Banning paraquat would prevent nearly 200 deaths from suicide per year in Taiwan Shu- Sen Chang, David Gunnell Taiwanese Journal of Psychiatry 2019 33(3):119-121

Unmet needs for the management of depression Yi-Ju Pan Taiwanese Journal of Psychiatry 2019 33(3):122-124

Tobacco and smoking cessation Nan- Ying Chiu, Cheng- Ju Chang Taiwanese Journal of Psychiatry 2019 33(3):125-134 Background: Tobacco products have been used by human for a long history. The prevalence of tobacco use varies in different countries. Tobacco use is different from tobacco use disorder. Tobacco use disorder is a problematic pattern of tobacco use leading to significant distress or impairment. Cigarette smoking is a chronic relapsing substance use disorder caused by addiction to nicotine. Tobacco smoke contains over 7,000 different chemical compounds, of which 93 of them are harmful substances. Methods: In this review, the authors intended to address the issues of harmful effects of cigarette smoking and how to cease smoking. Results: Abundant studies showed that tobacco use is the main risk factor of morbidity and mortality in the world. People who use tobacco products should be advised to quit smoking and offered appropriate treatment. It is better for health-care providers to make the smoking cessation treatment as a standard component of medical care. Data from evidence-based literature showed that smoking cessation therapy can significantly raise smoking cessation rates and should be routinely in persons who are willing to quit tobacco smoking. Smoking cessation treatment includes psychosocial interventions and pharmacological treatment, which may be used in combination. Nonpharmacological management may be individual or group sessions, and it may include motivational interviewing, cognitive behavioral therapy, and others. Delivery formats of stop-smoking interventions are varied. Pharmacological therapy includes nicotine replacement treatment and smoking aids such as bupropion and varenicline. Morbidity and mortality rates are decreased with tobacco cessation at any point in time, although cessation before the age of 40 years has the most significant effect. Conclusion: The Tobacco Hazards Prevention Act took effect since 1997 in Taiwan. Rates of Taiwanese tobacco use have been steadily declining. Brilliant achievements in the field of tobacco control in Taiwan draw international attention.

Treatment effectiveness of shifting from risperidone long-acting injectable to first-generation long-acting injectable antipsychotics in patients with schizophrenia Ching- Yin Chang, Hung- Yu Chan Taiwanese Journal of Psychiatry 2019 33(3):135-141 Objectives: Most studies of long-acting injectable antipsychotic (LAI) drugs have been focused on the efficacy of second-generation antipsychotic (SGA) LAIs through observation of the various outcomes of shifting from first-generation antipsychotic (FGA) LAIs to SGA LAIs. Rare studies have assessed the effectiveness of shifting from SGA LAIs to FGA LAIs. In this study, we intended to investigate the effectiveness of shifting from risperidone LAI to FGA LAIs in patients with schizophrenia. Methods: We included patients with schizophrenia and with the ownership of catastrophic illness card in the study. All the study patients had received risperidone LAI at least two months with a minimal dose of 50 mg per month. The case group included the patients who had been shifting from risperidone LAI to FGA LAIs (fluphenazine, haloperidol, or flupentixol). The control group included the patients who were continuously maintaining on risperidone LAI. The primary outcome was the time to hospitalization. The secondary outcomes were the side effects requiring to receive the use of concomitant anticholinergics, propranolol, and benzodiazepines. Results: We had 15 patients in the case group and 98 patients in the control group. The primary outcomes showed no significant between-group difference in the time to hospitalization (hazard ratio = 3.676, 95% confidence interval = 0.833 - 16.222). The secondary outcomes also showed no significant differences between the case and control groups. Conclusion: This study showed no significant differences in the treatment effectiveness and side effects between FGA LAIs and risperidone LAI. The results are compatible with those from a previous LAI study from the National Institute of Mental Health of the United States. But the relatively small effect with inadequate statistical power is the major study limitation, which may produce no significant differences in side effects. We suggest that further large-sample study is needed to confirm the results of this study.

