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OBJECTIVE Studies examining coprescription and dosages of mood stabilizers (MSs) with antipsychotics for psychotic disorders are infrequent. Based on sparse extant data and clinical experience, we hypothesized that adjunctive MS use would be associated with certain demographic (e.g., younger age), clinical factors (e.g., longer illness duration), and characteristics of antipsychotic treatment (e.g., multiple or high antipsychotic doses). METHODS Within an Asian research consortium focusing on pharmaco-epidemiological factors in schizophrenia, we evaluated rates of MS coprescription, including high doses (>1000 mg/day lithium-equivalents) and clinical correlates. RESULTS Among 3557 subjects diagnosed with schizophrenia in 14 Asian countries, MSs were coprescribed with antipsychotics in 13.6% (n = 485) of the sample, with 10.9% (n = 53) on a high dose. Adjunctive MS treatment was associated (all p < 0.005) with demographic (female sex and younger age), setting (country and hospitalization), illness (longer duration, more hospitalizations, non-remission of illness, behavioral disorganization, aggression, affective symptoms, and social-occupational dysfunction), and treatment-related factors (higher antipsychotic dose, multiple antipsychotics, higher body mass index, and greater sedation). Patients given high doses of MSs had a less favorable illness course, more behavioral disorganization, poorer functioning, and higher antipsychotic doses. CONCLUSIONS Schizophrenia patients receiving adjunctive MS treatment in Asian psychiatric centers are more severely ill and less responsive to simpler treatment regimens.

Introduction Patterns of clinical use of long-acting injectable (LAI) antipsychotic drugs in many countries, especially in Asia, for treatment of patients diagnosed with chronic psychotic disorders including schizophrenia are not well established. Methods Within an extensive research consortium, we evaluated prescription rates for first- (FGA) and second-generation antipsychotic (SGA) LAI drugs and their clinical correlates among 3557 subjects diagnosed with schizophrenia across 15 Asian countries and region. Results Overall, an average of 17.9% (638/3557; range: 0.0%-44.9%) of treated subjects were prescribed LAI antipsychotics. Those given LAI vs orally administered agents were significantly older, had multiple hospitalizations, received multiple antipsychotics more often, at 32.4% higher doses, were more likely to manifest disorganized behavior or aggression, had somewhat superior psychosocial functioning and less negative symptoms, but were more likely to be hospitalized, with higher BMI, and more tremor. Being prescribed an FGA vs SGA LAI agent was associated with male sex, aggression, disorganization, hospitalization, multiple antipsychotics, higher doses, with similar risks of adverse neurological or metabolic effects. Rates of use of LAI antipsychotic drugs to treat patients diagnosed with schizophrenia varied by more than 40-fold among Asian countries and given to an average of 17.9% of treated schizophrenia patients. We identified the differences in the clinical profiles and treatment characteristics of patients who were receiving FGA-LAI and SGA-LAI medications. Discussion These findings behoove clinicians to be mindful when evaluating patients' need to be on LAI antipsychotics amidst multifaceted considerations, especially downstream adverse events such as metabolic and extrapyramidal side effects.

Anxious distress in major depressive disorder (MDD) is common and associated with poor outcomes and management difficulties.This post hoc analysis aimed to examine the socio-demographic and clinical correlates of anxiety distress in Asian outpatients with MDD.Instead of two out of five specifiers defined by the Diagnostic and Statistical Manual Version-5, anxious distress defined in this study was operationalized as the presence of at least two out of four proxy items drawn from the 90-item Symptom Checklist, Revised (SCL-90-R). Other measures included the Montgomery-Asberg Depression Rating Scale (MADRS), the Fatigue Severity Scale, the Sheehan Disability Scale and the Multidimensional Scale of Perceived Social Support.The data of 496 patients with MDD were included. Anxious distress was found in 371 participants (74.8%). The binary logistic regression analysis found that anxious distress was independently and significantly correlated with working status, higher MADRS scores, severe insomnia and functional impairment.Three-fourths of Asian patients with MDD in tertiary care settings may have DSM-5 anxious distress of at least moderate distress. Its prevalence may vary among working groups. The specifier was associated with greater depressive symptom severity, severe insomnia and functional impairment.

As most reports concerning treatment with combinations of mood stabilizer (MS) with antidepressant (AD) drugs are based in the West, we surveyed characteristics of such cotreatment in 42 sites caring for the mentally ill in 10 Asian countries.This cross-sectional, pharmacoepidemiologic study used 2004 and 2013 data from the REAP-AD (Research Study on Asian Psychotropic Prescription Patterns for Antidepressants) to evaluate the rates and doses of MSs given with ADs and associated factors in 4164 psychiatric patients, using standard bivariate methods followed by multivariable logistic regression modeling.Use of MS + AD increased by 104% (5.5% to 11.2%) between 2004 and 2013 and was much more associated with diagnosis of bipolar disorder than major depression or anxiety disorder, as well as with hospitalizationoutpatient care, psychiatricgeneral-medical programs, and young age (all P0.001), but not with country, sex, or AD dose.The findings provide a broad picture of contemporary use of MSs with ADs in Asia, support predictions that such treatment increased in recent years, and was associated with diagnosis of bipolar disorder, treatment in inpatient and psychiatric settings, and younger age.

Aim We aimed to estimate the network structures of depressive symptoms using network analysis and evaluated the geographic regional differences in theses network structures among Asian patients with depressive disorders. Methods Using data from the Research on Asian Psychotropic Prescription Patterns for Antidepressants (REAP-AD), the network of the ICD-10 diagnostic criteria for depressive episode was estimated from 1174 Asian patients with depressive disorders. The node strength centrality of all ICD-10 diagnostic criteria for a depressive episode was estimated using a community-detection algorithm. In addition, networks of depressive symptoms were estimated separately among East Asian patients and South or Southeast Asian patients. Moreover, networks were estimated separately among Asian patients from high-income countries and those from middle-income countries. Results Persistent sadness, fatigue, and loss of interest were the most centrally situated within the network of depressive symptoms in Asian patients with depressive disorders overall. A community-detection algorithm estimated that when excluding psychomotor disturbance as an outlier, the other nine symptoms formed the largest clinically meaningful cluster. Geographic and economic variations in networks of depressive symptoms were evaluated. Conclusion Our findings demonstrated that the typical symptoms of the ICD-10 diagnostic criteria for depressive episode are the most centrally situated within the network of depressive symptoms. Furthermore, our findings suggested that cultural influences related to geographic and economic distributions of participants could influence the estimated depressive symptom network in Asian patients with depressive disorders.

