Stigma towards mental illness in Asian nations and low-and-middle-income countries, and comparison with high-income countries: A literature review and practice implications.

Background: Stigma related to mental illness (and its treatment) is prevalent worldwide. This stigma could be at the structural or organizational level, societal level (interpersonal stigma), and the individual level (internalized stigma). Vulnerable populations, for example, gender minorities, children, adolescents, and geriatric populations, are more prone to stigma. The magnitude of stigma and its negative influence is determined by socio-cultural factors and macro (mental health policies, programs) or micro-level factors (societal views, health sectors, or individuals' attitudes towards mentally ill persons). Mental health stigma is associated with more serious psychological problems among the victims, reduced access to mental health care, poor adherence to treatment, and unfavorable outcomes. Although various nationwide and well-established anti-stigma interventions/campaigns exist in high-income countries (HICs) with favorable outcomes, a comprehensive synthesis of literature from the Low- and Middle-Income Countries (LMICs), more so from the Asian continent is lacking. The lack of such literature impedes growth in stigma-related research, including developing anti-stigma interventions. Aim: To synthesize the available mental health stigma literature from Asia and LMICs and compare them on the mental health stigma, anti-stigma interventions, and the effectiveness of such interventions from HICs. Materials and Methods: PubMed and Google Scholar databases were screened using the following search terms: stigma, prejudice, discrimination, stereotype, perceived stigma, associate stigma (for Stigma), mental health, mental illness, mental disorder psychiatric* (for mental health), and low-and-middle-income countries, LMICs, High-income countries, and Asia, South Asian Association for Regional Cooperation/SAARC (for countries of interest). Bibliographic and grey literature were also performed to obtain the relevant records. Results: The anti-stigma interventions in Asia nations and LMICs are generalized (vs. disorder specific), population-based (vs. specific groups, such as patients, caregivers, and health professionals), mostly educative (vs. contact-based or attitude and behavioral-based programs), and lacking in long-term effectiveness data. Government, international/national bodies, professional organizations, and mental health professionals can play a crucial in addressing mental health stigma. Conclusion: There is a need for a multi-modal intervention and multi-sectoral coordination to mitigate the mental health stigma. Greater research (nationwide surveys, cultural determinants of stigma, culture-specific anti-stigma interventions) in this area is required.

Post-traumatic stress disorder and related factors in students whose school burned down: Cohort study.

AIMS: This research examines the prevalence of post-traumatic stress disorder (PTSD) and its related factors in students whose school burned down, one month and six months after the incident. METHODS: A total of 56 students from grades one through six were invited to participate in this study with permission from their parents. Subjects were screened for PTSD by using UCLA PTSD Reaction Index (DSM-5 Version) during three periods: 1, 6, and 12 months after the incident. Children diagnosed with PTSD were interviewed by a child and adolescent psychiatrist to confirm their diagnosis and obtain related factors. Percentage and logistic regression were used for statistical evaluation. 5 out of the 56 students (8.9 %) had PTSD one month after the incident, 2 of them recovered after six months. 6 out of 56 students (10.7 %) had PTSD at six months and 2 of 40 (5%) had PTSD at one year after the incident. Students who lived in the school's dorms had significantly more PTSD than those who lived elsewhere, p < 0.01, RR = 5.16 (4.04-6.6). After one year, age was the only factor related to PTSD (p = 0.01, odds ratio = 0.452). CONCLUSION: Post-traumatic stress disorder is a common disorder in children after a disaster. Although some can recover shortly after an incident, others develop symptoms one month after the incident. Age is a risk factor that can lead to the development of PTSD.

Emotional and behavioral problems among sexual minority youth in Thailand.

