16th Pacific Rim College of Psychiatrists Scientific Meeting, October 5 - 7, 2014, Vancouver, Canada.

Ofﬁcial journal of the Paciﬁc Rim College of Psychiatrists

The 16th Pacific Rim College of Psychiatrists Scientific Meeting


7 Protein expression analysis on human embryonic carcinoma (NCCIT) cell-derived neuronal cells line with treatment of fluoxetine DY Oh,1 JH Choi,2,3 YC Park2,3 1 Department of Psychiatry, CHA Bundang Medical Center, CHA University, Bundang-gu, Seongnam-si, Gyeonggi-do, South Korea 2 Department of Neuropsychiatry, College of Medicine, Hanyang University and Hanyang University Guri Hospital, Seoul, South Korea 3 Department of Neuropsychiatry and Mental Health Institute, College of Medicine, Hanyang University, Seoul, South Korea

Introduction: Embryonic stem (ES) cells in their gene expression profile as well as self-renewal capacity and the potential to differentiate into three embryonic germ layers.1 Adult hippocampal neurogenesis hypothesis states that the generation of neurons in the postnatal brain is important for understanding and treating anxiety disorders, like post-traumatic stress disorder (PTSD).2 The aim of this study was to identify the protein expression characteristics in NCCIT cell-derived neurons after

long-term treatment (7 days) with fluoxetine, which is well-known for treatment of anxiety disorders. Materials and methods: EBs from NCCIT cells (CRL-2073) were incubated with 10 μM retinoic acid and 10 μM fluoxetine for 7 days. Proteins samples were subjected to two-dimensional gel electrophoresis (2-DE) using PDQuest software to quantify the spot densities. Ultraflex MALDI-TOF MS was used for the peptide analysis. To identify the pathway network analysis, the MetaCore pathway software was used. Results: Effects of treatment of fluoxetine on NCCIT cell-derived neurons was shown in Tables 1 and 2. Upregulated proteins in fluoxetine-treated NCCIT cellderived neurons included 14-3-3 protein epsilon, heat shock protein 90-alpha isoform 2 (Tables 1 and 2). The pathway networks was identified as scored by MetaCore. To confirm the protein related to underlying mechanism of anxiety disorder, we performed the western blot analysis. We chose Heat shock protein 90 (HSP90) because of its function in glucocorticoid receptor regulation.3 Treatment of 10 μM fluoxetine on NCCIT cell-derived neurons resulted in increasing the expression of HSP90 compared to no treatment as control.

Table 1. Upregulated proteins in treatment of fluoxetine on NCCIT cell-derived neurons Spot ID 102 104

1702 2504 3003 3208 6402 6504 6505 8307

2

Spot intensity Protein

Control

Fluoxetine

Estimated Z

Accession number

14-3-3 protein epsilon Tyrosine 3-monooxygenase/tryptophan 5-monooxygenase activation protein, zeta polypeptide heat shock protein 90-alpha isoform 2 3-hydroxy-3-methylglutaryl-Coenzyme A synthase 1 (soluble) myosin, light polypeptide 6, alkali, smooth muscle and non-muscle Ribosomal protein, large, P0 alpha enolase seryl-tRNA synthetase Dihydropyrimidinase-like 3 proteasome (prosome, macropain) 26S subunit, ATPase, 5, isoform CRA_a

13 1

1015 694

1.19 2.33

gi5803225 gi68085578

1 1

623 683

1.99 2.42

gi154146191 gi53734504

1

512

2.19

gi119617308

1 1 1 1 1

543 1391 580 1328 634

2.43 2.43 2.34 2.38 2.13

gi12654583 gi2661039 gi1050527 gi24659471 gi119614675

© 2015 The Authors Asia-Pacific Psychiatry © 2015 Wiley Publishing Asia Pty Ltd


Table 2. Downregulated proteins in treatment of fluoxetine on NCCIT cell-derived neurons Spot ID 9 3408 4210 5015

6412 7208 7514 8002 8202 8506

Spot intensity histone-lysine N-methyltransferase SUV39H2 isoform 4 eukaryotic translation initiation factor 4A, isoform 1, isoform CRA_a ribosomal protein, large, P0, isoform CRA_a Chain A, A Folding Mutant Of Human Class Pi Glutathione Transferase, Created By Mutating Glycine 146 Of The Wild-Type Protein To Valine rab5 GDP/GTP exchange factor acetyl-CoA acetyltransferase, cytosolic pyruvate kinase K63-Linked Di- And Tri-Ubiquitin malate dehydrogenase 1 fascin homolog 1, actin-bundling protein

Conclusion: In anxiety disorders, fluoxetine might have the mechanism of action of antianxiety treatment through increasing HSP90 during adult hippocampal neurogenesis.

Fluoxetine

Estimated Z

Accession number

624

1

2.43

gi|301171613

857

1

2.21

gi119610572

715 1098

1 1

2.43 2.4

gi119618576 gi23200510

1009 768 717 583 612 618

1 1 1 1 1 1

2.12 1.49 2.38 1.12 1.63 2.15

gi77176721 gi|148539872 gi35505 gi|259882301 gi|119620368 gi|119607750

Control

Protein

9 Prevalence of mental illness, intellectual disability, and developmental disorders among homeless in Nagoya City, Japan

References 1. Guan K, Rohwedel J, Wobus AM. Embryonic stem cell differentiation models: cardiogenesis, myogenesis, neurogenesis, epithelial and vascular smooth muscle cell differentiation in vitro. Cytotechnology 1999; 30: 211–226. 2. Bremner JD, Elzinga B, Schmahl C, Vermetten E. Structural and functional plasticity of the human brain in posttraumatic stress disorder. Progress in Brain Research 2008; 167: 171–186. 3. Galigniana NM, Ballmer LT, Toneatto J, Erlejman AG, Lagadari M, Galigniana MD. Regulation of the glucocorticoid response to stress-related disorders by the Hsp90-binding immunophilin FKBP51. Journal of Neurochemistry 2012; 122: 4–18.


A Nishio,1,2 R Horita,1 T Sado,1,3 H Ueki,2 S Mizutani,4 T Watanabe,5 K Matsuura,6 O Tamura,7 R Uehara,8 M Yamamoto1,9 1 Heath Administration Center, Gifu University, Gifu, Japan 2 Department of Psychopathology, Division of Neuroscience, Graduate School of Medicine, Gifu University, Gifu, Japan 3 Faculty of Health Promotional Sciences, Tokoha University, Hamamatsu, Japan 4 Department of Nursing, Nihon Fukushi University, Mihama, Japan 5 Midori Hospital, Gifu, Japan 6 Kanazawa Johoku Hospital, Kanazawa, Japan 7 Hokkaido Labor Hospital, Sapporo, Japan 8 Yoshida Hospital, Nara, Japan 9 United Graduate School of Drug Discovery and Medical Information Sciences, Gifu University, Gifu, Japan

Introduction: While it has been reported that the prevalence of mental illness is higher among homeless people, few studies have investigated the prevalence of intellectual disability and developmental disorders. In this preliminary study, we conducted a survey to assess these mental problems entirely among homeless in Nagoya, Japan. Materials and methods: The subjects were 18 homeless men. Mental illness was diagnosed by semistructured interviews, conducted by psychiatrists. WAISIII was used to diagnose intellectual disability. Discrepancies between WAIS-III subtest scores were used as index of developmental disorders.

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Results: Eleven of the 18 participants were diagnosed as mental illness. Of these, 7 had a mood disorder, 2 had a psychotic disorder, and 6 had alcohol problem. The mean IQ of them s was 83.4 ± 27.4. Seven participants were found to have intellectual disability. Three men showed discrepancies between subtest scores of more than 10, and all of these had been diagnosed as mental illness. We divided the participants into 4 groups: those

with mental illness only, those with intellectual disability only, those with both problem, and those with no diagnosed (Figure 1). The men with intellectual disability only were, on average, significantly younger and had been homeless since a younger age than other groups. Participants diagnosed with a mental illness had, on average, been homeless for longer than those without mental health problems (Table 1).

Figure 1. Mapping diagnosis of homeless subjects along two axes: presence of mental illness (with/without) and degree of intellectual disability. Table 1.

Group A Group B Group C Group D

Only intellectual disability Mental illness + intellectual No diagnosis Only mental illness

Age

History of current street life

Age when street life initiated

46.0 ± 4.0* 58.0 ± 2.3 58.0 ± 2.5 58.0 ± 2.5

4.5 ± 0.5 9.8 ± 4.2 2.8 ± 0.8 7.8 ± 3.1

36.5 ± 9.5 47.2 ± 4.0 51.6 ± 2.2 46.8 ± 5.1

Mean ± SE *p < 0.05.

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Conclusion: The small sample size of this preliminary study is a limitation. However, the finding that 61% of participants had a mental illness, and 39% has an intellectual disability is interesting and deserves further study. Parts of this report including the figure and the table were accepted by Psychiatry and Clinical Neuroscience (doi:10.1111/pcn.12265). 10 The psychosocial correlation of suicidal attempt and ideation in urban middle school adolescents A Min,1 EY Jang,1 YC Park1 1 Department of Psychiatry, Hanyang University Guri Hospital, Gyeonggido, Korea

Introduction: This study was to explore the prevalence of suicidal ideation and attempt and the risky or protecting factors of them. Especially, we hypothesized that school bullying might have adverse effect on suicide, while social support might have protective role. Materials and methods: The data were collected by self-report questionnaire from 1219 students selected from 2 middle schools in Guri. For statistical analyses, Chi-square test, post hoc test, hierarchical linear regression analysis and hierarchical logistic regression analysis were performed. Results: The prevalence of suicidal attempt was 1.1% from total sample. The meaningful predictor of suicidal ideation were female, low socioeconomic status, low self-esteem, emotional abuse, neglect, delinquent behavior, perpetrating of school bullying, family support and friend support, in addition to the significant effect of depressive mood in Table 1. Finally, in the case of suicidal attempt, gender (especially female), low socioeconomic status, low self-esteem or delinquent behavior showed the significant incremental effect, in addition to the explaining variance of depressive mood and suicidal ideation in Table 2. Conclusion: Our results implied that gender, socioeconomic status, self-esteem and delinquency had direct effect on suicidal attempt and indirect effect by increasing depression and suicidal ideation. Childhood emotional abuse and neglect predicted depression in adolescents, which also resulted in suicidal ideation indirectly.


Table 1. Hierarchical linear regression predicting suicidal ideation Suicidal ideation B

beta

2.09 −0.76 0.32 −1.92 1.36 0.80 0.92 1.29 1.72 −0.07 0.13 −1.15 1.10 0.02

0.16 5.58 −0.085 −2.927 0.50 18.511 −0.18 −6.40 0.12 3.84 0.05 1.94 0.07 2.56 0.06 2.30 0.14 5.02 −0.01 −0.18 0.02 0.84 −0.12 −3.46 0.11 3.39 0.00 0.09 0.46 0.46 5.64 0.00

Sex† Socioeconomic status Depressive mood Self esteem Emotional abuse Physical abuse Neglect Delinquent behavior Bullying-perpetrator Bullying-victim Academic stress Social support-family Social support-friend Social support-teacher R2 Adjusted R2 F Change Sig. F Change

t

p 0.000 0.003 0.000 0.000 0.000 0.053 0.011 0.022 0.000 0.856 0.403 0.001 0.001 0.928

†Sex; Male = “1”, Female = “2”. Sig: significantly. Table 2. Hierarchical logistic regression predicting suicidal attempt

Suicidal attempt† B Sex‡ Socioeconomic status Depressive mood Suicidal ideation Emotional abuse Physical abuse Neglect Delinquent behavior Bullyingperpetrator Bullying-victim Academic stress Social supportfamily Social supportfriend Social supportteacher 2 Log likelihood Nagelkerke R2

SE

P

OR

95% CI

0.67 0.26 0.010 1.95 1.18–3.24 −0.38 0.16 0.017 0.68 0.50–0.93 0.02 0.32 0.41 0.51 −0.58 0.70

0.02 0.03 0.28 0.33 0.36 0.41

0.339 0.000 0.153 0.126 0.154 0.050

1.02 1.38 1.50 1.67 0.50 1.79

0.99–1.05 1.30–1.46 0.86–2.62 0.87–3.20 0.25–1.00 0.80–3.99

−0.41 0.32 0.899 0.96 0.51–1.80 −0.27 0.33 0.417 0.76 0.40–1.47 −0.22 0.18 0.210 0.80 0.57–1.13 −0.40 0.34 0.247 0.67 0.34–1.32 −0.06 0.32 0.841 1.07 0.57–1.98 0.15 0.23 0.527 1.16 0.74–1.82 367.02a 0.57

†Suicidal attempt; Attempted = “1”, Never attempted or Interrupted = “0”. ‡Sex; Male = “1”, Female = “2”. SE: Standard error, OR: Odds ratio.

