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Bringing out the leader in you--Malaysian Psychiatric Association Leadership Certification for Early Career Psychiatrists

Umi Adzlin S, Rafidah B, Rahima D, Chan LF, Vincent W, Ahmad Qabil AK, et al.

Asian J Psychiatr, 2012 Dec;5(4):370.
PMID: 23174453 DOI: 10.1016/j.ajp.2012.07.009
Fulltext Exploring Malaysian parents' and teachers' cultural conceptualization of adolescent social and emotional competencies: A qualitative formative study

Abd Hadi NH, Midin M, Tong SF, Chan LF, Mohd Salleh Sahimi H, Ahmad Badayai AR, et al.

Front Public Health, 2023;11:992863.
PMID: 37033063 DOI: 10.3389/fpubh.2023.992863

INTRODUCTION: Global implementation of social and emotional learning (SEL) has been suggested to incorporate a systematic cultural adaptation process which relies on ground-up empirical data of a target cultural group in tailoring a culturally sensitive SEL intervention. Preliminary formative studies among local parents and educators were done to explore the conceptualization of social and emotional competencies (SECs) in various cultural settings, such as the continent of Africa and among the indigenous and refugee groups. Unfortunately, little scholarship has been devoted to studying the SEL adaptation process in Southeast Asian regions. This formative study aimed to explore Malaysian parents' and teachers' cultural conceptualization of adolescent SECs.
METHODS: This qualitative study interviewed 12 Malaysian parents and 10 Malaysian teachers comprising of Malay (82%), Chinese (9%) and Indian (9%) races in an online focus group discussion. Sampling is purposive to parents of adolescents and teachers at secondary school only. Data were analyzed thematically to determine the culturally sensitive SEL constructs for Malaysian adolescents.
RESULTS: All themes and sub-themes of SEC regarded as crucial for Malaysian adolescents are aligned with CASEL's five domains of competencies. Our findings extended the conceptualization of subskills under CASEL's relationship skills and responsible decision-making domains, which reflect Asian cultural values. The main themes of social competency: (a) preserving interpersonal relationships, (b) utilizing intrapersonal skills, and (c) communicating effectively, are shared with the established CASEL constructs. However, the underlying subthemes denote the unique cultural manifestation of social competency in Malaysia. Two of the emotional competency themes represent the established CASEL constructs: (a) practicing self-regulation, (b) demonstrating help-seeking behavior, and the other two themes signify Asian values: (c) upholding altruism, and (d) maintaining cultural display rules.
DISCUSSIONS: This formative study revealed the habitual use of experiential and expressive suppressions as adaptive emotion regulation strategies in Malaysian collectivist culture and offered a potential alternative emotion regulation pathway suitable for Malaysian adolescents. It also informed the feasibility of implementing SEL modules developed based on the CASEL framework in Malaysia and suggested two key lessons to enhance the cultural sensitivity of SEL in Malaysia: effective, respectful communication and expressive writing.
Prevalence of cognitive impairment using the Montreal Cognitive Assessment questionnaire among patients with systemic lupus erythematosus: a cross-sectional study at two tertiary centres in Malaysia

