An analysis of Chinese nursing electronic medical records to predict violence in psychiatric inpatients using text mining and machine learning techniques.

BACKGROUND: The prevalence of violence in acute psychiatric wards is a critical concern. According to a meta-analysis investigating violence in psychiatric inpatient units, researchers estimated that approximately 17% of inpatients commit one or more acts of violence during their stay. Inpatient violence negatively affects health-care providers and patients and may contribute to high staff turnover. Therefore, predicting which psychiatric inpatients will commit violence is of considerable clinical significance. OBJECTIVE: The present study aimed to estimate the violence rate for psychiatric inpatients and establish a predictive model for violence in psychiatric inpatients. METHODS: We collected the structured and unstructured data from Chinese nursing electronic medical records (EMRs) for the violence prediction. The data was obtained from the psychiatry department of a regional hospital in southern Taiwan, covering the period between January 2008 and December 2018. Several text mining and machine learning techniques were employed to analyze the data. RESULTS: The results demonstrated that the rate of violence in psychiatric inpatients is 19.7%. The patients with violence in psychiatric wards were generally younger, had a more violent history, and were more likely to be unmarried. Furthermore, our study supported the feasibility of predicting aggressive incidents in psychiatric wards by using nursing EMRs and the proposed method can be incorporated into routine clinical practice to enable early prediction of inpatient violence. CONCLUSIONS: Our findings may provide clinicians with a new basis for judgment of the risk of violence in psychiatric wards.

Increased Risk of Chronic Obstructive Pulmonary Disease in Patients with Hyperlipidemia: A Nationwide Population-Based Cohort Study.

The coexistence of chronic obstructive pulmonary disease (COPD) and cardiovascular disease is common and causes poor prognoses. Hyperlipidemia is the most common risk factor for cardiovascular disease, but the association between hyperlipidemia and COPD remains ambiguous. This study aimed to investigate the risk of COPD development in patients with hyperlipidemia. This retrospective cohort study used information from the National Health Insurance Research Database in Taiwan. We enrolled 21,790 patients with hyperlipidemia and 87,160 control patients without hyperlipidemia for comparison, with a follow-up period of over 10 years. The incidence of new-onset COPD was higher in patients with hyperlipidemia (36.14 per 1000 person-years) than in the controls (22.29 per 1000 person-years). Patients with hyperlipidemia were 1.48 times more likely to develop subsequent COPD than the controls without hyperlipidemia (95% confidence interval 1.44 to 1.53, p < 0.001) following adjustments for age, sex, and comorbidities. In addition, nephropathy, hypertension, congestive heart failure, age, and sex (female) were potential risk factors for developing COPD in patients with hyperlipidemia. Patients with hyperlipidemia may have an increased risk of developing COPD.

Rechallenge with Amisulpride in a Patient with Schizophrenia following a Manic Episode during Previous Therapy.

Amisulpride is an atypical antipsychotic. It is also effective in treating depression. The potential antidepressant effect raises the concern that amisulpride can induce mania. However, reports of amisulpride-induced mania have been rare. Here, we present the case of a Taiwanese woman with a 22-year history of schizophrenia. At the age 57 years, she developed manic symptoms while on treatment with amisulpride for six weeks. She was immediately admitted to the psychiatric in-patient unit. The manic symptoms completely subsided within eight days without the administration of any mood stabilizer. Readministration of a single dose of 200 mg amisulpride during hospitalization induced the same manic symptoms, which remitted completely within 24 hours without any mood stabilizer administration.

Periodontitis is a potential risk factor for transient ischemic attack and minor ischemic stroke in young adults: A nationwide population-based cohort study.