ObjectiveUsing data from the Research on Asian Psychotropic Prescription Patterns for Antidepressants (REAP-AD) study, we aimed to present the rates and clinical correlates of suicidal thoughts/acts in patients recruited from a total of 40 centres in 10 Asian countries/areas: China, Hong Kong, India, Indonesia, Japan, Korea, Malaysia, Singapore, Taiwan, and Thailand.MethodsData from 1122 patients with depressive disorders in the REAP-AD study were used. The ICD-10 was employed to diagnose depressive episodes and recurrent depressive disorder. The presence or absence of suicidal thoughts/acts and profile of other depressive symptoms was established using the National Institute for Health and Clinical Excellence guidelines for depression. Country/area differences in rates of suicidal thoughts/acts were evaluated with the χ2 test. In addition, depressive symptom profiles, other clinical characteristics, and patterns of psychotropic drug prescription in depressed patients with and without suicidal thoughts/acts were compared using analysis of covariance for continuous variables and logistic regression analysis for discrete variables to adjust the effects of covariates.ResultsThe rates of suicidal thoughts/acts in 10 countries/areas varied from 12.8% in Japan to 36.3% in China. Patients with suicidal thoughts/acts presented more persistent sadness (adjusted odds ratio [aOR]=2.64, pppppppppConclusionSuicidal thoughts/acts can indicate greater severity of depression, and are associated with a poorer response to antidepressants and increased burden of illness. Hence, suicidal thoughts/acts can provide a clinical index reflecting the clinical status of depressive disorders in Asians.

Purpose To examine subjective depressive symptoms associated with physical pain symptoms (PPSs) in Asian patients with major depressive disorder (MDD). Design and methods Four PPSs, including headache, chest pain, low back pain, and muscle pain, and subjective depressive symptoms were assessed using the Symptom Checklist-90-Revised. Findings Out of 528 participants, 390 (73.9%) had at least one PPS. After adjusting for sex, depression severity, disability, fatigue, physical health status, and mental health status, PPSs were found to be associated with crying easily, blaming oneself, feeling lonely, feeling blue, and worrying too much. Practical implications Almost three-quarters of Asian patients with MDD experience PPSs. PPSs are associated with some subjective feelings of depression.

Depressive disorders are common in old age. Antipsychotics (APs) are often used as an adjunctive treatment with antidepressants (ADs) in this population but its patterns of use in Asia are not known. This study explored the rate of combination of APs and ADs in older adult psychiatric patients in Asia.This is a secondary analysis of the database of a multicentre study which recorded participants' basic demographical and clinical data in standardised format in 10 Asian countries and territories. The data were analysed using univariate and multivariate logistic regression analyses.A total of 955 older adult psychiatric in- and outpatients were included in this study. The proportion of concurrent AP and AD use was 32.0%, ranging from 23.3% in Korea to 44.0% in Taiwan. Multivariate logistic regression analysis found that younger age, inpatient status and diagnosis of schizophrenia, anxiety and other mental disorders were significantly related to a higher proportion of concurrent use of APs and ADs.Around a third of older adult psychiatric patients had concurrent AP and AD use in the Asian countries/regions surveyed. Considering the uncertain effectiveness and questionable safety of the AP and AD combination in this patient population, such should be cautiously used.

Background: Depression is often comorbid with chronic somatic diseases. Few previous studies have investigated the prevalence of somatic diseases in depression or the prescription pattern of antidepressants in comorbidly depressed patients in Asia. This study aimed to investigate the prevalence of somatic comorbidity (SC) in depression and compared the prescriptions of antidepressants in depressed patients with and without SC. Methods: A total of 2320 patients treated with antidepressants in 8 Asian countries were examined, and a diagnosis was based on the International Classification of Disease, 10 th revision. We listed 17 common chronic somatic diseases. Patients' socio-demographic and clinical characteristics and psychotropic drug prescriptions were recorded using a standardized protocol and data collection procedure. Results: Of the patients examined, 1240 were diagnosed with depression and 30% of them ( n = 375) had SC. The most common comorbid condition was diabetes (23.7%). The patients with SC were more likely to seek help at a general hospital (74.7% vs. 47.2%), and had a higher incidence of symptoms involving sadness, disturbed sleep, and poor appetite. Noradrenergic and specific serotonergic antidepressant was prescribed more for patients with SC than for those without SC (30.4% vs. 22.9%). Conclusions: SC is common in depressed Asian patients. It is important to strengthen the recognition of depression, especially in general hospitals and when patients report some somatic discomfort. It is also a matter of urgency to establish evidence-based guidelines for the use of new antidepressants in depressed patients with SC.

Background Subjective cognitive impairment (SCI) in major depressive disorder (MDD) is prevalent and correlated with disability. This study aimed to examine the prevalence rates and correlates of subjective memory deficit (SMD) and subjective concentration deficit (SCD) in medication-free, non-elderly Asians with MDD. Methods The SMD and SCD were assessed by using two items of the Symptom Checklist-90-Revised (SCL-90-R). Other measurements of interest included the Montgomery–Asberg Depression Rating Scale (MADRS), the Fatigue Severity Scale (FSS), the Sheehan Disability Scale (SDS), and the Short Form Health Survey (SF-36). Adjusted odds ratios with 95% confidence intervals were calculated. Results Of 515 participants from China, Korea, Malaysia, Singapore, Taiwan, and Thailand, 347 (67.4%) and 377 (73.2%) had SMD and SCD, respectively. In total, 420 participants (81.6%) had SMD alone, SCD alone, and both deficits. Severe depression and poor mental health were significant correlates of SMD. Severe depression, clinically significant disability, poor physical health, and poor mental health were significantly independent correlates of SCD. Compared with young adults (18–34 years), older adults aged 50–65 years had a significantly lower risk of SCD (OR=.33, 95% CI: .19–.57). Limitations Only two SCL-90-R items were used to assess the SMD and SCD. The exclusion of MDD patients treated with psychotropic medications eliminated many patients commonly seen in typical clinic settings. Conclusion SMD and SCD are prevalent in medication-free, non-elderly Asians with MDD. Both deficits are correlated with depression and mental health status. The independent correlation between SCD and disability underscores the crucial role of SCI in MDD.