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16 Perceptions towards video technologies and augmented reality in psychiatry education MWB Zhang,1 RCM Ho1 1 Department of Psychological Medicine, National University Healthcare Systems, Singapore

analysis conducted revealed there is also no noted difference between gender and student’s perception of having clinical OSCE videos (χ2 = 1.278, p = 0.865). Conclusions: This is one of the initial studies that have demonstrated the effectiveness of including videos to augment psychiatry education, and one of the first studies to determine student’s perception of using augmented reality in psychiatry. Our methods might apply to future research involving the use of technology in education.

Background: Over the past decade, there have been major advances in terms of Web 2.0 technologies as well as in terms of smartphone-based technologies that will definitely have an impact on the way undergraduate and postgraduate students learn. In psychiatry, the most recent application of these advances has been in the usage of tele-technologies for training, educational smartphone applications and virtual reality technologies in role-play simulation. Several other disciplines have described the added efficacy of augmentation of students’ education needs using video technologies and augmented reality. There are currently no studies looking into the educational efficacy of videos and augmented reality specifically for psychiatry. Objective: The objectives of the current research are thus to (a) to determine whether undergraduates students will be receptive towards clinical psychiatry videos as an added aid for learning and (b) to determine whether students will be receptive towards augmented reality technologies in enhancing their learning experience in psychiatry. Methodology: We have described the methodology involved in setting up the online video vault, as well as in integrating augmented reality technologies into our hardcopy textbook. All of the students were provided with information about the portal and shown a demonstration on the first day of their clinical posting. A user perspective survey was administered to the students, right after the completion of their end of posting clinical assessment, looking specifically into student’s perception of the features made available to them. Results: Since the introduction of the online video portal to the undergraduate students until the end of their final examinations in January 2014, there has been a cumulative total of 58,635 independent views of the videos online. For the augmented reality features incorporated, a response rate of 78.3% was obtained for the interactive elements on the cover pages and a response rate of 83.3% was obtained for the interactive elements on the OSCE grids in the book. A total of 185 students participated in the perspective survey and 92.5% of the students perceive that clinical OSCE videos have been helpful for their psychiatry education. Further statistical

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17 Promoting mental health awareness amongst GPs MWB Zhang,1 RCM Ho1 1 Department of Psychological Medicine, National University Healthcare Systems, Singapore

Background: With the development in smartphone technology, there have been an increased number of mobile phone applications designed for delivering medical and mental health care and prevention. Aims: This paper aims to illustrate the feasibility of using information technology for mental health care through the illustration of the development process of a prototype of the new Mental Health Wellness (MHWell) application, developed mainly for primary healthcare providers. A feasibility study, a formative evaluation and a qualitative survey will be conducted. Methods: The MHWell smartphone prototypical application was developed using an online application builder using HTML5 as the core programming language to build the model. A five-phase developmental method including a) formulation of user requirements, b) system design, c) system development, d) system evaluation and finally e) system application and implementation was adopted. Illustration of the use of the MHWell App and its features will be displayed. An expert panel determined the relevance of the content. A pilot prototype was launched as part of the formative evaluation, followed by a qualitative evaluation to evaluate applicability of the prototype. Results: The initial pilot yielded a total of 136 downloads. Qualitative evaluation highlighted the core components as well as the limitations of the application. The barriers encountered by the authors during the development process were also discussed with feasible solutions. Conclusions: This article has proposed a new paradigm for using mobile technology in mental health care. © 2015 The Authors Asia-Pacific Psychiatry © 2015 Wiley Publishing Asia Pty Ltd


More exploration of the use of hand-held devices for primary health care is warranted.

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integrated trained mental health professionals and cultural therapists with primary school teachers, catalyzing teacher task-sharing and task-shifting in the management of academic underachievement and behavioral disorders in the children in their schools; and increased parental engagement in their children’s development.

Dream-A-World Cultural Therapy “scale-up” intervention for school-aged high-risk primary school Jamaican children

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FW Hickling,1 J Guzder,2 HA Robertson-Hickling,3 GW Walcott4

Immigration and psychosis: A qualitative study

1 Caribbean Institute of Mental Health and Substance Abuse, University of the West Indies, Mona, Jamaica 2 Department of Psychiatry, McGill University, Montreal, Quebec, Canada 3 Mona School of Business and Management, University of the West Indies, Mona, Jamaica 4 South East Regional Health Authority, Ministry of Health, Kingston, Jamaica

Introduction: Dream-A-World Cultural Therapy (DAW CT) is a multimodal afterschool and summer intervention for school-aged high-risk primary school Jamaican children living in impoverished inner-city communities in Kingston Jamaica, selected by their teachers for severe disruptive disorders and academic underachievement. Materials and methods: 30 teacher selected children and 30 controls matched for age sex and social class from 1 Kingston inner-city Primary School who had failed the Grade 3 Primary School Test and exhibited severe disruptive disorders in 2006 formed the initial “proof of concept” pilot project. 100 teacher selected children and 100 controls matched for age sex and social class who had had failed the Grade 3 Primary School Test and exhibited severe disruptive disorders in 2013 from 4 Kingston inner-city Primary Schools formed the subsequent “scale up” project. All were exposed to 3 consecutive 40-hour DAW CT summer workshops and 20 hours of DAW CT refueling “top up” sessions over 6 school terms. All were evaluated for improvements in school social and behavior adjustment using the Achenbach System of Empirically Based Assessment Teacher Report Form (ASEBA TRF); in academic performance in language arts, science, mathematics and social studies using standardized end-of-year School Grade testing, and videotaped performance in artistic, music and drama were qualitatively evaluated using AtlasTi and grounded theory. Results: All study cohort children had made statistically significant ASEBA TRF measured improvements in school social and behavior adjustment; in school grade academic performance in language arts, science, mathematics and social studies; and qualitatively in artistic, musical and dramatic performances. The process © 2015 The Authors Asia-Pacific Psychiatry © 2015 Wiley Publishing Asia Pty Ltd

A Rudnick,1,2 L Pallaveshi,3,4,5 A Jwely,6 P Subramanian,3,4,5 MO Malkin,4 L Alia,4 R Odesh4 1 Department of Psychiatry, Vancouver Island Health Authority, Victoria, BC, Canada 2 Department of Psychiatry, University of British Columbia, Victoria, BC, Canada 3 Department of Psychiatry, Lawson Health Research Institute, London, ON, Canada 4 Department of Psychiatry, University of Western Ontario, London, ON, Canada 5 Psychosis Program, St Joseph’s Health Care, London, ON, Canada 6 Canadian Mental Health Association, Windsor, ON, Canada

Introduction: This qualitative study reports Ontarian (Canadian) mental health care providers’ views about the impact of immigration on people with psychosis and related service challenges, barriers, facilitators and opportunities. Methods: We used a phenomenological approach to elicit views of 12 sampled providers of mental health care to immigrants with psychosis. Semi-structured individual interview data obtained were coded and thematically analyzed. Results: Six themes (Table 1) in relation to the experience of service provision to immigrants with psychosis were found that referred to: the immigration process, service availability and accessibility, social determinants of health, cultural context, psychosocial stressors, and enablers and facilitators of recovery. The most prominent challenges/barriers were related to cultural context, language, social and health services, and support. Most mental health care providers believed that immigration precipitates the first episode of psychosis in the majority of served immigrants, and that psychosis was usually undetected or not present in the country of origin. Conclusion: This study demonstrated system challenges and related opportunities for service provision for immigrants to Canada with psychosis. We identified important areas for intervention to reduce disparities for this population in its use of social and health services. Further research in this area is needed in Canada and elsewhere.

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Table 1. Frequency of the emerged themes and subthemes Themes & Subthemes (Frequency) Immigration Process (141) ■ Reason for immigration ■ Type of immigration process ■ Lengthy and complicated ■ Criteria/method of selection ■ Information/knowledge (lack of it) ■ Potential trigger of psychosis

Cultural Context (166) ■ Culture differences ■ Culture sensitivity ■ Illicit drug ■ Mental illness ■ Lifestyle ■ Religion/beliefs

Service Availability & Accessibility (128) Access to healthcare Access to social services Seeking health care Interpreters service Needs for improvement

Psychosocial Stressors (137) ■ Emotional stress ■ Increase of emotional stress of persons with psychotic symptoms ■ Fear of hospitalization ■ Fear of separation from family and/or their children ■ Stressful environment ■ Feeling embarrassed and stigmatized ■ Feeling isolated ■ Unable to communicate due to language barriers

Social Health Determinants (146) Social support and isolation Stigmatization Social environments Economy and employment Language, education and literacy i.e. health literacy

Enablers and Facilitators of Recovery (152) ■ Governmental support ■ Family support: openness to treatment ■ Community support services ■ Professional responsibility ■ Cooperation between services ■ Education on culture differences and mental illness ■ Developing cultural competency

■ ■ ■ ■ ■

■ ■ ■ ■ ■

21 Mental health of unskilled migrant labourers in Indian socio-historical context: Exploring the experiential dimensions S Yadav Department of Humanities and Social Sciences, Indian Institute of Technology Kanpur, Kanpur, India

The new understanding of mental health represents a paradigm shift, emphasizes the interdisciplinary approach and focuses on the cultural understanding of psychiatric disorders, cultural specific notions of well-being, and experiential dimensions of mental health. In this context, the present study adopts a social constructionist approach to explore the socio-historically contextualized experiences of mental health among unskilled migrant labourers. Migrant labourers in India, as a consequence of

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diminishing employment opportunities in rural areas, constitute a large section of the urban unorganized sector that is characterized by the lack of social security, organizational support and labour law coverage. They also have to face distressing living conditions related to the challenges presented by an often inhospitable new city culture and unhygienic living conditions besides a deep sense of being uprooted from their home culture. In the study 44 (21 M + 33 F) semis-structured interviews were conducted, and analysed by using constructivist grounded theory. Emerged themes show that migration leads (1) demoralization (2) feeling of disempowerment and deprivation and (3) sense of defeated self. Simultaneous to these distressing situation there are things, which help them to develop positive meanings in their life. The conditions which give them an enabling meaning are (1) maintaining the relational being (2) hoping for future (3) adhering to cultural-moral values and (4) focusing on the positive aspects of migration. © 2015 The Authors Asia-Pacific Psychiatry © 2015 Wiley Publishing Asia Pty Ltd


27 Rac1 activity in hippocampus regulates the forgetting of contextual fear memory L Jiang,1 R Mao,2 Q Zhou,2 Y Yang,2 J Cao,2 Y Ding,3 Y Yang,4 X Zhang,5 L Li,1* L Xu2* 1 Mental Health Institute, The 2nd Xiangya Hospital, and Key Lab of Psychiatry and Mental Health of Hunan Province, Central South University, Changsha 410011, China 2 Key Lab of Animal Models and Human Disease Mechanisms, Kunming Institute of Zoology, the Chinese Academy of Sciences, Kunming 650223, China 3 Tongji University School of Medicine, Shanghai 200092, China 4 Department of Physiology, Kunming Medical University, Kunming 650031, China 5 Institute of Mental Health Research and Departments of Psychiatry and Cellular & Molecular Medicine, University of Ottawa, Ottawa, Canada

*Corresponding authors

Introduction: Posttraumatic stress disorder (PTSD) is marked by hypermnesia of the trauma. Inhibition of the Rac GTPase is recently suggested to impair the forgetting of initially acquired memory in Drosophila.1 However,

whether Rac1 activity in the rat hippocampus could contribute to the hypermnesia of contextual fear remains unclear. Materials and methods: We compare the effects of spaced, massed training and extinction of contextual fear conditioning on the Rac1 activity in hippocampus and contextual fear memory in rats, and inhibiting Rac1 activity in massed training and extinction, activating Rac1 in spaced training rats on contextual fear memory in rats. Results: Spaced, but not massed training, of contextual fear conditioning caused obviously inhibition of Rac1 activity in hippocampus at 1 h after fear conditioning and heightened contextual fear (Figure 1). Intrahippocampal injection of the Rac1 inhibitor NSC23766 in massed training or activator CN04-A in spaced training not only caused inhibition or activation of Rac1 activity in the hippocampus but also heightened or weakened contextual fear, respectively (Figure 2). Massed but not spaced extinction training caused robust Rac1 activity and more extinction of the contextual fear (Figure 3), which was prevented by intrahippocampal injection of the Rac1 inhibitor NSC23766 (Figure 4).

