Background: Community based epidemiological data on postpartum depression in Malaysia is scarce. Aim: To determine the prevalence and risk factors for developing postpartum depression among Malay women from a rural area in Kedah, North West of Peninsular Malaysia. Method: We screened 185 women at 4-12 weeks postpartum attending the selected health centers using the Malay versions of Edinburgh Postnatal Depression Scale (EPDS) and Beck Depression Inventory II (BDI-11). Those scoring 12 and / or 9/10 on BDI-11 were interviewed using the Composite International Diagnostic Interview (CIDI) and the 17-items Hamilton Rating Scale for Depression (HDRS-17). All diagnoses were based on the Tenth Edition of the International Classification for Disease: Diagnostic Criteria for Research (ICD-I0: DCR-10). Results: The prevalence of postpartum depression was 21.08%. The condition was found to be significantly linked to polygamous marriages, high number of life events and financial problems over the last one year prior to delivery, and low scores on the Malay version of the MOS Social Support Survey and all its components (overall support index, informational support, affectionate support/ positive social interactions and instrumental support). Conclusions: Postpartum depression is indeed a reality among Malay women in rural areas In Kedah, North West of Peninsular Malaysia. These findings have implications for policies regarding maternal and childcare programs.
Aim: To evaluate the psychometric performance of the Malay version of the Medical Outcome Study (MOS) Social Support Survey among a sample of postpartum Malay women in Kedah, North West of Peninsular Malaysia.
Materials and methods: 354 women between 4 to 12 weeks postpartum were recruited for the validation study. They were given questionnaires on socio-demography, the Malay versions of the MOS Social Support Survey, the Edinburgh Postnatal Depression Scale (EPDS) and the 21-items Beck Depression Inventory-II (BDI-II). 30 of the participants, who were bilingual, were also given the original English version of the instrument. A week later, these women were again asked to complete the Malay version of MOS Social Support Survey.
Results: The median number for item 1 (the single item measure of structural support) was 3 (inter-quartile range = 2 - 4). Extraction method of the remaining 19 items (item 2 to item 20) using principle component analyses with direct oblimin rotation converged into 3 dimensions of functional social support (informational support, affectionate support / positive social interaction and instrumental support) with reliability coefficients of 0.93, 0.74 and 0.72 respectively. Overall the scale displayed good internal consistency (Cronbach's alpha = 0.93), parallel form reliability (0.98) and test-retest reliability (0.97) (Spearman's rho; p<0.01). Its validity was confirmed by the negative correlations between the overall support index (total social support score) and all the three dimensions of functional support with the Malay versions of EPDS and BDI-II. The overall support index also displayed low but significant correlations with the single measure structural social support in the instrument (Spearman's rho = 0.14; p <0.01).
Conclusions: The MOS Social Support Survey demonstrated good psychometric properties in measuring social support among postpartum Malay women in Kedah, North West of Peninsular Malaysia and could potentially be used as a simple instrument in primary care settings.
In recent years, more cases of manic switches on Mirtazapine have been reported. In this report, we discuss a case of manic switch in a gentleman who was treated as unipolar depression. A 66-year-old man presented to psychiatry 8 months following a nephrectomy for symptoms of depression. Treatment with Sertraline 50mg daily was initiated and titrated to 150mg, along with Zolpidem and Clonazepam to aid his sleep. Despite these medications he never achieved remission and continued to have persistent anxiety and insomnia. Due to suboptimal control, treatment was changed to Mirtazapine 15mg daily. At day 20 he showed symptoms of mania which included talkativeness, increased goal directed activities, reduced need for sleep and socially disinhibited behavior. Mirtazapine was discontinued, and treatment was changed to Sodium Valproate, optimized to 1000mg daily, augmented with Quetiapine 150mg daily. Remission was achieved after 4 months and he has remained asymptomatic for 2 months. This was his first episode of mania, and a diagnosis of Bipolar I disorder was made. In conclusion, antidepressant induced manic switches are common, they are relatively under-appreciated and under-reported, especially with the use of sleep-promoting antidepressants. All antidepressants should be considered to be a potential mediator of a switch in view of its pharmacological properties.
