Understanding cannabis use in Singapore: profile of users and drug progression.

Introduction: Cannabis has consistently been the third most commonly abused drug among drug arrestees in Singapore over the past few years. Accordingly, this study aimed to understand the profile of cannabis users in Singapore and explore the effects of cannabis use on drug progression. Methods: A total of 450 participants who had used cannabis at least once in their lifetime were recruited from the National Addictions Management Service, prisons, the Community Rehabilitation Centre and halfway houses from August 2017 to May 2018. A face-to-face questionnaire was administered and descriptive analyses were conducted. Results: The mean participant age was 40.9 ± 14.51 years, and 93.1% of them were male. The participants generally initiated cannabis use during adolescence, at a mean onset age of 16.5 ± 4.46 years. Most (89.6%) were introduced to cannabis by peers. Approximately half of them (46.9%) had used cannabis before other illicit drugs and 42.1% of them had used heroin as the succeeding drug. Conclusion: In Singapore, cannabis use is often initiated during adolescence, largely under peer influence. Cannabis users may progress to other illicit drugs, particularly heroin, later in life.

Unnatural Death among Treatment Seeking Substance Users in Singapore: A Retrospective Study.

Substance use carries a higher risk of unnatural death. A retrospective analysis of 42 treatment seekers between 2011-2015 was conducted through medical record review to understand the profile and circumstances leading to premature deaths. Ninety percent of the subjects were males. The mean age at death was 44.9 (SD ± 13.1). Opioids (52.4%), benzodiazepines (45.2%) and alcohol (35.7%) were the main substances used by the group. Suicide was the most common cause of death (n = 27, 64.3%) followed by accidents (n = 15; 35.7%). Among the suicide cases, alcohol was the main substance used (33.3%) followed by opioids (25.9%). A total of 58.5% (n = 24) deaths occurred within a year of their last visit while 41.5% (n = 17) were dead more than a year after their last visit. Of the total cases (n = 41), 63% had a history of mental illness with depressive disorder (53.8%) being the most common. History of suicide attempts were reported in 34.1% (n = 14) of cases and 50% of the subjects (n = 21) had a history of suicidal ideation. Drug related offences were reported in 57.1% of the subjects, of which 60% (n = 18) committed suicide. The findings support the need for appropriate treatment resources to reduce the untimely deaths among substance users.

Utilisation patterns of helpline and Web chat services among gamblers in Singapore.

We evaluated the utilisation of a helpline and Web chat system by the public for gambling-related services in Singapore over a period of 12 months. The profile of callers, call characteristics and actions taken were descriptively analysed using aggregate data. The majority of helpline calls and Web chats were from gamblers aged 40-49 years (23.3%, n = 644). Gamblers made 85.4% (n = 8,010) of the calls to the helpline and 73.3% (n = 546) of the Web chats. About four-fifths of the gamblers were Chinese (79.5%, n = 6,381) and employed full time (79.9%, n = 4,125). Table games (67.6%, n = 2,605) were the most popular gambling activity reported by callers, 55.8% of which involved local casinos. Enquiries were mostly casino related (92.4%, n = 5,739). Approximately 1,827 calls were received per month during the study period and 185 referrals were made to the clinic, 80.5% of whom sought treatment.

Correlates of Non-Medical Prescription Drug Misuse Among a Treatment-Seeking Population: A Comparison with Illicit Drug Users.

