Question of the Week (31st August 2016)

From your expert perspective, at what age is it deemed OK for parents to leave their child at home alone?

It is difficult to define a specific age as children vary in their development and maturity. Pre-schoolers and those under 10 years of age must not be allowed to stay alone at home. Beyond ten, it becomes controversial. In the legislation of some foreign jurisdiction, children up to 15 years old are not allowed to stay at home. As each child is different, it will be best for parents to understand their child's temperament, maturity level and his or her propensity towards being impulsive to determine if their child can be safely left alone at home. 

If a child has to be left alone for any period of time, what tips do you recommend to parents in order for them to keep their child safe?

Firstly, never take safety for granted. Look into safety features such as locking the window grilles. Also, make sure that you are contactable so that the child can reach you immediately if he becomes frightened or has any needs. Having a good relationship with your neighbours will be important as they can sometimes keep a look out for you and the child can also approach them should any emergencies or needs arise.

Bipolar Disorder FAQs Part 3

8. What new treatments/ medications are currently available for this group of patients, and how do the medications work to help patients alleviate symptoms? I read a new study which say that antidepressants may in fact, worsen episodes of mania in this group of patients. See link. What is your take on this?

The main stay of treatment for Bipolar Disorder are mood stabilisers which include medications such as Lithium, Sodium Valproate and Lamotrigine. Antipsychotic medications have been shown to have mood stabilising properties as well and are often used in Bipolar Treatment. Antidepressants can be used in the depressive phase of the Bipolar illness but must be used with caution as they may trigger a manic episode. Many a times, multiple medications may be needed to stabilise the high and low episodes that a Bipolar patient encounters. After the mood has been stabilised and the patient is well, he and his loved ones should be educated about the illness process and prevention strategies. Therapy such as social rhythm therapy, a type of behavioral therapy used to treat the disruption in circadian rhythms that is related to bipolar disorder, is beneficial.

9. What are the chances of a remission with treatment? Possible for patients to lead a normal and fulfilling life?

Although we still do not have a cure, Bipolar Disorder is a very treatable illness. Chances of remission is remarkably high at 80% with treatment and most patients return to where they are in their lives before the mood episodes. Most patients with Bipolar Disorder will require long term treatment and it is important for them to remain on treatment when the illness goes into remission as those who are compliant to their treatment are much less likely to experience a relapse.

10.  Can someone having  manic episodes manifest aggressive or unusual behaviours that may warrant hospital admission?

Patients can become aggressive and even physically violent during episodes of mania. They may pick fights over small day to day issues with their family members and this can escalate to physical altercations needing police intervention and admission to a hospital to keep the patient safe. Some patients develop grandiose delusions thinking they are important people and may become paranoid that others want to harm them. They can become aggressive and violent towards the perceived perpetrators. There have been instances where patients think they have special power,

Bipolar Disorder FAQs Part 2

 4. Some women experience mood swings, for instance, during certain times of their menstrual cycle. When are "mood swings" not considered normal, and may warrant medical attention?

 Many women may notice that they have dysphoric or irritable mood before and during their period, These mood changes are often described as mood swings. These mood swings are generally unrelated to Bipolar Disorder as there is no swing into a manic state. However, if the individual experiences irritability, tension or low mood severe enough to interfere with work, social relationships and activities, they may be suffering from Premenstrual Dysphoric Disorder (PMDD).

 5. A local 2010 Singapore Mental Health Study found that the average time taken for bipolar disorder sufferers to seek help was 9 years. - Why do you think they take so long to seek professional help?

When the symptoms of Bipolar disorder is mild, it can be hard to detect. Most of the time, the afflicted individual may not have insight into their symptoms. In fact, many enjoy their "new found" confidence and inflated self esteem. Family members may think that the individual is just stressed out or being difficult instead of recognising the symptoms as due to Bipolar Disorder. The strong stigma that remains associated with psychological conditions also prevents individuals and there loved ones from seeking help with professionals until the condition becomes severe.

6. Based on your experience working with these patients, what usually prompts patients to seek medical attention for their symptoms?

Many seek help during their depressive phase, when they feel lousy about themselves. and through careful history taking with the patient and their loved ones, a history of previous manic episodes can be obtained. Many patients may be admitted by their loved ones to the hospital when they display unusual behaviours or become aggressive during their manic episodes.

