Training eldercare workers in mental healthcare

<p><b>INTRODUCTION</b>A significant proportion of older persons who require support or care services have mental health concerns. There is a need to equip frontline eldercare workers with the necessary skills in caring for older persons with mental illnesses. The Community Psychogeriatric Programme aims to support community eldercare providers with training and consultation. We sought to measure eldercare workers' perceived levels of stress and knowledge about caring for older persons with mental illness before (pre-workshop), immediately after (post-workshop) and three months after (three-month follow-up) they underwent standardised training workshops on dementia and depression.</p><p><b>METHODS</b>Participants who attended two four-hour workshops on dementia and depression were recruited for the study. Their knowledge of topics was evaluated pre-workshop, post-workshop and at three-month follow-up. Perceptions of working with older persons with mental health problems were rated pre-workshop and at three-month follow-up.</p><p><b>RESULTS</b>A total of 71 staff members from various eldercare centres participated in the study, of which 51 (71.8%) were women. At three-month follow-up, there was a significant change in most measures on Ryden's Perception Scale (p < 0.05). There were significant improvements in knowledge scores for dementia and depression (p < 0.001). Knowledge gains after the workshop were maintained at three-month follow-up.</p><p><b>CONCLUSION</b>Training of eldercare workers in mental healthcare is helpful for knowledge improvement and altering perceptions of caring for older persons. With continued support from mental health professionals, such training could contribute to better care for this vulnerable population.</p>

Personal Recovery in Serious Mental Illness: Making Sense of the Concept

Traditionally, clinicians and healthcare users alike use the term "recovery" to imply a return to a premorbid state. This form of clinical recovery is objective, measureable and is a clear health outcome. In the past decade, an alternative to clinical recovery, also known as personal recovery, has gained traction in mental health and has impacted numerous mental health systems. Originally, personal recovery was conceptualised as an individually unique ongoing process for individuals with serious mental illness that emphasises on growth and potential for recovery, but it has also been proposed to be a clinical outcome for mental health professionals. In this commentary, we discuss the differences in the 2 models of recovery and attempt to illustrate the concepts behind personal recovery so as to clarify its usage in people with serious mental illnesses.

Does Cannabis Consumption Negatively Affect Cognition? A Review Of The Scientific Evidence

Objective: This review summarises the existing evidence on the effects that recreational and medical use of cannabis and cannabinoids have on cognitive performance. Methods: Databases (PubMed, Medline, and Google Scholar) were searched from inception to March 2017 by adopting the following key terms: dronabinol, nabilone, nabiximols, cannabis, marijuana, cognition, neurology, and neuropsychology. A total of 94 documents, including reviews, preclinical and clinical studies, industrial and government agencies reports were included in this review. Results: We found that recreational use of cannabis doubles the risk of a fatal traffic accident by impairing attention and lengthening reaction time. Short-term use lowers performance in working memory, attention, executive functions and visual perception tasks. Chronic recreational use in adolescents also doubles the risk of early school-leaving, cognitive impairment and psychoses in adulthood. Adverse effects of cannabis-based medication – dronabinol, nabiximol and nabilone – and ingestion/inhalation of marijuana allowed for medical use include dizziness, drowsiness and short-term memory impairment. Conclusion: Cannabis consumption is associated with significant impairments in a range of cognitive abilities. Of particular concern, early and chronic exposure to cannabis, especially in the adolescence, seems to be associated with irreversible cognitive impairments.

A Systematic Review of the Effectiveness of Medical Cannabis for Psychiatric, Movement and Neurodegenerative Disorders

