Showing papers by "Roger C.M. Ho published in 2016"

Prevalence of depression amongst medical students: a meta-analysis

Abstract: CONTEXT: Medical schools are known to be stressful environments for students and hence medical students have been believed to experience greater incidences of depression than others. We evaluated the global prevalence of depression amongst medical students, as well as epidemiological, psychological, educational and social factors in order to identify high-risk groups that may require targeted interventions. METHODS: A systematic search was conducted in online databases for cross-sectional studies examining prevalences of depression among medical students. Studies were included only if they had used standardised and validated questionnaires to evaluate the prevalence of depression in a group of medical students. Random-effects models were used to calculate the aggregate prevalence and pooled odds ratios (ORs). Meta-regression was carried out when heterogeneity was high. RESULTS: Findings for a total of 62 728 medical students and 1845 non-medical students were pooled across 77 studies and examined. Our analyses demonstrated a global prevalence of depression amongst medical students of 28.0% (95% confidence interval [CI] 24.2-32.1%). Female, Year 1, postgraduate and Middle Eastern medical students were more likely to be depressed, but the differences were not statistically significant. By year of study, Year 1 students had the highest rates of depression at 33.5% (95% CI 25.2-43.1%); rates of depression then gradually decreased to reach 20.5% (95% CI 13.2-30.5%) at Year 5. This trend represented a significant decline (B = - 0.324, p = 0.005). There was no significant difference in prevalences of depression between medical and non-medical students. The overall mean frequency of suicide ideation was 5.8% (95% CI 4.0-8.3%), but the mean proportion of depressed medical students who sought treatment was only 12.9% (95% CI 8.1-19.8%). CONCLUSIONS: Depression affects almost one-third of medical students globally but treatment rates are relatively low. The current findings suggest that medical schools and health authorities should offer early detection and prevention programmes, and interventions for depression amongst medical students before graduation.© 2016 John Wiley & Sons Ltd. Language: en

The Effects of High-fat-diet Combined with Chronic Unpredictable Mild Stress on Depression-like Behavior and Leptin/LepRb in Male Rats.

Abstract: Leptin plays a key role in the pathogenesis of obesity and depression via the long form of leptin receptor (LepRb). An animal model of comorbid obesity and depression induced by high-fat diet (HFD) combined with chronic unpredictable mild stress (CUMS) was developed to study the relationship between depression/anxiety-like behavior, levels of plasma leptin and LepRb in the brains between four groups of rats, the combined obesity and CUMS (Co) group, the obese (Ob) group, the CUMS group and controls. Our results revealed that the Co group exhibited most severe depression-like behavior in the open field test (OFT), anxiety-like behavior in elevated plus maze test (EMT) and cognitive impairment in the Morris water maze (MWM). The Ob group had the highest weight and plasma leptin levels while the Co group had the lowest levels of protein of LepRb in the hypothalamus and hippocampus. Furthermore, depressive and anxiety-like behaviors as well as cognitive impairment were positively correlated with levels of LepRb protein and mRNA in the hippocampus and hypothalamus. The down-regulation of leptin/LepRb signaling might be associated with depressive-like behavior and cognitive impairment in obese rats facing chronic mild stress.

Mental health issues amongst medical students in Asia: a systematic review [2000–2015]

Abstract: Background: Studies have shown that the stress experienced by medical students is far greater than that experienced by other university students. In this study, we aim to understand the consequent mental health issues that are experienced by medical students, particularly in Asia, via a systematic review of the current literature. Methods: Initial searches on MEDLINE, Embase and SpringerLink came up with a total of 1,033 unique articles. Studies not focusing on medical students alone, not mentioning mental health issues or not containing prevalence values were excluded. Results: We included 14 articles in our analysis. ADs had a prevalence of 7.04% (100/1,420). Depression was prevalent in 11.0% (1,115/10,147) of students. A total of 12.9% (54/420) and 12.9% (41/319) of male and female medical students respectively were screened for depression. Preclinical students were also 1.63 times more likely to be depressed compared to clinical students, with 98.0% (48/49) pre-clinical students having screened for depression, compared to 60% (27/45) clinical students. Home staying medical students are 1.33 times more likely to be depressed compared to hostel-stayers, with 12.1% (29/239) of home stayers being depressed compared to 9.2% (37/402) of hostel stayers. Conclusions: We found that mental health issues affect a significant proportion of medical students and they are more prevalent in certain subpopulations of medical students. Our data revealed that preclinical and home staying students can be more susceptible to depression. More research should be done regarding this issue. With such information, it is hoped that appropriate interventions can be designed to improve the mental health of medical students.

Is off-label repeat prescription of ketamine as a rapid antidepressant safe? Controversies, ethical concerns, and legal implications.