BACKGROUND: This study aims to determine whether periodontitis is a risk factor for transient ischemic attack (TIA) in young adults. METHODS: The National Health Insurance (NHI) Research Database in Taiwan was the source of the data used in this retrospective cohort study. Individuals aged 20 to 53 years with periodontitis in 2001 and 2002 (n = 792,426) and an age- and sex-matched control group (n = 792,426) were selected. All participants were followed up until TIA diagnosis, 55 years of age, removal from the NHI program, death, or December 31, 2016. The incidence density and hazard ratio (HR) of new-onset TIA were compared between individuals with periodontitis and controls. Periodontitis was defined by dentists according to the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes 523.3-5 with concurrent antibiotic prescription or periodontal treatment excluding scaling performed by certified dentists. TIA was defined according to the ICD-9-CM code 435.x at hospital discharge. RESULTS: After adjustment for confounding factors, the risk of developing TIA/minor ischemic stroke was calculated to be higher in participants with periodontitis (HR, 1.24; 95% confidence interval, 1.15-1.32; P <0.001) than in those without. The HR was slightly higher among people aged 20 to 40 years than among those aged 40 to 53 years. CONCLUSION: Periodontitis is associated with an increased risk of developing TIA/minor ischemic stroke. Periodontitis might be a modifiable risk factor for stroke in young adults. Clinicians must devote greater attention to this potential association to develop new preventive and therapeutic strategies for stroke in young adults.

Hip, vertebral, and wrist fracture risks and schizophrenia: a nationwide longitudinal study.

BACKGROUND: Fractures are a great health issue associated with morbidity, quality of life, life span, and health care expenditure. Fractures are correlated with cardiovascular disease, type 2 diabetes mellitus, cerebrovascular disease, and some psychiatric disorders. However, representative national data are few, and longitudinal cohort studies on the association between schizophrenia and the subsequent fracture risk are scant. We designed a nationwide population-based cohort study to investigate the association of schizophrenia with hip, vertebral, and wrist fractures over a 10-year follow-up. METHODS: Data of patients with schizophrenia (International Classification of Diseases, Ninth Revision, Clinical Modification code 295) and matched over January 2000-December 2009) were extracted from Taiwan National Health Insurance Research Database. A Cox proportional-hazards regression model was constructed to calculate hazard ratios (HRs) for fractures between the schizophrenia and control cohorts. RESULTS: Of 2028 people with schizophrenia (mean age: 36.3 years, 49.4% female), 89 (4.4%) reported newly diagnosed fractures-significantly higher than the proportion in the control population (257, 3.2%; P = 0.007). The incidences of hip (1.2%, P = 0.009) and vertebral (2.6%, P = 0.011) fractures were significantly higher in the schizophrenia cohort than in the control cohort. In Cox regression analysis, hip (adjusted HR: 1.78, 95% confidence interval [CI]: 1.08-2.93) and vertebral (adjusted HR: 1.40, 95% CI: 1.01-1.95) fracture risks were significantly higher in patients with schizophrenia. Furthermore, a sex-based subgroup analysis revealed that the risk of hip fracture remained significantly higher in female patients with schizophrenia (HR: 2.68, 95% CI: 1.32-5.44) than in female controls. On the other hand, there was no significant interaction between effects of sex and schizophrenia on the risk of fractures. CONCLUSIONS: Over a 10-year follow-up, hip and vertebral fracture risks were higher in the people with schizophrenia than in the controls. The risk of fractures in patients with schizophrenia does not differ between female and male.

Risk of Parkinson's disease following gout: a population-based retrospective cohort study in Taiwan.

BACKGROUND: The progressive neurodegenerative disorder Parkinson disease (PD) is well-established as the second most common neurodegenerative disease. Associations between the sequential risk of PD and gout have been addressed in other studies, but findings have been inconclusive. Accordingly, we executed the present study with the purpose of assessing PD risk in patients with gout. METHODS: From Taiwan's National Health Insurance Research Database, we identified the data of patients newly diagnosed as having gout between January 1, 2000 and December 1, 2000. A cohort of patients without gout, matched for sex and age, was constructed for comparison. Hazard ratios (HRs) and the incidence rate of subsequent PD were calculated for both cohorts and separately for male and female groups. The gout and comparison cohorts consisted of 7900 patients each. RESULTS: The HR for PD was not significantly higher in the gout cohort compared with the control cohort (HR 1.01, 95% confidence interval [CI], 0.93-1.31, P = .268), even after adjustment for age, urbanization, monthly income, sex, and comorbidities. We did not observe gender differences in the gout-PD association (male: HR 1.01, 95% CI, 0.88-1.36, P = .400; female: HR 1.11, 95% CI, 0.84-1.46, P = .466). CONCLUSIONS: Our study identified that there was no protective effect of gout for the risk of PD in the Taiwanese population.