Figure 1. Spaced training of contextual fear induced hypermnesia and inhibited Rac1 activity in hippocampus.


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Figure 2. Inhibition of Rac1 activity in the hippocampus caused hypermnesia, and activation of Rac1 induced hypomnesia of contextual fear.

Figure 3. Massed extinction training caused robust Rac1 activity and more extinction of the contextual fear.

Reference 1. Shuai Y, Lu B, Hu Y, Wang L, Sun K, Zhong Y. Forgetting is regulated through Rac activity in Drosophila. Cell 2010; 140(4): 579–589.

Figure 4. Inhibition of Rac1 activity in the hippocampus caused weaker extinction of the contextual fear in massed extinction training rats.

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31

33

Psychotropic drug utilization in child and adolescent psychiatry inpatients of a university hospital

Psychiatric comorbidities in patients with major depressive disorder

1

1

1

A Kamath, S Hadigal, P Kamath, AK Shenoy

1

P Thaipisuttikul,1 P Ittasakul,1 P Waleeprakhon,1 P, Wisajun,1 S Jullagate1

1 Department of Pharmacology, Kasturba Medical College, Manipal University, Mangalore, India

1 Department of Psychiatry, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand

Introduction: With a predominantly younger population, psychiatric morbidity in children in India is relatively high. Studies from around the world show an increase in the use of psychotropic medication in children. The patterns of drug utilization vary internationally and within regions. The objective of our study was to determine the psychotropic drug utilization pattern in child and adolescent psychiatry inpatients in a university hospital in India and determine the presence of any gender difference. Method: Hospital records of all psychiatry inpatients ≤18 years of age admitted over a period of one year were studied. Drugs prescribed before hospitalization, during hospital stay and on discharge were recorded. The drug classes were delineated as follows – antidepressants, antipsychotics, mood stabilizers, anxiolytics/hypnotics and stimulants. Results: Of the 82 patients admitted, 59.8% were males. The mean age was 11.47 ± 5.09 years in males and 13.67 ± 4.09 years in females (p < 0.05). Adjustment disorder was the commonest psychiatric illness followed by anxiety disorder. 54.88% of the patients did not receive any psychotropic drugs. 18.3% were prescribed antidepressants, 24.4% antipsychotics and 36.6% anxiolytics. Lorazepam was the most commonly prescribed drug followed by olanzapine (22% and 9.8% respectively). Use of antidepressants, antipsychotics and anxiolytics was significantly more in females (p < 0.05). 26.6% of the patients were prescribed more than one psychotropic drug on discharge. Conclusion: The age and gender presentation was similar to those reported by other studies. Anxiolytics and antipsychotics were the most commonly prescribed psychotropic drugs. No psychostimulants were prescribed. No significant difference in the drug use was seen on admission and discharge. Polypharmacy seen in our study is less than those reported by other studies among psychiatry inpatients. A gender difference in the use of psychotropic medications was seen which could be due to the difference in the pattern of psychiatric morbidity.

Introduction: Psychiatric comorbidities are common in patients with major depressive disorder (MDD). They may complicate treatment course and cause more economic burden. The study objective was to examine MDD comorbidities and differences in comorbidities between patients with current MDD and past MDD. Methods: This cross-sectional study was conducted at psychiatric clinic. We enrolled all patients with lifetime diagnosis of MDD. Mini International Neuropsychiatric Interview (MINI) Thai-version was used to classify comorbidities. Patients with bipolar disorder were excluded. Results: Of 190 patients with MDD, 80% were woman. Mean age at enrollment was 50 and at MDD onset was 41. Most patients were married (53.2%), employed (54.8%), and had 12 years of education or over (66.9%). Twenty-six percent had current MDD and 74% had past MDD. Comorbidities include suicidality (within the past month) (32.1%), panic disorder (6.8%), agoraphobia (5.8%), social phobia (3.7%), obsessive-compulsive disorder (OCD) (4.7%), post-traumatic stress disorder (4.2%), alcohol dependence (0.5%), generalized anxiety disorder (GAD) (5.3%), and antisocial personality (1.1%). Compared with past MDD, patients with current MDD had significantly higher suicidality (p < 0.001), past panic disorder (p = 0.017), psychotic disorder (p = 0.016), and OCD (p < 0.001). Patients with suicidal risk had more comorbid any anxiety disorders (p = 0.019) and psychotic disorder (p = 0.032). Conclusions: Several psychiatric comorbidities were associated with MDD. Patients with current MDD had higher suicidality, past panic disorder, psychotic disorder and OCD. Patients with suicidal risk had more comorbid any anxiety disorders and psychotic disorder.


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34 Factors affecting mental wellness among public on the east Japan earthquake: A national survey 18 months later the event T Katsuki,1 A Moriyama,2 C Sato3 1 The Jikei University School of Medicine, Tokyo, Japan 2 Saitama Prefectural University, Koshigaya, Japan 3 Ohtsuka Medical Clinic, Tokyo, Japan

Introduction: We examined mental effects among public all over Japan 18 months after the great east Japan earthquake and to clarify significant factors affecting mental outcomes. Materials and methods: Two outcomes were examined: an estimated IES-R score greater than 24points (PTSD morbidity rate) and an estimated GHQ30 score greater than 6 points (mental health problem). Multivariate logistic regression was used to calculate ORs and 95% confidence intervals (95% CIs) after controlling simultaneously for potential confounders. Variables considered in the models, Age, Sex, Experiences, Damages, Witness, Managements. We conducted all analyses using SPSS version 22. Results: We estimated “Age ≥ 60 y,” “Felt shaking,” “Power failure,” “Witness buildings broken on TV,” “Tried to support others,” “I live in a high risk area” as the factors for PTSD, and “Age ≥ 60 y,” “Sex (female),” “Stayed in a building broken” as the factors for mental health problems 18 months after the disaster. Significant factors are 1) uneasy living in the area with a high risk for the next great earthquake and tsunami disaster, 2) imaging a great deal of damage in the future, and 3) advanced age over 60 years old with a lack of physical ability.

psychiatry inpatients of a university hospital in India and determine the presence of any gender difference. Method: Hospital records of all psychiatry inpatients ≥65 years of age admitted over a period of two years were studied. The drug classes were delineated as follows – antidepressants, antipsychotics, mood stabilizers and anxiolytics/hypnotics. Results: Of the 51 patients admitted, 58.8% were males. The mean age was 73.67 ± 5.8 years in males and 68.57 ± 4.7 years in females (p < 0.05). Unspecified dementia was the commonest psychiatric illness followed by bipolar affective disorder. 23.53% of the patients did not receive any psychotropic drugs. 41.2% were prescribed antidepressants, 29.4% antipsychotics, 7.8% mood stabilizers and 47.1% anxiolytics. No gender difference was seen in the use of psychotropic medications. 45.1% patients were prescribed more than one psychotropic drug on hospital discharge. Conclusion: A larger percentage of the patients were males and were of significantly older age as compared to females. This is contrary to some of the data reported by other similar studies. Anxiolytics and antidepressants were the most commonly prescribed psychotropic drugs. No gender difference was seen. Polypharmacy seen in our study is less than those reported by other studies although the appropriateness of the prescribed medications needs to be determined.

40 Ten years follow-up study of 278 inpatients at a private psychiatric hospital in Japan T Komahashi,1 S Katsuragawa2

37 Psychotropic drug utilization in geriatric psychiatry inpatients of a university hospital AK Shenoy,1 S Hadigal,1 P Kamath,1 A Kamath1 1 Department of Pharmacology, Kasturba Medical College, Manipal University, Mangalore, India

Introduction: Psychotropic drug polypharmacy is common in elderly patients. A gender based difference in the prescription of potentially inappropriate psychotropic medication has been described with more use in elderly females. The objective of our study is to describe the psychotropic drug utilization pattern in elderly

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1 Department of Psychiatry, Kanuma Hospital, Kanuma, Tochigi, Japan 2 Department of Psychiatry, Toho University Sakura Medical Center, Sakura, Chiba, Japan

Background: The aim of this study is to know prognosis of psychiatric inpatients at a private psychiatric hospital in Japan. World Health Organization criticized that there were too much psychiatric beds in Japan and the period of being admitted at psychiatric hospitals were too long. Methods: Two hundred and seventy-eight patients who were admitted at Kanuma Hospital on June 30, 2002 were followed up for ten years (up to June 30, 2012). Their medical records were reviewed. Results: Eighty-five (30.6%) were still admitted at the hospital on June 30, 2012. Forty-three (15.5%) were discharged to home. Eighteen (6.5%) were discharged to © 2015 The Authors Asia-Pacific Psychiatry © 2015 Wiley Publishing Asia Pty Ltd


other facilities. Sixty-six (23.7%) were transferred to other hospitals. Sixty-six (23.7%) died at the hospital. In eighty-five patients who were still admitted, sixty-six (77.6%) have schizophrenia, seven (8.2%) have mental retardation, and five (5.9%) have dementia. Average age of the eighty-five patients was 65.8 y.o. in total, was 63.6 y.o. for men, was 69.8 y.o. for women. In sixty-one patients who were discharged to home or facilities, fortytwo (68.9%) have schizophrenia, nine (14.8%) have dementia, five (8.2%) have mood disorders, and three (4.9%) have anxiety disorders. Average age of the sixtyone patients was 49.4 y.o. in total, 45.9 y.o. for men and 54.5 y.o. for women. In sixty-six patients who died at the hospital, thirty-three (50.0%) died from pneumonia, seven (10.6%) died from cancer, seven (10.6%) died from acute myocardial infarction, six (9.1%) died from sepsis, four (6.1%) died from cerebral infarction. Average age of the sixty-six patients who died at the hospital was 66.0 y.o. in total, 64.3 y.o. for men, 70.2 y.o. for women. In sixty-six patients who were transferred to other hospitals, ten (15.2%) were transferred for cancer, ten (15.2%) were for bone fracture, eight (12.1%) were for pneumonia, five (7.6%) were making gastrostoma, and four (6.1%) were cerebral infarction. Average age of the sixty-six patients who were transferred to other hospitals was 60.4 y.o. in total, 59.8 y.o. for men, 61.7 y.o. for women. Conclusions: One hundred and ninety-three (69.7%) of inpatients were discharged from Kanuma Hospital at least at once for ten year. There are no data for comparison so that we do not know if the rate of being discharged of inpatients is good enough or not in comparison with other psychiatric hospitals in Japan. According to my experience practicing in Canada, our data revealed that the period of being admitted were long compare to Canadian one.

41 Most physical complications in geriatric patients with dementia develop during early days of their hospitalization R Kumagai,1 K Asano,2 N Sato,2 Y Ichimiya1 1 Department of Psychiatry, Juntendo Tokyo Koto Geriatric Medical Center, Tokyo, Japan 2 Department of Nursing, Juntendo Tokyo Koto Geriatric Medical Center, Tokyo, Japan

Introduction: Elderly patients with dementia find it difficult to talk about their physical complications (PCs) due to cognitive impairment and presence of related atypical symptoms. To help prevent misdiagnosis or © 2015 The Authors Asia-Pacific Psychiatry © 2015 Wiley Publishing Asia Pty Ltd

delayed treatment, we studied the clinical features of patients with dementia who were treated for PCs in the psychiatric ward of our hospital. Methods: The clinical features of 155 patients with behavioral and psychological symptoms of dementia (BPSD) were examined retrospectively. In particular, patients with PCs were grouped, and their clinical data were reviewed for pertinent information, related to diagnosis and onset of PCs. Results: Thirty-eight patients developed PCs (52 cases). No significant differences were noted in the average age and sex ratio between the patients with and without PCs. The duration of hospital stay was longer for the patients with PCs. The PCs included pneumonia (13 cases), malignant tumor (7), digestive disease (6), bone fracture (5), circulatory disease (4), cranial nerve disease (4), diabetes mellitus (3), and the others (10). Further, 34 patients developed PCs within 30 days of hospitalization, 5 between from 31 to 60 days, and 13 after 61 days; 21 showed abnormalities during the examinations on the first day of hospitalization. Conclusions: Geriatric patients hospitalized for BPSD treatment may develop PCs during their stay, in the psychiatric ward of the hospital. The prevention of these PCs is currently limited and hence, general physical examinations should be performed on such patients both prior to admission and during their hospital stay.

