Prescription Patterns for Bipolar Disorder in Asian Countries:Findings from Research on Asian Prescription Pattern-Bipolar Disorder

Objective@#Pharmacotherapy including mood stabilizers and antipsychotics are frequently used in bipolar disorder (BD); however, the lack of consensus regarding the definition of polypharmacy hinders conducting comparative studies across different settings and countries. Research on Asian Prescription Pattern (REAP) is the largest and the longest lasting international collaborative research in psychiatry in Asia. The objective of REAP BD was to investigate the prescription patterns of psychotropic medications across Asian countries. The rates of polypharmacy and psychotropic drug load were also analyzed. @*Methods@#The data collection was web-based. Prescription patterns were categorized as (1) mood stabilizer monotherapy: one mood stabilizer; (2) antipsychotic monotherapy: one antipsychotic; (3) simple polypharmacy: one mood stabilizer and one antipsychotic; and (4) complex polypharmacy: ≥ 2 mood stabilizers or/and antipsychotics. The psychotropic drug load in each patient was calculated using the defined daily dose method. @*Results@#Among 2003 patients with BD (52.1% female, 42.4 years) from 12 countries, 1,619 (80.8%) patients received mood stabilizers, 1,644 (82.14%) received antipsychotics, and 424 (21.2%) received antidepressants, with 14.7% mood stabilizer monotherapy, 13.4% antipsychotic monotherapy, 48.9% simple polypharmacy, 20.3% complex polypharmacy, and 2.6% other therapy. The average psychotropic drug load was 2.05 ± 1.40. Results varied widely between countries. @*Conclusion@#Over 70% of psychotropic regimens involved polypharmacy, which accords with the high prevalence of polypharmacy in BD under a permissive criterion (2 or more core psychotropic drugs) worldwide. Notably, ≥ 80% of our sample received antipsychotics, which may indicate an increasing trend in antipsychotic use for BD treatment.

A Call for a Rational Polypharmacy Policy: International Insights From Psychiatrists

Objective@#Recently, rational polypharmacy approaches have been proposed, regardless of the lower risk and cost of monotherapy. Considering monotherapy as first-line treatment and polypharmacy as rational treatment, a balanced attitude toward polypharmacy is recommended. However, the high prevalence of polypharmacy led the Japanese government to establish a polypharmacy reduction policy. Based on this, the association between the policy and psychiatrists’ attitude toward polypharmacy has been under debate. @*Methods@#We developed an original questionnaire about Psychiatrists’ attitudes toward polypharmacy (PAP). We compared the PAP scores with the treatment decision-making in clinical case vignettes. Multiple regression analyses were performed to quantify associations of explanatory variables including policy factors and PAP scores. The anonymous questionnaires were administered to psychiatrists worldwide. @*Results@#The study included 347 psychiatrists from 34 countries. Decision-making toward polypharmacy was associated with high PAP scores. Multiple regression analysis revealed that low PAP scores were associated with the policy factor (β=-0.20, p=0.004). The culture in Korea was associated with high PAP scores (β=0.34, p<0.001), whereas the culture in India and Nepal were associated with low scores (β=-0.15, p=0.01, and β=-0.17, p=0.006, respectively). @*Conclusion@#Policy on polypharmacy may influence psychiatrists’ decision-making. Thus, policies considering rational polypharmacy should be established.

Clinical Characteristics of Bipolar Disorder Patients with Mood Stabilizer-Induced Cognitive Side Effects findings from the REAP-BD Survey in Korea / 신경정신의학

