Institute of Mental Health, Singapore

Background To date, there has not been an evaluation of antipsychotic prescription practices specific to the Association of Southeast Asian Nations (ASEAN) region. This study examined antipsychotic prescription for schizophrenia patients in ASEAN countries based on Research on Asian Psychotropic Prescription (REAP) survey. Methods This study used data from the fourth REAP antipsychotic survey (REAP-AP4), conducted between March and May 2016 using standardized procedures. In total, 1817 adult schizophrenia patients from six ASEAN countries were analysed. Results Prescription formulation was significantly associated with illness duration ( G (24) = 150.595, p < .001) and prescribing country ( G (20) = 571.423, p < .001). Oral antipsychotic monotherapy was the most common prescription across all illness durations, with a decreasing trend from 3–6 months to 10–20 years. Oral antipsychotic monotherapy was also the most commonly used prescription in almost all countries. The frequency of long-acting injection (LAI)-oral combination antipsychotic prescription increased with the patient’s illness duration and is more commonly prescribed in Malaysia, Singapore, and Thailand. Conclusion LAI-oral combination antipsychotics were prescribed more frequently within patients with longer duration of illness in more developed countries. Antipsychotic monotherapy and oral antipsychotic prescriptions were prevalent across all illness durations and in most ASEAN countries.

Aims This systematic review aims to examine how climate change and its related stressors may affect the mental health of workers in industries vulnerable to climate change. The review also seeks to evaluate coping strategies used by affected workers, as well as potential interventions to mitigate and prevent these mental health effects. Method A literature search was conducted in June 2024 in databases such as PUBMED, EMBASE, PsycINFO and Web of Science, using a combination of keywords about climate change, mental health or illness, and vulnerable industries. Results A predominance of accessed literature was related to the agricultural industry, with a minority pertaining to the aquaculture, construction and aviation industries. They suggest an increased vulnerability of workers to mental health-related problems, including increased depression, anxiety, psychological distress and suicidality in response to stressors such as increased temperatures and prolonged drought conditions. Besides socioeconomic effects resulting from reduced productivity, climate-related stressors may contribute to increased uncertainty, isolation, a perceived lack of control, and challenges to their sense of identity. Coping methods varied and influenced outcomes of mental wellbeing, with community wellbeing and social connectedness in the agricultural setting being observed to have beneficial effects on levels of psychological distress. Interventions that promoted mental health literacy, the availability of mental health first aid, social cohesion, and adaptability to climate stressors were deemed helpful. Conclusion Environmental stressors interact with mental health in an intricate manner, exerting influence on biological and socioeconomic aspects of a person’s well-being. In an occupational setting, such stressors may also affect social cohesion and one’s personal sense of identity or self-esteem. Building strong social networks and structures to enable self-efficacy and adaptability towards climate change may be key towards promoting mental health resilience amongst workers in vulnerable industries.

Although meta-analytic studies have shown that 25-33% of those at Clinical High Risk (CHR) for psychosis transition to a first episode of psychosis within three years, less is known about estimating the risk of transition at an individual level. Digital phenotyping offers a novel approach to explore the nature of CHR and may help to improve personalized risk prediction. Specifically, digital data enable detailed mapping of experiences, moods and behaviors during longer periods of time (e.g., weeks, months) and offer more insight into patterns over time at the individual level across their routine daily life. However, while novel digital health technologies open up many new avenues of research, they also come with specific challenges, including replicability of results and the adherence of participants. This paper outlines the design of the digital component of the Accelerating Medicines Partnership® Schizophrenia Program (AMP SCZ) project, a large international collaborative project that follows individuals at CHR for psychosis over a period of two years. The digital component comprises one-year smartphone-based digital phenotyping and actigraphy. Smartphone-based digital phenotyping includes 30-item short daily self-report surveys and voice diaries as well as passive data capture (geolocation, on/off screen state, and accelerometer). Actigraphy data are collected via an Axivity wristwatch. The aim of this paper is to describe the design and the three goals of the digital measures used in AMP SCZ to: (i) better understand the symptoms, real-life experiences, and behaviors of those at CHR for psychosis, (ii) improve the prediction of transition to psychosis and other health outcomes in this population based on digital phenotyping and, (iii) serve as an example for replicable and ethical research across geographically diverse regions and cultures. Accordingly, we describe the rationale, protocol and implementation of these digital components of the AMP SCZ project. **Link to video interview: https://vimeo.com/1060935583 *.