Tinnitus and risk of Alzheimer's and Parkinson's disease: a retrospective nationwide population-based cohort study.

Tinnitus has been implied as a "soft" sign of neurodegenerative disease, which is characterized by progressive loss of neuronal function, such as Alzheimer's disease (AD) and Parkinson's disease (PD). This study aimed to determine whether the risk of developing AD/PD increases after having tinnitus. We conducted a retrospective matched cohort study with 12,657 tinnitus patients and 25,314 controls from the National Health Insurance Research Database (NHIRD) in Taiwan with almost 10 years follow-up. Tinnitus-related risk on developing AD/PD followingly was determined by the Cox regression to identify potential confounding factors. Through the 10-year follow-up period, 398 individuals with tinnitus (3.1%) and 501 control individuals (2.0%) developed AD (P < 0.001), and 211 tinnitus patients (1.7%) and 249 control patients (1.0%) developed PD (P < 0.001). Compared with controls, patients with tinnitus were 1.54 times more likely to develop AD (95% confidence interval (CI) 1.34-1.78, P < 0.001) and 1.56 times more likely to develop PD (95% CI 1.29-1.89, P < 0.001), after adjusting confounding factors. Our results indicate an association between tinnitus and higher risk of developing AD and PD. Additional physical comorbidities may also increase the risk of developing AD and PD.

Tinnitus Among Patients With Anxiety Disorder: A Nationwide Longitudinal Study.

OBJECTIVES: The association between tinnitus and anxiety disorder remains debated. We used a retrospective cohort study to investigate the relationship between anxiety disorder and tinnitus, aiming to decipher possible risk factors for tinnitus in patients with anxiety disorder. METHOD: Data on a total of 7,525 patients with anxiety disorder and 15,050 patients without (comparison cohort) were extracted from the Longitudinal Health Insurance Database 2005 in Taiwan. The Kaplan-Meier estimator with the log rank test and the Cox proportional-hazard regression model were used to compare the incidence of tinnitus in both groups and to identify risk factors that predicted tinnitus. RESULTS: After adjusting for related covariates, the hazard ratio for the development of tinnitus during the follow-up period was 3.54 (95% confidence interval: 3.11-4.02, P < .001) for anxiety disorder cohort relative to comparison cohort. Age ≧ 60 years, female sex, hypertension, and hyperlipidemia were statistically significant predictive risk factors of tinnitus in patients with anxiety disorder. CONCLUSION: A significant increase in the lifetime incidence of tinnitus was exhibited in patients with anxiety disorder. Elderly subjects, female sex, hypertension, and hyperlipidemia were risk factors. Clinicians should be alert to the possibility of tinnitus in subjects with anxiety disorder.

Critical Predictors for the Early Detection of Conversion From Unipolar Major Depressive Disorder to Bipolar Disorder: Nationwide Population-Based Retrospective Cohort Study.