Background:Little is known about the combined use of benzodiazepines and antidepressants in older psychiatric patients. This study examined the prescription pattern of concurrent benzodiazepines in older adults treated with antidepressants in Asia, and explored its demographic and clinical correlates.Methods:The data of 955 older adults with any type of psychiatric disorders were extracted from the database of the Research on Asian Psychotropic Prescription Patterns for Antidepressants (REAP-AD) project. Demographic and clinical characteristics were recorded using a standardized protocol and data collection procedure. Both univariate and multiple logistic regression analyses were performed.Results:The proportion of benzodiazepine and antidepressant combination in this cohort was 44.3%. Multiple logistic regression analysis revealed that higher doses of antidepressants, younger age (Conclusions:Nearly, half of the older adults treated with antidepressants in Asia are prescribed concurrent benzodiazepines. Given the potentially adverse effects of benzodiazepines, the rationale of benzodiazepines and antidepressants co-prescription needs to be revisited.

The present study explored the patterns of physical comorbidities and their associated demographic and clinical factors in older psychiatric patients prescribed with antidepressants in Asia.Demographic and clinical information of 955 older adults were extracted from the database of the Research on Asian Psychotropic Prescription Patterns for Antidepressants (REAP-AD) project. Standardized data collection procedure was used to record demographic and clinical data.Proportion of physical comorbidities in this cohort was 44%. Multiple logistic regression analyses showed that older age (OR = 1.7, P 0.001), higher number of depressive symptoms (OR = 1.09, P = 0.016), being treated in psychiatric hospital (OR = 0.5, P = 0.002), living in high income countries/territories (OR = 2.4, P = 0.002), use of benzodiazepines (OR = 1.4, P = 0.013) and diagnosis of 'other psychiatric disorders' (except mood, anxiety disorders and schizophrenia) (OR = 2.7, P 0.001) were significantly associated with physical comorbidities.Physical comorbidities in older patients prescribed with antidepressants were common in Asia. Integrating physical care into the treatment of older psychiatric patients should be urgently considered.

The Research on Asian Psychotropic Prescription Patterns for Antidepressants (REAP-AD) study aimed to survey and review antidepressant prescribing patterns in different clinical settings in Asian countries/areas. The REAP-AD study collected comprehensive data for psychiatric patients prescribed antidepressants in 10 Asian countries/areas during the period from March to June 2013. Depressive disorders have been an important issue closely associated with ill-health and disability in the realm of mental health. Impaired concentration was found to be a consistent symptom in depressive disorders regardless of clinical course, and a predictor of poor treatment outcome. In this work we aimed to identify clinical characteristics independently associated with impaired concentration in patients with depressive disorders, using data from the REAP-AD study. A total of 336 depressive disorder patients with impaired concentration and 786 depressive disorder patients without impaired concentration were recruited from 40 centers in 10 Asian countries/areas. A binary logistic regression model was fitted to identify the independent correlates of impaired concentration in patients with depressive disorders. After adjusting the effects of covariates, the binary logistic model showed that impaired concentration was independently associated with higher rates of loss of interest (P < 0.0001), fatigue (P < 0.0001), low self-confidence (P < 0.0001) and appetite disturbance (P < 0.0001) and with a lower rate of adjunctive antipsychotic prescription (P = 0.007). Our findings suggest that impaired concentration and its associated depressive symptom profiles constitute a unitary depressive symptom cluster that is also an intervening variable for poor social function.

This study compared the demographics, clinical characteristics, and antidepressant prescription patterns between Asian patients aged 50 years and older attending psychiatric hospitals and those attending general hospitals.In total, 955 patients (604 in general hospitals, 351 in psychiatric hospitals) aged 50 years or older treated with antidepressants in 10 Asian countries and territories were examined. Patients' demographics, clinical features, and prescriptions of psychotropic drugs were recorded using a standardized protocol and data collection procedure.Binary logistic regression revealed that high income and diagnosis of schizophrenia were independently associated with psychiatric hospital treatment, whereas outpatient care, diagnosis of anxiety disorders, and multiple major medical conditions were independently associated with general hospital treatment. In addition, tetracyclic and noradrenergic and specific serotonergic antidepressants were more likely to be prescribed in general hospitals.Older adults treated with antidepressants showed different demographic and clinical features between general hospitals and psychiatric hospitals in Asia.

Objective The aim of this study was to survey the use of antipsychotic polypharmacy (APP) in older Asian patients with schizophrenia and examine its demographic and clinical correlates. Methods Information on hospitalized patients with schizophrenia aged 55 or older was extracted from the database of the Research on Asian Psychotropic Prescription Patterns study. Data on 1439 patients in 6 Asian countries and territories including China, Hong Kong, Japan, Korea, Singapore, and Taiwan were analyzed. Sociodemographic and clinical characteristics and antipsychotic prescriptions were recorded using a standardized protocol and data collection procedure. Results The frequency of APP prescription was 51.6% in the pooled sample with wide intercountry variations. Multiple logistic regression analysis of the whole sample showed that patients on APP had higher antipsychotic doses and also were more likely to receive first-generation antipsychotics. Conclusions Use of APP was common in older Asian patients with schizophrenia. Given the limited evidence supporting its efficacy, the potentially severe side effects and high costs, APP should be used with caution in this population. The reasons for and outcomes of the use of APP in this patient population merit further exploration.