Kanapathy A, Nik Jaafar NR, Shaharir SS, Chan LF, Rozita M, Ch'ng SS

Lupus, 2019 Jun;28(7):854-861.
PMID: 31159651 DOI: 10.1177/0961203319852153

INTRODUCTION: Cognitive impairment is a common neuropsychiatric manifestation of systemic lupus erythematosus (SLE). However, it is not routinely assessed for despite its high prevalence and significant disease burden.
AIMS: This study aimed to determine the prevalence of mild cognitive impairment (MCI) using the Montreal Cognitive Assessment (MoCA) and its associated factors among patients diagnosed with SLE in Malaysia.
METHODS: A total of 200 SLE patients were recruited prospectively from the outpatient clinics of two tertiary hospitals in Malaysia. Standardized clinical interview was utilized to obtain information on socio-demographic characteristics. All patients were then assessed using the MoCA questionnaire for presence of cognitive impairment; the Patient Health Questionnaire 9 (PHQ-9) for presence of depressive symptoms; and the Wong-Baker Faces Pain Scale (WBFPS) for severity of pain. The evaluation of disease activity and severity were performed by the treating rheumatologists and nephrologists using the Systemic Lupus Erythematosus Disease Activity Index (SLEDAI) and Systemic Lupus International Collaborating Clinics Damage Index (SLICC DI).
RESULTS: The prevalence of MCI was 35%. The significant associated factors from the bivariate analysis were male gender (p = 0.04), educational level (p = 0.00), WBFPS score (p = 0.035) and anticardiolipin IgM (p = 0.01). Further analysis using logistic regression model found that male gender (OR = 7.43, 95% confidence interval 1.06-52.06, p = 0.04), lower educational level (OR = 4.4, 95% confidence interval 1.47-13.21, p = 0.01) and presence of anticardiolipin IgM (OR = 6.81, 95% confidence interval 1.45-32.01, p = 0.031) were associated with impaired MoCA scores. Also, increasing pain scores increased the risk of patients being affected by cognitive impairment.
CONCLUSION: Over one-third of patients with SLE in our cohort were found to have MCI. Risk factors included male gender, lower educational level, higher pain score and presence of anticardiolipin IgM. Physicians are encouraged to perform routine screening to detect cognitive dysfunction in patients with SLE in their clinical practice as part of a more comprehensive management.
Malaysian Stakeholder Perspectives on Suicide-Related Reporting: Findings From Focus Group Discussions

Ng YP, Pheh KS, Panirselvam RR, Chan WL, Lim JBY, Lim JTY, et al.

Front Psychol, 2021;12:673287.
PMID: 34079502 DOI: 10.3389/fpsyg.2021.673287

Media guidelines on safe suicide-related reporting are within the suicide prevention armamentarium. However, implementation issues beleaguer real-world practice. This study evaluated the perspectives of the Malaysian media community, persons with lived experience of suicidal behavior (PLE), and mental health professionals (MHP) on suicide-related reporting in terms of the impact, strategies, challenges, and the implementation of guidelines on safe reporting. Three focus group discussions of purposively sampled Malaysian media practitioners (n = 8), PLE (n = 6), and MHP (n = 7) were audio-recorded, transcribed, coded and thematically analyzed. Inclusion criteria were: English fluency, no clinical depression or suicidal ideation (current), no recent previous suicide attempts or suicide bereavement. Three major themes emerged: (1) Unsafe Reporting; (2) Impact; and (3) Safe Reporting. Most described current reporting as unsafe by being potentially triggering to media users and may contribute to contagion effect. Positive impacts identified included raised awareness toward suicide and its prevention. Unsafe reporting was attributed to inadequate awareness, knowledge, and guidance, lack of empathy and accountability, job-related factors, popularity-seeking, lack of monitoring and governance, and information source(s) with unsafe content. Majority agreed on how suicide stories should be framed to produce a safe report. The media community diverged on how detailed a suicide story should be. Safe reporting challenges included difficulties in balancing beneficial versus harmful details, social media ubiquity and its citizen reporters. Participants suggested these safe reporting strategies: stakeholder engagement, educational approaches, improving governance and surveillance, and guidelines revision. Most acknowledged the relevance of guidelines but were unaware of the existence of local guidelines. Implementation challenges included the dilemma in balancing media industry needs vis-à-vis safe reporting requirements, stakeholder engagement difficulties and social media regulation. There is poor awareness regarding safe suicide-related reporting across all groups. PLE and MHP were negatively impacted by current unsafe messaging which aggravated trauma and grief reactions. Postvention support gaps for mental health professionals were highlighted. Safe reporting promotion strategies should include stakeholder engagement to increase awareness on minimizing Werther and maximizing Papageno effects. Strategic re-examination and dissemination of local media guidelines to address new media issues, and effective surveillance mechanisms, are crucial in sustainable improvement of safe reporting practices.
Suicidal behaviour prediction models using machine learning techniques: A systematic review

Nordin N, Zainol Z, Mohd Noor MH, Chan LF

Artif Intell Med, 2022 10;132:102395.
PMID: 36207078 DOI: 10.1016/j.artmed.2022.102395