BACKGROUND: Unipolar major depressive disorder (MDD) and bipolar disorder are two major mood disorders. The two disorders have different treatment strategies and prognoses. However, bipolar disorder may begin with depression and could be diagnosed as MDD in the initial stage, which may later contribute to treatment failure. Previous studies indicated that a high proportion of patients diagnosed with MDD will develop bipolar disorder over time. This kind of hidden bipolar disorder may contribute to the treatment resistance observed in patients with MDD. OBJECTIVE: In this population-based study, our aim was to investigate the rate and risk factors of a diagnostic change from unipolar MDD to bipolar disorder during a 10-year follow-up. Furthermore, a risk stratification model was developed for MDD-to-bipolar disorder conversion. METHODS: We conducted a retrospective cohort study involving patients who were newly diagnosed with MDD between January 1, 2000, and December 31, 2004, by using the Taiwan National Health Insurance Research Database. All patients with depression were observed until (1) diagnosis of bipolar disorder by a psychiatrist, (2) death, or (3) December 31, 2013. All patients with depression were divided into the following two groups, according to whether bipolar disorder was diagnosed during the follow-up period: converted group and nonconverted group. Six groups of variables within the first 6 months of enrollment, including personal characteristics, physical comorbidities, psychiatric comorbidities, health care usage behaviors, disorder severity, and psychotropic use, were extracted and were included in a classification and regression tree (CART) analysis to generate a risk stratification model for MDD-to-bipolar disorder conversion. RESULTS: Our study enrolled 2820 patients with MDD. During the follow-up period, 536 patients were diagnosed with bipolar disorder (conversion rate=19.0%). The CART method identified five variables (kinds of antipsychotics used within the first 6 months of enrollment, kinds of antidepressants used within the first 6 months of enrollment, total psychiatric outpatient visits, kinds of benzodiazepines used within one visit, and use of mood stabilizers) as significant predictors of the risk of bipolar disorder conversion. This risk CART was able to stratify patients into high-, medium-, and low-risk groups with regard to bipolar disorder conversion. In the high-risk group, 61.5%-100% of patients with depression eventually developed bipolar disorder. On the other hand, in the low-risk group, only 6.4%-14.3% of patients with depression developed bipolar disorder. CONCLUSIONS: The CART method identified five variables as significant predictors of bipolar disorder conversion. In a simple two- to four-step process, these variables permit the identification of patients with low, intermediate, or high risk of bipolar disorder conversion. The developed model can be applied to routine clinical practice for the early diagnosis of bipolar disorder.

The caregivers' dilemma: Care burden, rejection, and caregiving behaviors among the caregivers of patients with depressive disorders.

Taking care of depressed patients significantly impacts caregivers' lives, both objectively and subjectively. The effects of caregivers' burden on their responses to their patients has yet to be investigated. The aim of this study is to explore the relationships among caregivers' subjective and objective burden, depression, frequency of caregiving behaviors, and rejective attitude. A cross-sectional study was conducted among 134 caregivers of patients diagnosed with depressive disorders. We administered questionnaire to assess caregivers' demographics, care burden, reassurance seeking, depression, rejective attitude and caring behaviors. Both caregivers' objective and subjective burdens were associated with their depressive symptoms. Rejection towards patients was determined by the caregivers' level of depressive symptoms, subjective feeling of sadness, and anger, rather than by their objective burden. On the other hand, the frequency of caregiving behavior was determined by perceived reassurance seeking and anger, rather than by caregivers' depression or objective burden. These findings suggest that caregivers' subjective burden plays a more salient role in predicting their rejection and frequency of caregiving behaviors toward the patients than objective burden. The caregivers in this study could recognize their rejective attitude toward depressed patients but still had difficulty withdrawing their care when they were already in distress.

Risk of Depressive Disorders Following Myasthenia Gravis: A Nationwide Population-Based Retrospective Cohort Study.

The chronic autoimmune disease myasthenia gravis (MG) is characterized by fluctuating muscle weakness, which can lead to a large amount of stress in the patient. The current investigation plans to assess the risk of depressive disorders in MG patients. A retrospective cohort study of patients ageing 20 years and older and also newly diagnosed with MG between January 1, 2000, and December 31, 2008, was conducted from the National Health Insurance Research Database (NHIRD) in Taiwan. Observations of all 349 MG patients and 1,396 control individuals were made until a diagnosis of a depressive disorder by a psychiatrist, until death, or until December 31, 2013. A range of comorbidities were found, such as coronary artery disease, hypertension, diabetes mellitus, and dyslipidemia, with cerebrovascular disease being reported more frequently in MG patients in comparison with control subjects. After adjustment of patients' sex, age, urbanization, comorbidities, and monthly income, results indicated that MG individuals are 1.94 times more at risk (95% confidence interval [CI], 1.15-3.27, P = 0.014) of developing depressive disorders than are controls. This showed an increased risk in the development of depressive disorders in people with MG. Thus, depressive symptoms in MG patients should be regularly assessed.

