Meperidine addiction or treatment frustration?

There have been few studies of the psychiatric characteristics of analgesics addiction. The physician's perceptions that patients were addicted to analgesics might be partially attributable to frustration with poor response to treatment. In this retrospective study, we evaluated the medical records of 20 subjects (15 male and 5 female) who were perceived as having addiction to meperidine by general physicians. The most common medical diagnosis among these patients was chronic pancreatitis (7/20). Among them, five had a past history of suicide attempt and three had self-injury behavior during the index admission. The fact that subjects were perceived as being addicted might be attributable to a vicious cycle of the following factors: 1) chronic intractable pain; 2) poor staff-patient relationship; 3) lower pain threshold or tolerance due to anxiety or depression; 4) patients with a history or tendency of substance abuse; 5) placebo use and inadequate analgesics regimen. The findings of this study suggest that the importance of the following diagnostic and treatment procedures in these patients: 1) suicide risk should be evaluated; 2) comorbid psychiatric diseases should be treated; 3) factors that cause a vicious cycle in pain control should be identified; 4) misconceptions of opiate analgesics among medical staff should be discussed; 5) poor staff-patient relationship should be managed aggressively; and 6) "addiction" is a critical diagnosis that should be avoided if possible.

Treatment refusal: analysis of 15 cases.

BACKGROUND: In this paper, we investigate the reasons for treatment refusal at Linkou and Kaohsiung Chang Gung Memorial Hospitals, and offer ways to improve the doctor-patient relationship. METHODS: Cases were collected during a 2-year period according to the criterion of notification of "refused treatment" on consultation sheets, with a total of 1631 consultation sheets. All cases were discussed once a week in detail by psychiatrists and the consulting medical staff, and were followed up from 1 to 4 weeks. All cases were treated by the processes of informed consent and crisis intervention. The final results for the reasons of treatment refusal and psychiatric diagnoses were made by psychiatrists and the consulting medical staff. RESULTS: The number of cases compatible with the criterion was 15 (10 men and 5 women). The reasons for treatment refusal included poor communication, inadequate information, lack of competency, denial and shock reaction, reappearance of the suffered experience, and autonomy of patients. The distribution of psychiatric diagnoses included 8 with major depressive disorders, 2 with delirium, 1 with schizophrenic disorder, 1 with adjustment disorder, 1 with acute stress disorder (post-traffic accident), 1 with alcohol dependence, and 1 was deferred. After adequate processes of informed consent and crisis intervention, 12 persons accepted medical treatment. CONCLUSION: We should give patients adequate informed consent and crisis intervention to establish a good doctor-patient relationship and to respect the patients' autonomy for their choice of treatment.

Self-destructive acts occurring during medical general hospitalization.

Although several articles about suicide in general hospitals have been published, the rates of self-destructive individuals among various diseases and departments have not been reported previously. Moreover, self-destructive acts in Chinese general hospital inpatients have been neglected. We retrospectively investigated self-destructive incidents among medical general inpatients. A total of 75 self-destructive incidents, including 15 fatalities, were identified during the 10-year study period. The self-destructive rate was 8.7 per 100,000, and the fatality rate was 1.8 per 100,000 admissions. The highest self-destructive rate occurred in patients admitted to the rehabilitation ward (33.4 per 100,000) followed by the neurology ward (29.9 per 100,000). The highest fatality rate occurred among patients in the neurology ward (6.7 per 100,000). The majority of self-destructive patients suffered from a chronic or terminal illness with the most frequent types of illnesses being malignant neoplasm (31.1%), neurological disease (20.3%), and chronic obstructive pulmonary disease (COPD, 10.8%). COPD patients had the highest rate of self-destructive behavior (64.0 per 100,000) and the highest fatality rate (16.0 per 100,000) due to these incidents. The most common self-destructive incident was knife-cutting. More than one-half (53.4%) of the self-destructive incidents occurred within the first 2 weeks of admission, and nearly one-half (46.7%) occurred during the night shift. Moreover, the majority of severe or fatal incidents also occurred during the night shift. The results suggest that close supervision of high-risk patients should be mandatory within the first 2 weeks following admission, especially during the night shift.