Introduction Adjunctive antidepressant (AD) use is prevalent for the treatment of bipolar disorder (BD) in many countries, but there is little information about this practice in Asia. Accordingly, we addressed the prevalence, dosing, and clinical correlates of adjunctive AD use with BD in a large Asian sample. Methods Patients with BD were recruited across 13 Asian sites (PR China, Hong Kong, India, Indonesia, Japan, South Korea, Malaysia, Myanmar, Pakistan, Singapore, Sri Lanka, Taiwan, and Thailand) for this cross‐sectional study. We examined differences between patients with versus without adjunctive AD treatment. Multivariable logistic regression was used to identify factors associated with the use of adjunctive AD. Results Among a total of 2114 adult participants (47.7% men; age 42.4 years [CI: 41.8–43.0]; BMI 25.0 kg/m ² [24.8–25.2]), the prevalence of AD use averaged 19.8% [18.1–21.6], at a mean imipramine‐equivalent dose of 113 [110–116] mg/day. Adjunctive AD use was associated with factors including older age, outpatient status, more depression, suicidal behavior, rapid cycling, and lower doses of MS and antipsychotics (APs). Discussion Usage of AD treatment for BD in Asia was less than half that reported in Western samples. Such use of AD treatment appeared to be well tolerated but underscores the need for close clinical follow‐up to avoid risks of excessive elevation of mood or behavior.

Aim The aim of this study was to investigate whether psychiatrists around the world believe they might encounter cases of hikikomori (prolonged social isolation), and how they formulate and treat such cases. Methods A hikikomori case vignette was sent to psychiatrists of 34 countries around the world. Participants rated for the vignette: frequency of similar cases in one's practicing country; and aspects of formulation, diagnosis, suicide risk, and treatment plan. Results In total, 344 complete responses from 34 countries were returned. Eight countries/areas had 10 or more respondents: Japan (61), South Korea (54), Nepal (48), Iran (40), Thailand (32), India (23), Hong Kong (12), and UK (10); the remainder were placed in the “others” group (64). Respondents from all countries except Thailand felt that similar cases were seen. Diverse patterns of response were obtained regarding formulation and treatment. Japan, South Korea, and “others” favored psychosocial aspects in the formulation, while Iran, Nepal, and India favored biological factors. Most respondents felt the case could be treated by an outpatient visit, while others preferred hospitalization. Psychotherapy was rated highly as an intervention; Iran, South Korea, and “others” also rated pharmacotherapy highly. Conclusion Despite its limitations as an exploratory study, we found evidence that hikikomori‐like cases might exist around the world. However, opinions on how such cases should be formulated and treated vary significantly among countries. We believe this reflects how the experience of hikikomori is dependent on the related sociocultural context. Further comparative work, preferably with standardized assessment tools, will help to clarify how society might influence the individual experiences of practitioner and hikikomori patients.