Objective: This study examined the prescribing patterns of several first- (FGAs) and second-generation antipsychotic (SGAs) medications administered to older Asian patients with schizophrenia during the period between 2001 and 2009. Method: Information on hospitalized patients with schizophrenia aged 65 or older was extracted from the database of the Research on Asian Psychotropic Prescription Patterns (REAP) study (2001–2009). There were no older patients in Thailand, therefore data on 467 patients in eight Asian countries and territories including China, Hong Kong SAR, India, Japan, Korea, Malaysia, Singapore, and Taiwan were analysed. Cross-sectional socio-demographic data, clinical characteristics and antipsychotic prescriptions were assessed using a standardized protocol and data collection procedure. Results: Of the 467 patients, 192 patients (41.1%) received FGAs only, 166 (35.5%) received SGAs only and 109 (23.3%) received a combination of FGAs and SGAs. Of the FGAs, haloperidol was the most commonly used (31.3%; mean 9.4 ± 6.7 mg/day), followed by chlorpromazine (15.4%; mean 126.4 ± 156.4 mg/day) and sulpiride (6.6%; mean 375.0 ± 287.0 mg/day). Of the SGAs, risperidone was the most commonly used (31.5%; mean 4.5 ± 2.7 mg/day), followed by olanzapine (13.1%; mean 13.6 ± 6.5 mg/day), quetiapine (7.3%; mean 325.0 ± 237.3 mg/day) and aripiprazole (1.9%; mean 17.6 ± 7.7 mg/day). Conclusions: FGAs and higher doses of certain SGAs (risperidone, olanzapine and quetiapine) were still commonly dispensed to older Asian patients with schizophrenia. Considering older patients’ reduced tolerability of potentially severe side effects associated with FGAs and higher doses of certain SGAs, continuing education and training addressing the rational use of antipsychotics in this population is clearly needed.

Objective The aim of the study was to survey the frequency of tardive dyskinesia (TD) in patients with schizophrenia and its demographic and clinical correlates in selected Asian countries. Method A total of 6,761 hospitalized schizophrenia patients in nine Asian countries and territories were examined from 2001 to 2009. TD was evaluated as "present" or "absent" according to the clinical judgment of experienced psychiatrists. The patients' socio-demographic and clinical characteristics and the prescriptions of psychotropic drugs were recorded using a standardized protocol and data collection procedure. Results The frequency of TD in the whole sample was 5.0% with wide variations between countries (0 - 14.9%). Multiple logistic regression analysis showed that the following variables were independently associated with TD: study time, study site, older age, male gender, more severe negative and extrapyramidal symptoms and less anticholinergic drugs. Conclusions A generally low frequency of TD in Asian schizophrenia patients with inter-ethnic variations was recorded. It is unclear whether the low prevalence of TD compared with Western data is real or the result of it being insufficiently recognized.

Recent studies indicate relatively high international rates of adjunctive psychotropic medication, includ- ing mood stabilizers, for patients with schizophrenia. Since such treatments are little studied in Asia, we examined the frequency of mood-stabilizer use and its clinical correlates among hospitalized Asian patients diagnosed with schizophrenia in 2001-2008. We evaluated usage rates of mood stabilizers with antipsychotic drugs, and associated factors, for in-patients diagnosed with DSM-IV schizophrenia in 2001, 2004 and 2008 in nine Asian regions : China, Hong Kong, India, Korea, Japan, Malaysia, Taiwan, Thailand, and Singapore. Overall, mood stabilizers were given to 20.4 % (n=1377/6761) of hospitalized schizo- phrenia patients, with increased usage over time. Mood-stabilizer use was significantly and indepen- dently associated in multivariate logistic modeling with : aggressive behaviour, disorganized speech, year sampled (2008 vs. earlier), multiple hospitalizations, less negative symptoms, younger age, with regional variation (Japan, Hong Kong, Singapore>Taiwan or China). Co-prescription of adjunctive mood stabil- izers with antipsychotics for hospitalized Asian schizophrenia patients increased over the past decade, and was associated with specific clinical characteristics. This practice parallels findings in other countries and illustrates ongoing tension between evidence-based practice vs. individualized, empirical treatment of psychotic disorders.

Objective The aim of this study was to survey the use of anticholinergic medication (ACM) in Asia between 2001 and 2009 and examine its demographic and clinical correlates. Method A total of 6 761 hospitalized schizophrenia patients in 9 Asian countries and territories were examined between 2001 and 2009. The patients' socio-demographic and clinical characteristics and the prescriptions of psychotropic drugs were recorded using a standardized protocol and data collection procedure. Results The frequency of ACM prescription decreased from 66.3% in 2001, to 52.8% in 2004 and 54.6% in 2009, with wide inter-country variations at each time period. Multiple logistic regression analysis of the whole sample showed that patients taking ACM presented with more severe positive, negative, and extrapyramidal symptoms. They were also more likely to receive first-generation and depot antipsychotics and antipsychotic polypharmacy, and less likely to receive second-generation ones. Conclusions The wide variation in ACM prescription across Asia suggests that a combination of clinical, social, economic and cultural factors play a role in determining the use of these drugs. Regular reviews of ACM use are desirable to reveal the discrepancy between treatment guidelines and clinical practice.