Abstract: Depressive disorders are a common form of psychiatric illness and cause significant disability. Regulation authorities, the medical profession and the public require high safety standards for antidepressants to protect vulnerable psychiatric patients. Ketamine is a dissociative anaesthetic and a derivative of a hallucinogen (phencyclidine). Its abuse is a major worldwide public health problem. Ketamine is a scheduled drug and its usage is restricted due to its abuse liability. Recent clinical trials have reported that ketamine use led to rapid antidepressant effects in patients suffering from treatment-resistant depression. However, various flaws in study designs, and possible biased reporting of results, may have influenced those findings. Further analyses of ketamine use are needed to ensure patient safety.

Conceptualization of an evidence-based smartphone innovation for caregivers and persons living with dementia

Abstract: Recent statistics released by Alzheimer's Disease International has highlighted how prevalent dementia will become in the next couple of years. Along with the increased incidence of individuals being diagnosed with dementia, there has also been an increment in the number of informal carers for people living with dementia. A recent report highlighted that in Australia, there are an estimated of 200,000 informal carers as of 2011. Caring for people who are living with dementia is not an easy task. Previous studies have highlighted that as much as 65% of caregivers do experience symptoms suggestive of depressive symptoms in the process of care. With the rapid advances in technology, it is of no surprise that information technology and its related innovations have been used in dementia care. A review of the existing literature shows that much of these innovations are focused on the care of patients affiliated with dementia. However, clearly interventions focusing on the needs of the dementia cohort of patient are limited. There are currently more emerging studies demonstrating the efficacy of web-based interventional toolkits for carers who are caring for individuals with dementia. Whilst there are previous studies demonstrating the effectiveness of smartphone interventions for dementia patients, there remains a paucity of smartphone based interventions for caregivers who are living with people with dementia. This technical note describes the conceptualization of an evidence based smartphone intervention for patients living with dementia, as well as for carers of these patients.

The alcohol tracker application: an initial evaluation of user preferences

Abstract: Background The prevalence of at-risk drinking and alcohol use disorders is increasing. Advances in technology have resulted in numerous smartphone applications for this disorder. However, there are still concerns about the evidence base of previously developed alcohol applications. Objective The following study aims to illustrate how the authors have made use of innovative methodologies to overcome the issues relating to the accuracy of tracking the amount of alcohol one has consumed; it also aims to determine user perceptions about the innovative tracker and various other features of an alcohol self-management application among a group of individuals from the general population of a developed country (Canada). Methodology A native alcohol self-management application was developed. In order to determine user perspectives towards this new innovative application, the authors took advantage and made use of crowdsourcing to acquire user perspectives. Results Our results showed that smartphone ownership is highest among the age group of 35–44 years (91%) and lowest for those aged between 55 and 64 (58%). Our analysis also showed that 25–34-year-olds and 35–44-year-olds drink more frequently than the other groups. Results suggest that notification and information were the two most useful functions, with psychotherapy expected to be the least useful. Females indicated that notification service was the most useful function, while males preferred the information component. Conclusions This study has demonstrated how the authors have made use of innovative technologies to overcome the existing concerns pertaining to the utilisation of the blood alcohol concentration levels as a tracker. In addition, the authors have managed to highlight user preferences with regard to an alcohol application.

Optical Topography in Psychiatry: A Chip Off the Old Block or a New Look Beyond the Mind–Brain Frontiers?

Abstract: Psychiatric conditions that include depression, schizophrenia, and dementia contribute most significantly to overall disability adjusted life years (DALYs), surpassing both cardiovascular disease and cancer (1, 2). Therefore, timely and accurate diagnosis and treatment are crucial in psychiatric disorders, for which the development of specific biomarkers would be of particular importance. Despite advances in the field of Psychiatry with more comprehensive classification and description of diagnostic criteria, a pathophysiologically oriented classification of psychiatric disorders based on neurobiological basis remains elusive. The human brain with its complex integrative functions of cognition, emotional regulation, and executive function is the most challenging object of study in human science. Mental illness occurs as a result of these brain dysfunctions, but they often do not lead to distinct pathologic lesions or tissue damage. Instead, they contribute to complications in synaptic relay, synaptic plasticity, and neural circuit function, in addition to influence by external psychosocial factors. Thus, standard imaging methodologies, such as computed tomography (CT) and magnetic resonance imaging (MRI), would not be adequate to delineate the underlying abnormality contributing to the dysfunction. Our inherent lack of understanding of the mind–brain interface and the difficulty in characterizing mental illness further makes the practice of Psychiatry all the more daunting. Being the only medical specialty without any objective diagnostic tool or marker, the current diagnostic process in Psychiatry is regretfully based on patients’ reports of symptoms, observed behavior, and disease progression, which can introduce subjectivity and bias. Many clinical symptoms are also common to various psychiatric disorders, such as depressive symptoms in unipolar depression, bipolar disorder, schizoaffective disorder, etc., thus making it challenging to diagnose complex cases accurately within a limited time frame. This is illustrated by studies in the United States that revealed approximately 70% of bipolar patients were initially misdiagnosed due to polymorphic clinical symptoms (3, 4). It is also not uncommon to find different psychiatrists having deferring opinions about a case due to their unique experiences and training. Therefore, there is an urgent need for specific, objective biomarker-based assessments to guide diagnosis and treatment. The use of such biomarkers could assist clinicians in establishing differential diagnosis, which may improve specific individualized treatment.