Methods@#This study analyzed 350 Korean adults who were diagnosed with bipolar disorder and prescribed mood-stabilizing drugs. The patients were divided into two groups—patients who experienced cognitive side effects and those who did not experience cognitive side effects.We also compared the demographic and clinical characteristics between both groups. @*Results@#The number of patients with an untreated illness longer than 1 year was higher in the group of patients who experienced cognitive side effects compared to the group of patients who did not experience cognitive side effects. Further, the number of patients with manic symptoms at onset was higher in the group of patients who experienced cognitive side effects compared to the group of patients who did not experience cognitive side effects. In addition, the proportion of patients in remission was higher in the group of patients who experienced cognitive side effects compared to the group of patients who experienced no cognitive side effects. However, there was no significant difference regarding the type of mood stabilizer used between the groups. On the other hand, more people experienced cognitive side effects as the valproic acid dosage increased. @*Conclusion@#Our findings suggest that there are clinical and demographic differences between people who experienced cognitive side effects and those who did not experience cognitive side effects due to prescription of mood stabilizers.

Clinical Characteristics and Psychotropic Drug Prescription Patterns of Bipolar Disorder Patients with a History of Suicidal Attempts: Findings from the REAP-BD, Korea

Our study aimed to analyze the clinical characteristics and psychotropic prescription patterns of a history of suicide attempts in South Koreans with bipolar disorder (BD), by using only Korean data from the Research on Asian Psychotropic Prescription Pattern for Bipolar disorder. The patterns of clinical characteristics and psychotropic drug use were compared among 53 patients with a history of suicide attempts and 297 without this history; the potential effects of confounding variables were adjusted with binary logistic analyses for discrete variables and analyses of covariance for continuous variables. After adjusting the effects of age, sex, duration of illness, and enrollment as an outpatient, patients with a history of suicide attempts were characterized by a significantly more prevalent depressive episode, lower prevalent remission state, lower levels of hemoglobin, and more use of antidepressants, anxiolytics, and hypnotics compared to those without lifetime suicide attempt. The inability to plan goal-directed behavior may be an intervening factor in the relationship between suicide attempts and depression in BD. Relatively low hemoglobin levels can be associated with manic episodes in patients with a history of suicide attempts and the use of antidepressants, anxiolytics, or hypnotics can be associated with suicide attempts in BD patients.

Examining Patterns of Polypharmacy in Bipolar Disorder: Findings from the REAP-BD, Korea

Based on Korean data from the Research on Asian Psychotropic Prescription Pattern for Bipolar Disorder, this study tried to present prescription patterns in biopolar disorder (BD) and its associated clinical features. Based on the information obtained from the study with structured questions, the tendency of prescription pattern was studied and analyzed. Polypharmacy was predominant, including simple polypharmacy in 51.1% and complex polypharmacy in 34.2% of patients. Subjects associated with simple or complex polypharmacy were significantly younger, had higher inpatient settings, a larger portion of onset with manic episode, a shorter duration of untreated illness, a shorter duration of current episode, were more overweight, used less antidepressants and used more anxiolytics. These findings can suggest higher polypharmacy rate in more severe BD and highlight the necessity of monitoring the weight of subjects with polypharmacy.

Differences in High Dose Antipsychotic Prescriptions in Patients with Schizophrenia in Asian Countries/Areas: Findings from the REAP-AP Study

The REAP-AP study recruited 3,746 patients with schizophrenia, in March and April 2016, from 71 centers in 15 Asian countries/territories namely Bangladesh, China, Hong Kong, India, Indonesia, Japan, Korea, Malaysia, Myanmar, Pakistan, Singapore, Sri Lanka, Taiwan, Thailand and Vietnam. Our findings reveal a trend according to which high dose antipsychotic prescription is more prevalent in Eastern Asia (especially, Japan and Korea) than in other regions of Asia. This historical factor may be associated with our finding of an Eastern Asian preponderance of high dose antipsychotic prescription.

