The discipline of psychiatry requires the use of thinking skills to perform a number of tasks. The assessment of a patient’s history, his mental state especially the evaluation of thought disorders, the formulation of a diagnosis and differential diagnosis, the formulation of a management plan for what are often complex human problems and the wise application of therapeutic techniques, all require complex thinking skills. The process of communication with patients and their relatives is often fraught with pitfalls that requires a thoughtful approach that makes use of consciously shared information as well as non-verbal information. Evaluating scientific papers is another area that requires critical thinking. At times the lack of critical thinking is painfully apparent. It appears that schools, and sadly universities too, are merely training people and not educating them. Occasionally, of course, one is pleasantly surprised to come across a student with a very sharp and critical mind.
Suicide statistics are generally recognised to be unreliable. This study of the reported rates of suicide in West Malaysia between 1966-1990 shows that the mean crude suicide rate between 1966-1974 was 6.1 per 100,000, but had dropped drastically between 1975-1990 to a mean of 1.6 per 100,000. Three lines of evidence are presented to show that this reduction in the suicide rate is due to a systematic misclassification of medically certified suicides as deaths due to undetermined violent deaths (which refers to violent deaths not known to be accidentally or deliberately inflicted). Firstly, the large drop in reported suicide rates corresponds closely to an increase in the rate of deaths due to undetermined violent deaths. There is a highly positive negative correlation between the two rates (coefficient of correlation, r = -0.9). Secondly, the misclassification appears to be mainly a problem with the medically certified deaths which follow the ICD classification. The mean ratio of uncertified to certified suicides before 1975 was 0.8, but from 1975 onwards the mean was 3.1. This is in contrast to the corresponding ratio for deaths due to all accidents which has remained fairly constant throughout these years. Thirdly, the race and sex differences for the rates of undetermined violent deaths are identical to those of suicide. Taking the misclassification into account the corrected suicide rate for West Malaysia is estimated to be between 8-13 per 100,000 since 1982.
Cameron Highlands has one of the highest suicide rates in the world, especially among Indians. Forty Indian families (19 suicides; 21 controls) were studied to compare family characteristics such as income, overcrowding, birth order of index cases of suicide, family history of suicidal behaviour or mental illness, marital disharmony, presence of alcohol abuse, availability of, and knowledge about, weedicides/insecticides, talk/threat of suicide among family members and experience of significant losses in the past year. Controls were matched for age, sex and educational level with the index cases of suicide. A significant difference was only found for one of the above factors, namely increased experience of significant losses in the past year in the family of index cases of suicide. More than 75% in both groups had alcohol related problems. About equal proportions in each group had a family history of suicidal behaviour and mental illness. There was more marital disharmony in families of suicides but this failed to reach significance. These results and methodological limitations of this study are discussed.
Two hundred and six patients attending an urban general practice were surveyed using a self-rating questionnaire, the 30-item version of the General Health Questionnaire. At a cut-off score of 6/7, 34.5% of the respondents were found to be high-scorers which gives a corrected estimate of psychiatric morbidity of 29.9% in this clinic. Among those who presented with general complaints, such as aches and pains for which no organic cause was found, a significant proportion (70%) were high-scorers. There were no significant differences in the sex and age distribution of the high-scorers. However the mean score of Malays was significantly higher than that of Chinese.
Five hundred and sixty-two consecutive attenders at an urban general practice were studied using the Consumption Index which has been successfully used in a general hospital sample. Seventy per cent of Chinese, 11% of Malays and 42% of Indians have used or are currently using alcohol-a vast majority of them were social drinkers. Among those who ever drank, 6% of Chinese and 22% of Malays drank more than 14 units per week. The hypotheses that more Indians used alcohol and used it more heavily were not supported in this urban sample. Possible explanations for these findings and the limitations of this study are discussed.
Ninety-five cases of suicide and 134 cases of parasuicide that occurred between October 1973 and September 1984 in the hill resort district of Cameron Highlands in Malaysia were analysed. Eighty-one per cent of suicides and 78% of parasuicides were of Indians, although they only form 25% of the population. The average annual suicide rate for Indians (over 10 years of age) was 157 per 100,000. About 94% of suicides and 66% of parasuicides were by ingesting agricultural poisons. The age- and sex-specific suicide rates for women were highest in the 20-24-year-old age group. Some possible reasons for high suicide rates among Indians are discussed.