Benzodiazepines are commonly prescribed to patients with schizophrenia in many countries, but as little is known about such treatment in Asia, we evaluated their adjunctive use for 6761 in-patients diagnosed with schizophrenia in nine Asian countries using a cross-sectional study design in 2001, 2004 and 2008. Multivariate logistic regression and multivariate linear regression analyses were performed to assess predictors of benzodiazepine use and dose, respectively. Overall, 54% of the patients received adjunctive benzodiazepines at an average daily dose equivalent to 30.3 mg diazepam, with minor changes over the years sampled. Benzodiazepine use was highest in Taiwan and Japan, lowest in Thailand and China, and was associated with fewer years ill, presence of delusions (OR 1.24), hallucinations (OR 1.22), disorganized speech (OR 1.17), social or occupational dysfunction (OR 1.16), and use of mood stabilizers (OR 3.15), antiparkinsonian (OR 1.79) or antidepressant drugs (OR 1.33), and lower doses of antipsychotics (all p=0.016 to

We evaluate sexuality in 100 natural menopausal women as pertains to hormones, symptoms related to intercourse, and marital relationship with sexual desire, orgasm and coital frequency. The mean age was 56.8 years while menopausal age was 50.3 years. The postmenopausal syndrome presented 55.0% occurring 1 to 7 years after menopause (mean 3.4 years). The common sexual problems after menopause were loss of libido, orgasmic dysfunction, and dyspareunia. Both sexual desire and activity decreased when compared with premenopausal period. Ninety percent of the subjects had sexual desire less than once a month. Only 14% of the subjects occasionally reached orgasm while the other 86% never had orgasm after menopause. The levels of FSH, LH, estradiol and testosterone were also reported. There was no correlation of hormone estradiol and testosterone, symptoms related to intercourse and marital relationship with sexual desire, orgasm, or coital frequency.

Aim \ud People with diabetes are at an increased risk of developing depression and other psychological disorders. However little is known about the prevalence, correlates, or care pathways in countries other than the UK and the US. A new study, the International Prevalence and Treatment of Diabetes and Depression (INTERPRET-DD) Study aims to address this dearth of knowledge and identify optimal pathways to care across the globe. \ud \ud Method\ud INTERPRET-DD is a two-year longitudinal study, taking place in 16 countries’ diabetes out-patients facilities, investigating the recognition and management of depressive disorders in people with type 2 diabetes. Clinical interviews are used to diagnose depression, with clinical and other data obtained from medical records and through patient interviews. Pathways to care and the impact of treatment for previously unrecognised depression on clinical outcomes and emotional well-being are being investigated. \ud \ud Results\ud Initial evidence indicates a range of pathways to care exist, with few of these based on available recommendations for treatment. Pilot data indicates that the instruments we are using to measure both symptoms and clinical diagnosis of depression are acceptable in our study population and easy to use.\ud \ud Conclusions \ud Our study will increase the understanding of the impact of co-morbid diabetes and depression and identify the most appropriate (country specific) pathways via which patients receive their care. It addresses an important public health problem and lead to recommendations for best practice relevant to the different participating centres with regard to the identification and treatment of people with co-morbid diabetes and depression.

Background Little has been known regarding the correlates of severe insomnia in major depressive disorder (MDD). This post-hoc analysis aimed to examine the sociodemographic and clinical correlates of severe insomnia in psychotropic drug-free, Asian adult outpatients with MDD. Methods Participants were psychotropic drug-free patients with MDD, aged 18–65 years. By using the Symptom Checklist-90 Items, Revised (SCL-90-R), a score of 4 (severe distress) on any one of three insomnia items was defined as severe insomnia. Other measures included the Montgomery–Asberg Depression Rating Scale (MADRS), the Fatigue Severity Scale (FSS), the nine psychopathology subscales of SCL-90-R, the Physical and Mental Component Summaries of Short Form Health Survey (SF-36 PCS and SF-36 MCS), and the Sheehan Disability Scale (SDS). Results Of 528 participants, their mean age being 39.5 (SD=13.26) years, 64.2% were females, and 239 (45.3%) had severe insomnia. The logistic regression model revealed that low educational qualifications (less than secondary school completion), high SCL-90- R Depression scores, high SCL-90-R Anxiety scores, and low SF-36 PCS scores were independently correlated with severe insomnia ( p 's Limitations Insomnia was determined only by the patient's distress. Middle insomnia was not assessed. Psychotropic drug-free patients with MDD are not commonly seen in psychiatric practice. Conclusion Severe insomnia is common in patients with MDD. It is closely related with low educational qualification, subjective depression and anxiety severity, and poor physical health. These findings may implicate the treatment of comorbid MDD and severe insomnia, for example, sleep hygiene education, pharmacological treatment.

Little is known about electroconvulsive therapy (ECT) use in Asian inpatients with schizophrenia. This study examined trends of ECT use for schizophrenia patients in Asia between 2001 and 2009 and its independent demographic and clinical correlates.Data on 6761 hospitalized schizophrenia patients (2001 = 2399, 2004 = 2136, and 2009 = 2226) in nine Asian countries and territories were collected by either chart review or interviews during a 1-month period. Patients' sociodemographic and clinical characteristics, prescriptions of psychotropic drugs and ECT use were recorded using a standardized protocol and data-collection procedure.The frequency of ECT was 3.3% in the whole sample; rising from 1.8% in 2001 to 3.3% in 2004 and 4.9% in 2009 (P 0.0001). However, this increased trend was driven solely by increased ECT use in China (P 0.0001), and the inclusion of India in the 2009 survey. There were wide inter-country variations: 2001, 0% (Hong Kong, Korea) to 5.9% (China); 2004, 0% (Singapore) to 11.1% (China); 2009, 0% (Hong Kong) to 13.8% (India) and 15.2% (China). Multiple logistic regression analysis of the whole sample revealed that patients receiving ECT were less likely in the 35-64-year age group, had shorter length of current hospitalization and fewer negative symptoms, and were more likely to receive second-generation antipsychotic medications compared to those who were not treated with ECT (R(2) = 0.264, P 0.001).ECT use for schizophrenia has increased over the past decade in China, being low/relatively stable in other Asian countries/regions. Reasons for substantial variations in ECT frequency in Asia require further study.

To examine correlates of disability in Asian patients with major depressive disorder (MDD).Participants were outpatients with DSM-IV MDD. Global disability and three disability domains (i.e., work/school, social life/leisure, and family/home life) were key outcomes. Several socio-demographic and clinical characteristics were determined for their associations with disability.The sample was 493 MDD patients. Apart from the number of hospitalizations, the global disability was significantly associated with depression severity, fatigue, physical health, and mental health. Several clinical but only few socio-demographic characteristics associated with the other three disability domains were similar.Disability among Asian patients with MDD correlates with the severity of psychiatric symptoms and the hospitalizations due to depression. Socio-demographic characteristics have little impact on the overall disability.