Tapping onto the Potential of Smartphone Applications for Psycho-Education and Early Intervention in Addictions.

Abstract: E-health, and in particular smartphone based technology, is increasingly becoming commonplace in healthcare. Whilst psychiatry has tapped onto these innovations for conditions such as affective disorders as well as schizophrenia and psychosis, the usage of these technologies in addiction is limited. Addiction psychiatry could harness the potential of smartphone technologies. Given the increasing incidences of substance related problems globally, and along with the normalization of the general public’s perspectives towards substances, and also in consideration of unwillingness for at-risk individuals in seeking help, the authors hope to illustrate how these issues could potentially be solved using E-Health and technological innovations. The objectives of the current perspective article are to illustrate how recent advances in smartphone-based technologies could help in terms of psycho-education, as well as in helping individuals who are at-risk users in seeking help earlier. The authors aim to illustrate how the above are possible, building on existing theory driven framework that has been extensively reviewed in previous literature. Limitations with regards to the implementation of such technologies will also be discussed.

Analysis of the Information Quality of Bariatric Surgery Smartphone Applications Using the Silberg Scale

Abstract: There is a paucity of literature that has evaluated the information quality of the current bariatric and obesity applications. Our objective was to evaluate the quality of currently available smartphone applications for bariatric-patient care using the Silberg scale. The two most widely used smartphone application online stores were searched in June 2014 and a total of 39 applications were evaluated. The average Silberg score of the 39 applications was 4.0 ± 1.76. The current gaps of information quality include the lack of provision of appropriate references, full disclosure of sponsorship, and accurate disclosure whether the application has been modified in the past month.

Genetic Variants That Are Associated with Neuropsychiatric Systemic Lupus Erythematosus

Abstract: Objective. While genetic risks have been implicated in systemic lupus erythematosus (SLE), the involvement of various genotypes in neuropsychiatric SLE (NPSLE) remains uncertain. The present metaanalysis aimed to combine data from different studies and evaluate the association between each genotype and the risk of developing NPSLE. Methods. Studies were searched and retrieved from online databases (PubMed, EMBASE, BIOSIS, and ScienceDirect). Case-control studies were chosen if they reported genotype frequencies of the γ Fc region (FCγR) receptors II-A, III-A, and III-B; tumor necrosis factor–α (TNF-α); mannan-binding lectin (MBL); integrin alpha M (ITGAM); interleukin (IL) 1, IL-1β, and IL-6; IL-10 promoter; and vitamin D genes. The OR were used to assess the strength of this association between patients with NPSLE and SLE. Results. A total of 33 studies were considered in this metaanalysis. The results suggest that these genotypes demonstrated a significant association with NPSLE: the homozygous FCγR IIIa 158 FF genotype (OR 1.89, p = 0.03 for FF vs VV + FV), heterozygous FCγR IIIb NA1/2 genotype (OR 2.14, p = 0.03 for NA1/2 vs NA1/1; OR 1.81, p = 0.04 for NA1/2 vs NA1/1 + NA2/2), and homozygous ITGAM rs1143679 HH genotype (OR 3.39, p = 0.04 for HH vs RH; OR 3.11, p = 0.048 for HH vs RR + RH). Polymorphisms of the TNF-α, MBL2, IL-1, IL-1β, IL-6, IL-10 promoter, and vitamin D receptor genes did not show a statistically significant association with the risk of developing NPSLE (p > 0.05). Conclusion. This metaanalysis indicates that polymorphisms in the pathways of immune complex clearance, such as the FcγRIIIa, FcγRIIIb, and ITGAM genotypes, are potential susceptibility genes for NPSLE.

Controversies of the Effect of Ketamine on Cognition.

