Ministry of Health clinical practice guidelines: bipolar disorder.

The Ministry of Health (MOH) has published clinical practice guidelines on Bipolar Disorder to provide doctors and patients in Singapore with evidence-based guidance on the management of bipolar disorders. This article reproduces the introduction and executive summary (with recommendations from the guidelines) from the MOH clinical practice guidelines on Bipolar Disorder, for the information of readers of the Singapore Medical Journal. Chapters and page numbers mentioned in the reproduced extract refer to the full text of the guidelines, which are available from the Ministry of Health website: http: //www.moh.gov.sg/content/moh_web/home/Publications/guidelines/clinical_practiceguidelines/2011/bipolar_disorder.html. The recommendations should be used with reference to the full text of the guidelines. Following this article are multiple choice questions based on the full text of the guidelines.

Psychiatric illness, personality traits and the irritable bowel syndrome.

INTRODUCTION: Irritable bowel syndrome is a common functional gastrointestinal disorder. Although its aetiology is still unknown, visceral hypersensitivity, disorders of motility and psychosocial factors have been proposed as possible factors that affect the "gut-brain" function. The objective of this study was to determine if psychiatric disorders exist in patients with irritable bowel syndrome. PATIENTS AND METHODS: During a 10-month period, 43 outpatients, after exclusion of organic bowel pathology and meeting Manning's criteria for the diagnosis of irritable bowel syndrome, were assessed using the Eysenck Personality Questionnaire. In addition, a psychiatric interview was conducted by two psychiatrists. Twenty patients with organic bowel disorders, who were age matched, were selected as patient control. RESULTS: Psychiatric diagnoses (62.5%) were present in significantly more female patients with irritable bowel syndrome than female patients with organic bowel disorders (16.7%, P < 0.05). On Eysenck Personality testing, female patients with irritable bowel syndrome scored significantly higher on neuroticism (15.25 versus 8.58) and lower on need for social desirability (14.04 versus 17.0) than the organic disease group. Male patients with irritable bowel syndrome were comparable with male patients with organic bowel disorders in terms of presence of minor psychiatric morbidity, psychiatric diagnoses and Eysenck Personality scores. CONCLUSION: There is a difference between male and female patients with irritable bowel syndrome in terms of psychopathology.

Resting and thrombin-stimulated cytosolic calcium in platelets of patients with alcoholic withdrawal, bipolar manic disorder and chronic schizophrenia.

Cytosolic calcium concentration ([Ca2+]i) in platelets during resting state and when stimulated by thrombin were measured in 7 alcoholic dependent patients in the state of withdrawal (AW) who were receiving diazepam, 7 bipolar manic patients (BM) who were receiving haloperidol, 15 drug free chronic schizophrenic patients (CS) and 26 normal controls (NC). Resting [Ca2+]i in these groups were quite similar at (mean +/- SEM) 112 +/- 20 nM, 127 +/- 18 nM, 103 +/- 16 nM and 106 +/- 8 nM respectively. Increase in platelet [Ca2+]i in response to 0.1 U/ml thrombin was expressed as delta[Ca2+]i and its percentage over resting [Ca2+]i as %[Ca2+]i. Both delta[Ca2+]i and %[Ca2+]i were significantly higher (p = 0.006 and 0.0045 respectively, ANOVA, Waller-Duncan) in AW (433 +/- 71 nM, 417 +/- 58%) than the other groups: NC (223 +/- 25 nM, 225 +/- 23%), BM (309 +/- 38 nM, 260 +/- 31%), and CS (261 +/- 34 nM, 280 +/- 29%) respectively. In vitro incubation of platelets from NC with diazepam or haloperidol did not affect the resting [Ca2+]i and %[Ca2+]i. The enhanced [Ca2+]i response to thrombin in platelets of AW is unlikely to be due to diazepam. It may indicate an abnormality in platelets during the withdrawal phase. Treatment with haloperidol resulted in slightly higher [Ca2+]i in platelets of BM. Platelet [Ca2+]i in drug-free CS was not different from NC.

A postmarketing surveillance study of zopiclone in insomnia.

