Faculty Bibliography

OBJECTIVE: This study surveyed the use of anticholinergic medications (ACMs) in older Asian patients with schizophrenia and examined its demographic and clinical correlates. METHOD: A total of 1452 hospitalized patients with schizophrenia aged 55 years or older in nine Asian countries and territories were surveyed between 2001 and 2009. The cross-sectional data of patients' socio-demographic and clinical characteristics and the prescriptions of antipsychotic drugs and ACM were recorded using a standardized protocol and data collection procedure. RESULTS: The frequency of ACM prescription was 64.6% in the pooled sample, with 72.4%, 61.9%, and 59.5% in 2001, 2004, and 2009, respectively. Multiple logistic regression analysis of the whole sample revealed that patients on ACM had a higher dose of antipsychotic medications, and were more likely to have extrapyramidal side effects and receive first-generation antipsychotic medications. CONCLUSIONS: Anticholinergic medications were frequently used in older Asian patients with schizophrenia. Considering the potential side effects of ACM, the rationale for their widespread use in this patient population should be revisited.

BACKGROUND: Depression is the third leading contributor to the worldwide burden of disease. We assessed the nature and severity of experienced and anticipated discrimination reported by adults with major depressive disorder worldwide. Moreover, we investigated whether experienced discrimination is related to clinical history, provision of health care, and disclosure of diagnosis and whether anticipated discrimination is associated with disclosure and previous experiences of discrimination. METHODS: In a cross-sectional survey, people with a diagnosis of major depressive disorder were interviewed in 39 sites (35 countries) worldwide with the discrimination and stigma scale (version 12; DISC-12). Other inclusion criteria were ability to understand and speak the main local language and age 18 years or older. The DISC-12 subscores assessed were reported discrimination and anticipated discrimination. Multivariable regression was used to analyse the data. FINDINGS: 1082 people with depression completed the DISC-12. Of these, 855 (79%) reported experiencing discrimination in at least one life domain. 405 (37%) participants had stopped themselves from initiating a close personal relationship, 271 (25%) from applying for work, and 218 (20%) from applying for education or training. We noted that higher levels of experienced discrimination were associated with several lifetime depressive episodes (negative binomial regression coefficient 0.20 [95% CI 0.09-0.32], p=0.001); at least one lifetime psychiatric hospital admission (0.29 [0.15-0.42], p=0.001); poorer levels of social functioning (widowed, separated, or divorced 0.10 [0.01-0.19], p=0.032; unpaid employed 0.34 [0.09-0.60], p=0.007; looking for a job 0.26 [0.09-0.43], p=0.002; and unemployed 0.22 [0.03-0.41], p=0.022). Experienced discrimination was also associated with lower willingness to disclose a diagnosis of depression (mean discrimination score 4.18 [SD 3.68] for concealing depression vs 2.25 [2.65] for disclosing depression; p<0.0001). Anticipated discrimination is not necessarily associated with experienced discrimination because 147 (47%) of 316 participants who anticipated discrimination in finding or keeping a job and 160 (45%) of 353 in their intimate relationships had not experienced discrimination. INTERPRETATION: Discrimination related to depression acts as a barrier to social participation and successful vocational integration. Non-disclosure of depression is itself a further barrier to seeking help and to receiving effective treatment. This finding suggests that new and sustained approaches are needed to prevent stigmatisation of people with depression and reduce the effects of stigma when it is already established. FUNDING: European Commission, Directorate General for Health and Consumers, Public Health Executive Agency.

BACKGROUND: To date there has been no large-scale international study that examined the use of clozapine in older patients with schizophrenia. This study examined the use of clozapine and its demographic and clinical correlates in older patients with schizophrenia in East Asia during the period between 2001 and 2009. METHOD: Information on 1,157 hospitalized patients with schizophrenia aged 50 or older in five East Asian countries and territories (China, Hong Kong, Korea, Singapore and Taiwan) was extracted from the database of the Research on Asian Psychotropic Prescription Patterns (REAP) project. Socio-demographic and clinical characteristics and prescription of psychotropic medications were recorded. RESULTS: Clozapine was prescribed for 20.6% of the pooled sample; 19.0% in 2001, 19.4% in 2004 and 22.9% in 2009. Multiple logistic regression analysis of the whole sample revealed that patients taking clozapine had a longer duration of illness, more negative symptoms and were less likely to receive first generation antipsychotic and anticholinergic drugs, but more likely to report weight gain compared to those not receiving clozapine. Compared to those in other sites, older patients in China were more likely to receive clozapine. CONCLUSIONS: The prescription of clozapine for older Asian schizophrenia inpatients has remained at a stable level during the past decade. The appropriateness of use of clozapine in China needs to be further explored.