42 Which can improve their belongingness and pride?: Predictors of group identification among nursing students YC Park,1 EY Jang,1 SM Lee2 1 Department of Neuropsychiatry, HanYang University Guri Hospital, Gyung Gi Do, South Korea 2 Department of Nursing, SongGok College, Gang Won Do, South Korea

Background: Identity or identification is defined as a feeling of belonging to the social world, and it is an essential source of self-esteem and pride. The model of domain identification (Osborne and Jones, 2011) suggested that the identity can be affected by family, peer, environment, educational experience, and individual’s goal and can affect motivation and academic outcomes. Our previous study (Jang, Lee, and Park, under review) found that identification with their domain (e.g., major) was meaningful mediator of major satisfaction and college adjustment of nursing students. As a subsequent work, this study was to explore the predictors of major identification.

13


Methods: A blinded associate briefed students (198 females and 71 males) on the purpose of the study and collected responses individually using a questionnaire. The questionnaire included scales to measure group identification and hypothesized predictors. Predictive variables can be divided into three categories. First, as personality variables, Big Five factors, narcissism, and self-esteem were included. Second, as social and environmental variables, social support, supportive supervision, educational supervision were included. Third, four sub-factors of work values (external reward, internal reward, and stability, and altruism) were also included. Results: The hierarchical model with four steps was significant (F = 17.68, p < .000) and incremental explanatory variance were all significant at each steps (ΔR2 = 0.02∼0.26, ps < 0.056). At step 1, age effect was significant (β = .14, p = .021). In other words, the older the nursing students, the stronger their identification with their major was. At step 2, conscientiousness (β = .13, p = .036), agreeableness (β = .26, p = .000), narcissism (β = .19, p = .002), and self-esteem (β = .25, p = .000) were associated with identification positively. At step 3, social support from friends or family (β = .45, p = .000) and supportive supervision from faculties (β = .13, p = .046) were associated with identification positively. At final and fourth step, the more valuable they regard altruism in work, the stronger their identification with their major was (β = .17, p = .017). However, there was no significant interaction effect including gender as a moderator. Conclusion: The results showed that multi-channel approach is needed to increase identification with nursing domain. Specifically, social network which can provide them with support and courage should be organized covering their individual and school lives. Also, educational course should be designed to make them consider which work value they want to actualize.

43 Cultural competency training in graduate medical education B Singh,1 D Groll1 1 Department of Psychiatry, Queen’s University, Kingston, Canada

Introduction: Cultural competency is an important skill that prepares physicians to care for patients from diverse backgrounds. It is a critical aspect of “professionalism” and “interpersonal and communication skills.” Cultural competency is an important part of medical

14

policy and practice, yet the evidence base for the effectiveness of training in this area is weak. The aim of this study was to measure knowledge, skill and attitudes on cultural training among post-graduate medical graduates. Material and methods: Seventy-one residents (family medicine, psychiatry, and other) completed Cross-Cultural Care Survey (CCSC) to assess their selfreported knowledge, skills and attitudes regarding the provision of cross-cultural care. Results: Sixty percent of the residents who completed the CCSC felt that it was important to consider the patient’s culture when providing medical care. Although greater than fifty percent of the residents did not feel helpless when providing care to patients of different culture, it appears that majority of the residents across specialties are not being trained or evaluated in crosscultural care.

44 Art making in patients with mental illness B Singh Department of Psychiatry, Queen’s University, Kingston, Canada

Introduction: Art can be used for facilitating emotional expression, increasing sense of control, promoting inner strength and sense of purpose and reducing stress and isolation. Art making enhances self-worth and identity through providing opportunities to demonstrate continuity, challenge and achievement. Materials and methods: Narrative research methods were used in this study to focus on changes in individual and their worldview. Participants were patients with mental illness who used art as an adjunct in an art group or individually to cope with their mental illness. Data were collected through in-depth interviews conducted by the author. The goal of analysis was to create a synthesis of what the patients said and to create a meaningful representation of what they meant by what they said. Results: Analysis of narratives yielded three story lines: Getting a clearer view, Clearing the way emotionally and Art as a Haven. The story lines show existence being affirmed, confirmed and proclaimed through artistic expression and the experience of mental illness changing both the artist and her art. Art making is helpful as means of psychosocial support for patients with mental illness. It helps them deal with their illness in ways support groups and art therapy cannot. The therapeutic © 2015 The Authors Asia-Pacific Psychiatry © 2015 Wiley Publishing Asia Pty Ltd


benefit of art making demonstrated in this study shows an avenue that can be used to enhance support services for patients with mental illness.

45 Establishing a virtual collaborative network in economically challenging times: Lessons from “AUSSIE” – The Australian United States Scandinavian Imaging Exchange JCL Looi,1,2,3* D Velakoulis,2 M Walterfang,2 LO Wahlund3 1 *Academic Unit of Psychiatry and Addiction Medicine, Australian National University Medical School, Canberra, Australia 2 Neuropsychiatry Unit, Royal Melbourne Hospital, Melbourne Neuropsychiatry Centre, University of Melbourne and Northwestern Mental Health, Melbourne, Australia 3 Karolinska Institute, Department of Neurobiology, Care Sciences and Society, Division of Clinical Geriatrics, Stockholm, Sweden

Introduction: We describe the lessons of the development, design and function of an innovative international clinical research network for neuropsychiatric neuroimaging biomarker research, based in Australia, within a joint state health service/medical school. This virtual research network was developed with minimal funding in the context of challenging economic times. Materials and methods: We describe the iterative development of the network, identifying characteristic features and methods that may serve as potential models for virtual clinical research networks. Results: The network has harnessed synergies from the individual expertise of the component groups, primarily clinical neuroscience researchers, to analyse a variety of clinical data. Based on a case study of our network, we describe how to: develop ideas for a collaborative research network; how to develop project plans; development of clinical research capacity by cosupervision and training of students/researchers; principles on how to keep the network active; and the strengths and pitfalls of our model. AUSSIE is an active virtual clinical research network that can act as a model for innovative collaborative research within challenging economic times. The lessons and principles from our network can potentially be applied to clinical psychiatric and mental health epidemiologic research across the Pacific Rim.


47 The importance of the learning environment during psychiatry clerkship in influencing Singapore medical students’ attitudes to psychiatry R Mahendran,1,2,3 HA Lim,1 S Verma,3,4 EH Kua1,2 1 Department of Psychological Medicine, National University of Singapore, Singapore 2 Department of Psychological Medicine, National University Hospital, Singapore 3 Duke-NUS Graduate Medical School, Singapore 4 Department of Early Psychosis Intervention, Institute of Mental Health, Singapore

Introduction: With psychiatry on the decline as a career choice, it is surprising that no published studies have examined the interplay of attitudes to psychiatry and the learning environment; this study addresses this lacuna. Methods: This ethics-approved study was conducted on 100 medical students (National University of Singapore) undergoing their psychiatry rotation. Baseline and post-rotation assessments of their attitudes to psychiatry (mAPS) and learning environment (DREEM) were obtained. Results: Analyses revealed that the clerkship significantly improved attitudinal scores (Z = −3.09, p = .002), and these were a result of the environment (rho[100] = .29, p = .003), specifically, their perception of learning, teachers, the atmosphere, and their social self-perceptions (rhos[100] = .21–.30, ps < .05), but not academic self-perceptions. Interestingly, the clerkship showed that the learning environment significantly influenced changes in all mAPS subscales (merits of psychiatry as scientific medicine, effectiveness of treatment, inspiration from medical school) except stigma of psychiatry (rho[100] = .18, p = .10). Conclusions: These preliminary results suggest the importance of the learning environment during clerkship in improving future physicians’ attitudes toward psychiatry; however, more still needs to be done to address the stigma of this discipline.

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48

49

Efficacy of a brief nurse-led psychosocial intervention for cancer patients in Singapore

Current activities of medical centers for dementia in Japan S Awata,1 K Ito,1,2 T Okamura,1,3 H Niikawa,1,3

1,2,3

R Mahendran, EH Kua1,2

1

2

4

HA Lim, J Chua, SE Lim,

1 Department of Psychological Medicine, National University of Singapore, Singapore 2 Department of Psychological Medicine, National University Hospital, Singapore 3 Duke-NUS Graduate Medical School, Singapore 4 National University Cancer Institute, Singapore, National University Health System, Singapore

Introduction: Individuals diagnosed with cancer are often highly distressed but less willing to commit to seeing psychiatrists, preferring, instead, informal nurseinteractions. In this study, we examined the efficacy of brief nurse-led psychosocial interventions for cancer patients. Methods: This ethics-approved study was conducted as part of a Healthcare Quality Improvement Project in Singapore. 110 participants were offered the intervention; 51 (46%) were not keen in participating and formed the Control group. Baseline and 5 months measurements of distress (DT), anxiety and depression (HADS), and quality of life (EQ-5D) were taken. The 20-minute intervention was delivered face-to-face by trained nurses monthly for 3 months, then bimonthly for 6 months. It included psycho-education on distress symptom recognition and management, and both cognitive and behavioral relaxation techniques. Results: Analyses revealed that there were significant reductions in DT and HADS (t[59] = 3.35–6.18, ps < .05), and significant improvements in EQ-5D scores (t[59] = 3.18, p < .05) in the intervention but not control group between baseline and 5 months. Conclusions: These preliminary results suggest that nurse-led interventions may be sufficient in managing pre-clinical levels of distress, anxiety, and depression in patients with cancer but must be supported by appropriate nurse training and empowerment.

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1 Research Team for Promoting Independence of the Elderly, Tokyo Metropolitan Institute of Gerontology, Tokyo, Japan 2 Department of Vascular Medicine, Tokyo Medical and Dental University, Tokyo, Japan 3 Department of Neuropsychiatry, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan

Aim: We investigated the current activities of medical centers for dementia (MCDs) and proposed recommendations for a national dementia strategy. Methods: A questionnaire was mailed to 172 hospitals designated as MCDs as of August 7, 2012. Results: Data from 117 MCDs that adequately responded and were designated by April 1, 2012 were analyzed. The mean and median numbers of medical consultations per MCD were 1,035 and 595 (range 114– 8,541)/year, those of patients diagnosed with dementiarelated disorders were 266 and 231 (3–1,179)/year, those of patients with dementia-related disorders admitted to the MCD hospital were 89 and 47 (0–1,176)/year, and mean and median proportions of patients discharged within two months were 45.5 and 36.8 (0–100) %. Outreach services in collaboration with a community general support center (CGSC) were provided in 23.9%, while training for CGSC staff members was conducted in 66.7%. Of MCD hospitals, 31.6% were designated as an emergency medical hospital and of these specialist liaison-team services for patients with dementia in the emergency room were provided in 56.8%. Conclusions: Most MCDs are considered to function fairly well in line with the guidelines published by the MHLW. However, there is a huge discrepancy in the number of patients diagnosed with dementia-related disorders and the length of stay for inpatient care among facilities. To make all MCDs function adequately, the activity of MCDs should be monitored longitudinally using the standardized assessment methods.



52 Genetic association between KIBRA with Alzheimer’s disease and dementia with Lewy bodies in a Japanese population K Kasanuki,1 N Shibata,1 T Ohnuma,1 E Iseki,1 M Kitazawa,1 Y Ichimiya,1 H Arai1 1 Department of Psychiatry, Juntendo University School of Medicine, Tokyo, Japan

Background: KIBRA has a potential relevance to the biology of memory. Previous paper reported an association of a common variant of the KIBRA gene with an increased risk for the onset age of Alzheimer’s disease (AD). The aim of this study was to identify whether common single nucleotide polymorphism (SNPs) of the KIBRA gene are associated with dementia with Lewy bodies (DLB). Methods: Among 236 AD patients, 46 DLB patients and 154 age-matched controls, SNPs genotyped using TaqMan technology was analyzed using a case–control study. Logistic analysis with apolipoprotein E (ApoE) status was also performed. Results: There was no statistical difference between AD and controls, nor was there between DLB and controls. We failed to detect any synergetic association among the SNPs, APO E, and AD/DLB. Conclusions: In our Japanese cohort, the SNPs studied here did not influence the risk for AD or DLB. Further genetic studies are needed to clarify the relationship between the KIBRA gene and DLB. 55 Psychotic and pasung in Indonesian population: A national study Sri Idaiani,1 Sri Prihatini,1 Lely Indrawati,2 Indri Yunita2 1 Center for Applied Health Technology and Clinical Epidemiology, National Institute of Health Research and Development, Ministry of Health of Republic of Indonesia, Jakarta, Indonesia 2 Center for Public Health Intervention Technology, National Institute of Health Research and Development, Ministry of Health of Republic of Indonesia, Jakarta, Indonesia

Background: A national basic health research or in bahasa is Riset Kesehatan Dasar (Riskesdas) was conducted to entire population of Indonesia. The mental health section of Riskesdas specifically aimed at investigating the prevalence of psychotic and the proportion of people with psychotic experiencing physical restraint and confinement (called pasung). © 2015 The Authors Asia-Pacific Psychiatry © 2015 Wiley Publishing Asia Pty Ltd