Risk of benign paroxysmal positional vertigo in patients with depressive disorders: a nationwide population-based cohort study.

OBJECTIVE: The association between depression and benign paroxysmal positional vertigo (BPPV) remains debated. This study aimed to investigate the risk of BPPV in patients with depressive disorders. DESIGN: Longitudinal nationwide cohort study. SETTING: National health insurance research database in Taiwan. PARTICIPANTS: We enrolled 10 297 patients diagnosed with depressive disorders between 2000 and 2009 and compared them to 41 188 selected control patients who had never been diagnosed with depressive disorders (at a 1:4 ratio matched by age, sex and index date) in relation to the risk of developing BPPV. METHODS: The follow-up period was defined as the time from the initial diagnosis of depressive disorders to the date of BPPV, censoring or 31 December 2009. Cox proportional hazard regression analysis was used to investigate the risk of BPPV by sex, age and comorbidities, with HRs and 95% CIs. RESULTS: During the 9-year follow-up period, 44 (0.59 per 1000 person-years) patients with depressive disorders and 99 (0.33 per 1000 person-years) control patients were diagnosed with BPPV. The incidence rate ratio of BPPV among both cohorts calculating from events of BPPV per 1000 person-years of observation time was 1.79 (95% CI 1.23 to 2.58, p=0.002). Following adjustments for age, sex and comorbidities, patients with depressive disorders were 1.55 times more likely to develop BPPV (95% CI 1.08 to 2.23, p=0.019) as compared with control patients. In addition, hyperthyroidism (HR=3.75, 95% CI 1.67-8.42, p=0.001) and systemic lupus erythematosus (SLE) (HR=3.47, 95% CI 1.07 to 11.22, p=0.038) were potential risk factors for developing BPPV in patients with depressive disorders. CONCLUSIONS: Patients with depressive disorders may have an increased risk of developing BPPV, especially those who have hyperthyroidism and SLE.

Should clinicians pay more attention to the potential underdiagnosis of osteoporosis in patients with ankylosing spondylitis? A national population-based study in Taiwan.

OBJECTIVES: There are limited studies describing the association between ankylosing spondylitis (AS) and osteoporosis. We conducted a nationwide retrospective cohort study to investigate this epidemiologic evidence. METHODS: Data were obtained from the Taiwan National Health Insurance Research Database (NHIRD). Of 10,290 participants, 2,058 patients with AS and 8,232 patients without AS were enrolled from the NHIRD between 2000 to 2013. Cumulative incidences of osteoporosis were compared between 2 groups. Cox regression model was used to estimate the hazard ratio (HR) of developing osteoporosis after controlling for demographic and other co-morbidities, and subgroup analyses were conducted to examine the risk factors for osteoporosis in AS patients. RESULTS: The incidence rate ratio (IRR) of osteoporosis in AS patients was 2.17 times higher than that non-AS group (95% confidence interval [CI], 1.83-2.57). The adjusted HRs of osteoporosis for AS patients after controlling for demographic characteristics and comorbid medical disorders was 1.99 (95% CI 1.68-2.36). Among AS group, after adjustment for major comorbidities, old age (≥65 years, HR 4.32, 95% CI 3.01-6.18), female sex (HR 2.48, 95% CI 1.87-3.28), dyslipidemia (HR 1.44, 95% CI 1.01-2.06) were risk factors associated with osteoporosis. CONCLUSIONS: This cohort study demonstrated that patients with AS had a higher risk of developing osteoporosis, especially in those aged over 65, female sex and with dyslipidemia in this patient group.

Risk of sexually transmitted infections following depressive disorder: A nationwide population-based cohort study.