Prescription drugs (PD) undoubtedly help people with various physical or psychiatric ailments. Nevertheless, they are often diverted and misused (use without prescription or for purposes/in ways not intended by the prescriber). This study compared the sociodemographic and clinical correlates of those who misused PDs, used illegal drugs and co-ingested both, to identify those who were at a high risk of misusing these drugs. Retrospective analysis of the treatment outcome monitoring (TOM) data for the period of 2013⁻2017 identified 1369 subjects for the study; 295 patients presented with PD use disorder (PDUD alone), 811 with illegal drug use disorder (IDUD alone), and 263 had both PDUD and IDUD. The study sample included treatment seeking population (Singaporeans and permanent residents). TOM data included data collected through direct interviews (addiction severity, quality of life) and from the clinical case notes (diagnosis, co-morbidities, socio demographic information, etc.). The most commonly misused prescription and illegal drugs were benzodiazepines (63.1%) and heroin (63.4%), respectively. Those who co-ingested both PD and illegal drugs (PDUD+IDUD) had a significantly higher addiction severity score, lower quality of life and higher psychiatric co-morbidities than that of IDUD alone at baseline. When compared to Chinese patients, Malay and Indian patients had lower odds (p < 0.05) of PDUD alone and PDUD+IDUD than Chinese patients; divorcees had higher odds of PDUD+IDUD than those who were married. Those with primary and secondary qualifications had higher odds (2.1 and 2.9 times, respectively) of PDUD+IDUD than those with tertiary qualification and those in managerial or professional roles had higher odds of PDUD alone than those who were unemployed. Gender, ethnicity, marital status, education and occupational classes were associated with PDUD and IDUD. These characteristics can be helpful to identify those who are at the risk of PDUD and incorporate strict prescription monitoring to their care.

Lofexidine versus diazepam for the treatment of opioid withdrawal syndrome: A double-blind randomized clinical trial in Singapore.

BACKGROUND: Many individuals leave costly inpatient detoxification programs prematurely because of the severity of withdrawal symptoms experienced. In the absence of opioid-assisted detoxification in Singapore, diazepam is used to manage withdrawal. However since diazepam is addictive, there is a need to explore the effectiveness of alternative medications. DESIGN AND PROCEDURES: The study aimed to examine the safety and efficacy of lofexidine, a non-opiate, non-addictive, alpha 2-adrenergic agonist in assisting opioid detoxification in Singapore, using a randomized, double-blind, investigator-initiated placebo-controlled trial comparing lofexidine against diazepam. Opioid dependent patients (n = 111) were randomized to receive a 10-day course of lofexidine (n = 56) or diazepam (n = 55). The primary endpoint was the Objective Opioid Withdrawal Scale (OOWS) score on days 3 and 4 and secondary outcomes were the Short Opioid Withdrawal Scale (SOWS) score, program retention rate, and ratings of opiate craving. MAIN FINDINGS: The OOWS, SOWS and opiate craving scores were consistently lower in the lofexidine group relative to the diazepam group over the 14-day study period; however no statistically significant differences were found on days 3 and 4 (peak withdrawal). Changes in mean pupil size during peak withdrawal were significantly smaller in the lofexidine group and more participants in the lofexidine group remained in treatment and completed detoxification. CONCLUSIONS: Lofexidine was at least as effective as diazepam in reducing the opioid withdrawal syndrome and increased treatment retention. In addition to its non-addictive and non-abuse properties, lofexidine has several clinical advantages over diazepam. The use of lofexidine is recommended when opioid-assisted medications are not available.

Clinical and Functional Outcomes in Young Adult Males With ADHD.

OBJECTIVE: To investigate clinical and functional outcomes in military men with ADHD. METHOD: Clinical outcomes were measured via the Zung Self-Rating Depression Scale (Zung SDS) and the Zung Self-Rating Anxiety Scale (Zung SAS). Functional outcomes were measured using the "Car, Relax, Alone, Forget, Friends, Trouble" (CRAFFT) questionnaire and questionnaires about relationships, conduct problems, substance use, and sleep. RESULTS: Men with ADHD ( n = 52) reported more depressive (34 [67.3%] vs. 19 [38%], p = .008) and anxiety symptoms (31 [61.5%] vs. 14 [28%], p = .009) compared with those without ( n = 50). They had relationships lasting less than 1 year (24 [80%] vs. 9 [37.5%], p = .006), were more likely to smoke (17 [32.7%] vs. 5 [10%], p = .005), were most likely to use illicit substances (6 [11.5%] vs. 0 [0%], p < .001), had more conduct problems at school (27 [51.9%] vs. 5 [10%], p < .001), and had longer sleep latency (53.96 min ± 46.48 vs. 25.78 min ± 25.93, p = .006). CONCLUSION: Military men with ADHD are significantly associated with worse clinical and functional outcomes. They should be screened and monitored for depression, anxiety, sleep disorders, and substance use.

Internet based personalized feedback interventions for gamblers in Singapore: First results.