Methods: The survey was conducted simultaneously in all regions of Indonesia spreading across 33 provinces or 497 municipals and cities from May to June 2013. Households were selected as samples of the study which was conducted in four stages, namely 1) determining primary sampling unit, 2) determining census block by means of probability proportional to size, 3) determining census building by means of systematic sampling, 4) determining selected households by means of random sampling. Assessment on people with existing psychotic is derived on the basis of an interview performed by well trained enumerators to the head of the household. Results: Response rate of the census blocks, census building, household, and household members are 93%99%. The prevalence of Indonesian population in all age groups experiencing psychotic is 1.7 per 1,000 populations. The proportion of households committed to do pasung to its member with psychotic is 14.3% with the highest rate (18.2%) occurring in rural areas. Coverage of health care service on the treatment is 61.8%. Conclusion: Strengthening integrating mental health into primary health centers is needed to address mental health problem especially for psychotic people living in rural to eliminate pasung practice by families. 57 Changes in job stressors and psychological distress among workers in Iwate Prefecture after the Great East Japan Earthquake and Tsunami M Kurosawa,1 M Ohsawa,2 S Sakashita,3 S Aoki4 1 Iwate Mental Health Center, Morioka, Japan 2 Department of Hygiene and Preventive Medicine, Iwate Medical University, Morioka, Japan 3 Iwate Occupational Health Promotion Center, Morioka, Japan 4 Faculty of Social Welfare, Iwate Prefectural University, Takizawa, Japan

Background: The 2011 Great East Japan Earthquake and Tsunami may have negative impacts on mental health of workers in Iwate Prefecture, an area severely affected by the disaster. Methods: Job stressors and psychological distress were collected from 20,819 male workers using a selfreport Multi-dimensional Job Stress Questionnaire. Proportions of subjects with the highest risk were estimated in the groups stratified by the year (2010 vs 2011) and the area (coastal vs inland). Results: In the coastal area, percentage of high-risk workers increased from 2010 to 2011, whereas the inland area workers remained unchanged. (Table 1; P < 0.05) Conclusions: The disaster contributes to adverse mental health status among Iwate coastal area workers.

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Table 1. Comparison of proportions of Iwate Prefecture male workers (n = 20819) with high mental health risks, stratified by the year (2010 vs 2011) and the area (coastal vs inland) Area

Year

Quantitative job overload

Physical demand

Fatigue

Depression

Coastal area

2010 2011 2010 2011

5.5% 8.2%* 6.3% 6.8%

6.7% 13.4%* 9.4% 10.6%

5.3% 10.7%* 7.8% 8.7%

7.6% 10.3%* 8.6% 8.5%

Inland area *p < 0.05.

58 Clozapine induced thrombocytopenia

into consideration to avoid unnecessary dose reduction or stoppage of clozapine, which might lead to relapse in this treatment resistant patient population.

C Enquan,1 C Tang,2 NB Tat,3 K Ng,1 J Hariram,1 L Cheng1

60

1 Department of Community Psychiatry, Institute of Mental Health, Singapore 2 Department of General Psychiatry, Institute of Mental Health, Singapore 3 Department of Pharmacy, Institute of Mental Health, Singapore

Developing a mental health research career: A review of early career opportunities in the U.S. AR Teo

Background: Clozapine is an inexpensive yet effective medication used for treatment resistant schizophrenia. While agranulocytosis is a well-known adverse effect of clozapine therapy, clozapine induced thrombocytopenia is not often reported. This case series highlights thrombocytopenia as a potential adverse effect of clozapine therapy, and aims to discuss a possible framework for the management of patients with clozapine induced thrombocytopenia. Methods: We report 4 patients treated with clozapine who developed thrombocytopenia, 3 of whom had mild thrombocytopenia (100 × 109 ≤ plt < 150 × 109) while 1 had moderate thrombocytopenia (50 × 109 ≤ plt < 100 × 109). Results: Mild thrombocytopenia resolved in 2 cases without any reduction in clozapine dose while in the remaining case, it resolved after the clozapine dose was reduced. In one of the cases with moderate thrombocytopenia, it resolved after valproate was stopped despite an increase in the clozapine dose. Conclusions: Although uncommon, clozapine therapy can lead to thrombocytopenia. It may also interact with other drugs known to cause thrombocytopenia such as valproate in reducing the platelet count. Therefore it is recommended that the platelet count of patients on clozapine should be monitored regularly. A set of guidelines for management of clozapine related thrombocytopenia is suggested according to the level of severity after reviewing the available literature. It might be useful for the clozapine service to take these guidelines

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Portland VA Medical Center and Oregon Health & Science University, Portland, OR, USA

Introduction: Opportunities for developing a research career are often not apparent to psychiatric trainees and early career psychiatrists. Partly as a result, many psychiatrists do not pursue research careers, have difficulty in obtaining research funding, and there is a significant shortage of psychiatric researchers. Methods: A literature review and discussions with academic stakeholders were conducted with a focus on clinical research training opportunities in the United States. Results: Though limited training opportunities for research careers can be traced back to the 1960s in the United States, significant development of formal training programs and curricula in the design and conduct of clinical research only began in the 1980s. The growing complexity of clinical trials and the emergence of evidence-based medicine had created great demand for psychiatrists with knowledge of clinical epidemiology and biostatistics. Currently available training opportunities range in intensity from graduate degree-granting programs to intensive summer institutes. They are financially supported by an assortment of institutions including government (e.g., National Institutes of Health), foundations (e.g., Robert Wood Johnson Foundation), and universities. Key components of successful research training programs include didactic coursework, practica, individual mentorship, supplementary workshops, and receipt of a certificate or degree. © 2015 The Authors Asia-Pacific Psychiatry © 2015 Wiley Publishing Asia Pty Ltd


Conclusions: A number of promising programs and opportunities exist to facilitate early stage development of a mental health research career. 61 A cross-national study of social withdrawal: Identification, diagnosis and psychosocial features of hikikomori in four countries AR Teo,1 MD Fetters,2 K Stufflebam,3 M Tateno,4 Y Balhara,5 TY Choi,6 S Kanba,7 CA Mathews,8 TA Kato7,9 1 Portland VA Medical Center and Oregon Health & Science University, Portland, OR, USA 2 Japanese Family Health Program and Department of Family Medicine, University of Michigan, Ann Arbor, MI, USA 3 FreshStart ClubHouse, Ann Arbor, MI, USA 4 Sapporo Hana Developmental Psychiatry Clinic and Department of Neuropsychiatry, Sapporo Medical University, Ch -ku, Sapporo, Hokkaid , Japan 5 National Drug Dependence Treatment Centre, All India Institute of Medical Sciences(AIIMS), New Delhi, India 6 Department of Psychiatry, Catholic University of Daegu School of Medicine, Daegu, South Korea 7 Department of Neuropsychiatry, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan 8 Department of Psychiatry, University of California San Francisco, San Francisco, CA, USA 9 Innovation Center for Medical Redox Navigation, Kyushu University, Fukuoka, Japan

Introduction: Researchers have suggested that hikikomori – a severe form of social withdrawal first reported in Japan – may exist globally, but no study has evaluated hikikomori cross-nationally. This study aimed to identify hikikomori in multiple countries and describe features of the condition. Methods: Adult participants were recruited from clinical and community sites in India, Japan, and the U.S. Hikikomori was determined by a standardized assessment tool. Participants self-report several measures including the UCLA Loneliness Scale, Lubben Social Network Scale, Sheehan Disability Scale, modified Cornell Treatment Preferences Index, Temperament and Character Inventory-140 and Internet Addiction Test. Participants in the U.S. and Japan also completed the Structured Clinical Interview for the DSM-IV (SCID) Axis I and Axis II Disorders. Results: Thirty-six cases of hikikomori were identified in all four countries (N = 11 each for Japan and the U.S., 10 for India, and 4 for Korea). Overall, individuals with hikikomori were very lonely, with impaired social networks and moderate functional disability. Twentyeight (78%) desired treatment for their social withdrawal. © 2015 The Authors Asia-Pacific Psychiatry © 2015 Wiley Publishing Asia Pty Ltd

Of the 22 participants who completed all diagnostic assessments, the most common psychiatric diagnoses were avoidant and paranoid personality disorders, major depressive disorder, social anxiety disorder, and posttraumatic stress disorder. Fifteen participants (68%) had multiple psychiatric disorders, but 5 (23%) had no psychiatric history. Conclusions: Hikikomori exists cross-nationally, can be assessed with a standardized assessment tool, and appears associated with substantial psychopathology, psychosocial impairment and disability, and desire for treatment. Future studies should include larger samples of individuals with hikikomori compared to control groups.

63 Risperdal Consta is a cost-effective treatment: A 5-year retrospective study GV Obrocea,1 S Abdijadid,1 S Vasan,1 A Kian,2 L Grayson,1 C Sevilla,1 TP Yoo1 1 UCLA-Kern Department of Psychiatry, David Geffen School of Medicine, Bakersfield, CA, USA 2 Department of Psychiatry Residency Program, Kaiser Permanente Fontana Medical Center, Fontana, CA, USA

Introduction: Risperdal-Consta, an atypical antipsychotic, is approved for bipolar disorder as monotherapy. There are a few studies examining its role when added to the treatment regimen for a longer time period Material and methods: This retrospective chart review study examines the Clinical Global Impression Scale (CGI-BP) every two weeks when Risperdal-Consta is added to the treatment regimen over a five-year period in patients with mood disorder. Age, gender, ethnicity, diagnosis, number of re-hospitalizations and RisperdalConsta dosage were recorded. Results: Gender and racial distribution for the 52 patients included was: 58% female and 42% male; with 63% Hispanic preponderance. 80% had a mood disorder. During the first year, 21% of patients had a CGI of Much Worse; however, with treatment continuation, the response recovered at 48 and 60 months. 62% of patients had a CGI of Very Much Improved at 1 month; 77% at 3 months, 83%, at 6 months, 90% at 9 months, 74% at 12 months, 77% at 24 months, 88%, at 36 months, 100% at 48 and 60 months of treatment. Only 10% of patients were re-hospitalized during this period. 3.8% patients were re-hospitalized 3 times; the rest had only one re-hospitalization in this five-year period. Only 4.76% of patients with bipolar disorder were hospitalized only once in this five-year period.

19


Discussion and conclusion: In this five-year follow-up study all patients with Risperdal-Consta added on experienced a certain degree of improvement in their CGI and fewer rates of re-hospitalizations.

65 Adjunct treatment with Metformin and/or Phentermine in treatment of over-weight patients GV Obrocea,1 S Abdijadid,1 S Vasan,1 A Kian,2 L Grayson,1 C Sevilla,1 TP Yoo1 1 UCLA-Kern Department of Psychiatry, David Geffen School of Medicine, Bakersfield, CA, USA 2 Department of Psychiatry Residency Program, Kaiser Permanente Fontana Medical Center, Fontana, CA, USA

Introduction: Weight gain an undesirable side effect of psychotropics, can cause medication non-adherence. Metformin and Phentermine are agents known to promote weight loss and can be effective in minimizing medication non-adherence. Material and methods: This retrospective chart review from 2004 to 2013, examines weight loss after treatment with the respective agent. Age, gender, ethnicity, Metformin dosage, Phentermine dosage, DSM-IV diagnosis, Medical Diagnosis and medication history were recorded. Weight loss was measured by patients’ reports and weight measured at each visit. Results: 35 patients age 22–71 years old received Metformin 500–1000 mg PO QD-BID and/or Phentermine 37.5 mg PO QD. 88% received Metformin, 11% received Phentermine alone and 1% received Phentermine and Metformin together. Gender and ethnicity distribution for patients treated with Metformin were 89% female, 11% male, 68% Hispanic and 32% Caucasian; while patients on Phentermine were 95% female, 5% male and 100% Caucasian. Patients on Metformin and Phentermine together were 100% female, 50% Hispanic and 50% Caucasian. 97% of patients on Metformin experienced weight loss. The Metformin weight loss observed in the antipsychotic treated arm was approximately 12 lbs while the Metformin weight loss observed in the Lithium treated arm was approximately 10.5 lbs. 100% of patients that received Metformin and Phentermine experienced weight loss. This was approximately 58.7 lbs for antipsychotic treated arm and approximately 30.5 lbs for the Lithium treated arm. Discussion and conclusion: The Metformin/ Phentermine combination leads to greater weight loss than either Metformin or Phentermine alone. Only one

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patient experienced side effects that warranted the decrease in Metformin in the daily dose, and none required discontinuation.