Little is known about the pattern of QT interval (QTc) prolongation in Asian patients with schizophrenia. This study examined trends of QTc prolongation in schizophrenia inpatients in six Asian countries and territories between 2004 and 2008/2009 and its independent demographic and clinical correlates.Data on 3482 hospitalized schizophrenia patients (2004 = 1826 and 2008/2009 = 1656) in six Asian countries and territories were collected by either chart review or interviews during a 1-month period. Patients' sociodemographic and clinical characteristics, prescriptions of psychotropic drugs, and QTc interval were recorded using a standardized protocol and data collection procedure.The frequency of QTc prolongation (456 ms) was 2.4% in the whole sample, decreasing from 3.1% in 2004 to 1.6% in 2008/2009 (p = 0.004) with wide intercountry variations. However, this decreased trend was driven by decreased QTc prolongation detected in China and Hong Kong (both p-values0.05). Multiple logistic regression analysis of the whole sample revealed that patients having more likely to have an illness lasting longer than 5 years and received antipsychotics classified as list-1 drugs according to the Arizona Centre for Education and Research on Therapeutics. Compared with 2004, patients in 2008/2009 were less likely to have QTc prolongation. Thioridazine caused QTc prolongation most frequently (odds ratio (OR) 4.4; 95% confidence interval (CI) 1.2-15.2), followed by sulpiride (OR 2.4; 95% CI 1.3-4.5), clozapine (OR 2.4; 95% CI 1.4-4.2), and chlorpromazine (OR 1.9; 95% CI 1.07-3.5).Frequency of QTc prolongation was low in Asian patients with schizophrenia. QTc prolongation in schizophrenia decreased in China and Hong Kong between 2004 and 2008/2009 but increased in Taiwan over the same period, remaining low in the other countries.

The aim of this study was to compare the symptomatic and clinical features of depression among five groups of patients with major depressive disorder (MDD) living in China, Korea, Malaysia/Singapore, Taiwan, and Thailand.Consecutive consenting adults (aged 18-65) who met DSM-IV criteria for non-psychotic MDD – based on the Mini International Neuropsychiatric Interview – and who were free of psychotropic medication were evaluated in a cross-sectional study. Depressive symptoms were evaluated using the 10-item Montgomery–Asberg Depression Rating Scale (MADRS) and the 13-item depression subscale of the Symptoms Checklist 90-Revised (SCL-90-R). In addition, the 10-item SCL-90-R Anxiety Subscale was completed. ancova were conducted, adjusting for confounders: age, completion of secondary education, marital status, work status, religion, index episode duration, and depressive severity. For the magnitude of differences, a threshold of 0.10 was taken as the minimum effect size representing clinical significance, and an effect size of 0.25 was considered moderate.Four MADRS symptoms differentiated these five groups, the most prominent being ‘lassitude’ and ‘inner tension’. Nine SCL-90-R depression items also differentiated the groups, as did eight SCL-90-R Anxiety Subscale items. The MADRS lassitude item had the largest effect size (0.131). The rest of those statistically significant differences did not exceed 0.10.MDD is more similar than different among outpatients in these diverse Asian countries. The between-country differences, while present and not due to chance, are small enough to enable the use of common clinician and self-report rating scales in studies involving Asians with MDD from various ethnic backgrounds.

BackgroundTo date there has been no large-scale international study that examined the use of clozapine in older patients with schizophrenia. This study examined the use of clozapine and its demographic and clinical correlates in older patients with schizophrenia in East Asia during the period between 2001 and 2009.MethodInformation on 1,157 hospitalized patients with schizophrenia aged 50 or older in five East Asian countries and territories (China, Hong Kong, Korea, Singapore and Taiwan) was extracted from the database of the Research on Asian Psychotropic Prescription Patterns (REAP) project. Socio-demographic and clinical characteristics and prescription of psychotropic medications were recorded.ResultsClozapine was prescribed for 20.6% of the pooled sample; 19.0% in 2001, 19.4% in 2004 and 22.9% in 2009. Multiple logistic regression analysis of the whole sample revealed that patients taking clozapine had a longer duration of illness, more negative symptoms and were less likely to receive first generation antipsychotic and anticholinergic drugs, but more likely to report weight gain compared to those not receiving clozapine. Compared to those in other sites, older patients in China were more likely to receive clozapine.ConclusionsThe prescription of clozapine for older Asian schizophrenia inpatients has remained at a stable level during the past decade. The appropriateness of use of clozapine in China needs to be further explored.

The objective of this study was to investigate the clinical features of depression in Asian patients.It was a cross-sectional, observational study of depression in China, Korea, Malaysia, Singapore, Taiwan, and Thailand. Participants were drug-free outpatients with depressed mood and/or anhedonia. Symptoms and clinical features were assessed using the Montgomery-Asberg Depression Rating Scale, Symptoms Checklist 90-Revised (SCL-90-R), and the Fatigue Severity Scale. Other measures included the Medical Outcome Survey 36-Item Short-Form Health Survey (SF-36), the Sheehan Disability Scale, and the Multidimensional Scale of Perceived Social Support (MSPSS).A total of 547 outpatients with major depressive disorder were included in the analyses. Among the Montgomery-Asberg Depression Rating Scale symptoms, "reported sadness" and "reduced sleep" had the highest severity, with means (SDs) of 3.4 (1.2) and 3.4 (1.6), respectively. Apart from the SCL-90-R depression and anxiety domains, the SCL-90-R obsession-compulsion syndrome had the highest domain score, with a mean (SD) of 1.9 (0.9). Among eight domains, the mean (SD) SF-36 pain subscale score of 58.4 (27.7) was only second to that for the SF-36 physical function. In comparison to other disability domains, the Sheehan Disability Scale work/school had the highest subscale score, with a mean (SD) of 6.5 (2.9). The mean (SD) MSPSS "family" subscale score of 4.7 (1.7) was higher than the MSPSS "friends" and "significant others" subscale scores.This study suggests that pain has a minimal impact on the quality of life in Asian patients with depression. Noteworthy issues in this population may include insomnia, obsessive-compulsive symptoms, working/school disability, and family support.