The media can be a double-edged sword in suicide prevention
with the Werther and Papageno effect as risk and protective factors
respectively. Objective: This article provides a brief overview of the impact
of media suicide reporting on suicidal behaviour and suicide prevention.
Results: In the Malaysian context, current practices of media suicide
reporting, advocacy strategies for responsible media suicide reporting as
well as challenges in stakeholder awareness and engagement are highlighted.
A review of the literature suggested limited implementaton and adherence of
media guidelines locally. Conclusions: Future research is warranted to
establish the evidence base for effective strategies to improve stakeholder
awareness, engagement and implementation of responsible media reporting
Dextromethorphan, an over the counter cough suppressant is gaining
popularity among teenagers and young adults because of its easy availability,
relatively low price and most importantly the feeling good effects that it
brought when used in megadoses. We are reporting three cases of
dextromethorphan abuse and its clinical presentations. We discussed about
the factors that contribute to the current situation of uncontrolled usage of
dextromethorphan in our population especially in Sarawak. We also looked
into some of the steps that we can take in order to prevent the situation from
Tianeptine is an atypical tricyclic antidepressant that is prescribed mainly for the treatment of depression and anxiety disorder. There have been scattered reported cases of tianeptine dependence and abuse in the literature. We report the case of a 32-year-old gentleman with resistant major depressive disorder that was initially successfully treated with Tianeptine. When his depression relapse due to work-related issue, he step-up his dosages without supervision. He developed tolerance and withdrawal to tianeptine making it difficult for him to stop without help. This case highlights the possibility of tianeptine abuse to its high tolerability and easy access for purchase.
Majority people with schizophrenia who smoke cigarettes, tend to be heavy smokers than other psychiatric patients and general population. Nicotine is one of the main components of cigarettes that can produce nicotinic interactions with antipsychotic drugs. Nicotine can also alleviate psychotic symptoms of schizophrenia. Aim: The objective for this systematic review is to examine the effects of nicotine and nicotine-based products in the treatment of schizophrenia, in comparison with placebo, no treatment or antipsychotic medication. Results: All studies comparing nicotine or other related products as the only treatment or adjunctive treatment for schizophrenia patients excluding the animal studies and case studies are reviewed. The use of traditional or known as typical antipsychotics may cause the patients to smoke frequently while patients taking atypical antipsychotics may smoke less. Patients who smoke may metabolize antipsychotics faster than non-smoking patients. There is less report related to smoking cessation among the schizophrenia patients. Conclusion: Neurobiological and psychosocial factors reinforce the high use of nicotine by patients with schizophrenia. Prior to smoking cessation implementation, it is crucial to understand on the ways and reasons for schizophrenia patients to consume nicotine for self-medicate symptoms which may lead to the development of new treatments for schizophrenia and nicotine dependence.
Klüver-Bucy syndrome was first diagnosed in humans in 1955, after a group
of people who had experienced temporal lobectomy. It is a rare
neuropsychiatry disease and of which little is understood about its
pathophysiological processes. Here we present a 60-year-old man seen in the
outpatient psychiatric department in a tertiary hospital in Kuala Lumpur
who presented to us with hyper sexuality, impulsivity, docility, amnesia and
hyperphagia for the past 10 months. He was diagnosed with Herpes Simplex
Virus with encephalitis 18 months ago and was shown to have bilateral
meningoencephalitis of his temporal lobes. Thus, a diagnosis of Klüver-Bucy
was made. We have taken a multi-disciplinary team approach to treat his
illness and specific goals has been laid out in each discipline. A written
consent has been taken by the patient and his family for the publication of
Osmotic demyelination syndrome (ODS) may occur as a consequence of a
rapid change in serum osmolality. We report a case of a 32-year-old woman
who presented to the hospital with symptoms suggestive of severe
hyperemesis gravidarum. Blood investigation results showed that patient had
severe hyponatraemia (serum sodium 109 mmol/L) and hypokalaemia
(serum potassium 1.7 mmol/L). Active and vigorous corrections to these
electrolyte imbalances had led to an overly increased of serum sodium levels
within a short duration of time. Four days after the rapid correction, patient
started exhibiting neuropsychiatric manifestations. Radiological findings
were consistent with the diagnosis of ODS. The neuropsychiatric symptoms
experienced by patient gradually worsened with time. Subsequently,
intravenous methylprednisolone was administered to patient. Patient showed
marked response to the steroid given. At the time of discharge, twenty-seven
days later, patient had recovered from most of the neuropsychiatric sequelae;
but still required assistance during ambulation. In conclusion, correction of
electrolyte imbalances should be done in a more judicious manner. Prudent
corrections of electrolyte alterations could have possibly prevented the onset
of ODS and its’ devastating neuropsychiatric sequelae in this patient.