Effectiveness of medical service quality promotion project for child and adolescent patients with mental disabilities and psychiatric disorders in Taiwan Chao- Wei Hsu, Ching- Hong Tsai, Yen- Cheng Chen, Hsin- Yi Chiang, Kai- Jong Huang, Cheng- Chung Chen Taiwanese Journal of Psychiatry 2019 33(3):142-147 Objective: The Ministry of Health and Welfare of Taiwan launched a project in June 2015 and provided community mental health outreach services and outpatient psychiatric treatment for child and adolescent patients with mental disabilities and psychiatric disorders from schools and institutions and in the community. The main purpose of this study project was intended to promote medical service quality for child and adolescent patients with mental disabilities and psychiatric disorders. Methods: Service team members from seven hospitals in Taiwan, including psychiatrists, clinical psychologists, and case managers, provided both outreach community services and outpatient psychiatric treatment. We collected the basic data and assessment scale scores of all outpatients from June 2015 to December 2018 (n = 163). Results: The findings revealed significant improvement in the scores of the Clinical Global Impression (CGI) – CGI-Severity Scale, Global Assessment of Functioning Scale, and Children's Global Assessment Scale (p < 0.001) and significant mild-to-moderate improvement of the CGI – Improvement Scale and internalizing problems (p < 0.05) and total problems (p < 0.01) of the Achenbach System of Empirically Based Assessment. Most outpatients presented fewer mood symptoms or behavioral disturbance, more improved adaptation, and higher academic performance at schools and institutions. Conclusion: This service model thus may provide effective medical services to the child and adolescent patients with mental disabilities and psychiatric disorders through both outreach community services and outpatient psychiatric treatment.

Respiratory sinus arrhythmia biofeedback therapy may increase heart rate variability activity and decrease reactivity in male patients with major depressive disorder: A pilot study Ching- En Lin, Li- Fen Chen, Chia- Chi Chen, Hsin- Yin Chang, Yue- Cune Chang, Jia- Fu Lee Taiwanese Journal of Psychiatry 2019 33(3):148-154 Objectives: Evidence suggests that depression is associated with a decreased trend of heart rate variability (HRV), which has been considered to be associated with unfavorable physical outcomes, and not resolved using various antidepressant medication treatments despite resolution of depression symptoms. In the present study, we intended to evaluate the effectiveness of HRV in respiratory sinus arrhythmia-biofeedback therapy (RSA-BT) on depression and HRV. Methods: We recruited 67 depressed male patients who received antidepressant or benzodiazepine treatments, received a psychological assessment, and were followed with a 3-week, 6-session RSA-BT. Results: After RSA-BT, HRV reactivity showed a significant mean decrease of 6.06 in low-frequency normal unit (p = 0.001) and 0.24 in the low-frequency/high-frequency (LF/HF) ratio (p < 0.05) and borderline but nonsignificant increase of 2.63 in HF normal unit (HFnu) during the stress task compared with those data at baseline (rest), indicating parasympathetic dominance during mental stress. At resting, post-RSA-BT showed a significant increase in LF, total power, variation (VAR), LFnu, and LF/HF (p = 0.001) and a significant decrease in HFnu (p = 0.001), indicating HRV activity increase and a shift autonomic nervous balance to sympathetic side compared to pre-RSA-BT data. Those patients also showed significant reductions in depression severity post-RSA-BT (p < 0.001) after controlling medication effect. Conclusion: The study results highlight the potential rôle of RSA-BT on the increased HRV activity with a shift sympathetic predominance at rest and decreased HRV reactivity toward parasympathetic dominance during mental stress in patients with depression, which is not related to the effects of antidepressant or benzodiazepine medication.

A gene–gene interaction between the vascular endothelial growth factor a and brain-derived neurotrophic factor genes is associated with psychological distress in the Taiwanese population Eugene Lin, Po- Hsiu Kuo, Yu- Li Liu, Albert C Yang, Shih- Jen Tsai Taiwanese Journal of Psychiatry 2019 33(3):155-159 Background: Vascular endothelial growth factor A (VEGFA) and brain-derived neurotrophic factor (BDNF), the most abundant and widely expressed neurotrophic factors in the brain, are believed to play an important rôle in depression and anxiety. In this study, we hypothesized that single-nucleotide polymorphisms (SNPs) within the VEGFA and BDNF genes would be linked with psychological distress through complex interactions in the general population. Methods: We analyzed 7,098 Taiwanese subjects from the Taiwan Biobank. Measures of anxiety and depression were evaluated using the Patient Health Questionnaire-4 (PHQ-4). Totally, 15 VEGFA and 43 BDNF polymorphisms were used in the genetic analysis. Results: In our analysis, an interaction was found between the VEGFA rs10434 and BDNF rs12418745 in significantly influencing depression state (p < 0.01). In addition, we found that influence of interaction existed between physical activity and VEGFA genetic variants including rs3025000, rs699947, rs833068, rs833069, rs3024998, and rs3025006 in depression state. But we found no association between 15 VEGFA genetic variants and depression state, after adjusting for age and gender. Furthermore, no VEGFA SNPs showed evidence of association with PHQ-4 scores. Conclusion: These results suggest that the VEGFA and BDNF genetic variants may contribute to psychological distress through gene-gene and gene-physical activity interactions in the general population.