Progressive myoclonic epilepsies syndrome (Ramsay Hunt syndrome) with mental disorder: report of two cases.

Ramsay Hunt syndrome (RHS) is a rare condition within the progressive myoclonic epilepsies syndrome (PME), with a triad of action myoclonus, grand mal seizure and severe cerebellar ataxia. There are few reports about the psychiatric disturbances associated with PME or RHS. The present study examines the evidence that RHS may accompany an organic mental syndrome, ethanol's effective suppression of myoclonus, and the possible resultant problem of alcohol dependence in RHS patients. Two brothers with the previous long-standing diagnosis of RHS and their mental symptoms of persecutory delusion and depression are reported, as well as the additional problem of alcohol dependence in one of them. The cerebellar dysfunction found in RHS may be associated with an underlying organic condition. Determination of the relationship between cerebellar dysfunction and psychosis in RHS will require further study. Although the mechanism of the suppression of myoclonus by alcohol remains unclear, patients should be allowed to drink socially, and alcohol consumption should not be totally prohibited. However, effective treatment of the problems of alcohol tolerance, abuse, or dependence requires the cooperation of both neurologists and psychiatrists.

Prevalence of suicide ideation and suicide attempts in nine countries.

BACKGROUND: There are few cross-national comparisons of the rates of suicide ideation and attempts across diverse countries. Nine independently conducted epidemiological surveys using similar diagnostic assessment and criteria provided an opportunity to obtain that data. METHODS: Suicide ideation and attempts were assessed on the Diagnostic Interview Schedule in over 40000 subjects drawn from the United States, Canada, Puerto Rico, France, West Germany, Lebanon, Taiwan, Korea and New Zealand. RESULTS: The lifetime prevalence rates/100 for suicide ideation ranged from 2.09 (Beirut) to 18.51 (Christchurch, New Zealand). Lifetime prevalence rates/100 for suicide attempts ranged from 0.72 (Beirut) to 5.93 (Puerto Rico). Females as compared to males had only marginally higher rates of suicidal ideation in most countries, reaching a two-fold increase in Taiwan. Females as compared to males had more consistently higher rates for suicide attempts, reaching a two- to three-fold increase in most countries. Suicide ideation and attempts in most countries were associated with being currently divorced/separated as compared to currently married. CONCLUSIONS: While the rates of suicide ideation varied widely by country, the rates of suicide attempts were more consistent across most countries. The variations were only partly explained by variation in rates of psychiatric disorders, divorce or separation among countries and are probably due to cultural features that we do not, as yet, understand.

Delusional disorder: retrospective analysis of 86 Chinese outpatients.

Patients who visited the psychiatric outpatient service of Chang Gung Medical Centre, Tao-Yuan, Taiwan during an 8-year period were studied retrospectively. Among the 10,418 outpatients, 86 (0.83%) were diagnosed as having DSM-IV delusional disorder (DD), including 61 (70.9%) with persecutory type, 12 (14.0%) with the mixed type, seven (8.1%) with jealous type, two (2.3%) with somatic type, two (2.1%) with unspecified type, one (1.2%) with erotomanic type, and another one with grandiose type. The ratio of women to men was 0.86. The mean age at onset was 42.4 +/- 15.41 years, with women being older than men. Thirty-seven cases (43.0%) presented with depressive symptoms at their first visit. Subjects were divided into four groups: persecutory type, jealous type, mixed type and others. There were no significant differences between the four groups in terms of gender, age at onset, time-lapse before seeking psychiatric help, the presence of hallucination or the presence of depression.

Alcohol-related problems in Taiwan with particular emphasis on alcoholic liver diseases.