BACKGROUND: Problem or pathological gambling has been a worldwide concern in the recent years, especially so with the advances in the technology, facilitating easier access to various means of gambling. Along with the advances in web-based and smartphone technologies, these technologies have been recently applied as adjunctive clinical tools to help gamblers. Taking into careful consideration the existing evidence base for Internet based interventions for pathological gambling, it seemed that the current published literature has demonstrated largely the efficacy of a personalized feedback intervention for pathological gambling; and further studies are still under-going to try and demonstrate the clinical feasibility of online web-based cognitive behavioral interventions for pathological gamblers. OBJECTIVES: Given this, the aims of the current study are to (a) replicate an online personalized feedback intervention and determine its receptiveness in an Asian cohort of gamblers; and (b) to identify the demographics and characteristics of Asian gamblers who would utilize an online intervention. METHODOLOGY: The workgroup at the National Addiction Management Service, Singapore conceptualized the online personalized feedback intervention for gamblers. The English version was launched on the 31st of March 2014 and the Chinese version was launched on the 30th of September 2014. RESULTS: A cumulative total of 708 participants took part with rhe mean age of the participants being 32.70 (SD = 11.638), with 89.1% males and 10.9% females. The mean problem gambling severity score (PGSI) was 10.80 (SD = 8.13), with the vast majority participating in Casino gambling on board a cruise (36.0%). Of significance, approximately 59.2% of the participants who sought help with our online e-intervention did have a diagnosis of problem gambling. CONCLUSIONS: This is one of the first few studies to demonstrate and replicate the potential use of an Internet based intervention for non-problem and problem gamblers. The current study has demonstrated that individuals are generally receptive towards such an intervention.

Gambling in Singapore: an overview of history, research, treatment and policy.

AIMS: This paper describes the current situation regarding gambling in Singapore in relation to its historical and cultural context. METHODS: A computerized search was performed of two databases (PubMed and PsychINFO) and the reference lists from the papers searched manually to identify relevant studies. The findings were synthesized and their implications assessed. RESULTS: In addition to state lotteries and much informal gambling, Singapore has two large resort casinos, which rank third after Las Vegas and Macau in terms of gross revenues. The major ethnic subgroups in Singapore have different cultural connections to gambling, including the active involvement of the Chinese and religious prohibition among the Malay. A range of secondary prevention and treatment services has been developed to attempt to minimize potential negative impacts. Overall, the prevalence of pathological gambling and problem gambling has decreased in recent years: an estimated 0.2% are classified as probable pathological gamblers compared with 1.4% in 2011, 1.2% in 2008 and 2.1% in 2005. CONCLUSIONS: Singapore has experienced a reduction in problem gambling prevalence which may reflect the influence of multiple initiatives.

Global Outreach of a Locally-Developed Mobile Phone App for Undergraduate Psychiatry Education.

BACKGROUND: Over the past decade, there have been massive developments in both Web-based and mobile phone technologies. Mobile phones are well accepted by students, trainees, and doctors. A review of the current literature has identified the following specialties that have used mobile phones in education: pediatrics, ophthalmology, nephrology, plastic surgery, orthopedics, pharmacology, and urology. However, to date, there are no published papers examining the application of the latest mobile phone technologies for psychiatry education internationally. OBJECTIVES: The main objectives of this study are (1) to determine the feasibility and receptiveness of a locally-developed psychiatry mobile phone app and user perspectives (both quantitative and qualitative) towards it, and (2) to determine the receptiveness of a locally-developed app for psychiatry education internationally. METHODS: A Web-based app that contained textbook contents, videos, and quizzes was developed using HTML5 technologies in 2012. Native apps were subsequently developed in 2013. Information about the apps was disseminated locally to Singaporean medical students, but the respective native apps were made available on the app stores. A user perspective survey was conducted locally to determine student's perception of the app. RESULTS: From the inception of the app until the time of preparation of this manuscript, there have been a cumulative total of 28,500 unique visits of the responsive HTML5 Web-based mobile phone app. There have been a cumulative total of 2200 downloads of the Mastering Psychiatry app from the Apple app store and 7000 downloads of the same app from the Android app store. The initial user perspective survey conducted locally highlighted that approximately a total of 95.2% (177/186) of students felt that having a psychiatry mobile phone app was deemed to be useful. Further chi-squared analysis demonstrated that there was a significant difference between males and females in their perception of having textbook contents in the mobile phone app (χ24=12.9, P=.0012). CONCLUSIONS: To the best of our knowledge, this is the first study to demonstrate the feasibility and global acceptance of a local, self-designed educational app for psychiatry education. Whilst the current research has managed to demonstrate the feasibility and acceptance of such an app, future studies would be warranted to look, in-depth, into whether there are cultural differences in terms of perceptions towards having such an app in psychiatry and what contents different cultures and cohorts of students might want within an app.