Underdiagnosis of delirium on admission and prediction of patients who will develop delirium during their inpatient stay: a pilot study

<p><b>INTRODUCTION</b>The study aimed to determine the prevalence and documentation of delirium among the elderly and if the Clock Drawing Test (CDT) can be used to predict which patients had delirium on admission and those who may develop delirium during their stay in acute medical wards.</p><p><b>METHODS</b>A single researcher performed the Mini-Mental State Examination (MMSE) and CDT on admission and discharge of 57 elderly adults at the National University Hospital, Singapore. Delirium was defined as a ≥ 3-point improvement or ≥ 2-point decline in MMSE scores from admission to discharge, where a fall denotes development of delirium and a rise denotes resolution. The case notes of the same patients were reviewed for documentation of delirium. All inpatients from two acute medical wards were examined. One CDT score and a pair of MMSE scores were collected from each patient.</p><p><b>RESULTS</b>A total of 57 patients (28 male, 29 female) were involved in the study. Their mean age was 76.0 ± 8.7 years. The prevalence of delirium based on MMSE scores was 40.4%; 16 patients had delirium on admission while seven developed delirium during their inpatient stay. However, delirium was documented in the case notes of only 7 (30%) of the 23 patients. CDT score was better than baseline MMSE score at predicting a decline in MMSE score.</p><p><b>CONCLUSION</b>The prevalence of delirium in the acute medical setting is high but underdiagnosed. The CDT may be a good screening tool to identify patients at risk of delirium during their inpatient stay. Baseline cognition screening should be performed in every elderly patient admitted to hospital.</p>

The Impact of Education Reform: An Asian Medical School's Experience

This study assessed the effectiveness of education reforms on student-reported learning outcomes at the end of the 5-year medical school (M5) and 1-year internship (HO) in 2006, 2007 and 2008. A self-administered anonymous survey with 17 learning outcomes assessed, derived from Harden's Three-Circle Outcomes Model for outcomes-based education, was administered to 683 students at the end of medical school (M5) and internship (HO) from 2006, 2007 and 2008. We identified learning outcomes which changed significantly for internship (Cohorts A, B and C) and medical school (Cohorts B, C and D) between cohorts from 2006 to 2008, and compared learning outcomes between medical school and internship within cohorts (i.e. Cohort B which was M5 in 2006 and HO in 2007; Cohort C which was M5 in 2007 and HO in 2008). The proportion of students who agreed that medical school helped them achieve learning outcomes increased significantly from 2006 to 2008 for 15 out of 17 learning outcomes assessed. The proportion of students who agreed that internship helped them achieve learning outcomes increased significantly from 2006 to 2008 for 6 learning outcomes assessed. For Cohorts B and C, internship was more effective than medical school in achieving 8 learning outcomes. Cohort C reported that internship was more effective than medical school in 3 additional learning outcomes than Cohort B: patient management, humility and dedication. We conclude that a successful journey of education reform is an ongoing process that needs to comprehensively address multifaceted components such as faculty, administration and curriculum.

Are medical students' views of an ideal physician eroding? A study on perceived qualities of a "role model" doctor before and after housemanship and between two cohorts five years apart

<p><b>INTRODUCTION</b>This study aimed to examine the impact of housemanship and cohort effect on the perceptions of what constitutes a "role model physician" between 2 cohorts of medical students.</p><p><b>MATERIALS & METHODS</b>Final year medical students of the Yong Loo Lin School of Medicine, National University of Singapore, from the classes of 2005 (pre- and post-housemanship) and class of 2009 (pre-housemanship) responded to an anonymous 25-statement questionnaire reflecting Fones et al's 25-item characterisation of a "role model" doctor. Qualitative data was also collected on student's perceived qualities of a role model doctor.</p><p><b>RESULTS</b>For the 2005 cohort pre- and post-housemanship, only 3 of the 25 items had increased in importance post-housemanship. However, when comparing the 2005 and 2009 cohorts pre-housemanship, the latter cohort placed significantly greater importance on 12 of the 25 items. Willingness to teach was identified via qualitative analysis as a new important quality of a role model doctor for medical students.</p><p><b>CONCLUSION</b>The importance placed on characteristics of "role model" physicians were relatively unchanged by housemanship within the same cohort but increased with time between 2 cohorts 5 years apart. This suggests that professional standards of an "ideal" doctor expected and aspired to by medical students may not be eroding as feared by the medical profession and society.</p>