Background/Objectives: Diagnosing ASD in adults presents unique challenges, and there are currently no specific biomarkers for this condition. Most existing studies on the gut microbiota in ASD are conducted in children; however, the composition of the gut microbiota in children differs significantly from that of adults. This study aimed to study the gut microbiota of young adults with high-functioning ASD. Methods: Using metagenomic sequencing, we evaluated the gut microbiota in 45 adults with high-functioning ASD and 45 matched healthy controls. Results: Adjusting for sociodemographic information, dietary habits, and clinical data, we observed a distinct microbiota profile of adults with ASD in comparison to controls, with the intensity of autistic traits strongly correlating to microbial diversity (correlation coefficient = −0.351, p-value < 0.001). Despite a similar dietary pattern, the ASD group exhibited more gastrointestinal symptoms than the healthy controls. An internally validated machine-learning predictive model that combines the Autism Spectrum Quotient questionnaire score of individuals with their microbial features could achieve an area under the receiver operating characteristic curve (AUC) of 0.955 in diagnosing ASD in adults. Conclusions: This study evaluates the gut microbiota in adult ASD and highlights its potential as a non-invasive biomarker to enhance the diagnosis of ASD in this population group.

Objective The clinical presentation of depressive disorders might be influenced by age, and its diagnosis and treatment can be affected by ageism-related bias. A network analysis can reveal symptom patterns unrecognized by the reductionistic approach. Therefore, this study explores the network structure of depression and anxiety symptoms in older Asian patients with depressive disorders and examines age-related differences in the context of ageism. Methods We used data from the Research on Asian Psychotropic Prescription Patterns for Antidepressants, Phase 3 study and included 2,785 psychiatric patients from 11 Asian countries. Depression and anxiety symptoms were assessed using the Patient Health Questionnaire -9 and Generalized Anxiety Disorder-7. Network analyses were conducted to identify symptom interconnections and centrality among older (>65 years), middle-aged (35-64 years), and young (18-34 years) adult groups. The network structures were also compared using a network comparison test. Results Depressed mood was the most central symptom across all age groups. Network comparisons revealed no significant structural differences among the three age groups, despite several variations in terms of global strength. The network structure of the older group was characterized by strong interconnections between somatic symptoms (insomnia-energy) and core depressive symptoms (little interest or pleasure-feelings of hopelessness).

Workplaces are potentially effective settings for promoting mental health. Changes to working styles from the pandemic offer opportunities for organizations to rethink traditional approaches to improve mental health in the workplaces. This includes digital health platforms with the capability to deliver information, resources and interventions at scale across the mental health continuum. This study explored the desired features of a workplace mental health app and potential drivers or barriers to adoption. Twenty-three participants aged 21–63 years working in Singapore were recruited for semi-structured interviews. A reflexive thematic analysis was used to extract constructs and themes from the data. Participants felt mental health apps increased accessibility to mental health services and reduced stigma towards help-seeking. Participants desired self-help features like educational content, reminders, social features like gamified challenges and online communities. Potential drivers of app adoption include incentives, timely and relevant campaigns, good user experience and the ability to integrate with existing platforms that users were familiar with. Potential barriers included data privacy and cost. Some participants preferred alternative coping strategies like social media over using mental health apps. Mental health apps could play a role in workplace mental health promotion. Self-help and social features are key elements desired by participants. Organizations could provide incentives and a good user experience for employees to promote app adoption while communicating transparency on data privacy policies.

Background Although quitting smoking benefits mental health, people with mental health conditions tend to have higher smoking rates and more severe tobacco use disorders. Integration of smoking cessation into mental healthcare, or vice versa, could help to meet the needs of this population. While Singapore offers specialist smoking cessation and mental health services, it is unclear how these services address the needs of people with comorbid tobacco use and mental health issues. This study aimed to explore the integration of smoking cessation and mental health services in Singapore from the perspective of healthcare professionals. Methods We conducted one-on-one semi-structured interviews with 21 Singaporean health professionals with expertise in mental health (n = 5), smoking cessation (n = 5), primary healthcare (n = 3), specialist respiratory or emergency care (n = 3) or health systems and policy (n = 5). We recruited participants from the authors’ professional networks and subsequently via snowballing. We used inductive coding methods to identify themes that emerged from the data. Results Health professionals were divided on whether smoking and mental health are sufficiently interconnected to justify more integrated or tailored services. Smoking cessation and mental health were generally approached in a siloed manner, reflecting systemic barriers to integration as well as ranging levels of awareness among health professionals on the association between smoking and mental health. While some participants welcomed the integration of smoking cessation and mental health services as a more convenient, effective and equitable way to address the needs of this population, others deemed it unnecessary and viewed smoking as a lifestyle habit, distinct from other mental health issues. Implications There is a need to educate health professionals on smoking as a mental health issue and to consider more tailored programmes designed to address smoking cessation and mental health needs simultaneously.