Application of low-cost methodologies for mobile phone app development.

BACKGROUND: The usage of mobile phones and mobile phone apps in the recent decade has indeed become more prevalent. Previous research has highlighted a method of using just the Internet browser and a text editor to create an app, but this does not eliminate the challenges faced by clinicians. More recently, two methodologies of app development have been shared, but there has not been any disclosures pertaining to the costs involved. In addition, limitations such as the distribution and dissemination of the apps have not been addressed. OBJECTIVE: The aims of this research article are to: (1) highlight a low-cost methodology that clinicians without technical knowledge could use to develop educational apps; (2) clarify the respective costs involved in the process of development; (3) illustrate how limitations pertaining to dissemination could be addressed; and (4) to report initial utilization data of the apps and to share initial users' self-rated perception of the apps. METHODS: In this study, we will present two techniques of how to create a mobile app using two of the well-established online mobile app building websites. The costs of development are specified and the methodology of dissemination of the apps will be shared. The application of the low-cost methodologies in the creation of the "Mastering Psychiatry" app for undergraduates and "Déjà vu" app for postgraduates will be discussed. A questionnaire survey has been administered to undergraduate students collating their perceptions towards the app. RESULTS: For the Mastering Psychiatry app, a cumulative total of 722 users have used the mobile app since inception, based on our analytics. For the Déjà vu app, there has been a cumulative total of 154 downloads since inception. The utilization data demonstrated the receptiveness towards these apps, and this is reinforced by the positive perceptions undergraduate students (n=185) had towards the low-cost self-developed apps. CONCLUSIONS: This is one of the few studies that have demonstrated the low-cost methodologies of app development; as well as student and trainee receptivity toward self-created Web-based mobile phone apps. The results obtained have demonstrated that these Web-based low-cost apps are applicable in the real life, and suggest that the methodologies shared in this research paper might be of benefit for other specialities and disciplines.

Academy of Medicine-Ministry of Health clinical practice guidelines: attention deficit hyperactivity disorder.

The Academy of Medicine (AMS) and the Ministry of Health (MOH) have developed the clinical practice guidelines on Attention Deficit Hyperactivity Disorder (ADHD) to provide doctors and patients in Singapore with evidence-based treatment for ADHD. This article reproduces the introduction and executive summary (with recommendations from the guidelines) from the MOH clinical practice guidelines on ADHD, for the information of SMJ readers. 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/healthprofessionalsportal/doctors/guidelines/cpg_medical.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.

Prevalence of electrocardiographic abnormalities in an unselected young male multi-ethnic South-East Asian population undergoing pre-participation cardiovascular screening: results of the Singapore Armed Forces Electrocardiogram and Echocardiogram screening protocol.