Abstract: Over the last couple of years, there have been numerous studies investigating the efficacy of ketamine, a non-competitive N-methyl-d-aspartic acid (NMDA) receptor antagonist as a rapid antidepressant. Most of the existing published literature describes the purported effectiveness of ketamine as a rapid antidepressant. The clinical efficacy of intravenous ketamine in the reduction of suicidal ideations ranged between that of 29% to as much as 79%. Researchers have noted the transient nature of intravenous ketamine’s rapid antidepressant efficacy and hence has recommended for long-term continued administration (1, 2). Clearly, with long-term utilization of ketamine, there are safety concerns and adverse effects that need to be considered. Prior systematic reviews have highlighted the acute adverse effects that could potential arise from the administration of intravenous ketamine (3). These adverse effects include that of dissociation, perceptual abnormalities, confusion, and transient instability in vital signs (3). Although studies have shown that serial infusions of ketamine in the short term (of 4 weeks) does not result in cognitive impairments (4), other studies have demonstrated that the administration of ketamine chronically would lead to memory impairments (5). More recently, Morgan et al. (5) in their recent article highlighted not only the increasing incidence of ketamine abuse globally but have also highlighted the mechanisms and implications of ketamine have on spatial memory. According to their study of 11 participants (of which 1 participants have had another mental health condition) who have been using ketamine recreationally, they discovered, through functional imaging studies that ketamine abusers experience spatial memory disturbances largely due to decreased activation in their right hippocampus and left parahippocampus gyrus (5). Morgan et al. (5) in their imaging studies also highlighted that chronic ketamine abusers do tend to experience dissociative symptoms, which are accounted for due to increased hippocampal activation. In addition, the functional studies also revealed that there are underlying disruption in the medial temporal lobe functioning. These resultant disruptions might also result in the psychotic symptoms that long-term ketamine abusers might experience. Clearly, the findings presented by Morgan et al. (5) are concerning if intravenous ketamine is being approved clinically and depressed individuals need to be receiving continuous administrations of intravenous ketamine. Although ketamine might seem like a promising antidepressant that could relieve treatment refractory depressive symptoms, the induction of memory impairments in the longer term is of concern. Memory impairments would result in further disabilities and consequential reduction in the overall quality of life. Aside to ketamine’s potential to result in memory impairments if used chronically, the chronic usage of ketamine does result in urological problems, such as cystitis (6). Although it is commonly assumed that acute and chronic usage of ketamine would have deleterious effect on cognition, researchers who have looked at the efficacy of sublingual ketamine, which despite its inherent lower bioavailability of 30%, have highlighted that sublingual variant of ketamine might helped to mitigate against the cognitive adverse effects (7). In a recent trial, 77% of patients demonstrated not only improvement in their mood but also their cognition (7). Lee et al. (8) in their recent systematic review proposed the procognitive efficacy of intravenous ketamine. Lee et al. (8) recent findings raises much discrepancies and controversies with the previous established findings of ketamine on cognition. Based on Lee et al. (8) systematic review, it has been shown in studies that acute administration of low dosages of ketamine not only did not affect memory but also helped in terms of improving visual memory, simple working memory, and complex working memory in individuals with treatment-resistant depression. It has been proposed that acutely, at low doses, ketamine does have procognitive efficacy through its mechanism of action on the intracellular proteins, such as BDNF and mTORC1. Through working on these intracellular proteins, executive functioning is also affected (Figure ​(Figure1).1). Lee et al. (8) proposed that ketamine’s acute effect on cognition might be the mediating factor that helps in the acute reduction of depressive symptoms and hence, the acute relief of suicidal ideations. It is postulated that suicidal ideations and planning for a suicide act involves much executive functioning capability. Usually, dysfunctional executive control would lead to poor impulse control and hence disinhibition. Thus, ketamine, if it does have procognitive effects could help improve the cognitive dysfunctions that usually accompanies treatment-resistant depression, as well as reduce the degree of acute suicidal ideations, through the enhancements of better executive functioning and control. Figure 1 Overview of ketamine and its precognitive effects. Much of the current studies have focused on investigating the efficacy of ketamine as a rapid antidepressant. Given the concerns about the adverse effects that might arise from the repeated administration, there has been a drive toward evaluating the potential of racemic mixture of ketamine. More recent studies have started to determine if the clinical efficacy of intravenous ketamine is comparable to that of conventional antidepressant, and whether ketamine could be used as an added augmentation strategy. Given the recent controversy about the commonly believed adverse effects of ketamine on cognition, this is certainly an area that deserves more research work to look into. In order to better understand whether ketamine has truly a procognitive effect, it would be worthwhile to compare sublingual or racemic variant of ketamine against antidepressants, such as Vortioxetine (9, 10), which have been hypothesized to have procognitive effects through its modulation of the 5HT7 and the 5HT3 receptors. Comparison of the racemic variant [R(−) variant of ketamine] would be key, given that prior studies have highlighted how the R(−) variant have had inherent greater potency and longer acting antidepressant efficacy (11).