OBJECTIVE: The aim of this study was to survey the use of antipsychotic polypharmacy (APP) in older Asian patients with schizophrenia and examine its demographic and clinical correlates. METHODS: Information on hospitalized patients with schizophrenia aged 55 or older was extracted from the database of the Research on Asian Psychotropic Prescription Patterns study. Data on 1439 patients in 6 Asian countries and territories including China, Hong Kong, Japan, Korea, Singapore, and Taiwan were analyzed. Sociodemographic and clinical characteristics and antipsychotic prescriptions were recorded using a standardized protocol and data collection procedure. RESULTS: The frequency of APP prescription was 51.6% in the pooled sample with wide intercountry variations. Multiple logistic regression analysis of the whole sample showed that patients on APP had higher antipsychotic doses and also were more likely to receive first-generation antipsychotics. CONCLUSIONS: Use of APP was common in older Asian patients with schizophrenia. Given the limited evidence supporting its efficacy, the potentially severe side effects and high costs, APP should be used with caution in this population. The reasons for and outcomes of the use of APP in this patient population merit further exploration.

OBJECTIVE: This study examined the prescribing patterns of several first- (FGAs) and second-generation antipsychotic (SGAs) medications administered to older Asian patients with schizophrenia during the period between 2001 and 2009. METHOD: Information on hospitalized patients with schizophrenia aged 65 or older was extracted from the database of the Research on Asian Psychotropic Prescription Patterns (REAP) study (2001-2009). There were no older patients in Thailand, therefore data on 467 patients in eight Asian countries and territories including China, Hong Kong SAR, India, Japan, Korea, Malaysia, Singapore, and Taiwan were analysed. Cross-sectional socio-demographic data, clinical characteristics and antipsychotic prescriptions were assessed using a standardized protocol and data collection procedure. RESULTS: Of the 467 patients, 192 patients (41.1%) received FGAs only, 166 (35.5%) received SGAs only and 109 (23.3%) received a combination of FGAs and SGAs. Of the FGAs, haloperidol was the most commonly used (31.3%; mean 9.4 +/- 6.7 mg/day), followed by chlorpromazine (15.4%; mean 126.4 +/- 156.4 mg/day) and sulpiride (6.6%; mean 375.0 +/- 287.0 mg/day). Of the SGAs, risperidone was the most commonly used (31.5%; mean 4.5 +/- 2.7 mg/day), followed by olanzapine (13.1%; mean 13.6 +/- 6.5 mg/day), quetiapine (7.3%; mean 325.0 +/- 237.3 mg/day) and aripiprazole (1.9%; mean 17.6 +/- 7.7 mg/day). CONCLUSIONS: FGAs and higher doses of certain SGAs (risperidone, olanzapine and quetiapine) were still commonly dispensed to older Asian patients with schizophrenia. Considering older patients' reduced tolerability of potentially severe side effects associated with FGAs and higher doses of certain SGAs, continuing education and training addressing the rational use of antipsychotics in this population is clearly needed.

BACKGROUND: Considering the relationships between diabetes and depression may enhance programs to reduce their individual and shared disease burden. METHODS: This paper discusses relationships between diabetes and depression, the range of influences on each, conceptual issues central to their definition, and interventions including comprehensive, population approaches to their prevention and management. Foundational and exemplary literature was identified by the writing team according to their areas of expertise. RESULTS: Diabetes and depression influence each other while sharing a broad range of biological, psychological, socioeconomic and cultural determinants. They may be viewed as: (a) distinct but sometimes comorbid entities, (b) dimensions, (c) parts of broader categories, e.g., metabolic/cardiovascular abnormalities or negative emotions, or (d) integrated so that comprehensive treatment of diabetes includes depression or negative emotions, and that of depression routinely considers possible diabetes or other chronic diseases. LIMITATIONS: The choice of literature relied primarily on the authors' knowledge of the issues addressed. Some important perspectives and research may have been overlooked. CONCLUSIONS AND CLINICAL IMPLICATIONS: Collaboration among primary care and specialist clinicians as well as program and public health managers should reflect the commonalities among diabetes, depression, and other chronic mental and physical disorders. Interventions should include integrated clinical care and self-management programs along with population approaches to prevention and management. Self management and problem solving may provide a coherent framework for integrating the diverse tasks and objectives of those living with diabetes and depression or many other varieties of multi-morbidity.