Prevalence and prescription of antidepressants in depression with somatic comorbidity in Asia: the Research on East Asian Psychotropic Prescription Patterns study / 中华医学杂志(英文版)

<p><b>BACKGROUND</b>Depression is often comorbid with chronic somatic diseases. Few previous studies have investigated the prevalence of somatic diseases in depression or the prescription pattern of antidepressants in comorbidly depressed patients in Asia. This study aimed to investigate the prevalence of somatic comorbidity (SC) in depression and compared the prescriptions of antidepressants in depressed patients with and without SC.</p><p><b>METHODS</b>A total of 2320 patients treated with antidepressants in 8 Asian countries were examined, and a diagnosis was based on the International Classification of Disease, 10 th revision. We listed 17 common chronic somatic diseases. Patients' socio-demographic and clinical characteristics and psychotropic drug prescriptions were recorded using a standardized protocol and data collection procedure.</p><p><b>RESULTS</b>Of the patients examined, 1240 were diagnosed with depression and 30% of them (n = 375) had SC. The most common comorbid condition was diabetes (23.7%). The patients with SC were more likely to seek help at a general hospital (74.7% vs. 47.2%), and had a higher incidence of symptoms involving sadness, disturbed sleep, and poor appetite. Noradrenergic and specific serotonergic antidepressant was prescribed more for patients with SC than for those without SC (30.4% vs. 22.9%).</p><p><b>CONCLUSIONS</b>SC is common in depressed Asian patients. It is important to strengthen the recognition of depression, especially in general hospitals and when patients report some somatic discomfort. It is also a matter of urgency to establish evidence-based guidelines for the use of new antidepressants in depressed patients with SC.</p>

Pathophysiology and animal models of schizophrenia

Animal models of schizophrenia are important for research aimed at developing improved pharmacotherapies. In particular, the cognitive deficits of schizophrenia remain largely refractory to current medications and there is a need for improved medications. We discuss the pathophysiology of schizophrenia and in particular the possible mechanisms underlying the cognitive deficits. We review the current animal models of schizophrenia and discuss the extent to which they meet the need for models reflecting the various domains of the symptomatology of schizophrenia, including positive symptoms, negative symptoms and cognitive symptoms.

Attitudes of first-year medical students in Singapore towards older people and willingness to consider a career in geriatric medicine

<p><b>INTRODUCTION</b>Training of future physicians in the care of elderly patients will need to evolve in accordance with the exponential increase of elderly patients, but some may have preconceived attitudes affecting their management. This study determined medical students' attitudes towards older people and their willingness to consider a career in Geriatric Medicine.</p><p><b>MATERIALS AND METHODS</b>All 250 first-year medical students, prior to any formal clinical exposure at the National University of Singapore School of Medicine, were asked to participate voluntarily in the study based on the UCLA Geriatrics Attitudes Scale. The 14-item questionnaire consisted of a mixture of positively and negatively worded questions answered on a 5-point Likert scale. A fifteenth question enquired about their willingness to consider Geriatric Medicine as a potential career choice.</p><p><b>RESULTS</b>The mean UCLA attitudes score was 3.58 [+/-standard deviation (SD), 0.41] suggesting a generally positive attitude. There was a strong association between attitude scores and willingness to consider Geriatric Medicine as a career (R = 0.48, P <001). However, only one third of the cohort was willing to consider a career in Geriatric Medicine. There was no difference in attitude scores between male and female students, but females were significantly more likely to consider Geriatric Medicine as a potential career choice.</p><p><b>CONCLUSION</b>First-year medical students in Singapore have a generally positive attitude towards older people, although only 1 in 3 persons was willing to consider a career in Geriatric Medicine. Higher attitude scores and female gender were the main predictors of willingness to consider a career in Geriatric Medicine.</p>