Background: Singapore has strict regulations for electronic nicotine delivery system (ENDS). Hence, its residents may have different risk perceptions of ENDS compared to countries with more liberal measures. This study examined the prevalence of perceived risk of harm for ENDS versus cigarettes, their correlates, and the moderating effect of smoking status on significant associations in Singapore. Method: This cross-sectional study utilized data from the Health and Lifestyle survey. The outcome was perceived risk of harm for ENDS versus regular cigarettes, categorized into “less harmful” and “about the same level of harm/more harmful.” The correlates of interest were sociodemographic characteristics, depressive symptoms, anxiety symptoms, and smoking status. Correlates were examined using multivariable logistic regression. The moderating effect of smoking status was examined using interaction terms. Results: A total of 6508 participants completed the question on perceived harm. Approximately 10.4% of them perceived ENDS to be less harmful than regular cigarettes. Moreover, 15.0% of never-smokers, 16.6% of former smokers, and 9.2% of ever-smokers reported that ENDS was less harmful than regular cigarettes. The following groups were more likely to perceive ENDS as less harmful than regular cigarettes: younger individuals, males, former smokers, current smokers, and those with higher depressive symptoms. Smoking status moderated the association between age group and perceived risk of harm. Conclusion: The harm perception of ENDS versus regular cigarettes is lower than in other countries. Future studies can examine the mediating role of harm perception of ENDS versus regular cigarettes on the association between depression and ENDS usage.

Schizophrenia is a complex psychiatric disorder marked by positive and negative symptoms, leading to mood disturbances, cognitive impairments, and social withdrawal. While anti-psychotic medications remain the cornerstone of treatment, they often fail to fully address certain symptoms. Additionally, treatment-resistant schizophrenia, affecting 30%-40% of patients, remains a substantial clinical challenge. Positive, negative symptoms and cognitive impairments have been linked to disruptions in the glutamatergic, serotonin, GABAergic, and muscarinic pathways in the brain. Recent advances using genome-wide association study and other approaches have uncovered a significant number of new schizophrenia risk genes that uncovered new, and reinforced prior, concepts on the genetic and neurological underpinnings of schizophrenia, including abnormalities in synaptic function, immune processes, and lipid metabolism. Concurrently, new therapeutics targeting different modalities, which are expected to address some of the limitations of anti-psychotic drugs currently being offered to patients, are currently being evaluated. Collectively, these efforts provide new momentum for the next phase of schizophrenia research and treatment.

Background The Sheehan Disability Scale (SDS), World Health Organization Disability Assessment Schedule 2.0 12-item version (WHODAS 2.0), and Social and Occupational Functioning Assessment Scale (SOFAS) are commonly used disability measures in patients with depression and anxiety disorders. The current study aimed to compare the responsiveness of these three disability measures and establish their minimal important differences (MID) in the same population. Methods A total of 308 patients (M = 36.1, SD = 12.7) who were recruited from outpatient clinics and completed all measures at the two assessment points were included in the current study. The MID was estimated using a triangulation approach while the internal and external responsiveness was evaluated using standardized response mean and receiver operating characteristic curves, respectively. Results The best MID estimates for the WHODAS, SDS, and SOFAS were three, four, and six points, respectively. The internal responsiveness analysis showed that all three disability measures were well responsive in patients with improved or stable Patient Health Questionnaire-8 and Generalized Anxiety Disorder-7 scores at the 6-month follow-up. Meanwhile, the external responsiveness analysis demonstrated that all three disability measures showed adequate responsiveness to improvement, with AUC values of at least 0.7. However, when improvement criteria incorporated MID, only WHODAS was found to be adequately responsive. Conclusion The results of this study will be a helpful guide for clinicians to track and detect meaningful improvements in patient functioning, ensuring continued high-quality clinical care and management.