Socioeconomic development has led to a progressive increase of alcohol consumption in Taiwan, with an accompanying increase in alcohol-related psychiatric problems, traffic accidents, and liver disease. The prevalent rates of alcohol dependence for Han Chinese and Fomosan aborigines were 0.1% and 1%, respectively in 1950. The rate of alcohol dependence increased to 23% for aborigines in 1995. The number of cases of death and serious injuries due to alcohol-related traffic accident has decreased, and the number of fatalities resulting from these accidents has decreased from third to eighth since the inception of a program of random traffic stops with alcohol breath test in 1997. Alcohol liver disease (ALD) was defined as daily alcohol consumption of 60 g, for a duration of longer than 5 years. We classified ALD patients into two groups: (1) those whose average daily consumption of alcohol exceeded 120 g for a duration longer than 15 years (group A); and (2) all other patients (group B). The case records of 33 cases of biopsy-confirmed ALD were obtained for study. The average of daily alcohol consumption in these cases was 160 g. All but one of these patients were male, age ranged from 26 to 69 years, with an average of 43.1. Clinically, ill-defined gastrointestinal symptoms were the most common presentation (61%), and hepatomegaly was the main physical sign (73%). The average mean corpuscular volume values of ALD and non-ALD patients were 102.3 +/- 10.94 and 94.5 +/- 8.1, respectively (p < 0.01). The mean corpuscular volume values of group A and group B were 102.9 +/- 9.7 vs. 96.5 +/- 9.11 (p < 0.05). Result from serum SGOT/SGPT and gamma-glutamyltransferase/alkaline phosphatase for ALD and non-ALD revealed statistically significant differences between these groups. Using the avidin-biotin complex technique, tissue IgA deposition for ALD patients was found to be different from that of non-ALD patients. Ten of 13 ALD patients vs. 2 of 13 non-ALD patients had continuous-form IgA deposition. Histologically, 45.5% of ALD patients had alcoholic cirrhosis, whereas alcoholic hepatitis was present in only 9.1% of patients. Overall, 88% of cases showed various severity of fatty metamorphosis.

Mental Health Law and development of mental health program in Taiwan.

The legislation of the Mental Health Law which came into effect on 7 December 1990 was the most important event among a series of innovatory measures and actions taken by the government during the 1980s and the years that followed to improve the nation's mental health program. The law consists of 52 articles classified into seven chapters. The impact of the law on the development of mental health program has been significant in many aspects. There are, however, issues and controversies in this new law which need continuous monitoring as the mental health program progresses.

What happens to depressed men? Application of the Stirling County criteria.

In a recent issue of the Harvard Review of Psychiatry, results from the Stirling County Study showed that the prevalence and incidence rates of depression were similar in men and women when "gender-fair" criteria were used and help-seeking was not required. We attempted to replicate these findings by applying the criteria for depression from the Stirling County Study to two national and six international epidemiologic surveys conducted in the 1980s and 1990s. Depression was defined as dysphoric mood and disturbances of sleep, appetite, and energy, with at least a mild degree of impairment. The rates of depression were computed using this algorithm with data from the US Epidemiologic Catchment Area Study, conducted in the 1980s, the US National Comorbidity Survey, conducted in the 1990s, and independent community surveys from Canada, Puerto Rico, France, Taiwan, Korea, and New Zealand. For the US studies, these rates were recalculated after persons seeking treatment were removed from the analyses, where such data were available. Using Stirling County Study criteria, the lifetime prevalence rate of depression remains approximately twice as high in women as in men cross-nationally, except in Puerto Rico. Excluding help-seeking as a criterion and controlling for birth cohort do not change the findings. The Stirling County findings on absence of a sex difference in rates of depression using "gender-fair" criteria may be due to methodological variance in the collection of data, sample size, or the social and/or genetic uniqueness of the Atlantic Canadian community.

The cross-national epidemiology of panic disorder.

BACKGROUND: Epidemiological data on panic disorder from community studies from 10 countries around the world are presented to determine the consistency of findings across diverse cultures. METHOD: Data from independently conducted community surveys from 10 countries (the United States, Canada, Puerto Rico, France, West Germany, Italy, Lebanon, Taiwan, Korea, and New Zealand), using the Diagnostic Interview Schedule and DSM-III criteria and including over 40,000 subjects, were analyzed with appropriate standardization for age and sex differences among subjects from different countries. RESULTS: The lifetime prevalence rates for panic disorder ranged from 1.4 per 100 in Edmonton, Alberta, to 2.9 per 100 in Florence, Italy, with the exception of that in Taiwan, 0.4 per 100, where rates for most psychiatric disorders are low. Mean age at first onset was usually in early to middle adulthood. The rates were higher in female than male subjects in all countries. Panic disorder was associated with an increased risk of agoraphobia and major depression in all countries. CONCLUSIONS: Panic disorder is relatively consistent, with a few exceptions, in rates and patterns across different countries. It is unclear why the rates of panic and other psychiatric disorders are lower in Taiwan.