BACKGROUND: Early detection and prediction of suicidal behaviour are key factors in suicide control. In conjunction with recent advances in the field of artificial intelligence, there is increasing research into how machine learning can assist in the detection, prediction and treatment of suicidal behaviour. Therefore, this study aims to provide a comprehensive review of the literature exploring machine learning techniques in the study of suicidal behaviour prediction.
METHODS: A search of four databases was conducted: Web of Science, PubMed, Dimensions, and Scopus for research papers dated between January 2016 and September 2021. The search keywords are 'data mining', 'machine learning' in combination with 'suicidal behaviour', 'suicide', 'suicide attempt', 'suicidal ideation', 'suicide plan' and 'self-harm'. The studies that used machine learning techniques were synthesized according to the countries of the articles, sample description, sample size, classification tasks, number of features used to develop the models, types of machine learning techniques, and evaluation of performance metrics.
RESULTS: Thirty-five empirical articles met the criteria to be included in the current review. We provide a general overview of machine learning techniques, examine the feature categories, describe methodological challenges, and suggest areas for improvement and research directions. Ensemble prediction models have been shown to be more accurate and useful than single prediction models.
CONCLUSIONS: Machine learning has great potential for improving estimates of future suicidal behaviour and monitoring changes in risk over time. Further research can address important challenges and potential opportunities that may contribute to significant advances in suicide prediction.
Fulltext Effectiveness of a Malaysian Media Intervention Workshop: Safe Reporting on Suicide

Lim JTY, Cheng Q, Ng YP, Pheh KS, Panirselvam RR, Tay KW, et al.

Front Psychol, 2021;12:666027.
PMID: 34975604 DOI: 10.3389/fpsyg.2021.666027

Background: Suicide remains an important cause of premature deaths and draws much media attention. However, unsafe reporting and portrayal of suicides by the media have been associated with increased risk of suicidal behavior. Current evidence suggests that media capacity-building could potentially prevent suicide. However, there are still knowledge gaps in terms of a lack of data on effective strategies for improving awareness and safe reporting of suicide-related media content. This study aims to investigate the effectiveness of a workshop conducted with members of the media community on the safe reporting of suicide-related content. Methods: An interventional single-arm pre and post pilot study was conducted on a sample of the Malaysian media community recruited through purposive and snowball sampling. The media safe reporting workshop was conducted by a suicide prevention expert with a media industry background. Thirty participants completed a self-reported evaluation questionnaire on their awareness and knowledge of reporting on suicide-related media content; before and after the interventional workshop. Results: There was a significant difference between the total scores before and after the intervention, with a large effect size. Post-intervention scores were significantly improved in 8 items, namely those related to the reporting of: (i) the content of any suicide note; (ii) headlines with methods of suicide; (iii) headlines with the location of suicide; (iv) cases of suspected suicide despite the unconfirmed cause of death; (v) suicide news to cater to readers' interests; (vi) cause of suicide; (vii) details of the location of suicide; and (viii) the negative impact to media community when reporting suicide stories. In particular, there was an improvement in the majority of items for people from the media community with no lived experience of suicidal behavior. Conclusion: The media safe reporting workshop is a potentially effective intervention for improving awareness and knowledge measures relating to safe reporting on suicide among the media community, with a more pronounced effect in those without lived experience of suicidal behavior. Limitations in the sample size, generalizability, short-term evaluation, and lack of a control group warrant future larger, longer-term controlled, and more representative studies.
Fulltext Looking Into Recent Suicide Rates and Trends in Malaysia: A Comparative Analysis

Lew B, Kõlves K, Lester D, Chen WS, Ibrahim NB, Khamal NRB, et al.

Front Psychiatry, 2021;12:770252.
PMID: 35069279 DOI: 10.3389/fpsyt.2021.770252

Background: Suicide is a preventable cause of death. Examining suicide rates and trends are important in shaping national suicide prevention strategies. Therefore, the objectives of this study were to analyze age-standardized suicide trends of Malaysia between 2000 and 2019 using the WHO Global Health Estimates data, and to compare the 2019 rate with countries from the Association of South-East Asian Nations (ASEAN), Muslim majority countries, and the Group of Seven (G7). Methods: The age-standardized suicide rates data were extracted from the WHO Global Health Estimates. We calculated the average age-standardized suicide rates of the last 3 years from 2017 to 2019. Joinpoint regression analysis was conducted to calculate the average annual percentage change (APC) of the age-standardized suicide rates in Malaysia from 2000 to 2019. Results: Between 2000 and 2019, the minimum and maximum suicide rates for both sexes in Malaysia were 4.9 and 6.1 per 100,000 population respectively, whilst the past 3-year (2017-2019) average rates were 5.6, 8.8, and 2.4 for both sexes, males, and females, respectively. The suicide rates decreased significantly for both sexes between 2000 and 2013. Between 2014 and 2019, the suicide rates increased significantly for males. In 2019, Malaysia recorded the rate of 5.8 per 100,000 population, with an estimated 1,841 suicide deaths, i.e., ~5 deaths per day. The Malaysian suicide rate was the second highest amongst selected Muslim majority countries, in the middle range amongst ASEAN countries, and lower than all G7 countries except Italy. Conclusions: There is a need to further explore factors contributing to the higher suicide rates among Malaysian males. In light of the rising suicide rates in Malaysia, national mental health and suicide prevention initiatives are discussed and the importance of high-quality suicide surveillance data is emphasized.
Olanzapine-induced and Risperidone-induced Leukopenia: A Case of Synergistic Adverse Reaction?