We are aware of the shortage of psychiatrists in Malaysia.
However, there is no formal report on the distribution and ratio of
psychiatrists in each state in Malaysia. We aim to do a detailed count of the
number of psychiatrists in the country. Methods: We obtained the figures for
the psychiatrists practicing in the government, private and university settings
by accessing the Ministry of Health database, information from the
Malaysian Psychiatric Association, Malaysian Mental Health Association,
National Specialist Register and websites of the respective Universities. The
total number and ratio of psychiatrists per 100,000 population are calculated.
Results: There was a total of 410 registered psychiatrists in Malaysia in the
private universities, private clinics, public universities and government
hospitals. The state with the highest number of psychiatrists is Wilayah
Persekutuan Kuala Lumpur with a total of 94 psychiatrists which has a ratio
of 5.24 per 100, 000 population followed by Wilayah Persekutuan Putrajaya
with 3.38 per 100,000 population. The states with the least ratio of
psychiatrists are Sabah with 0.54 and Kedah with 0.55 per 100, 000
population. Conclusion: There is a discrepancy in the geographical
distribution of psychiatrists in Malaysia. People living in larger, urban states
have better access to mental health care whereas the smaller states face a
serious lack of psychiatrists. More effort should be taken to improve mental
healthcare in Malaysia as recommended by WHO with one psychiatrist for
every 10, 000 population.
Decision making capacity is the basis for medical decision making. A person’s right to determine his or her own health care related decision has long been established and this forms the essence of medical treatment. This fundamental right extends to patients with mental health disorder who have the capacity to make such decisions. Where a mental disorder is evident, our experiences in the local settings suggested that clinicians are inclined to state that incapacity to decide for medical treatment is present without much assessment or exploration and explanation on the proposed treatment. Many patients with mental disorder in fact are capable at making decisions related to health care. Their rights to decide on medical treatment should be respected and not to be ignored.
Alcohol-induced psychotic disorder (AIPD) is a rare complication of alcohol
abuse which is characterized by an acute onset of auditory or visual
hallucinations that occur either during or after a period of heavy alcohol
consumption. Other symptoms include delusions, thought disorder,
psychomotor disturbances, and abnormal affect. To establish the diagnosis,
one must rule out other disorders such as alcohol withdrawal delirium or
other psychotic disorders. Although it is well recognised, relatively little is
known about the condition. Moreover, the pathogenesis and treatment of
AIPD are still unclear despite high co-morbidity with other psychiatric
disorders, high re-hospitalization as well as mortality rates and suicidal
behaviour. Therefore, the prognosis appears less favourable. We present a
case of young man with AIPD with suicidal attempt secondary to auditory
Manic symptoms secondary to post dengue fever are rare or might be underreported. Awareness of this phenomenon is important for therapeutic
considerations of patients. We present a case of late onset mania in an elderly
gentleman who developed manic symptoms post dengue fever.