Depressive disorder is a severe mental disorder associated with functional and cognitive impairment. Numerous papers in the literature investigated associations between sexually transmitted infections (STIs) and psychiatric illnesses. However, the results of these studies are controversial.We explored the relationship between depressive disorder and the subsequent development of STIs including human immunodeficiency virus (HIV) infection, primary, secondary, and latent syphilis, genital warts, gonorrhea, chlamydial infection, and trichomoniasis.We identified patients who were diagnosed with the depressive disorder in the Taiwan National Health Insurance Research Database. A comparison cohort was constructed of patients without the depressive disorder who were matched according to age and sex. The occurrence of subsequent new-onset STIs was evaluated in both cohorts.The depression cohort consisted of 5959 patients, and the comparison cohort consisted of 23,836 matched control patients without depressive disorder. The incidence of subsequent STIs (hazard ratio [HR] 1.54, 95% confidence interval [CI] 1.34-1.76) was higher among the depressed patients than among the patients in the comparison cohort. Furthermore, female gender compared to male (HR 1.58, 95% CI 1.24-2.01) and young age <40-year-old (HR 1.79, 95% CI 1.38-2.32) are both risk factors for acquisition of STIs in depression patient. For individual STI, the results indicated that the patients with depressive disorder exhibited a markedly higher risk for subsequent STIs including HIV infection, syphilis, genital warts, gonorrhea, chlamydial infection, and trichomoniasis.Depressive disorder might increase the risk of subsequent newly diagnosed STIs including HIV infection, syphilis, genital warts, gonorrhea, chlamydial infection, and trichomoniasis in Taiwan population. Clinicians should pay particular attention to STIs in depression patients. Depression patients, especially those with the history of high-risk sexual behaviors, should be routinely screened for STIs.

Increased risk of osteoporosis in patients with nonalcoholic fatty liver disease: A population-based retrospective cohort study.

The study aims to investigate the association between nonalcoholic fatty liver disease (NAFLD) and osteoporosis.We employed a retrospective cohort study design using the National Health Insurance Research Database in Taiwan. Our study included 2 cohorts: 4318 patients with NAFLD and 17,272 patients without NAFLD for comparison. They were matched by sex and age on the date of enrollment between January 1, 2000 and December 31, 2003. The study population in both groups was observed from the enrollment date until December 31, 2013. The incidence and the risk ratios of subsequent osteoporosis were calculated separately in both cohorts. A Cox proportional hazards model was used to assess the potential confounding variables of NAFLD on the pathogenesis of osteoporosis.The eligible study participants comprised 4318 patients in the NAFLD and 17,272 in control cohorts. The median follow-up duration was 10.7 and 10.83 years in the NAFLD and control groups, respectively. The risk of new-onset osteoporosis was higher in patients with NAFLD than in the comparison cohort. In addition, the difference of the incidence of new-onset osteoporosis remained significant among the 2 cohorts in the follow-up durations of within 1 year and more than 10 years. Patients with NAFLD were 1.35 times more likely to develop subsequent osteoporosis compared with those without NAFLD (95% confidence interval = 1.20-1.53).Our finding indicates that NAFLD might increase the risk of developing new-onset osteoporosis. For earlier detection and intervention, screening for osteoporosis in patients with the NAFLD, especially those with lower income and co-morbid with diabetes mellitus and chronic obstructive pulmonary disease, may be recommended.

Risk of sexual transmitted infection following bipolar disorder: a nationwide population-based cohort study.