Avoidable mortality among long-stay patients with schizophrenia under different smoking-restriction settings Kan- Yuan Cheng, Shu- Yuan Chen Taiwanese Journal of Psychiatry 2019 33(3):160-163 Objective: Patients with schizophrenia are at a greater risk of avoidable death. Although smoking is a modifiable factor to reduce the mortality gap, the rate of quitting smoking in these inpatients is still lower than that in the general population. We examined avoidable mortality among long-stay patients with schizophrenia under different smoking-restriction environments. Methods: A total of 1998 male and 459 female patients with schizophrenia who was admitted to Taipei Veterans General Hospital, Yuli Branch, in Taiwan, received follow-ups for 11 years to be estimated for the standardized mortality ratios (SMRs) of avoidable causes of death. During that period, all the male patients had stayed in smoking-allowed wards, but all the female patients had not. Results: The mean ± standard deviation age of the patients was 57.8 ± 17.0 years. Of the 993 decedents in total, 411 died of avoidable causes (41.4%). Compared with the general population, male patients had significantly higher mortality due to avoidable causes (SMR = 1.96, 95% confidence interval [CI] = 1.77–2.16, p < 0.05) and in terms of indicators of medical care (SMR = 2.41, 95% CI = 2.17–2.67, p < 0.05); however, the female patients did not (SMR = 1.22, 95% CI = 0.67–2.05; SMR = 1.57, 95% CI = 0.86–2.64, respectively). Conclusion: Male patients had higher mortality gaps due to avoidable causes and in terms of indicators of medical care. But female patients who all had stayed in tobacco-free settings did not. Environmental smoking restriction might be related to the diminished avoidable mortality gaps in patients with schizophrenia.

The moderator Rôle of family support between depression and suicidal ideation: discrepancy between male and female military population in Taiwan Jen- Hung Huang, Yueh- Ming Tai, Szu- Nian Yang Taiwanese Journal of Psychiatry 2019 33(3):164-169 Objectives: In this study, the authors intended to study the moderator rôle of family support (FS) between depression and suicidal ideation (SI) as well as between the mediation effects of the following three components of the interpersonal theory of suicide – thwarted belongingness, perceived burdensomeness, and capacity for suicide among the military population. sMethods: We enrolled 845 military active-duty personnel (male: female = 679: 166) who attended our mental health education series from 2017 to 2018 in Taiwan. The participants were asked to complete self-administrated copies of the Interpersonal Needs Questionnaire, the Acquired Capability for Suicide Scale, the Beck Depression Inventory, the Columbia-Suicide Severity Rating Scale for SI, and the family Adaptation, Partnership, Growth, Affection, and Resolve scale for FS. After comparing baseline characteristics between genders, we did moderated mediation linear analysis, to clarify the moderation effects of FS on the relationship between depression and SI as well as the possible mediation in the relationship. Results: In general, FS plays a protective moderator rôle in the depression → SI (Dep - SI) path (p < 0.05). In male samples, perceived burdensomeness was significantly mediated the effect of depression on SI (p < 0.05). But FS failed to reach a significant level for moderating the medication effect of perceived burdensomeness on the Dep–SI pathway (p > 0.05). On the other hand, in female samples, perceived burdensomeness failed to significantly mediate the effect of depression on suicidal ideation (p > 0.05), but FS significantly and negatively moderated the effect of depression on perceived burdensomeness (p < 0.05). Otherwise, FS showed negative moderation effect for the effect of depression on capacity for suicide in the male samples (p < 0.05) although capacity for suicide failed to become a statistically significant mediator in the Dep–SI path (p > 0.05). Conclusion: In this study, we found that, among military population, a protective moderation effect of FS can reduce the effect of depression on SI and different mechanisms between sexes. We suggest that programs improving FS could be another consideration for military suicidal prevention.

Valproate-induced hyperammonemia manifested with delirium Wei- Jen Chang, Ding- Lieh Liao Taiwanese Journal of Psychiatry 2019 33(3):170-171