BACKGROUND: Sexual minority youth (SMY) had more risk behaviors and mental health problems than heterosexual youth. Relatively little research has differentiated among lesbian/gay, bisexual, and questioning (LGBQ) youth. OBJECTIVE: To examine the differences in emotional and behavioral problems between LGBQ youth in the city of Northern Thailand. METHODS: Data were from a school-based, cross-sectional study of grade 7-12 students in secondary and vocational schools. Five hundred and forty-three students who identified themselves as LGBQ and 3829 heterosexual peers completed the Youth Self-Report (YSR). RESULTS: Of 12.4% of LGBQ participants, 4.1% identified themselves as lesbian/gay, 4.8% as bisexual, and 3.5% were unsure. SMY had significantly higher scores in internalizing problems (16.84 VS 13.99, 95% confidence interval [CI] 1.94-3.77, P < 0.001), externalizing problems (15.23 VS 13.51, 95% CI 0.97-2.45, P < 0.001), and total behavioral scores (55.26 VS 47.16, 95% CI 5.55-10.63, P < 0.001) than their heterosexual peers. In sexual minority subgroup analyses, all syndrome subscales were highest in the bisexual group followed by the lesbian/gay group, and the questioning group, respectively. CONCLUSION: LGBQ high school students had greater psychosocial problems than their heterosexual counterparts. Bisexual students were at the greatest risks of emotional and behavioral problems. Pediatricians and school mental health providers should be aware of emotional and behavioral problems among LGBQ students.

Quetiapine monotherapy versus placebo in the treatment of children and adolescents with bipolar depression: a systematic review and meta-analysis.

BACKGROUND: Some studies have indicated the efficacy of quetiapine in the treatment of bipolar depression in adult patients. However, its efficacy has been not shown in child and adolescent patients. OBJECTIVE: This systematic review purposefully determined the efficacy and acceptability of quetiapine in the treatment of children and adolescents with bipolar depression. DATA SOURCES: A database search of EMBASE, PubMed, CINAHL, and Cochrane Controlled Trials Register was carried out in March 2016. All randomized controlled trials (RCTs) of bipolar depression in children and adolescents were considered for inclusion in this review. STUDY ELIGIBILITY CRITERIA PARTICIPANTS AND INTERVENTIONS: RCTs of quetiapine in the treatment of child and adolescent patients with bipolar depression with end point outcomes were included in this study. Languages were not limited. STUDY APPRAISAL AND SYNTHESIS METHODS: The full-text versions of relevant clinical studies were thoroughly examined and extracted. The primary efficacy of outcome was measured by using the pooled mean-changed scores of the rating scales for bipolar depression. However, the response and remission rates were also measured. RESULTS: A total of 251 randomized patients in the three RCTs of quetiapine versus placebo in the treatment of bipolar depression for children and adolescents were eligible in this review. The pooled mean-changed score of the quetiapine-treated group was not greater than that of the placebo-treated group. Similarly, the pooled response and remission rates were not different between the two groups. The pooled overall discontinuation rate and the discontinuation rate due to adverse events were not different between the two groups. LIMITATIONS: Limited studies were eligible in this review. CONCLUSION: According to the findings in this review, quetiapine may not be efficacious in the treatment of bipolar depression in children and adolescents. Its acceptability, however, was comparable to a placebo. Therefore, the use of quetiapine in children and adolescents with bipolar depression is not recommended. Further well-defined clinical studies should be performed to confirm these outcomes.

Comparative efficacy, acceptability, and tolerability of dexmethylphenidate versus placebo in child and adolescent ADHD: a meta-analysis of randomized controlled trials.