BACKGROUND: Bipolar disorder is a severe mental disorder associated with functional and cognitive impairment. Numerous studies have investigated associations between sexually transmitted infections (STIs) and psychiatric illnesses. However, the results of these studies are controversial. OBJECTIVE: We explored the association between bipolar disorder and the subsequent development of STIs, including human immunodeficiency virus infection; primary, secondary, and latent syphilis; genital warts; gonorrhea; chlamydial infection; and trichomoniasis. RESULTS: The bipolar cohort consisted of 1293 patients, and the comparison cohort consisted of 5172 matched control subjects without bipolar disorder. The incidence of subsequent STIs (hazard ratio (HR) = 2.23, 95% confidence interval (CI) 1.68-2.96) was higher among the patients with bipolar disorder than in the comparison cohort. Furthermore, female gender is a risk factor for acquisition of STIs (HR = 2.36, 95% CI 1.73-4.89) among patients with bipolar disorder. For individual STIs, the results indicated that the patients with bipolar disorder exhibited a markedly higher risk for subsequently contracting syphilis, genital warts, and trichomoniasis. CONCLUSIONS: Bipolar disorder might increase the risk of subsequent newly diagnosed STIs, including syphilis, genital warts, and trichomoniasis. Clinicians should pay particular attention to STIs in patients with bipolar disorder. Patients with bipolar disorder, especially those with a history of high-risk sexual behaviors, should be routinely screened for STIs. METHODS: We identified patients who were diagnosed with bipolar disorder in the Taiwan National Health Insurance Research Database. A comparison cohort was constructed of patients without bipolar disorder who were matched with the bipolar cohort according to age and gender. The occurrence of subsequent new-onset STIs was evaluated in both cohorts.

Risk of hip fractures in patients with depressive disorders: A nationwide, population-based, retrospective, cohort study.

BACKGROUND: Some studies have suggested that depressive disorders may play a vital role in the incidence of hip fractures. However, nationwide data are lacking regarding the association between depressive disorders and hip fractures. OBJECTIVE: We aimed to explore the association between depressive disorders and new-onset hip fractures. METHODS: We conducted a retrospective study of 11,207 patients with depressive disorders and 11,207 control patients using Taiwan's National Health Insurance Research Database. A Cox regression model was used to evaluate the risk of hip fractures in patients with depressive disorders. RESULTS: The incidence rate ratio of hip fractures between patients with depressive disorders and controls was 1.6 (95% confidence interval [CI] = 1.29-1.99, P < .001). After adjustment for potential confounders in multivariate analysis using the Cox regression model, patients with depressive disorders were found to have 1.34 times higher risk of hip fractures than controls (95% CI = 1.08-1.66, P = .008). Furthermore, age (hazard ratio [HR] = 7.43, 95% CI = 4.94-11.19, P < .001), hypertension (HR = 1.63, 95% CI = 1.17-2.28, P = .004), diabetes mellitus (HR = 1.47, 95% CI = 1.08-1.99, P = .014), cerebrovascular disease (HR = 1.76, 95% CI = 1.31-2.35, P < .001), living in rural areas (HR = 1.88, 95% CI = 1.30-2.70, P = .001), and low monthly income (NT$0-NT$19,000: HR = 4.08, 95% CI = 1.79-9.29, P = .001 and NT$19,100-NT$42,000: HR = 4.09, 95% CI = 1.76-9.49, P = .001) were independent risk factors for new-onset hip fractures in patients with depressive disorders. CONCLUSION: Depressive disorders might increase the risk of new-onset hip fractures, particularly in older patients and patients with hypertension, diabetes mellitus, cerebrovascular disease, or low socioeconomic status.

Risk stratification for the early diagnosis of borderline personality disorder using psychiatric co-morbidities.

AIM: To develop a risk stratification model for the early diagnosis of borderline personality disorder (BPD) using Taiwan National Health Insurance Research Database. METHODS: We conducted a retrospective case-control study of 6132 patients (292 BPD patients and 5840 control subjects) who were selected from the National Health Insurance Research Database. Psychiatric co-morbidities including depressive disorder, bipolar disorder, anxiety disorder, substance-use disorder, personality disorders other than BPD, sleep disorder, eating disorder, autistic spectrum disorder, mental retardation and attention-deficit hyperactivity disorder, which were diagnosed within 3 years before enrolment, were collected. A logistic regression was used to calculate the odds ratio of psychiatric co-morbidities between subjects with and without BPD. The classification and regression tree method was used to generate a risk stratification model. RESULTS: The odds ratios for depressive disorder, bipolar disorder, anxiety disorder, substance-use disorder, personality disorders other than BPD, sleep disorder, eating disorder, mental retardation and attention-deficit hyperactivity disorder were greater for BPD patients than for the control subjects. Furthermore, the risk of BPD can be reliably estimated using age and psychiatric co-morbidities including bipolar disorder, substance-use disorder and depressive disorder. CONCLUSIONS: Most psychiatric disorders were more common in BPD patients than in the control subjects. Using psychiatric co-morbidities, we identified four variables as significant risk predictors of BPD and permitted identification of subjects with low, intermediate or high risk for BPD. The accuracy of the risk stratification model is high and can be easily applied in clinical practice.