The discovery of endocannabinoid’s role within the central nervous system and its potential therapeutic benefits have brought forth rising interest in the use of cannabis for medical purposes. The present review aimed to synthesize and evaluate the available evidences on the efficacy of cannabis and its derivatives for psychiatric, neurodegenerative and movement disorders. A systematic search of randomized controlled trials of cannabis and its derivatives were conducted via databases (PubMed, Embase and the Cochrane Central Register of Controlled Trials). A total of 24 reports that evaluated the use of medical cannabis for Alzheimer’s disease, anorexia nervosa, anxiety, dementia, dystonia, Huntington’s disease, Parkinson’s disease, post-traumatic stress disorder (PTSD), psychosis and Tourette syndrome were included in this review. Trial quality was assessed with the Cochrane risk of bias tool. There is a lack of evidence on the therapeutic effects of cannabinoids for amyotrophic lateral sclerosis and dystonia. Although trials with positive findings were identified for anorexia nervosa, anxiety, PTSD, psychotic symptoms, agitation in Alzheimer’s disease and dementia, Huntington’s disease, and Tourette syndrome, and dyskinesia in Parkinson’s disease, definitive conclusion on its efficacy could not be drawn. Evaluation of these low-quality trials, as rated on the Cochrane risk of bias tools, was challenged by methodological issues such as inadequate description of allocation concealment, blinding and underpowered sample size. More adequately powered controlled trials that examine the long and short term efficacy, safety and tolerability of cannabis for medical use, and the mechanisms underpinning the therapeutic potential are warranted.

The Needs and Problems in Epilepsy Caregiving: A Qualitative Exploration

Objective: Living with epilepsy imposes great challenges on both patients and their family caregivers but most researchers only explored the impact on patients, with less attention given to family caregivers. Our study intended to explore the needs and problems of epilepsy family caregivers of epilepsy patients encountered during the caregiving process. Methods: Respondents were recruited from the Neurology Clinic of Hospital Sultanah Nur Zahirah (HSNZ), Kuala Terengganu. A semi-structured interview was conducted using openended and broad questions asking about their general experience in caregiving, daily routine activities, caregiving effects, caregiving difficulties and caregivers’ needs. The interviewed data were later transcribed into verbatim before further analysis using the QSR International’s NVivo10 software. Results: Fifteen Malay Muslim family caregivers between the age of 19 and 66 years participated. Most were females (53%), married (67%), with education level at secondary school or equivalent (73%) and were homemakers (40%). In particular, respondents expressed the need for extra support from their family members and experts in terms of physical (care relief), mental, and financial aspects. In addition, the major caregiving problems identified included: (i) emotional disturbances (sad, angry, depressed, and anxious); (ii) care giving challenges (family adjustments, physical burden, psychological burden, and time management); and (iii) financial issues (not working and limited family income). Some advantages in caregiving were also reported. Conclusion: In conclusion, their experiences while taking care of their loved ones in terms of feelings, beliefs and needs exposed the difficulties in caregiving, causing substantial emotional pressure which could later lead to poor quality of caregiving.

Regulation of Interleukin-6 and Leptin in Schizophrenia Patients: A Preliminary Analysis

OBJECTIVE: Immune-inflammatory mediators play a pivotal role in brain signaling and have been increasingly associated with the pathophysiology of schizophrenia. Many studies have indicated an increased level of immune-inflammatory interleukin-6 (IL-6) in schizophrenia. IL-6 is a well-known chief stimulator of inflammation. Of late leptin has also been implicated in the inflammatory pathway of schizophrenia. In this study we measured and compared serum levels of IL-6 and leptin in patients with schizophrenia to healthy controls, and investigated the relationship between IL-6 and leptin. METHODS: Serum IL-6 and leptin were determined in 20 patients diagnosed with schizophrenia and in 19 healthy controls matched by gender, age and body mass index (BMI) using commercial Bioplex assays. RESULTS: Using Mann-Whitney U-test, significantly increased IL-6 levels were found in the patients but there was no significant difference in leptin levels though a trend towards higher leptin was observed in the patients. Spearman correlations did not show any correlation between IL-6 and clinical variables except antipsychotic dosage. Leptin significantly correlated with gender and BMI. A large effect size correlation was observed between IL-6 and leptin in the patients but not in the controls. Multiple regression analysis performed on patients, after adjusting for gender and BMI, revealed there was no significant association between IL-6 and leptin. CONCLUSION: IL-6 and leptin levels may reflect the chronic inflammatory state associated with schizophrenia but further evaluation is required. Also, it is important to consider the confounding effects of obesity in any examination of relationships between groups with regard to cytokines and adipokines.