BACKGROUND: The efficacy of dexmethylphenidate (d-MPH) has been proven in the treatment of children and adolescents with attention-deficit hyperactivity disorder (ADHD). OBJECTIVE: The aim of this systematic review is to determine the efficacy, acceptability, and tolerability of d-MPH in child and adolescent ADHD. METHODS: The searches of SCOPUS, MEDLINE, CINAHL, and Cochrane Controlled Trials Register were performed in February 2015. All randomized controlled trials of d-MPH versus placebo that were performed in children and adolescents with ADHD up to 18 years of age were included in the study. The efficacy was measured by using the pooled mean-endpoint or mean-changed scores of ADHD rating scales and the response rate. Acceptability and tolerability were measured by using the pooled rates of overall discontinuation and discontinuation due to adverse events, respectively. RESULTS: A total of 1,124 children and adolescents diagnosed as having ADHD were included in this review. In a laboratory school setting, the pooled mean-change and mean-endpoint scores in the d-MPH-treated group were significantly greater than those of the placebo-treated group with standardized mean difference (95% confidence interval [CI]) of -1.20 (-1.73, -0.67), I (2)=95%. Additionally, the pooled mean-changed scores of the ADHD rating scales for teachers and parents in the d-MPH-treated group were significantly greater than that of the placebo-treated group with weighted mean difference (95% CI) of -13.01 (-15.97, -10.05), I (2)=0% and (95% CI) of -12.99 (-15.57, -10.42), I (2)=0%, respectively. The pooled response rate in the d-MPH-treated groups had a significance higher than that of the placebo-treated group. The rates of pooled overall discontinuation and discontinuation due to adverse events between the two groups were not significantly different. CONCLUSION: Based on the findings in this review, it can be concluded that d-MPH medication is efficacious and tolerable in child and adolescent ADHD. However, the acceptability of d-MPH is no greater than that of the placebo. Further systematic studies may confirm these findings.

An open-label, prospective study to evaluate social function and overall improvement of extended-release paliperidone treatment in Thai schizophrenia patients.

BACKGROUND: Previous studies with extended-release (ER) paliperidone have reported an effective outcome in terms of personal and social functioning improvement and also reported schizophrenia symptom improvement. The main objectives of this study were to further investigate improvements in symptom control and social functioning of paliperidone ER and acknowledge the safety profile of paliperidone ER in Thai patients with schizophrenia. PATIENTS AND METHODS: Patients with schizophrenia according to Diagnostic and Statistical Manual of Mental Disorders criteria were allowed flexible 3-12 mg/day dosing during the 10-week study duration. Patients were interviewed and assessed in social functioning using the Personal and Social Performance (PSP) scale. Patients were also rated on overall severity of illness using the Clinical and Global Impressions - Severity (CGI-S) scale. RESULTS: In total, 40 patients were enrolled, 80% of enrolled patients (n = 32) completed the 10-week study period. Thirty-eight eligible patients were included in the intention-to-treat analysis set (male 39.5%, female 60.5%). One patient was lost to follow-up without postbaseline-efficacy measurements. Another patient was terminated early due to a change in diagnosis during the trial. Statistically significant improvements from baseline in PSP total score were observed at all time points. Clinically relevant improvement in PSP (increase of at least one 10-point category) was observed in 47.40% of patients at end point. Improvement in CGI-S was observed at end point (P < 0.001). The mean reduction ± standard deviation at end point in CGI-S was 0.8 ± 1.04 (95% confidence interval 0.48-1.16). The most commonly reported adverse events (≥5% of patients) were daytime drowsiness (15%) and headache (15%). Three subjects (7.5%) discontinued due to adverse events. CONCLUSION: This study suggests that paliperidone ER is well tolerated in Thai patients with schizophrenia. Paliperidone ER showed improvement in schizophrenic symptom control and social functioning.

Reliability and validity of the Thai version of the Calgary Depression Scale for Schizophrenia.

AIM: The purpose of this study was to assess the reliability and validity of the Thai version of the Calgary Depression Scale for Schizophrenia (CDSS) for the evaluation of depression in patients with schizophrenia. METHODS: Sixty patients with schizophrenia according to Diagnostic and Statistical Manual of Mental Disorders: Fourth Edition; Text Revision (DSM-IV-TR) criteria were recruited to the study The Thai version of the CDSS, the Montgomery-Åsberg Depression Rating Scale (MADRS), the Hamilton Depression Rating Scale, 17-item version (HDRS-17), and the Positive and Negative Syndrome Scale (PANSS) were administered. A major depressive episode diagnosed by a psychiatrist according to the DSM-IV-TR was used as a gold standard. RESULTS: The internal consistency of the Thai version of the CDSS was very good (Cronbach's alpha = 0.869). The inter-rater reliability was found to be in substantial agreement with the intra-class correlation coefficient of 0.979. The test-retest reliability over a period of 3 days was high, with an intra-class correlation coefficient of 0.861. The Thai version of the CDSS showed significant correlations with the MADRS (r = 0.887), the HDRS-17 (r = 0.865), and the depression item of the Positive and Negative Syndrome Scale (PANSS-G6) (r = 0.833). The areas under the receiver operating characteristic curve of the CDSS, MADRS, HDRS-17, and PANSS-G6 against the DSM-IV-TR criteria for major depressive episode were 0.993, 0.954, 0.966, and 0.933, respectively. The optimal cut-off score to discriminate between depressed and non-depressed patients was 6/7, with a sensitivity of 92.31% and specificity of 97.87%. CONCLUSION: The Thai version of the CDSS is a reliable and valid measure for the evaluation of depression in Thai patients with schizophrenia.