Alcohol problems and long-term psychosocial outcome in Chinese patients with bipolar disorder.

BACKGROUND: A high comorbidity of alcohol use disorders among Western bipolar patients is recognized and worsens the outcome of bipolar illness. In view of lower prevalence of alcohol use disorders in some Asian groups, we attempted to investigate the alcohol problems among Chinese bipolar patients in Taiwan. METHODS: The clinical data of bipolar patients (DSM-III-R) having been followed-up naturally for at least 15 years were obtained by a combination of chart reviews and interviews with patients and family members. RESULTS: Based on a retrospective chart review of 158 patients, 8.2% of them were found to have alcohol problems. The lifetime prevalence of alcohol abuse was 6.9%, and of alcohol dependence 3.0% among 101 subjects accepting interview. According to the Global Assessment of Functioning Scale (APA, 1994) nearly one-third of them were clearly dysfunctional. LIMITATION: As subjects had a greater mean age, the age-related effects probably worsened the psychosocial outcome and reduced the incidence of new substance abuse. CONCLUSION: Chinese bipolar patients, despite a lower comorbidity of alcohol use disorders, do not have a more favorable long-term psychosocial outcome (marriage, work, and social adjustment) than Western patients.

Major depressive disorder in Taiwan defined by the Chinese diagnostic Interview Schedule.

The lifetime prevalence rate of major depressive disorder (MDD), as defined by the Chinese Diagnostic Interview Schedule, is 1.14% in Taiwan. This is significantly lower than the lifetime prevalence rates reported in Western studies and similar to other studies in the Chinese population using similar methods for assessing cases of MDD. Epidemiological data from 136 MDD cases were analyzed to provide possible explanations for this difference in lifetime prevalence rates. The low rate of broken families in Chinese culture, low comorbidity rate, and older age of onset of MDD may suggest a reality of low lifetime prevalence rates of MDD in Taiwan.

Cross-national epidemiology of major depression and bipolar disorder.

OBJECTIVE: To estimate the rates and patterns of major depression and bipolar disorder based on cross-national epidemiologic surveys. DESIGN AND SETTING: Population-based epidemiologic studies using similar methods from 10 countries: the United States, Canada, Puerto Rico, France, West Germany, Italy, Lebanon, Taiwan, Korea, and New Zealand. PARTICIPANTS: Approximately 38000 community subjects. OUTCOME MEASURES: Rates, demographics, and age at onset of major depression and bipolar disorder. Symptom profiles, comorbidity, and marital status with major depression. RESULTS: The lifetime rates for major depression vary widely across countries, ranging from 1.5 cases per 100 adults in the sample in Taiwan to 19.0 cases per 100 adults in Beirut. The annual rates ranged from 0.8 cases per 100 adults in Taiwan to 5.8 cases per 100 adults in New Zealand. The mean age at onset shows less variation (range, 24.8-34.8 years). In every country, the rates of major depression were higher for women than men. By contrast, the lifetime rates of bipolar disorder are more consistent across countries (0.3/100 in Taiwan to 1.5/100 in New Zealand); the sex ratios are nearly equal; and the age at first onset is earlier (average, 6 years) than the onset of major depression. Insomnia and loss of energy occurred in most persons with major depression at each site. Persons with major depression were also at increased risk for comorbidity with substance abuse and anxiety disorders at all sites. Persons who were separated or divorced had significantly higher rates of major depression than married persons in most of the countries, and the risk was somewhat greater for divorced or separated men than women in most countries. CONCLUSIONS: There are striking similarities across countries in patterns of major depression and of bipolar disorder. The differences in rates for major depression across countries suggest that cultural differences or different risk factors affect the expression of the disorder.

[Organic mental disorders in psychiatric consultation: a preliminary report].