66 Lithium and Lamotrigine combination in treatment of cyclic mood disorders GV Obrocea,1 S Abdijadid,1 H Shacket,3 L Dolowich,2 S Vasan,1 A Kian,4 C Sevilla,1 TP Yoo1 1 UCLA-Kern Department of Psychiatry, David Geffen School of Medicine, Bakersfield, CA, USA 2 Veterans Affairs Palo Alto Health Care System, Department of Stanford Psychiatry Residency Program, Stanford School of Medicine, Palo Alto, CA, USA 3 Department of Child and Adolescent Psychiatry, Dartmouth Hitchcock Medical Center, Lebanon, NH, USA 4 Department of Psychiatry Residency Program, Kaiser Permanente Fontana Medical Center, Fontana, CA, USA

Introduction: Lithium and Lamotrigine are prophylactic agents for bipolar disorder. Lithium is effective against manic symptoms, whereas Lamotrigine is effective in bipolar depression. Combination may provide efficacious treatment for patients with bipolar disorder. Material and methods: This retrospective chart review study examines the efficacy of Lithium and Lamotrigine combination in the treatment of cyclic mood disorder. The Clinical Global Impression Scale (CGI-BP) was obtained every month for a one-year period, when the above combination was applied. Age, gender, ethnicity, diagnosis, and Lithium/Lamotrigine dosage were recorded. Results: 87 patients were identified that have received this combination. The Lithium dose was 300–900 mg orally at bedtime. The Lamotrigine dose was 100–300 mg orally daily. Gender and racial distributions were: 75% female and 25% male; with 61% Hispanic preponderance. The diagnoses were: 76.5% Bipolar (I & II), 19% Major Depressive Disorder, and 4.5% Schizoaffective Disorder. Combined CGI improvement for both genders totaled 73% at 1 month, 63% at 6 months and 71% at 12 months. Looking at male response, the CGI improvement was 63% at 1 month, 57% at 6 months and 86% at 12 months. The female CGI improvement was 76% at 1 month, 65% at 3 months and 68% at 12 months. Discussion and conclusion: The treatment combination with Lithium-Lamotrigine is well-tolerated and effective modality for cyclic mood disorders. No patients have developed Steven-Johnson Syndrome. The female response was sustained from the first to the 12th month of the treatment, whereas the males displayed a biphasic © 2015 The Authors Asia-Pacific Psychiatry © 2015 Wiley Publishing Asia Pty Ltd


response. Male response was overall superior to female response.

Conclusion: The author referred to the decision for surgical treatment made from a psychiatric standpoint supported by obtained data.

68 69 The role of psychiatrists in determining surgical treatment for obesity patients Y Fujii,1 S Katsuragawa,1 K Hayashi,1 N Kuroki1

The efficacy of a rehabilitation program for workers who were given leaves of absence

1 Department of Psychiatry, Toho University Sakura Medical Center, Chiba, Japan

S Katsuragawa,1 Y Fujii,1 K Hayashi,1 N Kuroki1

Introduction: The problem of obesity is spreading

1 Department of Psychiatry, Toho University Sakura Medical Center, Chiba, Japan

throughout the whole world, though differences exist between countries and regions. In Japan, the number of obese people is increasing and becoming a social problem due to the westernization of our eating customs and food contents. Toho University Sakura Medical Center has been treating obesity patients since 1997, with surgical treatment beginning in 2010. The Japanese surgical treatment guidelines for obesity patients were published in 2013. Within these guidelines, emphasis is placed on partnership and cooperation among a team of healthcare professionals including not only a surgeon, but also physicians of internal medicine and psychosomatic medicine, a psychiatrist, a registered nurse, a dietitian, and a physical therapist. Methods: Obesity patients who visited our hospital were surveyed retrospectively within the four-year time period from January 2010 to January 2014. Results: There were 58 cases in the stated time period. 35 cases received surgical operations. There were significant differences between the group who had received surgical operation and another group who did not, concerning of sex, the presence of joint disturbances and the presence of hypertension. 24 cases had psychiatric diagnoses; 14 cases of F3 depressive disorders and bipolar disorders, 3cases of F5 eating disorders, 1 case of F2 schizophrenia, 1 case of F4 anxiety disorders and 5 cases of others. Discussion: Regular case conferences are held and various professionals meet together to discuss problems which might affect weight gain for each patient. Psychiatrists and psychologists analyze socio-psychological factors affecting the patient’s personality, which might lead to overeating behavior. It is especially important that the discussion should be extra careful when we conclude surgical treatment is appropriate, as the patient may have mental disorders or problems, which are considered to have a relationship to obesity.


Introduction: Recently the number of workers who were given leaves of absence caused by depression or other mental disorders is increasing in Japan. The Ministry of Health, Labor and Welfare declared that mental health measures among workers are required urgently. We started a new rehabilitation program at our hospital daycare center in 2007. Methods: All patients who participated in the program in the time period from September 2007 to August 2014. Results: There were 381 participants. 80% of them were male. Within them, 352 participants who attended re-work program, in order to return to the workplace were analyzed. As for diagnosis according to ICD-10, 60% of them had Major Depressive Disorders (F32 or F33), 11% had Bipolar Disorders (F31), 20% had Neurotic Disorders (F4) including Phobic Anxiety disorders (F40) and other Anxiety Disorders (F41), and 5% had Schizophrenia (F2). About 30% of participants received treatment for 3 months, another 30% for 6 months, another 30% for 12 months, and about 10% for over a year. 79% of them succeeded in returning to their workplaces and 21% failed. Discussion: At present there are about 140 facilities that provide such programs in Japan. There was a significant difference in preventing a recurrence between the patients who participated in the program and those who did not. On the other hand, the concept of depression is diversifying. We also have new treatment problems that are not typical depressive disorders. Conclusion: In order to achieve the goals of our effective rehabilitation program further development is required.

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74

79

Omega-3 polyunsaturated fatty acids supplements and cognitive function in older Chinese adults: Findings from the Singapore Longitudinal Aging Studies

The Asahi Model: A model for deinstitutionalization in Japan

Q Gao,1,2 L Feng,1,2 MSZ Nyunt,1,2 XY Gwee,1,2 ML Lim,1,2 S Collinson,3 M Niti,4 KB Yap,5 TP Ng1,2 1 Gerontological Research Programme, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 2 Department of Psychological Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 3 Department of Psychology, National University of Singapore, Singapore 4 Research and Evaluation, Ministry of Health, Singapore 5 Department of Geriatric Medicine, Alexandra Hospital, Singapore

Introduction: To examine the relationship between long chain omega-3 polyunsaturated fatty acid (n-3 PUFA) supplements intake and cognitive function in an older Chinese population. Methods: Among community-dwelling non-demented Chinese adults aged ≥55 years in the Singapore Longitudinal Aging Studies (SLAS) cohort, we measured selfreported habitual intake of omega-3 supplements (daily and non-daily consumptions) and administered the MiniMental State Examination (MMSE) and a battery of neuropsychological tests at baseline and 1–2 years follow-up. Cognitive decline was defined as at least 2-point drop in MMSE score from baseline to follow-up. Composite domain scores on attention, memory, executive function, and information processing speed were computed using raw test scores. We performed cross-sectional analysis of baseline data from 2,306 participants and longitudinal analysis of data from 1,475 participants. Odds ratios (ORs) of association were calculated in binomial logistic regression that controlled for potential confounders. Results: At baseline, after adjusting for potential confounders, daily intake of n-3 PUFA supplements was independently associated with better cognitive performance on memory (β = 0.098, SE = 0.31, P = 0.006), executive function (β = 0.071, SE = 0.43, P = 0.046) and information processing speed (β = 0.074, SE = 0.24, P = 0.036). For cognitive decline, daily intake of n-3 PUFA supplements was significantly associated with lower risk cognitive decline, independent of other risk factors (P = 0.015, OR = 0.23, 95% C.I. 0.07–0.75). Omega-3 supplements consumption was independently associated with better cognitive performance on domains of memory, executive function and information processing speed, and lower risk of cognitive decline in elderly Chinese.

22

T Aoki,1 A Ito,1 Y Otsuka,1 H Hasegawa,1 T Isono,1 H Ogura,1 Y Hosoda,1 K Fujii,1 M Kimura,1 K Idemoto,1 H Watanabe,2 N Yano1 1 Department of Psychiatry, Asahi General Hospital, Asahi, Japan 2 Department of Psychiatry, Chiba University, School of Medicine, Chiba, Japan

Introduction: Japanese psychiatric services are still typically hospital-based. The Asahi Project was initiated to make a well-balanced services model in Japan. Methods: To investigate a well-balanced services model, we looked at main points, the number of inpatients beds, the average length of stay, and the data of psychiatric emergency of Department of Psychiatry, Asahi General Hospital. Results: It was established in 1965, with 120 inpatient beds, increasing to 237 in 1985. In 2002 the Asahi Project, a multidisciplinary team project to integrate mental health services had been available. A subsequent study determined that 152 of 233 patients (65.2%) were inpatients for over one year, but that 76 of the 152 (50%) could have been discharged if housing and outreach services had been available. We initiated discharge programs and eventually discharged 29 of these patients. In 2005 working groups, such as housing, outreach and in-patient care services, in 2012 a community mental health team were established. We now have one inpatient ward with 42 beds. These changes have resulted in a rapid decrease in the average length of stay and the average number of emergency psychiatric outpatient visits. Conclusion: Firstly, it is possible to be deinstitutionalized by both elements of community care with a limited provision of hospital care even in Japan. Secondly, this model might be useful for effecting transition from hospital to community care in Japan and other countries where such changes have been proposed.



80

16 14

Cognitive stimulation and cognitive training program in mild cognitive impairment (MCI)

12

1 Department of Psychiatry, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand 2 Department of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand 3 Department of Family Medicine, Phramongkutklao College of Medicine, Bangkok, Thailand 4 Srithanya Hospital, Nonthaburi, Thailand 5 Department of Psychiatry, Siriraj Hospital, Mahidol University, Bangkok, Thailand

0


Pre-test

8 6

program covering 4 domains, namely attention, memory, visuospatial and executive functions is proposed to improve cognitive functions of MCI patients. Materials and methods: Firstly, a series of neuropsychological tests have been applied to 91 elderly MCI patients to evaluate their 4 cognitive domains. Thereafter, patients were separated into 2 groups. 49 patients is an intervention group (IG), receiving 6 sessions of groupbased multicomponent cognitive training in every 2 weeks. 42 patients is a control group (CG) with no intervention. After 6 months, evaluation was carried out to track the change of cognitive functions in each group. Results: At the end of training, patients in IG have significantly improved their targeted cognitive abilities compared with baseline (p < 0.05). To compare the results of pre-and post-tests from both IG and CG, a ratio between number of patients with improved score from learning slope subtest of Weshler Memory Scale (WMS) and those with reduced score indicates difference that the ratio of IG is 2:1 while that of CG is 1:1 (p = 0.05). In addition, the detailed mean analysis of difference between pre-and post-tests also suggests that each cognitive function of IG is improved compared with that of CG. The results are illustrated in Figure 1. Conclusion: The results of this study indicate that proposed multicomponent cognitive training is effective to help MCI patients improve cognitive functions that relate to activities designed in the proposed training program. It is also found that patients who participate in training program regularly tend to better maintain their brain capabilities.

*

10

D Nakawiro,1 S Chansirikarnjana,2 P Srisuwan,3 O Aebthaisong,4 P Sudsakorn,5 C Vidhyachak,1 P Visajan1

Introduction: A newly developed cognitive training

* P < 0.001 *

*

4

Post-test

*

2

Attention/ Visuospatial fn.

Executive fn. Memory

Figure 1. Comparison between pre-test and post-test in intervention group.