Twelve-month, prospective, open-label study of repetitive transcranial magnetic stimulation for major depressive disorder in partial remission.

BACKGROUND: The purpose of this study was to evaluate the long-term effect of repetitive transcranial magnetic stimulation (rTMS) as adjunctive treatment in patients with partial remission of major depressive disorder. METHODS: This was a 12-month, prospective, open-label study in patients meeting the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision criteria for nonpsychotic major depressive disorder who responded to 8 weeks of medication treatment but did not reach remission. All patients were assigned to receive 10 sessions of rTMS applied at the left dorsolateral prefrontal cortex. During the course of rTMS, the patients were still taking their usual medication. Patients were followed up for 12 months to determine the long-term antidepressant effect. RESULTS: There were nine patients (seven women and two men) who met the inclusion criteria and agreed to receive rTMS. The mean Hamilton rating scale for depression (HAM-D) score prior to treatment with rTMS was 12.89 ± 2.15. At 12 months after treatment, the mean HAM-D score was 6.45 ± 1.67 using a Friedman test, and in patients with partial remission of major depressive disorder, the HAM-D score significantly decreased after treatment with rTMS at 12 months (P = 0.001). Seven patients (77.78%) had reached the stage of remission (HAM-D < 8) after treating with rTMS at 12 months. There were no serious adverse events. One patient had vertigo after the first session of treatment and one patient felt scalp contractions during treatment, and both fully recovered within half an hour with no medical intervention. CONCLUSION: For patients with major depressive disorder in partial remission, high frequency rTMS at the left dorsolateral prefrontal cortex may provide benefits in adjunctive treatment with well tolerability. Also, follow-up findings show a long duration of benefit.

An open-label study of adjunctive repetitive transcranial magnetic stimulation (rTMS) for partial remission in major depressive disorder.

OBJECTIVE: This study aimed to evaluate the effect of adjunctive treatment with rTMS in patients with partial remission major depressive disorder. METHOD: Subjects were patients meeting DSM-IV-TR criteria for non-psychotic major depressive disorder who responded to 8 weeks of medication treatment but still had residual symptoms (HAM-D score between 7 and 18). All patients were assigned to receive 10 daily sessions (total of 12,500 magnetic pulses) of rTMS applied at the left dorsolateral prefrontal cortex as adjunctive treatment. The antidepressant effect was measured repeatedly at 6 days, and at 4 and 8 weeks after treatment with the Thai version of HAM-D scale as a primary outcome scale. RESULTS: Seven of nine patients (78%) reached the stage of remission (HAM-D < 8) after being treated with adjunctive rTMS. There was a statistically significant difference in decreasing of the HAM-D score during the treatment, χ(2) (df 3) = 17.929, P < 0.001. There was no severe adverse event. One patient had vertigo after the first session of treatment and one patient had a scalp contraction feeling during treatment but full recovered in half an hour with no medical intervention. CONCLUSION: For patients with a major depressive disorder in partial remission, high frequency rTMS may provide benefits in adjunctive treatment which are tolerated well. However, the long term effects should be observed.

Attention deficit hyperactivity symptoms in children with autistic disorder: a cross-sectional descriptive study.