In 200 cases for psychiatric consultation, 73 (36.5%) cases, 51 males and 22 females, were diagnosed as suffered from organic mental syndrome/disorder according to DSM-III-R criteria. Their mean age was 47.9 +/- 18.9 years. The leading psychiatric diagnosis were delirium (45.2%) and substance intoxication/withdrawal (20.5%). The main reasons for psychiatric consultation were psychotic symptoms (31.5%) and conscious disturbance (19.2%). The most common presumed etiologies for organic mental disorders were psycoactive substance related (39.7%) and metabolic (15.1%) causes. The comparisons of the results reported by several medical centers in recent years were further discussed in the text.

Low frequency of the ADH2*2 allele among Atayal natives of Taiwan with alcohol use disorders.

Genetic variation at two polymorphic alcohol dehydrogenase loci, ADH2 and ADH3, and at the polymorphic mitochondrial aldehyde dehydrogenase locus, ALDH2, may influence the risk of developing alcoholism by modulating the rate of elimination of ethanol and the rate of formation and elimination of acetaldehyde. Populations differ in allele frequencies at these loci. We determined the genotypes at all three of these loci in Atayal natives of Taiwan. The frequencies of ADH2*2, ADH3*1, and ALDH2*1 alleles (0.91, 0.99, and 0.95, respectively) were significantly higher among the Atayal than among a predominantly Han Chinese population from Taiwan. Among the Atayal, the group with alcohol use disorders (alcohol dependence and alcohol abuse) had a significantly lower frequency of the ADH2*2 allele (0.82) than those without alcohol use disorders (0.91). The ADH2*2 allele encodes the beta 2 subunit; isozymes containing beta 2 subunits oxidize alcohol faster in vitro than the beta 1 beta 1 isozyme encoded by ADH2*1. Thus, the simplest explanation for these data is that individuals with a beta 2 isozymes have a higher rate of ethanol oxidation, which is a deterrent to alcohol abuse and dependence in some individuals. The Atayal with alcohol use disorders also had a lower frequency of ALDH2*2 than the controls; this allele is known to be responsible for the alcohol-flush reaction among Asians, and thereby deters drinking.

New methods in cross-cultural psychiatry: psychiatric illness in Taiwan and the United States.

OBJECTIVE: Cross-cultural psychiatric research has suffered from many methodological shortcomings. To answer some of these shortcomings, the present study compared rates of psychiatric disorders in Taiwan and the United States by combining data from both countries into a single data set. METHOD: Results from large, community-based surveys in the United States and Taiwan, the National Institute of Mental Health (NIMH) Epidemiologic Catchment Area survey and the Taiwan Psychiatric Epidemiological Project, were combined into a single data set. This integration of the data sets was possible because both surveys used the NIMH Diagnostic Interview Schedule to ascertain cases. The integrated data sets were then analyzed with identical algorithms to generate lifetime prevalence rates of psychiatric disorders according to DSM-III criteria for both the United States and Taiwan. RESULTS: Lifetime prevalence rates of psychiatric illness in Taiwan were generally lower than U.S. rates. The rates of any disorder were 21.56% in Taiwan and 35.55% in the United States (Z = 22.34, p less than 10(-109]. The rates of most specific disorders were lower in Taiwan, and none of the rates was higher in Taiwan. CONCLUSIONS: While a culturally determined response bias may have lowered the rates in Taiwan somewhat, the results appear to be valid. Implications for the future use of structured diagnostic interviews in cross-cultural research are discussed.

Aldehyde dehydrogenase deficiency, flush patterns and prevalence of alcoholism: an interethnic comparison.