Woon LS, Tee CK, Gan LLY, Deang KT, Chan LF

J Psychiatr Pract, 2018 Mar;24(2):121-124.
PMID: 29509183 DOI: 10.1097/PRA.0000000000000292

Leukopenia is a known hematological side effect of atypical antipsychotics. We report a case of an antipsychotic-naive patient with schizophrenia who developed leukopenia after a single dose of olanzapine, which worsened during subsequent treatment with risperidone. Normalization of the white blood cell counts occurred within 24 hours of risperidone discontinuation. Possible synergistic mechanisms underlying olanzapine-induced and risperidone-induced leukopenia are discussed. This case highlights the challenges in identifying and managing nonclozapine antipsychotic-induced leukopenia in a susceptible patient.
An explainable predictive model for suicide attempt risk using an ensemble learning and Shapley Additive Explanations (SHAP) approach

Nordin N, Zainol Z, Mohd Noor MH, Chan LF

Asian J Psychiatr, 2023 Jan;79:103316.
PMID: 36395702 DOI: 10.1016/j.ajp.2022.103316

Machine learning approaches have been used to develop suicide attempt predictive models recently and have been shown to have a good performance. However, those proposed models have difficulty interpreting and understanding why an individual has suicidal attempts. To overcome this issue, the identification of features such as risk factors in predicting suicide attempts is important for clinicians to make decisions. Therefore, the aim of this study is to propose an explainable predictive model to predict and analyse the importance of features for suicide attempts. This model can also provide explanations to improve the clinical understanding of suicide attempts. Two complex ensemble learning models, namely Random Forest and Gradient Boosting with an explanatory model (SHapley Additive exPlanations (SHAP)) have been constructed. The models are used for predictive interpretation and understanding of the importance of the features. The experiment shows that both models with SHAP are able to interpret and understand the nature of an individual's predictions with suicide attempts. However, compared with Random Forest, the results show that Gradient Boosting with SHAP achieves higher accuracy and the analyses found that history of suicide attempts, suicidal ideation, and ethnicity as the main predictors for suicide attempts.
Fulltext Effectiveness of online advanced C.A.R.E suicide prevention gatekeeper training program among healthcare lecturers and workers in national university of Malaysia: A pilot study

Roslan AF, Pheh KS, Mahadevan R, Bujang SM, Subramaniam P, Yahya HF, et al.

Front Psychiatry, 2023;14:1009754.
PMID: 36741120 DOI: 10.3389/fpsyt.2023.1009754

BACKGROUND: Suicide is a major cause of death among adolescents and young adults, especially students. This is particularly true for healthcare students with a higher risk and more access to lethal means. Thus, it is vital for healthcare educators who have regular contact with these healthcare students to be trained as gatekeepers in preventing suicide. Evidence of the effectiveness of such gatekeeper training, mainly using an online module, is lacking predominantly in Malaysia. This study aims to investigate the effectiveness of an online gatekeeper suicide prevention training program that is conducted for healthcare lecturers.
METHODS: A single-arm interventional pre-and post-pilot study was conducted on a sample of healthcare lecturers and workers who are involved in supervising healthcare students. A purposive sampling technique was used to recruit 50 healthcare educators in Malaysia. The program was conducted by trained facilitators and 31 participants completed a locally validated self-rated questionnaire to measure their self-efficacy and declarative knowledge in preventing suicide; immediately before and after the intervention.
RESULTS: Significant improvement was seen in the overall outcome following the intervention, mostly in the self-efficacy domain. No significant improvement was seen in the domain of declarative knowledge possibly due to ceiling effects; an already high baseline knowledge about suicide among healthcare workers. This is an exception in a single item that assesses a common misperception in assessing suicide risk where significant improvement was seen following the program.
CONCLUSION: The online Advanced C.A.R.E. Suicide Prevention Gatekeeper Training Program is promising in the short-term overall improvement in suicide prevention, primarily in self-efficacy.
Fulltext The Role of Oxidative Stress in Suicidal Behaviour Among Bipolar Patients: A Cross-Sectional Study in a Malaysian Sample

Loo JL, Mohamad Kamal NA, Goon JA, Ahmad Damanhuri H, Tan JAC, Abdul Murad NA, et al.