Anxiety and Depression in Patients with Atopic Dermatitis in a Southeast Asian Tertiary Dermatological Centre.

Abstract: INTRODUCTION This study aimed to assess the frequency of anxiety and depression in a cohort of adult patients with atopic dermatitis (AD) in a tertiary dermatological centre, using the Hospital Anxiety and Depression Scale (HADS). We looked for any correlation between anxiety and depression with skin disease severity. MATERIALS AND METHODS Patients with AD were recruited from the National Skin Centre, Singapore, from 2008 to 2009 for a prospective cross-sectional study. The scoring atopic dermatitis (SCORAD) grade was determined and the HADS was administered via interviews. RESULTS A total of 100 patients (78 males, 22 females) were enrolled (92% Chinese, 4% Malays and 4% Indians). Their average age was 25.7 years. Sixty-five percent used topical steroids, 14% had previously taken oral prednisolone for the control of disease flares, and 20% were on concurrent systemic therapy. The mean SCORAD was 55.0, with 99% of patients having moderate or severe AD. The mean HADS anxiety score was 7.2 and the mean depression score was 5.0. The level of anxiety correlated well with that of depression (Spearman's rank correlation coefficient, ρ = 0.59, P <0.05); 18% were considered as cases of anxiety and 5% as cases of depression. These patients also had higher SCORAD values compared to other patients with lower scores for anxiety or depression (P <0.05). Linear regression demonstrated a statistically significant positive relationship between anxiety and depression scores, and SCORAD scores. CONCLUSION Our study identified, by means of the HADS, the frequency of anxiety and depression amongst a cohort of Singaporean patients with AD. More severe skin disease correlated to greater psychological burden. The HADS is a useful screening tool that can constitute part of the overall holistic management of patients with AD so as to improve patient care.

Gender Differences in Self-assessed Health-related Quality of Life in Children with Atopic Dermatitis.

Abstract: Atopic dermatitis (AD) has a significant impact on the quality of life (QoL) of affected children and their families.1-3 As in adults, childhood health-related (HR) QoL is commonly assessed by means of generic and/or specific instruments, including dermatology-specific and disease-specific measures.4 Measurement of HRQoL in pediatric dermatology helps to assess the impact of a single skin disease on a child’s life, to register the patient’s view on the efficacy of different treatment methods, educational programs, and consultations. It makes it possible to compare the impact of skin diseases and results of the treatment in children from different age groups on local, regional, national, and international levels.5 The vast majority of publications concerning HRQoL assessment in children with skin conditions is dedicated to AD.4 For the effective use of HRQoL results, it is important to know about existing gender differences in HRQoL assessment. Contradictory results concerning gender differences in HRQoL of children with AD under four years measured by the Infant’s Dermatitis Quality of Life Index (IDQoL) questionnaire were previously reported. Park et al6 found more severe impact of AD on boys in 48 non-matched boys and 53 girls. Meanwhile, Alzolibani7 did not find gender differences in non-matched AD children. Chernyshov8 also had not found a significant gender difference of the overall IDQoL scores in 102 non-matched AD children, but found significant gender differences when each child in the group of boys was matched to a corresponding child in the group of girls whose age in months and scoring atopic dermatitis (SCORAD) value were almost identical.8 Figure 1. CDLQI results in boys and girls with atopic dermatitis Kiebert et al9 found a significant gender difference in self-assessed HRQoL of older children with AD. The Children’s Dermatology Life Quality Index (CDLQI) scores were significantly higher in girls in that study. Hon et al10 and Ang et al11 reported that girls had more problems with issues of clothes and shoes than did boys10 and had higher scores on the swimming and other sports item.11 Recently, the authors did not find significant gender differences in self-assessed HRQoL of non-matched children from Ukraine, Italy, Czech Republic, and Singapore.12 In this study, the authors decided to analyze gender differences in self-assessed HRQoL of children with AD matched by country, age, and disease severity.

Ketamine as a rapid antidepressant: the debate and implications

Abstract: Ketamine, a synthetic derivative of phencyclidine, is a commonly misused party drug that is restricted in high-income countries because of its addictive potential. Ketamine is also used as an anaesthetic in human and veterinary medicine. In the 1990s, research using ketamine to study the pathophysiology of schizophrenia was terminated owing to ethical concerns. Recently, controversy surrounding the drug has returned, as researchers have demonstrated that intravenous ketamine infusion has a rapid antidepressant effect and have therefore proposed ketamine as a novel antidepressant. This article debates the question of ketamine as an antidepressant, considering the drug’s addictive potential, ethical concerns about prescribing a hallucinogen, the evidence base and motives behind ketamine trials.

