and intellectual disability. About 20%–40% of patients with ADHD would not achieve the treatment response and symptomatic remission, increasing future risks of substance abuse, suicidal behavior, and premature mortality. However, there is no standard consensus for defining treatment resistance in ADHD. Method: In this systematic review, we intend to focus on treatment-resistant ADHD in the aspects of disease definition, psychopathology, pathophysiology, and treatment. Results: We suggest that the more ideal strategy of defining treatment resistance should consider the improvement of ADHD symptoms and the global functioning simultaneously. Psychiatric comorbidities (i.e. destructive behavior disorders and mood disorders), physical comorbidities (i.e. epilepsy), and psychosocial adversities (i.e. parental psychopathology and poor family functioning) should be the first to be assessed in the evaluation of treatment response or resistance. The optimal medication adjustment or the combination of medications and psychotherapy may be the potential therapeutic strategy for treatment-resistant ADHD. Conclusion: Further studies would be necessary to elucidate the underlying mechanisms of treatment-resistant ADHD and to research the novel treatment strategies for ADHD.

Risk of cancer in patients with eating disorders: A population-based study Yi-Chun Liu, Mong-Liang Lu, Ko-Jung Chen, Yao-Hsu Yang, Vincent Chin-Hung Chen Taiwanese Journal of Psychiatry 2019 33(2):76-82 Objectives: Patients with eating disorder (ED) have been associated with some risk factors for cancer, including nutritional deficiency, chaotic life styles, alcohol or tobacco use, dysfunctional immune system, and impaired organ functions. In this study, we intended to study the risk of cancer in ED patients. Methods: During the period of January 1998 to December 2013, 13,755 ED patients were identified from Taiwan's National Health Insurance Research Database. We enrolled 13,276 patients as study cohort, and 53,104 patients that had never been diagnosed with ED as age- and sex-matched comparisons. Participants were monitored for diagnoses of cancer during the follow-up period. We used the Cox proportional hazards model to investigate the risk of cancer between patients with ED and those without ED. Results: Compared with the non-ED controls, the study cohort had significantly higher prevalence of comorbidities, alcohol abuse, tobacco use disorder, and chronic obstructive pulmonary disease. After adjusting demographic data and comorbidities, there was no significant risk for later occurrence of cancer in ED patients, irrespective of anorexia nervosa (AN) type (hazard ratio [HR] = 1.10, 95% confidence interval [CI], = 0.83 – 1.47, nonsignificant difference) or non-AN type (HR = 0.98, 95% CI = 0.79 – 1.23, nonsignificant difference). Conclusion: There is no established evidence to support the relationship between cancer incidence and ED.

Relations of genetic variants in superoxide dismutase 2 and dystrobrevin-binding protein 1 to methamphetamine psychosis among methamphetamine dependents in Taiwan Ying-Ching Lai, Shih-Ku Lin, Ming-Chyi Huang, Hsing-Cheng Liu, Yen-Lung Chiou, Chun-Hsin Chen, Wei J Chen Taiwanese Journal of Psychiatry 2019 33(2):83-91 Objectives: Both superoxide dismutase 2 gene (SOD2), encoding a free radical scavenger, and dystrobrevin-binding protein 1 gene (DTNBP1), a candidate gene for schizophrenia, have been implicated in methamphetamine (METH) psychosis. In this study, we intended to compare the distribution of those two genes between METH users with and without psychosis and to evaluate whether the length of time of METH exposure influenced such relationship. Methods: The study sample consisted of 84 cases of patients with METH-induced psychosis and 187 controls (METH users without psychosis). Five single-nucleotide polymorphisms (SNPs) in SOD2 and three SNPs in DTNBP1 were genotyped. We did both single-locus and haplotype analyses, and adjusted for multiple comparisons with an effective number of markers, and multivariable logistic regression analyses for adjusting for age, sex, and duration of METH use. Results: None of the individual SNPs were associated with METH-induced psychosis after adjustment for multiple comparisons. In the subgroup analysis, both rs4880 and rs2855116 in SOD2 were significantly associated with prolonged METH-induced psychosis (p < 0.01 and p < 0.01, respectively). Under the assumption of a codominant model, the CC genotype of rs4880 was significantly associated with METH-induced psychosis after adjustments for age, sex, and the duration of METH use (p < 0.01). This association was not supported by the haplotype analyses or gene–gene interactions between SOD2 and DTNBP1. Conclusion: Functional C-allele of rs4880 in SOD2 was associated with the prolonged subtype of METH-induced psychosis in Taiwanese population. Oxidative stress mechanisms show a rôle in the development of METH-induced psychosis.

Comparison of insight in patients with schizophrenia, bipolar I disorder, and major depressive disorder in a real-world setting Si-Sheng Huang, Cheng-Chen Chang Taiwanese Journal of Psychiatry 2019 33(2):92-98 Objective: In this study, we intended to compare the insight in patients with schizophrenia (SCH), bipolar I disorder (BD), and major depressive disorder (MDD). Methods: This cross-sectional study was conducted from December 2017 to July 2018. We recruited 102 patients with SCH (n = 55), BD (n = 25), and major depression (n = 22) to assess insight with the Taiwanese version of Self-Appraisal of Illness Questionnaire (SAIQ), and to test the differences of those patient groups. Results: Patients with SCH had a significantly lower average SAIQ score compared with MDD (25.95 ± 9.70 vs. 36.38 ±7.75, p < 0.01), but no significant difference existed in patients between the SCH and bipolar disorder. For the SAIQ worry subscale, patients with SCH (p < 0.05) and those with bipolar disorder (p < 0.01) had significant lower scores than those with major depression. For the need for treatment subscale, patients with SCH had significantly lower scores than those with bipolar disorder (p < 0.05) and those with major depression (p < 0.05). For the presence/outcome of illness subscale, patients with SCH had significant lower scores than those with bipolar disorder (p < 0.01) and those with major depression (p < 0.001). Conclusion: Patients with SCH had lower total insight as well as individual domain than patients with MDD. Patients with SCH had poorer insight than those with bipolar disorder in need for treatment and presence/outcome of illness, but not in the worry subscale. The significant difference in patients with BD and those with major depression were on the worry domain.