Front Psychiatry, 2021;12:698911.
PMID: 34916966 DOI: 10.3389/fpsyt.2021.698911

Background: Oxidative stress markers are found to be linked with depression and suicide attempts in bipolar disorder (BD), although the role of DNA damage as a marker of suicidal ideation and attempt has yet to be determined. We aim to investigate the association between DNA damage and suicidal behaviour, i.e., suicidal ideation and suicide attempt, among suicidal ideators in BD patients while accounting for clinical and psychosocial risk factors. Methods: A cross-sectional study was conducted in the Universiti Kebangsaan Malaysia Medical Centre on 62 consecutive BD patients diagnosed using the M.I.N.I. Neuropsychiatric Interview and 26 healthy control participants. Socio-demographic and clinical assessments were performed using the Columbia Suicide Severity Rating Scale (C-SSRS) for lifetime suicidal ideation and attempt, Quick Inventory of Depressive Symptomatology (QIDS) for depression severity, Clinical Global Impression for Bipolar Disorder (CGI-BD) for illness severity [both mania (CGI-Mania) and major depressive episode (CGI-MDE)], Social Readjustment Rating Scale (SRRS) for change in life events, and Barratt Impulsiveness Scale (BIS) for behavioural impulsivity. The degree of DNA damage in peripheral blood samples was determined using a standard protocol of comet assay. Results: Multivariable logistic regression revealed higher scores of CGI-MDE as the sole significant factor for lifetime suicidal ideation (OR = 1.937, 95% CI = 1.799-2.076). Although initial bivariate analysis showed a significant association between DNA damage, malondialdehyde (MDA), catalase (CAT), and suicidal behaviour, the findings were not seen in multivariable logistic regression. Bivariate subgroup analysis showed that moderate and severe DNA damage (p = 0.032 and p = 0.047, respectively) was significantly associated with lifetime suicide attempts among lifetime suicidal ideators. The study is the first to look at the connexion between DNA damage and suicidal risk in bipolar patients. It is limited by the small sample size and lack of information on illicit substance use. Conclusions: More severe DNA damage was significantly associated with lifetime suicide attempts among lifetime suicidal ideators in BD. However, the severity of depression was found to be independently associated with lifetime suicidal ideation per se rather than DNA damage in BD. Larger prospective studies are required to ascertain the potential of DNA damage as a biomarker for the transition from suicidal ideation to a suicide attempt.
The role of tyrosine hydroxylase gene variants in suicide attempt in schizophrenia

Hu J, Chan LF, Souza RP, Tampakeras M, Kennedy JL, Zai C, et al.

Neurosci Lett, 2014 Jan 24;559:39-43.
PMID: 24275212 DOI: 10.1016/j.neulet.2013.11.025

Evidence has shown that attempted suicide in psychiatric disorders is a complex interplay of genes and environment. Noradrenergic dysfunction due to abnormalities in the tyrosine hydroxylase (TH) gene has been implicated in the pathogenesis of suicidal behavior in mood disorders. However, suicide is a leading cause of mortality in schizophrenia too. Recent evidence suggests that TH gene variants may also increase the risk of suicide attempts in schizophrenia patients, although the interaction with established clinical risk factors is unclear. This study aimed to identify TH gene variants conferring risk for suicide attempt in schizophrenia while accounting for the interaction between this gene and clinical risk factors. We performed analysis on four TH SNPs (rs11564717, rs11042950, rs2070762, rs689) and the common TCAT repeat (UniSTS:240639) for 234 schizophrenia patients (51 suicide attempters and 183 non-attempters). Clinical risk factors and ethnic stratification were included as covariates. Single marker analysis identified the SNP rs11564717 (p=0.042) and the TCAT(6) (p=0.004) as risk variants for suicide attempt. We also identified the haplotype A-A-A-G as a risk factor for suicide attempt (p=0.0025). In conclusion, our findings suggest that TH polymorphisms may contribute to the risk of attempted suicide in schizophrenia even after accounting for established clinical risk factors and ethnic stratification. Further larger scale studies are needed to confirm these findings and to understand the mechanisms underlying the role of TH gene variants in suicide attempt in schizophrenia.
Surveillance of pesticide poisoning in an East and a West Malaysian hospital: characteristics of pesticide poisoning and the early impact of a national Paraquat ban

Chan LF, Chin SJ, Loo TH, Panirselvam RR, Chang SS, Chang HY, et al.