Waist circumference is a potential indicator of metabolic syndrome in Singaporean Chinese

<p><b>INTRODUCTION</b>Metabolic Syndrome (MetS) is associated with cardiovascular morbidity and mortality. Studies proposed that waist circumference (WC) and body mass index (BMI) are good indicators of MetS. In this study, we examined and compared the predictive utility of clinical measures such as WC, blood pressure and BMI and determined the cutoff points in which these measures are most reliable in identifying MetS in Singaporean Chinese.</p><p><b>MATERIALS AND METHODS</b>Two hundred and forty-four subjects aged between 21 and 50 years of Chinese ethnicity were recruited into the study. Sociodemographic, height, weight and blood pressure information were obtained. High-density lipoprotein cholesterol (HDL-C), triglycerides (TG) and glucose levels were evaluated. Presence of MetS was examined according to American Heart Association (AHA)/National Heart, Lung and Blood Institute (NHLBI) guidelines. Predictive utility of BP, WC and BMI was examined using receiver operating curve and discriminant indices were determined accordingly.</p><p><b>RESULTS</b>Forty-one (16.8%) subjects were identified to have MetS. Our analysis revealed that waist circumference was most accurate in identifying MetS (area under the curve (AUC) = 0.88, 95% confidence interval (CI), 0.83 to 0.93, P <0.001) followed by BMI (AUC = 0.84, 95% CI, 0.77 to 0.91, P = 0.035), systolic BP (AUC = 0.83, 95% CI, 0.76 to 0.90, P = 0.036) and diastolic BP (AUC = 0.80, 95% CI, 0.71 to 0.88, P = 0.042). Waist circumference cut-off values of >92.5 cm in males and >86.5 cm in females were found to be most sensitive and specific in discriminating MetS.</p><p><b>CONCLUSION</b>Our finding has immediate and significant clinical implications as WC can be easily obtained. However, as the study included only Singaporean Chinese, findings cannot be generalised for other ethnic groups.</p>

The mandatory treatment order - The experience in the first year in SIngapore

The Mandatory Treatment Order (MTO) became a sentencing option for select offenders with psychiatric illness in Singapore in 2011. This article aimed to study the psychiatric characteristics of the offenders in the first year of the MTO; Methods: A clinical audit was conducted on all the cases referred to the Institute of Mental Health for assessment as to their suitability to receive an MTO from January to December 2011. A psychiatrist went through all the case records. Data on the demographics, forensic history and psychiatric diagnoses were obtained from records; Results: There were differences seen between the genders in the likelihood of being granted an MTO. Gender also played a role in the length of MTOs granted and in the diagnoses of the individuals. The reasons for an MTO not being granted are presented. Conclusion: Some discussion is made regarding the availability of court diversion legislature in other countries for mentally ill offenders and the directions such diversion might take are highlighted. Potential areas for future research are pointed out.

Annual Review Clinic: A Chronic Disease management model of care for schizophrenia and delusional disorder in Singapore

Schizophrenia and delusional disorders are recognised as chronic mental conditions. During this time, the clinical course may fluctuate and co-morbidities may set in. Individuals with these conditions often lack insight and have high rates of default. We report the need to develop a chronic disease model of care to cater to this unique group of individuals in Singapore. Methods: The Ministry of Health in Singapore recently funded the Institute of Mental Health to develop a model of psychiatric care for individuals with schizophrenia and delusional disorders. Crucial to the success was the development of an information technology (IT) enabled platform to track and monitor the clinical status of this group of individuals. On a yearly interval, patients undergo a comprehensive review and needs analysis of their psychiatric and medical needs in the Annual Review Clinic (ARC). Clinical ratings and metabolic parameters of every patient were obtained, and every patient was assigned a case-tracker or case manager to monitor their engagement with the relevant services. Results: In the first year of operations, ARC reviewed 1525 patients with schizophrenia and delusional disorders. The median GAS score for the cohort seen was 75 (slight impairment in functioning). The median CGI-S score was 2 (borderline mentally ill). 48.5% of reviewed patients were classified as overweight and above with BMI ≥ 25. After the needs analysis, 100 patients received referrals to primary healthcare services for medical conditions that were recently diagnosed or for which they have defaulted medical treatment. Conclusions: In the first year of this program, a snapshot of the clinical status of the outpatient population was obtained and we also identified a high prevalence of obesity among the patients. Through this program, we can continuously monitor the health status of every patient and monitor for developing trends so as to plan the necessary interventions.