OBJECTIVE: This study surveyed the prescribing patterns of antipsychotic medications in Asian older schizophrenia patients with extrapyramidal side effects (EPS) during the period between 2001 and 2009. METHOD: Information on 848 hospitalized patients with schizophrenia aged 60 or older was extracted from the database of the Research on Asian Psychotropic Prescription Patterns (REAP) study (2001 - 2009). Data from those patients with reported EPS from 8 Asian countries and territories including China, Hong Kong, Japan, Korea, Singapore, Taiwan, India and Malaysia were analyzed. The cross-sectional data of sociodemographic and clinical characteristics and antipsychotic prescriptions were collected using a standardized protocol and data collection procedure. RESULTS: Of the 309/848 (36%) patients suffering from EPS, 210 patients (210/309; 68.0%) received at least one type of first generation antipsychotic (FGA), and 99 (99/309; 32.0%) received second generation antipsychotics (SGAs) only. Of SGAs prescribed in patients with EPS, risperidone was the most commonly used (100/309; 32.4%) followed by olanzapine (33/309; 10.7%) and quetiapine (25/309; 8.1%). CONCLUSIONS: FGAs were frequently used in Asian older schizophrenia patients with EPS. Considering the potential adverse effects of FGAs on existing EPS, the reasons for the frequent use of FGAs need to be urgently identified.

Objective: This study surveyed the use of adjunc- tive mood stabilizers (MS) and benzodiazepines (BZD) in older Asian schizophrenia patients and examined their demographic and clinical corre- lates. Method: Information on hospitalized schizo- phrenia patients aged 55 years or more were extracted from the database of the Research on Asian Psychotropic Prescription Patterns (REAP) study. A total of 1 452 patients from 9 Asian countries and territories was included in the study. The patients' sociodemographic and clini- cal characteristics and the prescriptions of anti- psychotics, MS and BZD were recorded using a standardized protocol and data collection proce- dure. Results: The frequency of MS prescription was 26.7 % in the pooled sample, with 25.5 % in 2001, 26.9 % in 2004 and 27.7 % in 2009. The corre- sponding fi gures for BZD were 20.7 %, 20.2 %, 18.4 % and 23.1 %, respectively. Multiple logistic regression analysis of the whole sample revealed that patients on MS were younger and more likely to be men and to have extrapyramidal side eff ects (EPS) and a longer duration of illness. Compared to patients in China, those in Japan were more likely to receive MS, while Korean pat- ents were prescribed less MS. In contrast, there were no signifi cant sociodemographic or clinical correlates of BZD use. Compared to patients in China, their Korean and Singaporean counter- parts were more likely to be on BZD. Conclusions: The use of MS and BZD is not uncommon in older Asian patients with schizo- phrenia. Given the paucity of empirical data on the effi cacy of these agents in individuals with schizophrenia of any age and concerns about added side eff ects in older patients in particular, the rationale for the prescription of these agents in this population warrants further examination.

This study surveyed the use of anticholinergic medications (ACMs) in older Asian patients with schizophrenia and examined its demographic and clinical correlates.A total of 1452 hospitalized patients with schizophrenia aged 55 years or older in nine Asian countries and territories were surveyed between 2001 and 2009. The cross-sectional data of patients' socio-demographic and clinical characteristics and the prescriptions of antipsychotic drugs and ACM were recorded using a standardized protocol and data collection procedure.The frequency of ACM prescription was 64.6% in the pooled sample, with 72.4%, 61.9%, and 59.5% in 2001, 2004, and 2009, respectively. Multiple logistic regression analysis of the whole sample revealed that patients on ACM had a higher dose of antipsychotic medications, and were more likely to have extrapyramidal side effects and receive first-generation antipsychotic medications.Anticholinergic medications were frequently used in older Asian patients with schizophrenia. Considering the potential side effects of ACM, the rationale for their widespread use in this patient population should be revisited.

Objective This study aimed to identify trends in the use of antipsychotic polypharmacy (APP) and their demographic and clinical correlates in the treatment of schizophrenia in Asia between 2001 and 2009. Method A total of 6,761 schizophrenia inpatients in 9 Asian countries and territories were examined; 2,399 in 2001, 2,136 in 2004, and 2,226 in 2009. Patients’ socio-demographic and clinical characteristics and prescriptions of psychotropic drugs were recorded using a standardized protocol and data collection procedure. Results The proportion of APP prescription decreased from 46.8 % in 2001, to 38.3 % in 2004, and increased to 43.4 % in 2009, with wide intercountry variations at each survey. Multiple logistic regression analysis of the whole sample revealed that patients on APP were younger, had a higher dose of antipsychotics in chlorpromazine equivalents, and more severe positive and negative symptoms. They were also more likely to receive depot and fi rst-generation antipsychotic drugs. Conclusions The frequency of APP prescription varied between countries and territories, suggesting that a host of clinical and socio-cultural factors played a role in determining APP use in Asia. To resolve the discrepancy between treatment recommendation and clinical practice, regular reviews of prescription patterns are needed.

Objective: Optimizing treatment and outcomes for people with schizophrenia requires understanding of how evidence-based treatments are utilized. Clozapine is the most effective antipsychotic drug for treatment-refractory schizophrenia, but few studies have investigated trends and patterns of its use over time internationally. This study examined the prescription patterns of clozapine and its demographic and clinical correlates in Asia from 2001 to 2009. Method: Clozapine prescriptions were collected in a sample of 6761 hospitalized schizophrenia patients in nine Asian countries and regions using a standardized protocol and data collection procedure. Results: Overall, the proportion of patients receiving clozapine prescriptions was stable across the three surveys from 2001 to 2009, ranging from 14.5% to 15.9%. However, the rates and patterns observed within different regions and countries at each survey differed considerably. Clozapine use decreased significantly over time in China, while it increased in Korea and Singapore. Multiple logistic regression analysis revealed that patients taking clozapine were significantly younger, had a higher dose of antipsychotic drugs in chlorpromazine equivalents, were more likely to be female, had fewer extrapyramidal symptoms, and had more negative symptoms, admissions and weight gain in the past month than those not receiving clozapine. Conclusion: The variability in overall rates and changes in prescription rates over time in these samples suggest that factors other than psychopharmacological principles play an important role in determining the use of clozapine in schizophrenia in Asia.