AIMS: Resting 12-lead electrocardiograms (ECGs) have been employed in the pre-participation evaluation of young asymptomatic subjects to detect pre-existing heart diseases. Although the incorporation of routine ECG in pre-participation screening remains controversial, there is increasing evidence that cardiomyopathies and ion channelopathies have ECG changes as the initial manifestation. The causes of sudden cardiac death in young people show significant geographical variation. We aim to determine the prevalence and spectrum of ECG abnormalities in a young male South-East Asian population. METHODS AND RESULTS: The Singapore Armed Forces Electrocardiogram and Echocardiogram (SAFE) protocol is an ECG-based pre-participation cardiac screening programme modelled after the Italian system. From October 2008 to May 2009, a total of 18 476 young male conscripts (mean age 19.5 years old, range 16-27) underwent mandatory pre-enlistment medical screening at a single medical facility. Subjects with abnormal ECG findings were classified into two groups: Group A had ECG changes that fulfilled a pre-specified checklist to screen for hypertrophic cardiomyopathy and were referred for transthoracic echocardiogram; Group B had other ECG abnormalities [such as Brugada pattern, Wolff-Parkinson-White (WPW) pattern, long QTc] and were referred for secondary screening at a tertiary institution. Of the 18 476 subjects screened, 7.0% (n= 1285) had ECG abnormalities. Of note, 19 (0.10%) had Brugada pattern, 25 (0.14%) had WPW pattern, and 31 (0.17%) had prolonged QT interval on ECG. The prevalence of ECG abnormalities was significantly higher in Chinese than in South Asians (7.2 vs. 5.7%, P= 0.003). CONCLUSION: The prevalence of ECG abnormalities in a young, South-East Asian male population was 7.0%. There were significant ethnic differences, with ECG abnormalities more prevalent in Chinese than in South Asians (7.2 vs. 5.7%, P= 0.003). The inclusion of universal ECG, in addition to history and physical examination, may increase the sensitivity of a cardiovascular screening programme. Knowledge of the spectrum and prevalence of ECG abnormalities and disease conditions would be pivotal in designing customized screening programmes.

Prevalence and correlates of psychotic symptoms among Asian males.

PURPOSE: Psychotic symptoms have been reported at varying rates in the general population in the West. We studied the association of psychotic symptoms with educational attainment and other psychiatric disorders in 23,248 male pre-enlistees for National Service in Singapore. METHODS: In a 2-stage assessment, these enlistees were first screened with the Self-Reporting Questionnaire (SRQ-24) and the CRAFFT. Those screened positive were then assessed by the Composite International Diagnostic Interview (CIDI) to establish the presence of psychiatric disorders based on the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV). RESULTS: The rate of psychotic symptoms (after excluding those with psychotic disorders) was 8.2% (n = 1,909). A multinomial logistic regression using the controls as the reference group revealed that younger age, lower PSLE scores, and mood and anxiety disorder remained significantly associated with both the diagnoses of psychotic disorders and the presence of psychotic symptoms. CONCLUSIONS: A combination of categorical and dimensional representation of psychopathology for the diagnosis of psychotic disorders would better inform treatment and prognosis as there is a considerable overlap in the presentation of psychotic symptoms and psychotic disorders.

Prevalence of hypertrophic cardiomyopathy on an electrocardiogram-based pre-participation screening programme in a young male South-East Asian population: results from the Singapore Armed Forces Electrocardiogram and Echocardiogram screening protocol.

AIMS: Hypertrophic cardiomyopathy is a leading cause of sudden cardiac death (SCD) in young people in the USA. Pre-participation screening for athletes might reduce the incidence of SCD. In Singapore, military service is compulsory for all young able-bodied male citizens. The Singapore Armed Forces Electrocardiogram and Echocardiogram (SAFE) pre-participation screening protocol based on the Italian programme was introduced. This study evaluates the prevalence of hypertrophic cardiomyopathy (HCM) in a young male South-East Asian population. METHODS AND RESULTS: From October 2008 to May 2009, all male military conscripts underwent pre-participation screening. For all conscripts whose electrocardiogram (ECG) findings fulfilled any of these pre-specified criteria (Group A), direct referral for a transthoracic echocardiogram was mandatory. Conscripts with ECG findings other than pre-specified criteria (e.g. T-wave inversions, repolarization abnormalities) were referred for secondary screening by cardiologists (Group B), which could include echocardiography. Out of 18 476 subjects screened during the study period, 988 (5.3%) subjects were fast tracked for echocardiogram (Group A). Of them, there were three (0.3%) cases with severe abnormalities; there was one case each of HCM, bicuspid aortic valve with significant aortic valve regurgitation, and atrial septal defect with right ventricular systolic dysfunction. The patient with HCM had left axis deviation on ECG. None of the 215 patients who underwent echocardiography following cardiology consult (Group B) had HCM. CONCLUSION: The prevalence of HCM in our young male population (mean age 19.5, range 16-27) using an ECG-based screening protocol was 0.005%; this appeared lower than published data from other geographical cohorts. Possible explanations include a later age of phenotypic manifestation in our population, limitations of the ECG criteria for screening, or a truly lower prevalence of HCM. More population-based longitudinal studies would be needed to ascertain the true prevalence of HCM in our South-East Asian population.