BMC Psychiatry, 2023 Jun 28;23(1):472.
PMID: 37380953 DOI: 10.1186/s12888-023-04974-8

BACKGROUND: Previous studies have shown that pesticide bans were associated with reduced fatal pesticide self-poisoning cases in high, and low-and-middle-income countries. We aimed to investigate the characteristics of pesticide poisoning patients admitted to two Malaysian hospitals and the early impact of the national paraquat ban implemented on 1st January 2020 in a culturally heterogenous South-East-Asian upper-middle-income setting.
METHODS: Data were collected from an East (Bintulu) and a West (Ipoh) Malaysian hospital medical records in 2015-2021 and 2018-2021, respectively. Logistic regression analyses were conducted to investigate the association of aspects such as socio-demographic and clinical characteristics, paraquat ban with the types of pesticides involved (paraquat versus non-paraquat versus unknown) ,and the outcomes (fatal versus non-fatal).
RESULTS: From the study sample of 212 pesticide poisoning patients aged 15 years or above, the majority were self-poisoning cases (75.5%) with a disproportionate over-representation of Indian ethnic minority (44.8%). Most pesticide poisoning cases had socio-environmental stressors (62.30%). The commonest stressors were domestic interpersonal conflicts (61.36%). 42.15% of pesticide poisoning survivors had a psychiatric diagnosis. Paraquat poisoning accounted for 31.6% of all patients and 66.7% of fatalities. Case fatality was positively associated with male gender, current suicidal intent, and paraquat poisoning. After the paraquat ban, the proportion of pesticide poisoning cases using paraquat decreased from 35.8 to 24.0%, and the overall case-fatality dropped slightly from 21.2 to 17.3%.
CONCLUSIONS: Socio-environmental stressors in specific domestic interpersonal conflicts, seemed more prominent in pesticide poisoning compared to psychiatric diagnosis. Paraquat accounted for the majority of pesticide-associated deaths occurring in hospitals in the study areas. There was preliminary evidence that the 2020 paraquat ban led to a fall in case fatality from pesticide poisoning.
Validation of the Malay version of the Life Events Checklist for DSM-5 among Malaysian undergraduates

Tan YK, Siau CS, Chan LF, Kõlves K, Zhang J, Ho MC, et al.

Asian J Psychiatr, 2023 Nov;89:103772.
PMID: 37748229 DOI: 10.1016/j.ajp.2023.103772

This cross-sectional study aimed to validate the Life Events Checklist for DSM-5 (LEC-5) among Malaysian undergraduates (N = 500; mean age = 21.66 ± 1.57), of which 90.4% had ever experienced a lifetime traumatic event. Cronbach's alpha of .87 (95% CI [.86, .89]) and McDonald's omega of .89 (95% CI [.89, .93]) indicated good reliability. Confirmatory factor analysis based on a six-factor structure showed the best fit. The measurement invariance showed that the six-factor structure was similar across sexes. Therefore, the Malay LEC-5 is a valid and reliable instrument to screen for traumatic events among Malaysian undergraduates.
Is Ketamine the Future Clozapine for Depression? A Case Series and Literature Review on Maintenance Ketamine in Treatment-resistant Depression With Suicidal Behavior

Chan LF, Eu CL, Soh SY, Maniam T, Shahidii Kadir Z, Chong BTW, et al.

J Psychiatr Pract, 2018 07;24(4):279-291.
PMID: 30427812 DOI: 10.1097/PRA.0000000000000316