Objectives: To determine the prevalence of self-reported depression among Malaysian patients with rheumatoid arthritis (RA) and to study the correlates and independent predictors for depression. Methods: The Hospital Anxiety and Depression Scale (HADS) questionnaire wasused to assess depressive symptoms. Disease activity was determined by theduration of morning stiffness, visual analogue scale for pain and fatigue, numberof swollen/tender joint and the modified disease activity score (DAS). The Health Assessment Questionnaire (HAQ) was used to assess the patients' functionalstatus. Results: Depression was recorded in 17.2% of the 93 patients. Painful joints(p<0.001), active disease (p<0.001) and poor joint function (p<0.001) correlatedsignificantly with depression. Poor functional status assessed by the HAO was themost significant Independent predictor for depression in RA patients, (OR=5.4,p=0.028). Conclusion: The prevalence of depression In this cohort of Asian RA patients was17.2%. Painful joints and functional disability were associated with a higherIncidence of depression. RA Patients with severe functional disability should beassessed for depression that may need to be treated Independently.
Globally women's mental health issues have been emphasized since many decades ago. World Health Organization (WHO) has highlighted the importance of justice and equality in term of social context related to gender in order to achieve good mental well-being. Gender differences in the prevalence of psychiatric disorders have been recognized long ago where women commonly exceeds the men for a number of psychiatric illnesses (1). Women are more likely to suffer from depression, anxiety, somatic problems and being victims of sexual or physical violence. At least 1 in 5 women suffer rape in their lifetime but the rate differ from various country (2). Much work has been done to look into the general well-being and psychological distress in women as well as to understand the reason for women become more vulnerable to stress as compared to men. Multiple factors such as biological determinants and psychosocial issues have been found to be correlated to depression. Women with chronic major depression tend to have a younger age at the onset of her illness, a more extensive family history of mood disorder, poorer social adjustment, and poorer quality of life compared to chronically depressed men (3). Women are also known to be more likely to seek help for their mental health problem from primary care physician. Furthermore, across socio-economic levels many women nowdays are doing multiple roles in the society. They are not only wives and mothers in their family, but women also go out to earn for living. Some women are holding a higher position at workplace or in any organization. These multitasking roles may cause stress to women especially if she has to handle family-work or work-family conflicts. Biological differences related to gender have been increasingly explored. Differences exist in brain anatomy and that male and female reproductive hormones i.e. estrogen and progesterone produce psychoactive effects (4). Estrogen's antidopaminergic (5) and serotonin-enhancing (6) effects may play a role in psychiatric disorders in women. These are the areas that need more research investigations.
The prevalence of psychiatric morbidity among patients attending primary care clinics is high and their attitudes towards psychiatry are often negative. The objectives of this study were to assess the prevalence of psychiatric morbidity and attitudes towards mental illness in relation to socio-demographic factors among primary care patients. A cross-sectional study was conducted on 245 patients attending the primary care clinic of Hospital Universiti Kebangsaan Malaysia at Bandar Tasik Selatan. A two-stage case identification process was used to detect psychiatric morbidity. The Malay translation of General Health Questionnaire-30 (GHQ-30) was used for screening and the Structured Clinical Interview for DSM-IV (SCID) was used to generate Axis-1 diagnosis. The Attitudes Towards Mental Illness Questionnaire was used to assess their attitudes towards mental illness. 8.2% of patients were found to have psychiatric morbidity, and they were significantly associated with the younger age group (p<0.05). Nevertheless, there was no significant association between psychiatric morbidity and sex, race, marital status, educational level, and social class of patients. The attitudes towards mental illness were significantly associated with age, race, marital status, educational level, social class and the presence of family history of psychiatry illness (p<0.05). There was no significant association between attitudes towards mental illness and patients'sex. Primary care doctors need to be equipped with psychiatry knowledge in order not to miss patients with psychiatry morbidity. Patients with psychiatry morbidity significantly believed in supernatural causes of mental illness compared with those without psychiatric morbidity. Keywords: Primary care, psychiatric morbidity, attitude towards psychiatry