81 Mental health services in rural areas in Siem Reap province, Cambodia T Marutani,1,2,4 A Nishio,2,5 P Tey,3 V Voeurn,3 N Shinohara,2,4,6 Y Hashizaki,2,4 A Kubota,2,4 T Aoki

2,7

1 Health Service Center, Tokyo Institute of Technology, Kanagawa, Japan 2 SUMH (Supporters for Mental Health), Tokyo, Japan 3 SUMH-Cambodia, Siem Reap, Cambodia 4 Kinshicho Kubota Clinic, Tokyo, Japan 5 Health Administration Center, Gifu University, Gifu, Japan 6 Yotsuya Yui Clinic, Tokyo, Japan 7 Asahi General Hospital, Chiba, Japan

Introduction: During the Pol Pot genocidal regime in Cambodia, all psychiatric patients, psychiatrists, and mental health specialists lost their lives. Mental health services remain limited, particularly in rural areas. In 1997, we launched Japan’s first NGO aimed at supporting international mental health care, Supporters for Mental Health (SUMH). The regional office SUMHCambodia began visiting twice-monthly psychiatric consultation services, offering a psychoeducational program, home visits, and key-person meetings at the Angkor Chum and Kralanh hospitals in 2010 and 2013 respectively. Both of these hospitals cover rural areas in Siem Reap province, in which psychiatric services were previously non-existent or very limited. Methods: The author collected activities data from the Angkor Chum and Kralanh projects, interviewed the SUMH-Cambodia director about the regional system, and visited patients in these rural areas in the presence of SUMH-Cambodia staff members. Results: The consultation frequency was 973 at Angkor Chum and 375 (for 6 months) at Kralanh hospital in 2013. Key-person meetings were held at 15 of 22 and

23


5 of 14 health centers in the Angkor Chum and Kralanh operational districts, respectively. SUMH-Cambodia invited village chiefs, village health support group (volunteers from each village), traditional midwives, traditional healers, monks, and families of patients to the meeting in cooperation with Health Center staff for the meetings. The prime target of their home visits is to follow up the schizophrenic patients. This project also intervened patients chained at home who had a relapse caused by medication noncompliance. Conclusions: SUMH-Cambodia offered mental health support projects in Cambodian rural areas, with services ranging from psychiatric consultation to outreach services. These projects improved mental health in the villages of Siem Reap province, in which access to professional services was previously non-existent or very limited. In the next step, we need to evaluate a relationship between the intervention and its effects on community mental health care.

82 Vitamin D3 as adjunct in treatment of depression C Sevilla,1 S Abdijadid,1 H Shacket,2 S Vasan,1 A Kian,3 TP Yoo,1 GV Obrocea1 1 UCLA-Kern Department of Psychiatry, David Geffen School of Medicine, Bakersfield, CA, USA 2 Department of Child and Adolescent Psychiatry, Dartmouth Hitchcock Medical Center, Lebanon, NH, USA 3 Department of Psychiatry Residency Program, Kaiser Permanente Fontana Medical Center, Fontana, CA, USA

Introduction: Vitamin D3 appears to be deficient in most patients in Southern California. There is a connection between Vitamin D induced osteoporosis and depression. This study ascertains whether treatment with Vitamin D3 is effective in treating the depression in cyclic mood disorder. Material and methods: A retrospective chart review was carried out using Clinical Global Impression Scale (CGI) as outcome measure when Vitamin D3 (1,000–50,000) is added to the treatment regimen of patients with cyclic mood disorder. Age, gender, ethnicity, Vitamin D3 dosage, DSM-IV diagnosis, Medical Diagnosis, Medication History, and pre and post treatment Vitamin D3 levels were recorded. Results: 20 patients between the ages of 18–84 were included in this study. Gender and racial distribution was 90% female, 10% male, 60% Hispanic and 40% Caucasian. The diagnosis were: 45% Major Depressive Disorder, 35% Bipolar (I & II) disorder, and 10% Schizoaffective

24

disorder. The CGI assessment was performed at 1, 3 and 9 months after initiation of treatment. 85% of patients experienced a certain degree of improvement. Of these patients, 45% had a CGI of Very Much Improved at 1, 50% at 3 and 55% at 9 months. CGI of Much Improved was seen in 25% of patients at 1, 35% at 6 and 9 months. A CGI of Minimally Improved was seen in 10% of patients at 1, 10% at 6 and 15% at 9 months. Discussion and conclusion: Adjunct treatment of Vitamin D3 is well tolerated and overall effective in management of cyclic mood disorder. There were no mood episodes reported.

84 Vitamin B12 as adjunct in treatment of refractory depression-phase II continuation study TP Yoo,1 S Abdijadid,1 H Shacket,2 S Vasan,1 A Kian,3 C Sevilla,1 GV Obrocea1 1 UCLA-Kern Department of Psychiatry, David Geffen School of Medicine, Bakersfield, CA, USA 2 Department of Child and Adolescent Psychiatry, Dartmouth Hitchcock Medical Center, Lebanon, NH, USA 3 Department of Psychiatry Residency Program, Kaiser Permanente Fontana Medical Center, Fontana, CA, USA

Introduction: Augmenting certain metabolic cofactors in treatment of cyclic mood disorder has been shown to be effective. This study was undertaken to observe the efficacy of vitamin B12 supplementation as adjuvant to regular pharmacotherapy in patients with cyclic mood disorder. Material and methods: This is a retrospective chart review examining the Clinical Global Impressions Scale as outcome measure at 1, 3, 6, 9 and12 months when Vitamin B12 1000 μg injection first every month in three months then once every three months in 12 months was added to the medication regimen of patients with cyclic mood disorders. Age, gender, ethnicity, dosage Vitamin B12, DSM-IV diagnosis (Axis I), Medical Diagnosis (Axis III), Medication history, as well as pre and post Vitamin B12 levels were recorded after bi-weekly follow-up appointments at 1, 3, 6, 9, and 12 months. Results: Data for this study was collected from 105 patients between the ages of 20–66. Gender and ethnicity distribution was 71% female, 29% male, 76% Hispanic and 24% Caucasian. The diagnoses were: 47% Bipolar (I & II) disorder, 42% Major Depressive Disorder, and 11% Schizoaffective disorder. The Clinical Global Impressions Scale (CGI-SI) after bi-weekly follow-up appointments. After 12 months of vitamin augmentation © 2015 The Authors Asia-Pacific Psychiatry © 2015 Wiley Publishing Asia Pty Ltd


therapy, notable improvement was observed in all patients. Overall remission of depressive symptoms was noted as much improved in 57% and very much improved in 10% of patients. Discussion and conclusion: Adjunct treatment of Vitamin B12 is well tolerated and overall effective in management of cyclic mood disorder. There were no mood episodes reported.

85 Long-term community support following the Great East Japan Earthquake: The process of establishing mental health awareness and care services Y Murakami,1 A Ito,1 M Suzuki1 1 NPO Kokoro no Kakehashi Iwate, Morioka, Iwate, Japan

Background: Few mental health resources exist in remote northeastern coastal areas affected by the 2011 earthquake and tsunami. Stigma surrounding psychiatric issues remains high in these communities, making care delivery difficult. Methods: For this project, 18 specialists conducted outreach over a series of weekends in Otsuchi, a town originally of 15,000 people. Goals were to: increase awareness of, and readiness to seek, mental health services; streamline the referral process for individuals needing services; and provide support to local agencies. Primary activities included: (1) tea-time sessions and educational activities focused on reducing stigma and increasing mental health awareness; (2) collaboration with local public/medical agencies; and (3) provision of individual counseling and medication. Results: The physical nature of tea-time sessions was welcomed as being less invasive; discussion of mental health issues followed. Much time was required before users came to trust services as something more than just temporary support. Ongoing activities over an extended period led to local agency referrals. Existing psychiatric patients were served first; these were followed by newly diagnosed individuals, individuals with disaster-related issues, and finally individuals who arrived via word-of-mouth. Conclusions: Initial awareness and care programs have gradually led to services becoming firmly established. However, much time is required before efforts bear fruit in this insulated culture. Continuing to patiently work with local resources will eventually lead to enhanced community care. © 2015 The Authors Asia-Pacific Psychiatry © 2015 Wiley Publishing Asia Pty Ltd

86 Gender difference in clinical factors associated with comorbid major depressive disorder in patients with panic disorder KS Oh,1 DW Lee,2 SW Lim1 1 Department of Psychiatry, Kangbuk Samsung Hospital, Sungkyunkwan University, Seoul, Republic of Korea 2 Department of Psychiatry, Sanggye Paik Hospital, Inje University, Seoul, Republic of Korea

Objective: Panic disorders are frequently accompanied by major depressive disorder (MDD). There is insufficient information about which clinical factors in panic disorder are associated with comorbid MDD. The aim of this study is to identify clinical factors related with comorbid MDD in patients with panic disorder. Methods: Two experienced psychiatrists diagnosed panic disorder based on DSM-IV criteria. This diagnosis in the 275 subjects (Male; 111, Female; 164) was confirmed again by Mini-International Neuropsychiatric Interview (MINI). Lifetime comorbid psychiatric diagnoses were examined by MINI. The Hamilton Depression Scale (HAMD), Hamilton Anxiety Scale (HAMA) and Panic Disorder Severity Scale (PDSS) were used to assess the severity of depressive, anxiety and panic symptoms. Results: The result of MINI showed that 95 patients (34%) with panic disorder satisfied the diagnosis of MDD. Multivariate logistic regression model showed that comorbid generalized anxiety disorder (GAD) (10.530 (3.635–30.500); adjusted OR (95% confidence interval (CI)) and the symptom of “fear of losing control or going crazy” were associated with MDD in patients with panic disorder (2.971(1.439–6.133); aOR (95%CI)). There was gender difference in this result; Men (4.919 (1.062– 22.780; aOR (95%CI)) showed more strong association than women (2.605 (1.059–6.408 aOR (95%CI)). In female patients, the “chills or hot flushes” symptom was also associated with comorbid MDD (3.638 (1.666– 7.941; aOR (95%CI)). Conclusion: These results showed that coexisting GAD and certain symptoms of panic disorder (“fear of losing control or going crazy” in both male and females, “chills or hot flushes” in females only) are associated with comorbid MDD. And the result of this study also showed that there is gender difference in clinical factors associated with comorbid MDD in panic disorder.

25


89

91

A systematic review of cognitive behavioral therapy in nursing field in Japan

Rational polypharmacy applied in a rural outpatient psychiatric clinic

1

2

1

3

N Yoshinaga, A Nosaki, K Unozawa, Y Hayashi, E Shimizu1

1 Department of Cognitive Behavioral Physiology, Chiba University Graduate School of Medicine, Chiba, Japan 2 Division of Psychiatric and Mental Health Nursing, Chiba University Graduate School of Nursing, Chiba, Japan 3 Inpatient Psychiatric Unit, Chiba University Hospital, Chiba, Japan

Introduction: In 2010, the inclusion of cognitive behavioral therapy (CBT) for mood disorders in national health insurance marked a milestone for psychiatric care in Japan, where pharmacotherapy has historically been much more common. Nurses can become one of the worthwhile providers of CBT because they have more opportunities to interact with patients than other professionals; however, research and practice trend of CBT in nursing field is still unclear. The purpose of this study was to clarify the applied area, methods of implementation and quality control, research trend of CBT in Japan through literature review and to obtain suggestions for developing future training system for nurses and designing outcome researches. Materials and methods: Articles were searched using MEDLINE, CHINAHL, PsycINFO, CiNii and Japana Centra Revuo Medicina with following keywords: (“cognitive therapy” or “behavior* therapy” or “cognitive behavior* therapy”) AND (nurse* or nursing) AND (Japan*). Results: The initial search identified 232 articles and 16 were excluded due to duplication. The number of articles has dramatically increased since 2005. Many of them targeted mental disorders and some studies applied in other areas. However, there were few outcome researches and articles reporting a method related to quality control. Conclusions: There have been various attempts to incorporate CBT into nursing field even before the year 2010. However, training system of CBT should be established in Japan so that more nursing professionals can receive adequate training and more patients will be able to receive such intervention. Further studies and evaluation of more research-based data are also required.

26

GV Obrocea,1 S Abdijadid,1 S Vasan,1 A Kian,2 C Sevilla,1 TP Yoo1 1 UCLA-Kern Department of Psychiatry, David Geffen School of Medicine, Bakersfield, CA, USA 2 Department of Psychiatry Residency Program, Kaiser Permanente Fontana Medical Center, Fontana, CA, USA

Introduction: Cyclic-mood disorders require a complex combination of medications for effective longterm treatment. The focus of this study is to explore the role of complex medication regimen administered as rational polypharmacy in patients with cyclic-mood disorder. Material and methods: This is a retrospectivechart review examining the Clinical Global Impressions Scale as outcome measure at 1, 3, 6, 9 and 12 months in patients treated with different combinations of psychotropic medications. Age, gender, ethnicity, DSM-IV diagnosis (Axis I), Medical Diagnosis (Axis III), medications and number of re-hospitalizations were recorded. Results: 200 patients ages 18–84 were included. There was 70% Hispanic preponderance. The diagnoses were: 59% bipolar (I and II), 29% Depression and 12% schizophrenia. Different psychotropic agent combinations were used. The percentage of patients on less than 4-agents displayed a CGI Much-Improved (MI) at 1, 3, 6, 9, 12 months 54%, 49%, 63%, 51%, 52% respectively. The percentage of patients on more than 4-agents displayed a Very Much Improved CGI at 1, 3, 6, 9 and 12 months – 68 %, 65%, 61%, 64%, 70%, respectively. Hospitalization records for 52 patients were examined for 5-yearperiod. Out of the 10% patient re-hospitalized only 3.8% were for 3 times in five-year period; the rest only once; in the ladder group 4.76% of patients had bipolar diagnosis. Discussion and conclusion: Side effects can be minimized if lower dosages of several agents are used. The average re-hospitalization for chronic persistent mental illness is three years. Patients in this study had a lesser number of re-hospitalizations due to use of rational polypharmacy.