Introduction Body dissatisfaction, often arising from the disparity between the perceived ideal and actual body, is prevalent among young individuals and is linked to various mental health issues. Previous research consistently indicates notable differences in body dissatisfaction between males and females. This study used data from a nationwide study to determine the prevalence of body dissatisfaction among young individuals in Singapore. It also aims to identify associated sociodemographic, health-related, and psychosocial factors using a gender-based approach. Methods Data were obtained from 2600 youths aged 15-35 who participated in the National Youth Mental Health Study. Information on sociodemographic background, body dissatisfaction, childhood trauma, BMI, self-esteem, and social media use was collected. Weighted multiple logistic regressions were performed to identify the sociodemographic variables, as well as other health-related and psychosocial factors associated with body dissatisfaction, stratified by gender. Results 20.2% (25.7% females; 14.8% males) reported moderate to marked body shape concerns. Among females, younger ages, Indians (vs. Chinese), those with diploma education (vs. university), those with overweight, those with childhood trauma, and those with greater daily social media usage were more likely to report moderate to marked body shape concerns. Among males, those with primary education and below (vs. university), those with overweight, and those with greater daily social media usage were more likely to report moderate to marked body shape concerns. Discussion These results emphasize the importance of creating specific public health programs that consider the different experiences and challenges related to body dissatisfaction based on gender. These programs could help promote body image positivity, increase self-compassion, and encourage critical engagement with social media content.

Background The COVID-19 pandemic is a global adverse event that affected many individuals’ well-being. Resilience is an essential component that allows one to cope during stressful events such as the pandemic. Not many studies have longitudinally explored changes in resilience across time during the pandemic in the Southeast Asia region. The current article investigates resilience and the sociodemographic and psychological factors associated with resilience across two waves of survey of a Singapore adult population. Methods The study was conducted across two timepoints from May 2020 to June 2021 (T1) and October 2021 to September 2022 (T2). 1129 participants partook during T1 (response rate = 54.8%) and 858 participants partook during T2 (response rate = 76.0%). The questionnaire included sociodemographic information and measures such as the Brief Resilience Scale, Patient Health Questionnaire-9, Generalized Anxiety Disorder Scale-7, the stress component of the Depression, Anxiety and Stress Scale, and four COVID-19-related stressors. Generalized estimating equations (GEE) were utilized to investigate the relationships adjusting for timepoints. Results Most participants had normal levels of resilience (M = 3.61, SD = 0.62), and resilience scores did not differ much over time (p = 0.852). Males, younger adults, university-educated, employed individuals, and individuals living in private housing had higher levels of resilience. Higher levels of anxiety symptoms, depressive symptoms, stress, and one specific COVID-19-related stressor (i.e., employment concerns) were associated with lower levels of resilience. Individuals who reported having moderate to severe depression and anxiety symptoms were more likely to have low resilience. Discussion The findings suggest that resilience levels remained within the normal range and unchanged over time, reflective of the population’s ability to cope with the pandemic. However, there is still a need for more targeted interventions for individuals who are more vulnerable to lower resilience. Continued research is also needed to understand the long-term psychological effects of the pandemic.