Obesity is highly prevalent among patient with schizophrenia. It is therefore important to know whether lifestyle factors could contribute to obesity. The objective of this paper is to study the prevalence of overweight, obesity and high waist circumference (WC) in relation to Binge eating and lifestyle factors among patients with schizophrenia. This is a cross sectional study for a period of three and a half months which systematically selected patients with schizophrenia who fulfilled the inclusion criteria. The diagnosis of schizophrenia was made using Structured Clinical Interview for DSM-IV (SCID). The diagnosis of Binge Eating Disorder (BED) and the assessment of lifestyle factors were made using Eating Disorder, Module H of SCID and Health Promoting Lifestyle Profile II (HPLP II) respectively. The prevalence of overweight was 39.2 %, obesity was 35.1 % and high waist circumference was 63.9 %. The difference between presence of BED among patients who had normal and either overweight or obese was not significant (?2 with Yates correction 3.34, p=0.06). BED was found to be more in patients with high WC (n=11, 78.6 %) than those with normal WC (n=3, 21.4 %) but the difference was not significant (?2=1.88, p=0.21). In term of lifestyle factors, no significant different found between those who smoke and those who did not smoke in relation to BMI (?2=0.00, p=0.98) and WC (?2=0.15, p=0.90). There was no difference between total score of diet and exercise among patients who had normal weight and those who were either overweight or obese in relation to BMI (t=1.30, p=0.20) and WC (t=0.91, p=0.36) and BMI (t=0.80, p=0.43) and WC (t=0.02, p=0.98) respectively. There were also no differences between total score of all four domains of psychological lifestyle i.e. stress management, health responsibility, spiritual growth and interpersonal relationship among patients who had normal weight and those who were overweight and obese in relation to BMI and WC (p>0.05). Presence of Binge eating disorder and the lifestyle factors did not contribute to obesity among patients with schizophrenia. Keywords: Schizophrenia, obesity, lifestyle, binge eating disorder
Objective: The aim of this study was to study the rate of readmission and look into factors that may contribute to this. Methods: This is a retrospective descriptive study of all psychiatric patients who were discharged from University Malaya Medical Center (UMMC). Case notes of those discharged during the study period was retrieved and analyzed. Those fulfilling the inclusion criteria were recruited and subjected to a questionnaire. Results: A total 107 patients were identified and only 95 participated. The readmission rate was 16.8%. Severity of illness was identified as the main risk factor for readmission in this study. Conclusion: Our readmission rate was similar to some developed nations and indicated good quality of care in UMMC. There appears to be other factors that may influence rate for readmission other than quality of in-patient care and outpatient community care. Keywords: readmission, mental illness, quality of care, Malaysia
The aim of this study is to validate the Malay version of CDI among children and adolescents attending outpatient clinics at Universiti Sains Malaysia Hospital (USM), Kota Bharu, Kelantan. Sixty children and adolescents attending outpatient clinics were interviewed using the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) and completed the Malay version of CDI. Reliability and validity of the Malay version of CDI were analyzed. Validation study showed that the Malay version of CDI had a satisfactory reliability (Cronbach's alpha 0.83). At the cut-off score of 18, the Malay version CDI had 90% sensitivity and 98% specificity in detecting depression. In conclusion, the Malay version of CDI has a satisfactory validity and reliability. Keywords :Children Depression Inventory, depression
Psychiatric community-based services are being developed in Malaysia currently to ensure more comprehensive mental health care to especially patients with severe mental illness. Assertive Community Treatment (ACT) as one of the earliest component of community-based services has been observed to be useful and able to provide favourable outcomes in this group of patients. Though the paradigm shift has gradually occurred among mental health practitioners and policy makers, challenges are mainly in the implementation process. This article will present the discussion and academic view on various aspects of ACT including the rationale, elements, clinical and psychosocial impacts on patients as well as the current challenges in the Malaysian context. Keywords: Psychiatric community-based services, Assertive community treatment (ACT), severe mental illness (SMI