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93

Role of scheduled PRN psychotropic agents in management of agitation in hospitalized patients

Cost-effectiveness of telehealth to reach at-risk aboriginal youth populations MC Chow,1,2 D Berrelkamp,1 K Lorenz1

1

1

1

1

C Sevilla, S Abdijadid, A Luminare, S Vasan, A Kian,2 TP Yoo,1 GV Obrocea1

1 UCLA-Kern Department of Psychiatry, David Geffen School of Medicine, Bakersfield, CA, USA 2 Department of Psychiatry Residency Program, Kaiser Permanente Fontana Medical Center, Fontana, CA, USA

Introduction: Agitation encountered in inpatient setting requires immediate attention. Management consists of administration of medications like antipsychotics, benzodiazepines, and Benadryl; either as single-agents or in combination. The goal is to assess the correlation between use of PRN oral-psychotropics and need for IM-psychotropics and the rate of seclusion. Material and methods: This study is a retrospective chart-review evaluating management of agitation in patients admitted to the inpatient unit. Age, Gender, Ethnicity, Diagnosis, Psychotropic medications, and number of seclusions were recorded. Results: Data for this study was collected from 348 patients age 19–77 admitted to the inpatient unit over a 6-month period from 7/2013–1/204. Gender and racial distribution was: 65% male, 35% female, 78% Caucasian and 28% Hispanic. The diagnoses were 52% psychotic disorder, 45% mood disorder, 2% anxiety disorder and 1% substance use disorder. 41% of patients received orders of PRN psychotropic medications. No patients with the PRN orders written in advance required IM psychotropic medication administration and 3% of this group had required to be placed in seclusion. 16% did not receive PRN psychotropic medication orders at admission. 15% from this group required IM psychotropic medication administration and 33% were placed in seclusion. Fisher Exact test p-value for needing IM medication was 7.069 × 10.−06 Discussion and conclusion: Early management of agitation in inpatient unit can reduce likelihood of patients requiring parenteral form of psychotropic agents. Further investigation to optimize and standardize treatment regimen is encouraged. Patients that had scheduled PRN order were less likely to receive PRN parenteral psychotropic medications and were less likely to require seclusion.


1 BC Children’s and Women’s Hospital, Vancouver, British Columbia, Canada 2 Department of Psychiatry, University of British Columbia, Vancouver, British Columbia, Canada

Introduction: Canadian aboriginal youth face 5–6 times the risk of suicide compared to their non-aboriginal peers. Many of these at-risk youth live in rural and remote areas where the provision of traditional psychiatric services is challenged by hostile terrain and weather; the cost of traveling to and from these communities often exceeds the cost of a trans-pacific airline ticket. We present here a cost-effective telemental health service operating from an academic health sciences centre that reaches more than a dozen remote communities with significant aboriginal populations. The Telehealth Outreach Psychiatric Services (TOPS) program, operating since 2011, and serves communities so remote that satellite communications are required to reach youth. Methods: We compared the cost of operating our telehealth service for a two year period from 2011-2013 to the cost of providing a comparable physical outreach service (where a clinician travels to the youth’s community). We accounted for payments for clinical services, incentive payments, staffing costs, technology purchases, maintenance, and travel. Results: Each individual telehealth service for an at-risk youth costs $240 less than providing a comparable service where a clinician travels to the youth’s community. Youth and their families also save more than $400,000 in travel costs every year by using telehealth rather than traveling for service. Conclusions: A telehealth service can be a costeffective way to serve aboriginal youth populations living in rural and remote communities. The cost of a telehealth service is substantially less than a comparable physical outreach service.

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96 Neuroleptic malignant syndrome and malignant catatonia as the manifestations of an anti-NMDAR encephalitis: A case report P Paholpak,1 P Rangseekajee,1 P Paholpak,1 K Kriengburapa,1 S Tiamkao,2 N Kasemsap2 1 Department of Psychiatry, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand 2 Division of Neurology, Department of Internal Medicine, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand

Introduction: Malignant catatonia is a neuropsychiatric syndrome presenting in a wide range of disorder. It was rarely reported as a presentation of Neuroleptic Malignant Syndrome (NMS) and anti N-methyl D-Aspartate receptor (anti-NMDAR) encephalitis. We described a young female who presented with malignant catatonia with multiple symptoms of NMS. After extensive investigations, the final diagnosis was an anti-NMDAR encephalitis. Case history: A previously healthy, 15-year-old, female developed bizarre behaviors, hallucinations, delusions, mumbling, and posturing for 2 weeks after having a significant psychological stressor. She was diagnosed with a brief psychosis and was treated with antipsychotics. She developed symptoms of catatonia (mutism, waxy flexibility and posturing), with an autonomic instability, but without dyskinesia. Laboratory data showed leukocytosis (WBC 16,500 cell/mm3) without any detectable infection, CK at 6000 mg/dL, and ALP of 120 mg/dL. Her brain MRI and CSF study was normal. She was treated with bromocriptine and ECT, multiple symptoms of NMS subsided but not mutism and posturing. AntiNMDAR antibody was tested, and methylpredinisolone (1 g/day) was given for 3 day while waiting for a test result. Her symptoms improved significantly and recovered to her baseline within 6 months. The result of antiNMDAR antibody was positive in both serum and CSF. Discussion and conclusion: Malignant catatonia and NMS could be a manifestation of anti-NMDAR encephalitis. Partial response from bromocriptine and ECT implied another underlying pathogenesis than NMS alone. In summary, an anti-NMDAR encephalitis should be included as a potential cause of NMS1 in the patient presenting with malignant catatonia who had a history of antipsychotic exposure.

Reference 1. Kayser MS, Titulaer MJ, Gresa-Arribas N, Dalmau J (2013) Frequency and characteristics of isolated

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psychiatric episodes in anti-N-methyl-d-aspartate receptor encephalitis. JAMA Neurology 70(9): 1133–1139.

99 Predictors of rehospitalization among long-stay psychiatric patients discharged under the EXITERS project in Hong Kong W Nip Department of Psychiatry, Pamela Youde Nethersole Eastern Hospital, Hong Kong SAR

Background: Successful and sustained community reintegration is often a challenge faced by chronic psychiatric patients after their discharge from long hospital stays. In Hong Kong, the EXITERS project was launched in 2000 to enhance the support to those long-stay psychiatric patients through a holistic multidisciplinary team approach, in line with the international trend of shifting care delivery from the traditional institution-based system towards a community-oriented model. Methods: A retrospective cohort study was conducted on all patients discharged under the EXITERS project from April 1, 2003 to March 31, 2008. Subjects were subgrouped into readmitters and non-readmitters naturalistically at 2 years post-discharge. The two subgroups were compared against socio-demographic variables, clinical variables and BPRS scores. Significant predictive factors for rehospitalization were compiled using survival analysis. Results: The cohort subjects consisted of 223 individuals. Among them, 75 patients were rehospitalized following 2 years of discharge. The cumulative rehospitalization rates were 3.1% at 1 month, 5.8% at 3 months, 22.7% at 1 year and 33.6% at 2 years. Significant predictors of rehospitalization included presence of psychiatric comorbidities (HR = 3.429, 95%CI = 1.651–7.122, p = 0.001), number of previous hospitalizations (HR = 1.091, 95%CI = 1.033–1.152, p = 0.002) and young age at discharge (HR = 0.968, 95%CI = 0.946–0.990, p = 0.005). Conclusions: Evidently, unmet needs existed among those young, repeatedly rehospitalized and dually diagnosed patients, rendering them at risk for rehospitalization. Clinicians and policy planners should facilitate better resource allocation and development of novel interventional strategies to enhance their successful and sustained community reintegration after discharge from hospital. © 2015 The Authors Asia-Pacific Psychiatry © 2015 Wiley Publishing Asia Pty Ltd


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103

Psychoeducation for chronic schizophrenia with long-term hospitalization

Deliberate self-harm with household poisons in Nigeria: Pattern of presentation and public health implications

Y Wake,1 H Kawahara,1 Y Izumi,1 M Masamori,1 K Ito,1 T Tomita,1 S Morita1

AO Adelufosi,1 O Abayomi,2 AK Ayankola,2 AO Oyewole2

1 Taiyo Hills Hospital, Takahashi City, Okayama, Japan

1 Community Mental Health Program, NHRA, Thompson, Manitoba, Canada 2 LAUTECH Teaching Hospital, Ogbomoso, Oyo State, Nigeria

Introduction: Stigma, discrimination, and the consequent self-stigma represent a powerful obstacle to success any recovery intervention undertaken to help the people with schizophrenia during their life. It is suggested that self-stigma is related to social isolation and discrimination. However, strategies for reducing self-stigma related with schizophrenia is still remain unclear. Our aim in this study determine the effect of psychoeducation on self-stigma. Methods: Twenty-six participants with the diagnosis of schizophrenia (DSM-IV-TR) were recruited. The participants had received psychiatric inpatient treatment in our hospital. Participants were devided in 2 groups which are psychoeducation group and non-psychoeducation group. All participants completed PANSS, Global Assessment of Functioning Scale (GAF), the Japanese version of the Social Distance Scale (SDS-J), the Knowledge of Illness and Drug Inventory (KIDI) questionnaire, the Drug Attitude Inventory 10 (DAI-10), the Birchwood’s Psychosis Insight Scale (BPIS), and the subjective Well-Being scale. Results: All the participants in psychoeducation group were completed our psychoeducation program twice during this research period. Significant differences between the two groups were observed for the SDS-J and KIDI (Table 1). Table 1.

SDS-J KIDI DAI-10 BPIS

PE group (n = 16) (mean ± SD)

NonPE group (n = 10) (mean ± SD)

p-value*

6.04 15.24 2.10 9.74

9.20 10.48 1.62 9.56

Abstracts of the 16th World Meeting on Sexual Medicine, October 8-12, 2014, São Paulo, Brazil.

16th International Society of Addiction Medicine Annual meeting October 2-6, 2014 Yokohama, Japan.

ECG Response: October 7, 2014.

The Australasian College of Dermatologists 47th Annual Scientific Meeting, 18-21 May, 2014, Melbourne, Victoria.

5th Annual Scientific Meeting NHF: 11 October 2005, Amsterdam.

Irish thoracic society annual scientific meeting 2014.

Abstracts of the Seventh Scientific Meeting of The TMJ Association, 7-9 September 2014, Bethesda, Maryland.

Abstracts of the 2014 combined scientific meeting: Imaging and Radiation in Personalised Medicine, 4-7 September, 2014. Melbourne, Australia.

Abstracts from the 30(th) Annual Meeting of the Histiocyte Society Toronto, Ontario, Canada October 28-30, 2014.

2017 Trauma Association of Canada Annual Scientific Meeting Abstracts.

Abstracts of the 62nd Annual and Scientific Meeting Science for Healthy & Active Ageing. October 9-11, 2014. Galway, Ireland.

2016 Trauma Association of Canada Annual Scientific Meeting Abstracts.

7th Asia Pacific Paediatric Endocrine Society (APPES) Biennial Scientific Meeting.

Abstracts from the 2014 ISDE World Congress, September 22-24, 2014, Vancouver, Canada.

Abstracts of the RACS Annual Scientific Congress and ANZCA Annual Scientific Meeting, 5-9 May 2014, Singapore.

Abstracts of presentations at the 2014 pacific division meeting.

Report of the 47th annual meeting of the Pacific Association of Pediatric Surgeons, Banff, Alberta, Canada, May 25th-29th, 2014.

British society of breast radiology annual scientific meeting 2014.

The College of Podiatry Annual Conference 2014: meeting abstracts.

College students' trait ratings of three age groups around the Pacific Rim.

Abstracts of the 3rd Annual Scientific Meeting Indonesian Heart Rhythm Society, October 23 - 24, 2015.

IOF Regionals - 5(th) Asia-Pacific Osteoporosis Meeting : Oral Communications.

Abstracts of the 2014 SGI 61st Annual Scientific Meeting, March 26-29, 2014, Florence Italy.

IOF Regionals - 5(th) Asia-Pacific Osteoporosis Meeting : Poster Presentations.