OBJECTIVE: (1) to examine the co-occurrence of attention deficit and hyperactivity symptoms in children with autistic disorder, and (2) to study the correlation between attention deficit hyperactivity symptoms and the severity of autistic disorder. MATERIAL AND METHOD: This was a clinical based study. The authors used Childhood Autistic Rating scale (CARs) to evaluate the severity of autistic disorder Swanson, Nolan, and Pelham Teacher and Parent Rating Scale, Version IV (SNAP-IV) was used to measure attention deficit and hyperactive symptoms in children with autism. RESULTS: Thirty (n=30) children enrolled in this study. All participants displayed attention deficit symptoms and 18 participants demonstrated hyperactivity as well. Nonparametric correlation showed a high positive correlation (Spa = 0.90, p = 0.00) between the severity of autistic disorder and hyperactivity and not the attention deficit symptoms (Spa = 0.29, p = 0.16). CONCLUSION: The authors finding shows a high comorbid rate of attention deficit and hyperactive symptoms among the participants.

Efficacy of atomoxetine in children with severe autistic disorders and symptoms of ADHD: an open-label study.

OBJECTIVE: This study aims to examine the efficacy of atomoxetine in treating symptoms of attention deficit hyperactivity disorder (ADHD) in children with severe autistic disorder. METHOD: Children with severe autistic disorder who had symptoms of ADHD were given atomoxetine for 10 weeks. The efficacy of atomoxetine was evaluated by using the Aberrant Behavior Checklist (ABC) to rate ADHD symptoms at baseline, week 6, and week 10. The Clinical Global Impression-Improvement (CGI-I) scale was used as secondary outcome to assess the overall improvement of the children's development at week 10. RESULTS: A total of 12 children participated in this study. Although CGI-I scores showed improvement at week 10, the ABC hyperactivity subscale did not show a significant improvement of the ADHD symptoms at baseline (M = 33.89) compared to those at week 10 (M = 31.78, p = .62). CONCLUSION: Atomoxetine did not benefit children with severe autistic disorder who have ADHD symptoms.

Disclosure of HIV/AIDS diagnosis to HIV-infected children in Thailand.

BACKGROUND: With the availability of highly active antiretroviral therapy, more HIV-infected children have lived longer. Many children are at the age that they should know the diagnosis. AIM: To identify the prevalence and patterns of disclosure of HIV/AIDS diagnosis to HIV-infected children. METHODS: A cross-sectional study was conducted among 103 main care givers of HIV-infected children aged > or =6 years who received highly active antiretroviral therapy at Chiang Mai University and Sanpatong district hospitals, northern Thailand. RESULTS: One-third (30.1%) of the children knew their HIV/AIDS status at an average age of 9.2 years. The care givers' understanding of 'knowing' did not always mean that the children were told the name of 'HIV' or 'AIDS'. Many of those care givers (84.3%) who reported that the child did not know their diagnosis had inaccurately explained to the child that he or she had some kind of disease such as allergy, lung, or liver disease. The most common reason for non-disclosure was the fear that disclosure might have negative psychological consequences to the child (53.4%). Almost all (88.7%) agreed that they should tell the children their diagnosis in the future but half needed health-care providers to help them at the event. CONCLUSION: There is a need for the development of disclosure guide-lines and models for health-care providers and care givers as there was a high rate of inaccurate disclosure and, in addition, care givers expressed their need for assistance from health-care providers for the future disclosure.

Quality of life of children with attention-deficit/hyper activity disorder.

OBJECTIVE: Attention-deficit/hyperactivity disorder (ADHD) has an impact on children and families. The purpose of this study was to assess the health-related quality of life between school-age children with ADHD compared with those without physical or mental disorders. MATERIAL AND METHOD: Self- and parent-reports describing the quality of life, covering 4 domains: physical, emotional, social, and school functioning, were obtained from 46 children with ADHD and 94 control children. At the time of the study, 17 of 46 children reported receiving medication for ADHD. RESULTS: After controlling for age and demographic background, both children with ADHD and their parents reported having a significantly lower quality of life score than controls and their parents. Children with ADHD also reported themselves to have a significantly low physical score, despite their physically healthy status. CONCLUSION: Children with ADHD had impairment of their quality of life in the physical and psychosocial domains. Improvement of health-related quality of life should be integrated in the overall planning of the treatment goals.