The untapped potential of smartphone sensors for stroke rehabilitation and after-care.

Abstract: With the increasing incidences of cerebrovascular disease, as well as the morbidity and mortality associated with it, it is of no surprise that there have been much global governmental interest in the primary prevention of this disorder; or at least in the secondary and tertiary prevention and rehabilitation of individuals who have suffered disabilities arising from a recent cerebrovascular attack. Developers and clinicians have not considered one of the key areas in Stroke prevention and management, which is that of secondary prevention, and in particular that of tapping onto smartphone technologies for stroke rehabilitation. There has been much interest in the development of devices for rehabilitation of stroke patients instead. One of the concerns with regards to conventional bio and mechanical sensors are the costs involved in development, as well as the costs involved when stroke survivors and their caregivers are required to purchase the devices for monitoring and rehabilitation. In view of the current limitations, the S3 Rehab application, which makes use of the smartphone build in sensors, has been conceptualized and has been developed for the two major platforms (Apple and Android platforms). The authors believe that by tapping onto these sensors and by programming a smartphone application that is specifically catered for rehabilitation, it would keep costs minimal for researchers, patients and caregivers. Whilst there is a growing interest in wearable devices and sensors, it is important for developers and researchers to be cognizant that certain interventions, such as rehabilitation could still be done through a smartphone device, instead of investing in new research and development. There are various untapped potential in the smartphone that researchers and developers need to be cognizant of.

Profile differences between overdose and non-overdose suicide attempts in a multi-ethnic Asian society.

Abstract: This study explores differences in characteristics of overdose (OD) and non-overdose (NOD) suicide attempts in Singapore. Four hundred eighty-five medical records of people who attempted suicide were extracted from a local general hospital patient database and classified into OD and NOD groups. Differences in socio-demographic factors, suicide characteristics and hospital admission types between both groups were examined. Indians were more likely than the Chinese and Malays to employ OD method in their attempts. More suicide attempts in the OD group than NOD group were self-reported. The most likely place for suicide attempts for both groups was at home, though more NOD suicide attempts were in public areas as compared to the OD group. Analgesics were the most used substance in the OD group. Those who attempted suicide using OD had a higher number of psychiatric ward admissions than the NOD group. Risk and protective factors varied between both groups. Differences in socio-demographics, suicide characteristics and admission characteristics between OD and NOD groups were observed. Recommendations for suicide prevention in the community are discussed. Further studies on the mediators and moderators of these trends and characteristics of suicide attempts are necessary to ensure maximal efficacy of prevention and management.

Inter-professional delirium education and care: a qualitative feasibility study of implementing a delirium Smartphone application

Abstract: Background Delirium is a common medical condition with a high prevalence in hospital settings. Effective delirium management requires a multi-component intervention, including the use of Interprofessional teams and evidence-based interventions at the point of care. One vehicle for increasing access of delirium practice tools at the point of care is E-health. There has been a paucity of studies describing the implementation of delirium related clinical application. The purpose of this current study is to acquire users’ perceptions of the utility, feasibility and effectiveness of a smartphone application for delirium care in a general surgery unit. In addition, the authors aimed to elucidate the potential challenges with implementing this application.

Global outreach and user preferences of a smartphone application developed for drinkers.

Abstract: INTRODUCTION Alcohol use disorders has been known and recently highlighted by the World Health Organization as a major worldwide problem. Harmful usage of alcohol has been linked to increased morbidity and mortality arising from common alcohol related disorders, such as liver disease, hypertension and violent deaths. Looking at the current literature, there have been previous peer reviewed publications about how technology has helped alcohol users. Of significance, a previous content analysis showed that the vast majority of the applications catered for alcohol use disorder which are currently available on the stores are not only not supported by evidence-base, but some of them seemed to be promoting drinking instead. Zhang et al. have described how they have attempted to overcome the limitations of current alcohol applications in their video feature recently published. OBJECTIVE The objective of this article is to evaluate (a) the receptiveness of the general population toward an alcohol tracker application and to determine (b) user preferences with regards to the different features present in an alcohol tracker. METHODS Android Java Developmental kit (ADK) was utilized to program the core functions of the applications. The entire developmental process took approximately 6 weeks to complete and the android version of the application was launched and offered for free download on the android play store since the 4th of February 2015. The utilization of the application was then monitored and recorded using Google analytics. User perspectives with regards to the individual features of the application were collated via an application feedback survey embedded within the application. RESULTS Based on the analytics, a total of 339 users have had access to the application. A cumulative total of 2029 downloads of the application have been made to date. Most of the participants are male (66%) and are of the age group of 30-39 years old (34%). The vast majority of the participants (94%) do not have any prior treatment for alcohol. Interestingly, the vast majority of the users have indicated that they have a drink 4 or more times a week (61%) and tend to drink between 3 to 4 drinks on a typical day they are out drinking. the vast majority reported that they were slightly and moderately comfortable with managing their alcohol use problem (25%). After the usage of the application, 27% of the individuals were moderately comfortable with managing their alcohol use problems and 20% of individuals were extremely comfortable with managing their alcohol use problems. CONCLUSION In conclusion, this is perhaps one of the first few studies to demonstrate the receptiveness of an alcohol tracker that has included other behavioral change methods within as well as a variant of the conventional methodology of tracking alcohol consumption. The current study shows the receptiveness of global users as well as how such an intervention could help them gain more control about managing their underlying alcohol issue.