Ketamine has shown effectiveness as a rapid-acting antidepressant with antisuicidal effects in terms of reduction of suicidal ideation in the short term. However, the evidence for long-term maintenance ketamine therapy for treatment-resistant depression (TRD) and suicidal behavior is limited. This case series (N=13) highlights the role of adjunctive serial maintenance ketamine infusions in restoring functionality in treatment-resistant unipolar and bipolar (mixed) depression with significant suicide risk and multiple comorbidities, including alcohol dependence. Two cases of TRD achieved functional remission with long-term maintenance ketamine treatment. The first case illustrates the potential synergistic interaction between ketamine and lamotrigine to achieve a sustained antidepressant response in the patient for 7 months. The second case may possibly be the longest reported case of maintenance ketamine therapy, with treatment continuing for 5 years to date. Ketamine treatment showed acute effectiveness in another 7 cases, especially in terms of reduction of suicidal ideation, albeit without significant long-term antidepressant effect. Factors that may contribute to lack of effectiveness of serial ketamine include inadequate mood stabilization in TRD in bipolar spectrum diagnoses, concomitant benzodiazepine use, complex comorbidities, and adverse effects such as significant hypertension and severe dissociation. Future systematic controlled studies are warranted to establish the efficacy and safety profile of long-term ketamine as maintenance therapy for TRD with suicidal behavior.
Are predictors of future suicide attempts and the transition from suicidal ideation to suicide attempts shared or distinct: a 12-month prospective study among patients with depressive disorders

Chan LF, Shamsul AS, Maniam T

Psychiatry Res, 2014 Dec 30;220(3):867-73.
PMID: 25240940 DOI: 10.1016/j.psychres.2014.08.055

Our study aimed to examine the interplay between clinical and social predictors of future suicide attempt and the transition from suicidal ideation to suicide attempt in depressive disorders. Sixty-six Malaysian inpatients with a depressive disorder were assessed at index admission and within 1 year for suicide attempt, suicidal ideation, depression severity, life event changes, treatment history and relevant clinical and socio-demographic factors. One-fifth of suicidal ideators transitioned to a future suicide attempt. All future attempters (12/66) had prior ideation and 83% of attempters had a prior attempt. The highest risk for transitioning from ideation to attempt was 5 months post-discharge. Single predictor models showed that previous psychiatric hospitalization and ideation severity were shared predictors of future attempt and ideation to attempt transition. Substance use disorders (especially alcohol) predicted future attempt and approached significance for the transition process. Low socio-economic status predicted the transition process while major personal injury/illness predicted future suicide attempt. Past suicide attempt, subjective depression severity and medication compliance predicted only future suicide attempt. The absence of prior suicide attempt did not eliminate the risk of future attempt. Given the limited sample, future larger studies on mechanisms underlying the interactions of such predictors are needed.
The mental health impact of bed bug infestations: a scoping review

Ashcroft R, Seko Y, Chan LF, Dere J, Kim J, McKenzie K

Int J Public Health, 2015 Nov;60(7):827-37.
PMID: 26298442 DOI: 10.1007/s00038-015-0713-8

OBJECTIVES: We conducted a scoping review to identify and summarize the current state of knowledge regarding the mental health effects associated with bed bugs.
METHODS: We employed a five-stage scoping review framework, to systematically identify and review eligible articles. Eligibility criteria included a focus on bed bug infestations and reference to mental health impacts. Descriptive information was then extracted from each article, including the specific mental health effects cited.
RESULTS: An initial search yielded 920 unique articles on the topic of bed bugs. Of these, 261 underwent abstract review, and 167 underwent full-text review. Full-text review and subsequent review of reference lists yielded a final sample of 51 articles. Numerous mental health effects were linked to bed bug infestations, including severe psychiatric symptoms. However, the majority (n = 31) of the articles were commentary papers; only five original research articles were identified.
CONCLUSIONS: Although significant mental health effects are often linked to bed bugs, such discussions remain largely anecdotal. Despite recognition that the impact of bed bugs constitutes an important public health concern, little empirical evidence currently exists on this topic.
Caregiver depression: The contributing role of depression in patients, stigma, social support and religiosity

Chai YC, Mahadevan R, Ng CG, Chan LF, Md Dai F

Int J Soc Psychiatry, 2018 09;64(6):578-588.
PMID: 30074421 DOI: 10.1177/0020764018792585

BACKGROUND: Depression has been well studied as part of caregiver burden among patients with severe mental illnesses. Curiously, though, there has been little data in terms of caregiver burden with specific focus on depression among caregivers of patients with major depressive disorder (MDD).
AIM: This study aims to determine the rate of depression among caregivers of person with depression and its psychosocial correlates, which include stigma, perceived social support, religious commitment and the severity of the patient's symptoms.
METHODS: A cross-sectional study was conducted among 165 patients diagnosed with MDD using the Mini-International Neuropsychiatric Interview (M.I.N.I.) together with their caregivers. Apart from gathering social demographic data, patients were administered the 16-item Quick Inventory of Depressive Symptomatology-Self-Rated Version (QIDS-SR 16), whereas the caregivers were required to answer Patient Health Questionnaire-9 (PHQ-9), Multidimensional Scale of Perceived Social Support (MSPSS), Duke University Religion Index (DUREL) and Depression Stigma Scale (DSS). Those who scored ⩾5 on PHQ-9 were further assessed with interviewer-rated M.I.N.I. to diagnose the presence of depression.
RESULTS: A total of 47 (28.5%) caregivers were found to have depressive symptoms. Out of that total, 13 (7.9%) were diagnosed to have MDD using M.I.N.I. From univariate analysis, factors associated with depression in caregivers were the severity of symptoms in patients ( p
Suicidal ideation in systemic lupus erythematosus: NR2A gene polymorphism, clinical and psychosocial factors