Objective: The aim of this study was to investigate the sex differences in prescribing patterns of psychotropic drugs and drug-induced side effects in schizophrenia patients in Asia using the data of the Research on Asian Psychotropic Prescription Pattern (REAP) surveys. Method: The prescription patterns of 6,441 schizophrenia inpatients in six Asian countries and regions were investigated during the 2001–2009 period. The patients' socio-demographic and clinical characteristics and their prescriptions for psychotropic drugs were recorded using a standardized protocol and data collection procedure. Results: Univariate analyses found the following factors to be significantly associated with the male sex: a younger age, higher doses of antipsychotics, less prominent delusions and hallucinations, more prominent negative symptoms, less likelihood of a prescription for second-generation antipsychotics (SGAs), greater use of antipsychotic polypharmacy, mood stabilizers and depot antipsychotics, more frequent tardive dyskinesia (TD), and less weight gain. In multivariate analyses, fewer prescriptions for SGAs, greater use of mood stabilizers, anticholinergics, antipsychotic polypharmacy and depot antipsychotics, extrapyramidal side effects (EPS) and TD, and less weight gain were independently associated with the male sex. Conclusions: Sex is one of the independent contributors to psychotropic prescription and side effects in Asian schizophrenia patients. Psychopharmacological treatment guidelines for schizophrenia should consider the sexes separately.

The purpose of the study was to evaluate the frequency of reported sexual dysfunction (SD) in schizophrenia and its associations with sociodemographic and clinical variables in selected Asian countries.A total of 5877 schizophrenia patients in nine Asian countries and territories were examined between 2001 and 2009. The patients' sociodemographic and clinical characteristics, prescription of psychotropic drugs, and drug-induced side effects were recorded using a standardized protocol and data collection. SD was evaluated as "present" or "absent" according to the clinical judgment of experienced psychiatrists.The frequency of reported SD in the whole sample in women and men was 3.0%, 0.8%, and 4.6%, respectively, with variations across study sites. In the multivariate analyses, male sex, more second-generation antipsychotics, benzodiazepines, and antidepressants were independently associated with higher likelihood of reported SD, whereas negative symptoms had an inverse association with reported SD.The results of this study indicate that SD was seldom recorded as a side effect by Asian psychiatrists while treating patients with schizophrenia. It is unclear whether the low prevalence of reported SD compared with Western data is real or whether the results are being insufficiently recognized.

Measurement in psychiatric services is important for the development of a psychiatric tool for budget allocation.To translate the Health of the Nation Outcome Scales (HoNOS) into Thai and to assess its psychometric properties.The HoNOS was translated into Thai, by using the standard of "forward-backward" translation procedure. Two psychiatric nurses interviewed subjects together but independently rated their scores. The subjects were 23 acute inpatients and 23 sub-acute inpatients. The reliability and validity was assessed.The Cronbach's alpha coefficient of the Thai HoNOS was 0.68. It had a high correlation (r0.80) with the Brief Psychiatric Rating Scale (BPRS), the Global Assessment of Functioning (GAF) and the Clinical Global Impression (CGI). It suggested high concurrent validity. It had a satisfactory power (p0.05) in discriminating overall clinical outcomes between acute and sub-acute psychiatric inpatients.The Thai HoNOS fulfils the requirements of a psychiatric outcome scale for routine use in inpatient service.

This study aimed to determine the impact of a particular clinical practice guideline (CPG) following its passive dissemination on Thai psychiatrists’ prescribing attitudes towards treatment-resistant schizophrenia (TRS). Two surveys were conducted before and after the dissemination of the CPG. Ninety-four questionnaires from the first survey and 84 from the second were analysed. Over 70% of the respondents were male. The mean age and duration of practice were 42.3 and 15.3 years, respectively. The respondents’ characteristics were not significantly different in sex, age, years of practice, specialty, or clinical setting. In the first survey, the first three favoured interventions for TRS were switching to risperidone alone, switching to another conventional antipsychotic (CA), and adding carbamazepine to the on-going CA. In the second round, the first three interventions were switching to risperidone alone, switching to another CA, and switching to clozapine alone. Although there was a trend in the direction suggested by the CPG, there was no significant difference between the two surveys. The interventions chosen as first, second-, and third-line treatments were also not significantly different. Of 80 respondents who expressed their opinions on the CPG, 55, 15, and 10 stated that they knew, did not know, and were uncertain about the availability of a guideline, respectively. Of 55 respondents who knew about the availability of the guideline, 40 had read it. The mean (SDs) of the guideline acceptance and the impact of the guideline on the practice obtained from those 40 respondents were 70.9 (13.7) and 58.9 (19.6), respectively.

Background East Asian countries have high suicide rates. However, little is known about clinical and sociodemographic factors associated with suicidality in Asian populations. The aim of this study was to evaluate the factors associated with suicidality in patients with major depressive disorder (MDD) from six Asian countries. Methods The study cohort consisted of 547 outpatients with MDD. Patients presented to study sites in China (n = 114), South Korea (n = 101), Malaysia (n = 90), Singapore (n = 40), Thailand (n = 103), and Taiwan (n = 99). All patients completed the Mini-International Neuropsychiatric Interview (MINI), the Montgomery–Asberg Depression Rating Scale (MADRS), the Global Severity Index(SCL-90R), the Fatigue Severity Scale, the 36-item short-form health survey, the Sheehan Disability Scale, and the Multidimensional Scale of Perceived Social Support (MSPSS). Patients were classified as showing high suicidality if they scored ≥6 on the MINI suicidality module. Multivariate logistic regression analysis was used to examine sociodemographic and clinical factors related to high suicidality. Results One hundred and twenty-five patients were classed as high suicidality. Unemployed status (adjusted odds ratio [OR] 2.43, p