Early cerebral volume reductions and their associations with reduced lupus disease activity in patients with newly-diagnosed systemic lupus erythematosus.

Abstract: We examined if cerebral volume reduction occurs very early during the course of systemic lupus erythematosus (SLE), and observed prospectively whether gray (GMV) and white matter volumes (WMV) of the brain would improve with lowered SLE disease activity. T1-weighted MRI brain images were obtained from 14 healthy controls (HC) and 14 newly-diagnosed SLE patients within 5 months of diagnosis (S1) and after achieving low disease activity (S2). Whole brain voxel-based morphometry was used to detect differences in the GMV and WMV between SLE patients and HC and those between SLE patients at S1 and S2. SLE patients were found to have lower GMV than HC in the middle cingulate cortex, middle frontal gyrus and right supplementary motor area, and lower WMV in the superior longitudinal fasciculus, cingulum cingulate gyrus and inferior fronto-occipital fasciculus at both S1 and S2. Whole-brain voxel-wise analysis revealed increased GMV chiefly in the prefrontal regions at S2 compared to S1 in SLE patients. The GMV increase in the left superior frontal gyrus was significantly associated with lowered SLE disease activity. In conclusion, GMV and WMV reduced very early in SLE patients. Reduction of SLE disease activity was accompanied by region-specific GMV improvement in the prefrontal regions.

Harnessing the potential of the Kinect sensor for psychiatric rehabilitation for stroke survivors.

Abstract: Dominques et al. in their recent article described how low-cost sensors, such as Microsoft Kinect could be utilized for the measurement of various anthropometric measures. With the recent advances in sensors and sensor based technology, along with the rapid advancement in E-health, Microsoft Kinect has been increasingly recognized by researchers and bioengineers to be a low-cost sensor that could help in the collation of various measurements and various data. A recent systematic review done by Da Gama et al. (2015) have looked into the potential of Kinect in terms of motor rehabilitation. The systematic review highlighted the tremendous potential of the sensors and has clearly stated that there is a need for further studies evaluating its potential for rehabilitation. Zhang et al. (2015) in their recent article have advocated several reasons as to why biosensors are pertinent for stroke rehabilitation. Of note, recent studies done by the World Health Organization have highlighted that stroke is a growing epidemic. Aside to the utilization of smartphone based sensors for stroke rehabilitation, as proposed by Zhang et al. (2015), researchers have also investigated the use of other low cost alternatives, such as Kinect, to facilitate the rehabilitation of stroke survivors. Whilst it may seemed like that has been quite extensive evaluation of the Kinect sensor for stroke rehabilitation, one core area that bio-engineers and researchers have not looked into is that of the psychiatric and mental health issues that might at times arise following a stroke. It is thus the aim of this letter to address how such a sensor could be tapped upon for psychiatric rehabilitation amongst stroke survivors. To this end, the authors have thus conceptualized a game that could help in the cognitive remediation for stroke survivors using low cost Kinect sensors.

The `WikiGuidelines' smartphone application: Bridging the gaps in availability of evidence-based smartphone mental health applications.

Abstract: Over the past decade, there have been massive advances in technology. These advances in technology have significantly transformed various aspects of healthcare. The advent of E-health and its influence on healthcare practice also implies that there is a paradigm shift in the way healthcare professionals work. Conventionally, healthcare professionals would have to refer to books and journals for updates in treatment algorithms, but with the advent of technology, they could access this information via the web or via various smartphone applications on the go. In the field of Psychiatry, one of the commonest mental health disorder to date, with significant morbidity and mortality is that of Major depressive disorder. Routinely, clinicians and healthcare professionals are advised to refer to standard guidelines in guiding them with regards to their treatment options. Given the high prevalence of conditions like Major Depressive Disorder, it is thus of importance that whatever guidelines that clinicians and healthcare professionals refer to are constantly kept up to date, so that patients could benefit from latest evidence based therapy and treatment. A review of the current literature highlights that whilst there are a multitude of smartphone applications designed for mental health care, previous systematic review has highlighted a paucity of evidence based applications. More importantly, current literature with regards to provision of treatment information to healthcare professionals and patients are limited to web-based interventions. It is the aim of this technical note to highlight a methodology to which the authors have conceptualized in the implementation of an evidence based mental health guideline applications, known as the `Wiki Guidelines' smartphone application. The authors hope to illustrate the algorithms behind the development of the application, and how it could be easily updated by the guidelines working group.