Background: Late-life depression has serious public health implications due to its impact on healthcare systems and the economy. As the prevalence of depression tends to change over time across populations, continuous disease surveillance is warranted to inform evidence-based preventive interventions. The well-being of the Singapore elderly (WiSE) is the second study in the series that looked at the prevalence and correlates of depression in a multiethnic population in Singapore. Methods: This single-phase and comprehensive cross-sectional study employed stage 1 diagnosis of geriatric mental state-automated geriatric examination for computer-assisted taxonomy (GMS-AGECAT) to capture depression and subsyndromal depression. Results: The prevalence of depression and subsyndromal depression was 4.4% and 11.9%, respectively, compared to 3.7% and 13.4% in 2013 (p=0.425). Indians, those who were divorced and had below primary education had higher odds of depression (2.2, 3.6, and 4.2 times, respectively). Depression was associated with severe disability, loneliness, suicidal ideations, poor life satisfaction, health status, and social connections. Conclusion: Despite a decade of preventive efforts for the population, there has not been any decrease in the prevalence of depression. There needs to be continued efforts to strengthen prevention, detection, and access to care of those with depression. A multiprong community–based preventive strategy focusing on social as well as health factors is needed to promote social connections, reduce loneliness, and promote the overall wellbeing of the elderly.

Background: The objective of the current study was to evaluate the trend and risk factors of antenatal depression (AD) among Chinese women in the third trimester of pregnancy, taking into account the impact of multiple fertility policy adjustments and economic development in China. Method: A repeated cross‐sectional study design was used. A total of 3404 pregnant women at 30–42 weeks’ gestation were recruited from the two largest maternity hospitals in Zhejiang Province, China, between 2016 and 2021. Results: The prevalence of AD among women in their third trimester of pregnancy had significantly increased from 31.8% to 60.6% ( p < 0.001) from 2016 to 2021. Pregnant women aged between 18 and 24 years reported the highest prevalence of AD. Those aged between 25 and 34 years (odds ratio [OR], 0.788; 95% confidence interval [CI]: 0.630–0.985), with a better self‐reported health status (OR, 0.929; 95% CI: 0.922–0.936) and higher perceived social support (OR, 0.948; 95% CI: 0.940–0.955), reported a lower prevalence of AD. Pregnant women who were housewives (OR, 1.399; 95% CI: 1.078–1.817), had an introverted personality (OR, 1.324; 95% CI: 1.119–1.568), and had experienced an unplanned pregnancy (OR, 1.303; 95% CI: 1.098–1.547) reported a higher prevalence of AD. Conclusions: The significant increase in the prevalence of AD from 2016 to 2021 has caused concern in society. To improve the aforementioned situation, it is imperative to implement further initiatives to address the challenges faced by pregnant women, especially those who are housewives, have introverted personalities, and have experienced unplanned pregnancies.

Background: Suicide remains a major risk factor for individuals suffering from schizophrenia and its prodromal state (i.e. Ultra High Risk for Psychosis). However, less is known about the prevalence of suicidal behaviour among the adolescent and youth UHR population, a demographic vulnerable to the psychosocial and environmental risk factors of suicide. This review aims to synthesise existing literature on the prevalence of suicidal ideation and behaviour in the adolescent and youth at Ultra High Risk for Psychosis (UHR), and the associations between suicidal behaviour and its correlates. Methods: The databases PsycINFO, PubMed, Embase, Cochrane Library, Web of Science and Scopus were accessed up to July 2024. A meta-analysis of prevalence was subsequently performed for lifetime suicidal ideation, lifetime non-suicidal self-injury, lifetime suicidal attempt and current suicidal ideation. A narrative review was also carried out for the correlates of suicidal behaviour amongst the adolescent and youth UHR population. Results: 15 studies were included in this meta-analysis. Meta-analysis revealed a high prevalence of lifetime suicidal ideation (58%), lifetime non-suicidal self-injury (37%), lifetime suicidal attempt (25%) and current (2-week) suicidal ideation (56%). Narrative review revealed that personal transition to psychosis and positive family history of psychosis were associated with suicidal attempt, while depression was also associated with both suicidal attempt and suicidal ideation. Conclusion: The prevalence of suicidal ideation and behaviour among UHR adolescent and youth is high and comparable to the general UHR population. Existing measures that mitigate suicide risk in the general UHR population should be adopted for the youth context.