Chronic obstructive pulmonary disease associated with increased risk of bipolar disorder.

Epidemiological studies have identified a trend in the development of depressive and anxiety disorders following a diagnosis of chronic obstructive pulmonary disease (COPD). However, the relationship between COPD and subsequent bipolar disorder remains unclear. From January 1, 2000, we identified adult patients with COPD from the Taiwan National Health Insurance Research Database. A nationwide population-based study was conducted; 46,778 COPD patients and 46,778 age-, sex-, and comorbidity-matched subjects between 2000 and 2011 were enrolled. The two cohorts were followed up till December 31, 2011 and observed for occurrence of bipolar disorder. We observed the COPD and comparison cohorts for 263,020 and 267,895 person-years, respectively, from 2000 to 2011. The incidence rate for bipolar disorder was 1.6/1000 person-years in the COPD cohort and 1.2/1000 person-years in the comparison cohort ( p < 0.001). After multivariate adjustment, the hazard ratio (HR) for subsequent bipolar disorder among the COPD patients was 1.42 (95% confidence interval [CI], 1.22-1.64; p < 0.001). In the COPD patients, short-acting beta-agonists (SABAs) was associated with a significantly increased risk of bipolar disorder development (HR = 1.83, 95% CI = 1.25-2.69, p = 0.002). Other COPD medications were not associated with the risk of bipolar disorder development. The study results indicate that COPD may be an independent risk factor for the development of bipolar disorder. The regular use of SABAs might increase the risk of bipolar disorder in COPD patients.

Bidirectional association between Bell's palsy and anxiety disorders: A nationwide population-based retrospective cohort study.

OBJECTIVE: Bell's palsy and anxiety disorders share numerous risk factors (e.g., immune response, ischemia, and psychological stress). However, there have been no studies on the bidirectional temporal association between the two illnesses. In this study, we used the Taiwan National Health Insurance Research Database (NHIRD) to test the bidirectional association between Bell's palsy and anxiety disorders. We hypothesized that patients with Bell's palsy would have an increased risk of subsequent anxiety disorders later in life and that, conversely, those with anxiety disorders would have an increased likelihood of developing Bell's palsy later in life. METHODS: We conducted two retrospective cohort studies using Taiwan's National Health Insurance Research Database (NHIRD). Study 1 included 8070 patients diagnosed with anxiety disorders and 32,280 controls without anxiety disorders who were matched with sex, age, and enrollment date to analyze the following risk of Bell's palsy among both groups. Study 2 included 4980 patients with Bell's palsy and 19,920 controls without Bell's palsy who were matched with sex, age, and enrollment date to analyze the following risk of anxiety disorders among both groups. The patient records selected for the studies were dated between January 1, 2000, and December 31, 2004. All subjects were observed until their outcomes of interest, death or December 31, 2009. RESULTS: After adjustment for age, sex, comorbidities, urbanization, and income, the hazard ratio (HR) for patients with anxiety disorders to contract Bell's palsy was 1.53 (95% CI, 1.21-1.94, P<.001), and the HR for patients with Bell's palsy to develop an anxiety disorder was 1.59 (95% CI, 1.23-2.06, P<.001). CONCLUSION: This study found a bidirectional temporal association between Bell's palsy and anxiety disorders. After one of these conditions develops, the morbidity rate for the other significantly increases. Additional studies are required to determine whether these two conditions share the same pathogenic mechanisms, and whether successfully treating one will reduce the morbidity rate for the other.