A study was performed to verify that the prevalence of alcohol abuse and dependence in Formosan aborigines differs from that of Taiwanese (Chinese Han people), using analysis of aldehyde dehydrogenase (ALDH) isozymes and flush patterns on randomly sampled 70 Atayal, 66 Paiwan, 61 Yami and 94 Taiwanese subjects were studied. The activity of an isomer of ALDH having a low Km (ALDH-I) in hair roots was analysed by isoelectric focusing assay. The subjective experience of flushing response after alcohol ingestion was assessed. Results showed that the rate of ALDH-I deficiency in Taiwanese (51.1%) was significantly higher than in aborigines, i.e., 6.4%, 3.9%, and 0% in Atayal, Paiwan, and Yami subjects, respectively. The percentage occurrence of ALDH-I deficiency and prevalence of alcohol dependence in Taiwanese and aborigines were negatively correlated. The predominant pattern of self-reported flush response after alcohol use among aborigines was of slow onset. The flush response to alcohol ingestion was examined in relation to aldehyde metabolizing enzyme. Since alcohol sensitivity is an important factor in the development and maintenance of the alcohol ingestion habit in humans, our results support the hypothesis that there is a biological basis in the different rates of alcohol abuse and dependence among different ethnic groups.

Maintenance lithium levels could be lowered: based on Taiwanese and Danish studies.

Twenty-two patients, 8 males and 14 females, who had been lithium-free for at least 1 week were included in this study. All patients took 900 mg of Lithonate at 8:00 a.m. while in a fasting state. A 5 ml blood sample was taken at 9:00 a.m., 10 a.m., 12 noon, 3 p.m., 5 p.m., 11 p.m., and at 9 a.m. and 3 p.m. on the next day. Plasma was separated immediately, and the lithium level was measured by atomic absorption spectrophotometry. The pharmacokinetic parameters were as follows: K12 (microconstant) = 0.3455 +/- 0.5345 (mean +/- SD) h-1; K21 (microconstant) = 0.1691 +/- 0.1242 h-1; K10 (microconstant) = 0.1320 +/- 0.1112 h-1; Vl (volume of distribution of central compartment) = 16.9057 +/- 5.9384 1; Vss (volume of distribution at steady state) = 38.8917 +/- 11.4540 1; V-beta (volume of distribution of elimination phase) = 46.3809 +/- 13.8742 1; alpha (distribution rate constant) = 0.5932 +/- 0.7090; and beta (excretion rate constant) = 0.0361 +/- 0.0141. The mean elimination half-life, AUC (the area under the curve) and clearance were 22.5 +/- 9.9 h (range from 9.6 to 50.4 h), 16.33 +/- 5.52 mmoll-1h (8.69 to 31.81 mmoll-1 h), and 1.65 +/- 0.53 1h-1 (0.76 to 2.28 1h-1) or 28.59 +/- 9.58 ml/kg-1 h-1, respectively. There were no statistically significant differences in beta, AUC and clearance between Taiwanese/Chinese and Danish results. The possibility of lowering the traditional prophylactic therapeutic range of lithium to around 0.5-0.8 mmol/L is supported by the results of this study.

Alcoholism among Taiwan aborigines defined by the Chinese Diagnostic Interview Schedule: a comparison with alcoholism among Chinese.

The prevalence of alcoholism was reported to be 0.1% in an aboriginal study on Taiwan using the census survey method in the 1950s. This study adopted a modified Chinese Diagnostic Interview Schedule to determine the prevalence of DSM-III-defined alcohol abuse (AA) and alcohol dependence (AD) in the Atayal, Paiwan and Yami ethnic groups of Taiwan aborigines. Stratified random sampling was used. The sample sizes of Atayal, Paiwan and Yami were 793, 656 and 106 respectively. The prevalence rates of DSM-III-defined AA and AD were 11.6%, 11.4% and 14.2%; and 9.0%, 8.1% and 6.4% respectively. No significant difference was found between the 3 ethnic groups. These prevalence figures are significantly higher than those for Chinese. In this comparative analysis, 2 distinct etiological hypotheses are proposed for the AA and the AD.

Risk factors of alcoholism in Taiwan Chinese: an epidemiological approach.

This study investigated the risk factors of alcohol abuse and alcohol dependence, as defined by DSM-III criteria, in 11,004 Chinese subjects in the Taiwan community. Risk factors were analyzed using chi-square and multivariate logistic regression statistics. The logistic regression shows that the risk factors of alcohol dependence include male, having had childhood or adulthood behavior problems; of alcohol abuse include male, having had childhood or adulthood behavior problems, non-metropolitan community, age cohort, job-holder. The etiological models proposed are biological for Chinese alcohol dependence and interactional for Chinese alcohol abuse.