Critical Appraisal of Existing Ketamine Trials: Existing Limitations and Limited Applicability for Treatment.

Abstract: TOTHEEDITOR: Newport et al. (1), in their systematic review of N-methyl-D-aspartate antagonists used for the treatment of depression that was published in the October 2015 issue of the Journal, noted that ketamine does indeed have a rapid but transient antidepressant effect. However, the authors cautioned against using ketamine as a novel antidepressant for treatment-resistant depression because they claimed that ketamine’s underlying mechanisms of action are not entirely understood. Moreover, they warned against the use of ketamine in the long term, in view of its inherent neurotoxicity as well as its potential for abuse (1). The authors’ findings and recommendations are in line with the reexamination by the Cochrane collaboration into the utility of ketamine as a rapid antidepressant for treatment of depression and of depression in bipolar disorder (2, 3). Part of the reason for the increasing popularity of ketamine as a rapid antidepressant worldwide has todowith theportrayalof its inherentclinicaleffectiveness by the media (4). If all previous studies were critically appraised, onewould seeflaws indicating that further rigorous evaluation is necessary prior to ketamine’s being recognized as a treatment modality. Follow-up intervals in previous studies have been too short, and hence, the addictive potential of ketamine could not be demonstrated (5). In addition, most of the previous studies did not use ketamine as a sole agent in treatment; other psychotropic medications were administered concurrently to patients (6). In some studies, there might be a practice effect, given that questionnaires were administered frequently (7). Moreover, some studies (8) have reported that ketamine has a role in the rapid reduction of suicidal ideation, but this interpretation isflawedbecause subjectswhowere recruited had low suicidal ideation scores to begin with. Hence, the reduction in scores would render those results statistically insignificant. In addition, the rapid antidepressant effect that ketamine induces might be due to its inherent amphetaminelike properties. More recent studies (9) have demonstrated how ketamine could help to successfully reverse the hypodopaminergic state following acute withdrawal from amphetamine. This does imply that ketamine has inherent stimulant properties. This property might cause a rapid improvement inmood,but itmightalsocausefurtheraddiction issues.While the authors have stated the risks associatedwith chronic ketamine use, they have neglected the genitourinary complications that result from chronic use of ketamine. The long-term use of ketamine could lead to chronic interstitial cystitis. This systematic review performed by the authors is timely and reminds psychiatrists to consider several issues with regard to the utilization of ketamine.

Rapid cross platform healthcare gaming design and implementation: The cost effective methodology.

Abstract: There have been massive advances in E-Health and M-Health technology, with recent interest in the utility of games for healthcare and the promotion of well-being and recovery as well as patient empowerment. There has been various review demonstrating the clinical effectiveness and efficacy of games for healthcare. It is the aim of this technical note to illustrate how appropriate gaming engines could be used by non-expert clinicians to program games that could run across various platforms, as well as games that could integrate well with existing mechanical sensors. This would address the limitations with regards to the evidence base of games, as well as the limitations in the deployment of games to various participants. More importantly, games designed are also more likely to be cost-effective and lower in cost. The ability of integration with existing mechanical sensors would value-add existing games and enable recovery and remediation in various domains of health. This would further expand the potential of games as an adjunctive treatment for patients, or at least, to maintain the gains that they have made in their recovery process.

Serum brain-derived neurotrophic factors (bdnf) levels in patients with alzheimer's disease (ad), individuals with mild cognitive impairment (mci), and healthy controls: a systematic review, meta-analysis, and meta-regression

Abstract: P4-374 SERUM BRAIN-DERIVED NEUROTROPHIC FACTORS (BDNF) LEVELS IN PATIENTS WITH ALZHEIMER’S DISEASE (AD), INDIVIDUALS WITH MILD COGNITIVE IMPAIRMENT (MCI), AND HEALTHY CONTROLS: A SYSTEMATIC REVIEW, META-ANALYSIS, AND META-REGRESSION Kheng Siang Ted Ng, Cyrus S. Ho, Wilson Tam, Ee Heok Kua, Roger Chun-Man Ho, National University of Singapore, Singapore, Singapore; National University Hospital, Singapore, Singapore; Alice Lee School of Nursing, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore. Contact e-mail: khengsiang_1988@yahoo.com