Prevalence of metabolic syndrome among patients with schizophrenia in Singapore

<p><b>INTRODUCTION</b>Schizophrenia has been associated with an increased risk of cardiometabolic morbidity and mortality. Metabolic syndrome (MetS), a reliable predictor of cardiovascular-related morbidity and mortality, has also been shown to be more prevalent in patients with schizophrenia. In this study, we investigated the prevalence of MetS in a sample of patients with schizophrenia in Singapore, and the potential risk factors associated with it.</p><p><b>MATERIALS & METHODS</b>One hundred patients with schizophrenia and 300 community controls were recruited. All subjects provided a fasted sample of venous blood to measure high-density lipoprotein cholesterol (HDL-C), triglycerides and glucose levels. Weight, height and waist circumference were measured. Presence of MetS was assessed according to the American Heart Association and the National Heart, Lung and Blood Institute (AHA/NHLBI) guidelines.</p><p><b>RESULTS</b>The prevalence of MetS in patients with schizophrenia was 46.0%. The adjusted odds ratio (OR) for MetS among patients was 2.79 (CI, 1.50 to 5.20, P = 0.001) when compared with controls. Increasing body mass index (BMI) was identifi ed to be signifi cantly associated with the prevalence of MetS.</p><p><b>CONCLUSION</b>This study found a high prevalence of MetS in Singapore patients with schizophrenia, and that BMI might be a risk factor in the development of MetS. This information is clinically relevant as BMI is routinely measured in psychiatric practice today, and could be used to monitor for development of MetS in schizophrenia.</p>

A Review of Brain-derived Neurotrophic Factor as a Candidate Biomarker in Schizophrenia

Brain-derived neurotrophic factor (BDNF), a neurotrophin known to be responsible for development, regeneration, survival and maintenance of neurons has been implicated in the pathophysiology of schizophrenia. This review seeks to complement previous reviews on biological roles of BDNF and summarizes evidence on the involvement of BDNF in the pathophysiology of schizophrenia with an emphasis on clinical relevance. The expressions of BDNF were altered in patients with schizophrenia and were found to be correlated with psychotic symptomatology. Antipsychotics appeared to have differential effects on expression of BDNF but did not restore BDNF expression of patients with schizophrenia to normal levels. In addition, evidence suggests that BDNF is involved in the major neurotransmitter systems and is associated with disruptions in brain structure, neurodevelopmental process, cognitive function, metabolic and immune systems commonly associated with schizophrenia. Besides that, BDNF has been demonstrated to be tightly regulated with estrogen which has also been previously implicated in schizophrenia. Evidence gathered in this review confirms the relevance of BDNF in the pathophysiology of schizophrenia and the potential utility of BDNF as a suitable biomarker for diagnostic and prognostic purposes for disease outcome and other co-morbidities. However, further investigations are warranted to examine the specificity of BDNF in schizophrenia compared to other neurodegenerative disorders and other neuropsychiatric illness. Longitudinal prospective studies will also be of added advantage for evaluation of prognostic utility of BDNF in schizophrenia.

Thrombocytopenia With Valproate And Clozapine Combination Therapy

Objective: The occurrence of thrombocytopenia with valproate and clozapine combination therapy has not been noted in the literature. This case report highlights thrombocytopenia as a potential outcome of drug-drug interaction between valproate and clozapine, and serves to remind practitioners that regular monitoring of platelet counts is necessary in such combination therapy. Method: We report on a patient on valproate therapy who developed thrombocytopenia when clozapine was added to her treatment regime. Results: Thrombocytopenia resolved 1 week after valproate was tailed off and the patient was placed on clozapine monotherapy. Conclusions: A precise pathophysiologic understanding of valproate and clozapine-induced thrombocytopenia is lacking, and further studies are required.