Traditional methods of treatment are extremely popular with Malaysians especially for psychiatric illnesses. Those who seek such treatment come from all cultures, social classes and different educational levels in this country. In one hospital as much as 49% of psychiatric patients had been to traditional healers . Some receive simultaneously traditional and modern modes of treatment. While many reports have been written on traditional healers such as the bomoh and spirit mediums, relatively less is written about Christian healers who practise exorcism. This paper describes two patients who had received psychiatric diagnoses of major illnesses, and who subsequently underwent Christian exorcism. The process of exorcism and the short-term and long-term outcome are reported.
Objective: The aim of this study is to compare the prevalence of life events among parasuicide patients
with the prevalence of similar life events among age, sex and race matched patients with non-chronic
medical illness. Methods: A hospital-based case-control study using convenience sampling method
was conducted in Hospital Kuala Lumpur for a period of three and a half months. A total of 50 patients
admitted consecutively after an episode of parasuicide and who fulfilled criteria for entry into the study
agreed to participate. For each case one age-, sex- and race-matched control was selected from the list of patients who were admitted to the same hospital for non-chronic medical illness. Result: Statistical analysis showed that compared with medically ill patients, parasuicide patients had significantly higher prevalence of threatening life events six months (p
Objective: This is a case report discussing about the Charles Bonnet Syndrome (CBS). CBS is a condition in which extremely vivid and well-formed visual hallucinations occur episodically with great profusion. They are typically experienced in clear consciousness, and
the insight is either retained or very quickly attained into the unreal nature of the phenomena. Method: We report a case of a 70 year-old Malaysian male who has been suffering from Tourette disorder for the past 40 years and was blind bilaterally. Results: He presented with episodic, nocturnal visual hallucinations. These occurred in clear
consciousness and the patient’s insight to these experiences was retained. There was no history of any other major psychiatric illness in this patient. Conclusion: This case illustrates a diagnosis of CBS with the differential diagnoses of epilepsy and other organic conditions.
Objective: To assess psychiatric morbidity, personality profiles and saliva cortisol levels in overweight and obese individuals at dietician clinic. Method: This cross-sectional study is based on individuals who attended dietician clinic between June to November 2008. They had completed questionnaires that included General Health Questionnaire 30-items, assessment for psychiatric illness using Structured Clinical Interview for DSM-IV and personality profiles using Personality Assessment Schedule. Saliva and body mass index were taken. Results: Of the 102 patients, 16 (15.7%) were diagnosed to have psychiatric illness. There were no differences between obese and overweight patients in terms of personality traits and psychological problem. Presence of psychiatric illness was associated with higher mean body mass index. Saliva cortisol levels were not elevated in patients who had psychiatric illness. Conclusions: Psychiatric illnesses are common in individuals who seek weight treatment. Careful psychological evaluation is important at (or before) commencement of a diet program.
Objective: This case report highlights the clinical dilemmas encountered in deciding the diagnostic status of persons with unipolar depression who develop hypomania during antidepressant/electroconvulsive therapy.
Methods: We report a case of a 52 year-old Chinese lady, diagnosed with unipolar depression, which developed hypomania after she was started on T. Fluvoxamine 100mg daily and completed 8 sessions of Electroconvulsive therapy.
Results: Her diagnosis was revised to Bipolar Disorder and she was treated with T. Sodium Valproate 400mg twice daily after which she improved.
Conclusion: Treatment-emergent hypomania is likely a subtype of bipolar spectrum disorder and patients with Treatment - emergent Hypomania should be treated as Bipolar Disorder.
Objectives: This paper aims to report on a case in which re-challenging with clozapine in combination with lithium in a patient who developed neutropenia was carried out. Methods: The patient was treated with clozapine for treatment- resistant schizophrenia. After five weeks he showed much improvement but developed neutropenia. Withdrawal of clozapine brought on a relapse of psychotic symptoms. Subsequently, clozapine was reintroduced along with Lithium. The neutrophil count was monitored closely. Results: The neutrophil and white blood cell count were noted to return to normal upon re-challenging, and the patient’s clinical condition also improved. Conclusion: Simultaneous administration of lithium and clozapine to patients experiencing neutropenia on clozapine is a possible strategy. However, very close monitoring of the white count is needed. ASEAN Journal of Psychiatry, Vol. 15 (1): January - June 2014: 90-92.