Buji RI, Abdul Murad NA, Chan LF, Maniam T, Mohd Shahrir MS, Rozita M, et al.

Lupus, 2018 Apr;27(5):744-752.
PMID: 29161964 DOI: 10.1177/0961203317742711

Background Systemic lupus erythematosus (SLE) patients are a high-risk population for suicide. Glutamatergic neurosystem genes have been implicated in the neurobiology of depression in SLE and suicidal behaviour in general. However, the role of glutamate receptor gene polymorphisms in suicidal behaviour among SLE patients remains unclear in the context of established clinical and psychosocial factors. We aimed to investigate the association of NR2A gene polymorphism with suicidal ideation in SLE while accounting for the interaction between clinical and psychosocial factors. Methods A total of 130 SLE patients were assessed for mood disorders (MINI International Neuropsychiatric Interview), severity of depression (Patient Health Questionnaire-9), suicidal behaviour (Columbia-Suicide Severity Rating Scale), socio-occupational functioning (Work and Social Adjustment Scale), recent life events (Social Readjustment Rating Scale) and lupus disease activity (SELENA-SLE Disease Activity Index). Eighty-six out of the 130 study participants consented for NR2A genotyping. Results Multivariable logistic regression showed nominal significance for the interaction effect between the NR2A rs2072450 AC genotype and higher severity of socio-occupational impairment with lifetime suicidal ideation in SLE patients ( p = 0.038, odds ratio = 1.364, 95% confidence interval = 1.018-1.827). However, only the association between lifetime mood disorder and lifetime suicidal ideation remained significant after Bonferroni correction ( p
Fulltext Depression and Suicidal Ideation in a Sample of Malaysian Healthcare Workers: A Preliminary Study During the COVID-19 Pandemic

Sahimi HMS, Mohd Daud TI, Chan LF, Shah SA, Rahman FHA, Nik Jaafar NR

Front Psychiatry, 2021;12:658174.
PMID: 34025479 DOI: 10.3389/fpsyt.2021.658174

Objective: The burden of suicidal behavior is anticipated to increase as a sequela of the COVID-19 pandemic. However, there is limited evidence on suicidal behavior among healthcare workers, an at-risk population. Our study aimed to investigate suicidal ideation in terms of the rate and associated factors in a sample of Malaysian healthcare workers during the early-phase of the COVID-19 pandemic. Methods: A subpopulation analysis (N = 171) was conducted within a larger, nation-wide cross-sectional study of Malaysian healthcare worker psychological distress from March 18-21, 2020. Current suicidal ideation was measured with item 9 of the Patient Health Questionnaire-9 (PHQ-9). The following independent variables were assessed: socio-demographic profile, occupation and service-related factors, health-anxiety (Health Anxiety Inventory, HAI), lifetime anxiety disorder and severity of depression (PHQ-9). Results: The proportion of healthcare workers with current suicidal ideation (19/171) and clinical depression (17/171) were 11.1 and 9.9%, respectively. Multivariable analysis showed that clinical depression was the most significant factor associated with current suicidal ideation (p < 0.001, OR = 55.983, 95% CI = 9.015-347.671) followed by mild (subthreshold) depression (p = 0.001, OR = 115.984, 95% CI = 2.977-85.804). Service duration of more than 10 years was associated with significantly less suicidal ideation (p = 0.049, OR = 0.072, 95% CI = 0.005-0.993). Conclusions: Depression (subthreshold and especially within the clinical range) and early-career status (<10 years in service) may be target areas of early intervention for reduction of suicidal ideation amongst healthcare workers who have served during the COVID-19 pandemic. Further research is warranted to elucidate specific occupational stressors related to COVID-19 work conditions to tailor appropriate suicide preventive strategies in this population.

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