Validity of a brief screening instrument-CRAFFT in a multiethnic Asian population.

AIM: To validate the CRAFFT screening test, against the DSM IV Axis 1-based diagnostic inventory in a population of adolescents and young adult males in Singapore. METHODS: The 23,248 participants belonged to a cohort of males who had undergone a medical examination prior to enlistment for military service. This study took place between August 2004 and August 2005. Subjects underwent a two-stage assessment and were administered the CRAFFT questionnaire and the Composite International Diagnostic Interview (CIDI). RESULTS: The mean age of the subjects was 19 years (range, 16 to 26 years). The CRAFFT showed moderately high levels of internal consistency (Cronbach's α=0.73). The optimum cutoff point for drug-related disorder either abuse or dependence and alcohol-related disorder either abuse or dependence criterions were found at CRAFFT score of 1 or higher. CONCLUSION: The CRAFFT test is a valid means of screening adolescents for substance-related disorders in a multiethnic population of adolescent and young adult males.

Nicotine dependence and psychiatric disorders among young males in Singapore.

INTRODUCTION: While the risk for a number of medical illnesses is well established for those who smoke, the risk for psychiatric disorders is not so well studied in Singapore. OBJECTIVES: This study sought to establish the lifetime prevalence of nicotine dependence in a population of young males in Singapore and to establish its relationship with other psychiatric disorders. METHODS: The study was conducted among a cohort of males reporting for their mandatory physical examination prior to their enlistment for National Service in a 1-year period between August 2004 and August 2005. Definitive diagnoses in accordance with DSM-IV criteria were made with the Composite International Diagnostic Interview (CIDI). RESULTS: In the population of 9,702 males assessed by CIDI, the prevalence of nicotine dependence was 12.3%. Academic attainments were significantly poorer in those with nicotine dependence than those without dependence. Nicotine dependence was most strongly associated with delusional disorder and major depressive disorder, which remained even after adjusting for ethnicity and educational attainments (odds ratio [OR] of 59.8 for delusional disorder and OR of 36.3 for major depressive disorder). DISCUSSION: Our study highlights the pervasive extent of nicotine dependence among a population of young men. The pervasiveness of nicotine dependence across different psychiatric disorders suggests either a shared biological substrate or a common consequence of these disorders.

Academic attainment: a predictor of psychiatric disorders?

AIM: Poor academic performance can reflect the neurobiological abnormalities underlying schizophrenia and has been suggested as a premorbid marker for the disorder. However, it is not clear as to how academic performance compares as a marker for other mental disorders. The objective of this study was to examine whether educational attainment is a candidate marker for certain psychiatric disorders. METHODS: Using a retrospective cohort design, we compared the early educational performance of 6957 National Service male conscripts. The presence of mental illness was assessed using the Composite International Diagnostic Interview. Academic performance was assessed using the results of a standardized national examination after 6 years of primary education. RESULTS: Adjusting for ethnicity, the scores from this examination revealed that those with schizophrenia spectrum disorders scored significantly lower than those without any mental illness. CONCLUSIONS: Poor educational attainment predicts the onset of schizophrenia spectrum disorders and could be a possible predictor for this specific group of mental illness.

The mental health screening of conscripts for the Singapore Armed Forces: rationale, objectives, and design.

Identification of mentally ill military conscripts is crucial, since these individuals may experience an exacerbation of their illness during training with dire consequences for them and the organization. This article describes the design of a study to validate a screening instrument for psychiatric disorders as well as to establish their prevalence among male army conscripts in Singapore. It involved a two-stage process: the conscripts were screened with a new instrument which we termed the Mental Wellness Screening Questionnaire; those who screened positive, and a random sample of those who did not, were administered the computerized Composite International Diagnostic Interview which was the gold standard in making the diagnosis. This study is unusual in that it involved almost the entire male population in 1 year but its relevance is the development of a screening instrument that can be used with ease in a large population of conscripts.