Creatine kinase (CK) is an enzyme that is found widely in muscle tissues. Raised levels would occur when there is muscle damage. Raised levels are used as one of the diagnostic criteria for Neuroleptic Malignant Syndrome (NMS). This study looks at CK levels in 30 psychotic inpatients without NMS and compares them with 10 patients with NMS. It was found that 67% of the patients without NMS had raised CK levels, 20% of whom had levels in excess of 1000 IU/L. The rest had a two to five-fold increase over normal limits. Raised levels were associated with the use of intramuscular injections and physical restraints, situations which are well known to result in muscle injury. All the NMS patients had raised CK levels but 40% had levels below 1000 IU/L. Our findings support the idea that CK levels, though helpful, should be interpreted with care as raised levels are nonspecific.
The prescriptions of all patients who attended an urban general practice from September 1987 to December 1987 were studied. Of the 111 patients (60 females and 51 males) who received a psychotropic prescription the commonest presenting complaint was insomnia (56 patients or 50.5%). This was followed by tension, headache and unexplained aches and pains (19 patients or 17.1%), and anxiety (nine patients or 8.1%). Consistent with these presentations a vast majority (92.8%) received a benzodiazepine. The commonest drugs prescribed were Lorazepam and Bromazepam whereas the longer acting benzodiazepines were rarely used. Polypharmacy was rare.
A case of paranoid psychosis in myxoedema is described. Though depression is commonly encountered in myxoedema, the disorder can also manifest itself with schizophrenic features; this can lead to problems in diagnosis and management.
Objective: This case report highlights the challenges in managing Frontal Lobe Syndrome (FLS) in a patient with end-stage renal disease. Methods: This is a case description of a 58 year-old gentleman who presented with behavioural changes: irritability, mood lability, aggression, psychosis, and overfamiliarity. His presenting symptoms were in keeping with (FLS) with positive findings on Computed Tomography (CT) scan of the brain and also neuropsychological assessments. Difficulties arose in attempts to control his aggression without further compromising his renal function. Results: The usage of the commonly used antipsychotics in controlling aggression was restricted in view of the patient’s renal impairment. Augmentation with low dose memantine proved to be beneficial in this case, without causing further deterioration in renal function. Conclusion: The use of memantine to augment the effect of risperidone was observed to be safe and successful in managing the behavioural changes associated with FLS in adults with end-stage renal disease. ASEAN Journal of Psychiatry, Vol. 15 (1): January - June 2014: 93-96.
Our study aimed to examine the interplay between clinical and social predictors of future suicide attempt and the transition from suicidal ideation to suicide attempt in depressive disorders. Sixty-six Malaysian inpatients with a depressive disorder were assessed at index admission and within 1 year for suicide attempt, suicidal ideation, depression severity, life event changes, treatment history and relevant clinical and socio-demographic factors. One-fifth of suicidal ideators transitioned to a future suicide attempt. All future attempters (12/66) had prior ideation and 83% of attempters had a prior attempt. The highest risk for transitioning from ideation to attempt was 5 months post-discharge. Single predictor models showed that previous psychiatric hospitalization and ideation severity were shared predictors of future attempt and ideation to attempt transition. Substance use disorders (especially alcohol) predicted future attempt and approached significance for the transition process. Low socio-economic status predicted the transition process while major personal injury/illness predicted future suicide attempt. Past suicide attempt, subjective depression severity and medication compliance predicted only future suicide attempt. The absence of prior suicide attempt did not eliminate the risk of future attempt. Given the limited sample, future larger studies on mechanisms underlying the interactions of such predictors are needed.
The aim of this paper is to review the literature on suicide attempts in Malaysia. PsycINFO, PubMed, and Medline databases from 1845 to 2012 and detailed manual search of local official reports from the Ministry of Health and the Malaysian Psychiatric Association and unpublished dissertations from 3 local universities providing postgraduate psychiatric training were included in the current review. A total of 38 studies on suicide attempts in Malaysia were found and reviewed. Twenty-seven (76%) of the studies on suicide attempts were descriptive studies looking at sociodemographic data, psychiatric illnesses, and methods and reasons for suicide attempts. No study has been conducted on treatment and interventions for suicide attempts and the impact of culture was rarely considered. The review showed that in order for researchers, clinicians, and public health policy makers to obtain a better understanding of suicide attempts in Malaysia, more systematic and empirically stringent methodologies and research frameworks need to be used.