Zopiclone, a novel cyclopyrrolone compound has recently become available for the treatment of insomnia in Singapore. Pharmacodynamic and pharmacokinetic studies have shown it to be an effective hypnotic with a good safety profile and minimal side-effects. The efficacy of Zopiclone was studied in a group of patients with insomnia (n = 40). The study group comprised patients with and without a psychiatric diagnosis. About two-thirds (65%) of the patients had been on hypnotics previously without relief of the insomnia. There was improvement in the various sleep parameters studied: sleep latency, sleep duration, night awakening, sleep quality, dreams, "day-after" effects. The drug was well-tolerated and only four patients experienced minor side-effects.

Helping patients to think better: cognitive therapy for individuals and couples.

A system of psychotherapy called cognitive therapy, emphasising that mood disorders are affected by distortions in thinking about self, the future and the world, has been found useful in the treatment of diverse neurotic disorders. Helping the patient restructure his thinking by examining such distortions and correcting them would be a vital process in the prevention or recovery of mood disturbances. Applications of cognitive therapy in depression, panic disorder, hypochondriasis and marital distress are described in this article.

The use of psychometric tests in the evaluation of patients presenting for orthognathic surgery--a preliminary report.

Psychological evaluation in some orthognathic patients may be necessary as the psychosocial stress of the deformity may lead to psychiatric morbidity such as depression or paranoid disorders. It is also possible for patients with underlying psychosis to present first to the dental surgeon for jaw correction. The use of several psychological tests appropriate for patients presenting with dentofacial deformities is discussed. Nine patients with skeletal malocclusions who were referred for psychiatric assessment are reported here. Three case vignettes are included to give an impression of the type of clinical situations where such an assessment may be helpful.

Psychological and psychiatric investigations of HIV infection in Singapore.

A psychosocial study was carried out on 10 out of the 18 HIV positive persons who were under surveillance and receiving counselling at either Middle Road Hospital or the Communicable Disease Centre in February 1988. The results of the psychological testing and psychiatric findings are presented. All 10 were male: 9 of them were homosexual and 1 heterosexual. Only one had significant depressive symptoms at the time of study. All had fears about their infection being found out by others and of the stigma that this might bring to their families. Psychometric tests on memory function did not show any signs of visuo-verbal memory impairment but did reveal a possible indication of audio-verbal memory dysfunction.

Water intoxication in psychiatric patients in Singapore.

The syndrome of water intoxication may occur in psychiatric patients and various hypotheses regarding its aetiology have been postulated. Twenty-seven patients in Woodbridge Hospital were found to have this syndrome. The aim of the study was to describe the clinical and biochemical findings of this group of patients. 70.4% had schizophrenia, 25.9% had mental retardation and 3.7% had a history of alcohol dependence. Many of them were on antipsychotic medication. The symptoms of water intoxication included polyuria, nausea, tremors, weight gain, disorientation, coma and fits. A majority of the patients had hyponatraemia during the acute stages and the osmolality of urine and plasma were correspondingly low. A few patients had abnormalities in electroencephalogram and computerised axial tomography of brain. The management of patients with water intoxication is discussed briefly.

The dexamethasone suppression test in depression--a Singapore study.

The Dexamethasone Suppression Test (DST) has been evaluated as a biological marker in psychiatry especially in depressive illness. A study on the DST involving 20 patients in Tan Tock Seng Hospital, Singapore, who fulfilled the Research Diagnostic Criteria for major depressive disorder and with 21 healthy controls was carried out. Two out of the 20 patients had abnormal DST responses.

Psychiatric referral pattern in a general hospital.

Between September 1986 and January 1988, a sixteen-month period, a total of 494 inpatients in Tan Tock Seng Hospital were referred for psychiatric opinion. 181 were referred for suicidal tendency and 313 for other reasons. An analysis of these two groups of referrals was done to study any change in referral trends. The findings show that while the basic diagnostic categories of patients do not differ drastically from an earlier study in Singapore General Hospital by Tsoi and Kok, Tan Tock Seng Hospital had its own pattern of requirements for psychiatric consultation because of its own unique patient characteristics.

Psychiatric complications of Erimin abuse.

Nimetazepam (Erimin) is a benzodiazepine which has become a new drug of abuse in Singapore. Three cases presenting with psychiatric complications had been treated as inpatients over a period of one and a half years (1986 to 1987) in Woodbridge Hospital and Tan Tock Seng Hospital. Their clinical presentations which included drug dependency, withdrawal psychosis and transient drug psychosis are described and discussed.