Increased brain-derived neurotrophic factor exon IV histone 3 lysine 9 dimethylation in patients with schizophrenia Men-Ting Hsieh, Chin-Chuen Lin, Tiao-Lai Huang Taiwanese Journal of Psychiatry 2019 33(2):99-104 Background: Studies have mentioned that mixed-lineage leukemia 1 (MLL1) and histone 3 lysine 4 trimethylation (H3K4me3) of brain-derived neurotrophic factor (BDNF) exon IV from the postmortem brain tissue of patients with schizophrenia are related to the psychopathology of schizophrenia. We intended to investigate the levels of MLL1 messenger RNA (mRNA) and BDNF exon IV histone H3K9me2 and K27me3 in peripheral blood of patients with schizophrenia and healthy controls and to evaluate the relationships between aforementioned biomarkers and patients with/without clozapine treatment. Methods: During a one-year period, we recruited 36 patients with schizophrenia and 32 healthy controls. Symptom severity was assessed using the Positive and Negative Syndrome Scale (PANSS). We sampled 10 mL of peripheral blood from each participant to analyze the MLL1 mRNA and BDNF exon IV H3K9me2 and K27me3 levels. Results: Significantly higher blood H3K9me2 (p < 0.01) levels were observed in patients with schizophrenia than those in healthy controls. However, no significant difference was found in H3K27me3 levels between patients with schizophrenia and controls. PANSS scores had significant correlations with H3K9me2 levels (p < 0.01). No significant differences were found in MLL1 mRNA levels, H3K9me2 levels, and H3K27me3 levels between patients with clozapine treatment and nonclozapine treatment. Conclusion: Blood BDNF exon IV H3K9me2 levels may be involved in the psychopathology of schizophrenia. More knowledge is needed before we can develop it to be a biomarker for schizophrenia.

Risk factors of psychiatric hospitalization of military service persons in Taiwan: Preliminary results from unsupervised clustering techniques Geng-Fu Tsai, Yueh-Ming Tai, Sy-Ming Guu Taiwanese Journal of Psychiatry 2019 33(2):105-109 Background: To understand the discrepancies of the use of mental health providers among different military ranks and/or compulsory/voluntary military services especially of the psychiatry admission during active services. Methods: We collected military medical records of one military psychiatry teaching hospital of north Taiwan from 2012 to 2015. All 3,513 samples were divided into three groups ─ enlisted females (EFs), enlisted males, and drafted males (DMs). The outcome measurement was the time period from the date of enlisted or drafted to the first psychiatric admission (E-A period). After comparing baseline characteristics and E-A period among three groups, we applied unsupervised clustering techniques, exhaustive Chi-squared automatic interaction detector, to cluster samples based on their military ranks and compulsory/voluntary service. Results: In general, the EF group showed the longest E-A period and the DM group the shortest. The most common diagnosis was major depression followed by anxiety or other nonpsychiatric disorders. The privates and recruits showed shorter E-A periods, and the younger enlistment age of officers showed the longer E-A period if we clustered based on military ranks. Those who entered army due to obligation showed shorter E-A period and those males who enlisted voluntarily at age over 22.5 years also showed shorter E-A period. Conclusion: This study demonstrates potential clusters associating with psychiatry admission in military. But, we caution that the findings here should be treated as preliminary.

The prevalence and correlates of depression of the elderly in local community centers in Nantou, Taiwan Pei-Chi Liu, Ming-Shun Chung Taiwanese Journal of Psychiatry 2019 33(2):110-113 Objectives: Depression in the elderly has become a serious health-care issue worldwide. In this study, we intended to evaluate the prevalence of depressive tendency among community-dwelling elderly in Nantou Prefecture, to assess sociodemographic factor in relation to depression, and to compare the characteristics of different community centers. Methods: We enrolled 133 old adult dwellers in five community centers in Nantou City and Zhongliao Township in Nantou Prefecture, Taiwan. Demographic and medical information was collected and participants filled Chinese versions of the Geriatric Depression Scale-Short Form (GDS-15). Results: The cutoff point of GDS-15 was set above 5. The prevalence of depressive tendency in community centers in Nantou was 24.1%. Multivariate logistic regression analysis demonstrated that having financial strain (odds ratio [OR] = 4.698, 95% confidence interval [CI] = 1.90–12.70, p < 0.01) and physical illness (OR = 2.144, 95% CI = 1.09–4.24, p < 0.01) were significant risk factors of depressive symptoms in this sample. However, no significant difference was found in depression in seniors between suburban and rural community. Conclusion: This result showed that depression was common in Nantou City and Zhongliao Township. Having financial strain and physical illness were the significant risk factors for depression in seniors. The intervention to reduce depressive symptoms in the elderly should include strategies about addressing those risk factors in local community.

Atypical depression associated with high-dose steroid treatment in an adolescent patient receiving liver transplantation Ming-Chia Liu, Kai-Ting Ko, Chau-Shoun Lee Taiwanese Journal of Psychiatry 2019 33(2):114-115

Probiotics Lactobacillus Plantarum PS128 intervention in two patients with major depressive disorder Jr-Shian Chang, Yi-Hang Chiu, Chien-Chih Pan, Chun-Hsin Chen Taiwanese Journal of Psychiatry 2019 33(2):116-117