7. How common is it for bipolar disorder to go undetected, or dismissed as something not serious? Why is that so?

 Although there are no available data, Bipolar Disorder is one of the most likely diagnosis to go undetected. Unlike many medical condition where lab tests or objective testing is available in making a diagnosis, the diagnosis of Bipolar Disorder can only be based on the history provided by the patient and his loved ones and observations made by the psychiatrist during the consult. In milder case of Bipolar Disorder where the individuals present with issues such as irritability, restlessness, insomnia, and excessive alcohol consumption. For someone who does not know the individual intimately, the mood changes may be assumed to be normal. Even loved ones may sometimes find it hard to decide if the individual's mood is unusually high or he is an exuberant person to begin with. They may see the change as a change in his personality rather than him having a mental illness.

ADHD in Children: FAQ Part 3

- What causes ADHD? 

The exact causes of ADHD are still not fully understood. However, it is likely to be due to a number of factors coming together. We know that ADHD can be inherited and that the genes controlling the chemicals or neurotransmitters in the brain are different in those with ADHD.

- What are common symptoms that parents can look for to identify that their child has ADHD? 

There are two main domains of symptoms; attention deficits and hyperactivity. The main symptom is difficulty in paying attention. A child with ADHD may have problems listening and following instructions, finishing tasks, is forgetful and easily loses his belongings. He distractible, tend to daydream and make careless mistakes. He will avoid activities that require sustained concentration or that might be boring. In the hyperactivity domain, he is restless and cannot sit still. He may run and climb on things constantly and when seated, may tend to squirm and fidget. The ADHD child is always on the go, will talk excessively and cannot play quietly.

- What are the most effective ways to treat patients between the ages of 3 and 10? 

Most of the time, we only start to diagnose ADHD for children who are 5 and above. This is because, unless very severe, inattention and hyperactivity can be quite common in children 3-5 and may improve naturally as they mature. ADHD can be treated with medications. Currently, two main types of medications are available, stimulants and norepinephrine uptake inhibitors. They help ADHD by increasing the level of neurotransmitters (chemical messengers) in the brain called dopamine and norepinephrine. Behavioural modifications and therapy are also useful treatments and are always given alongside medications.

- Many proponents of ‘food as medicine’ claim that ADHD symptoms can be controlled through a change in dietary habits – how much truth is there to this claim? 

There has not been any proof about these claims and studies done have consistently shown that dietary changes have no bearing on ADHD symptoms. The exception to this is fish oil which has shown to improve attention deficits symptoms and decrease hyperactivity in some cases.

How Common is Depression?

http://www.washingtonpost.com/blogs/worldviews/wp/2013/11/07/a-stunning-map-of-depression-rates-around-the-world/

This picture shows the rates of depression worldwide. The redder the colour, the higher the rates of depression in that country.

This picture is based on a study published recently in the journal PLOS Medicine. In this study, they found depression to be the second leading cause of disability globally, with slightly more than 4 percent of the world diagnosed with it.

However, due to stigmatisation and taboo, many with depression still do not step forward for treatment and suffer silently. If you or your family suffer from symptoms of depression, seek treatment now. Remember, early intervention brings about the best outcome.

ADHD in Children: FAQ Part 2

- How is it diagnosed in children?

The diagnosis of ADHD is made with careful clinical assessment by a trained specialist, usually a psychiatrist. A detailed history from the parents and teachers is taken to assess for ADHD symptoms and during the interviews, the child is observed for ADHD behaviour. Clinical scales may be used to determine the severity of ADHD and to assess improvement in subsequent follow-ups after treatment.

- In your opinion, do you think ADHD is over- or under-diagnosed in Singapore ? Why?

ADHD continues to be under-diagnosed in Singapore. Even though, parents and teachers are more likely to pick up the symptoms of ADHD and know that their kids have difficulties, many continue not to to bring their children to psychiatrists for formal diagnosis and  treatment. Parents are fearful that their children will be stigmatised and they have misconceptions about the illness and medication. They are unaware that without treatment, the consequences of ADHD is debilitating and affects the child negatively in the long term.  

- Why is it easy for ADHD (especially the milder cases) to go unnoticed? How common is it for parents/ teachers to think that the child is simply "naughty"? How to tell when the child's "naughtiness" could be ADHD?

Parents and teachers often think that children with milder forms of ADHD as being naughty and lazy. This is especially so when the symptoms are predominantly in the attention deficit domain. As these children do not display hyperactive behaviour and are often well behaved in school, adults may not realised that they are having problems concentrating in class and are not fulfilling their potential academically.

It is very common for ADHD symptoms to be misconstrued as "bad" or "naughty" behaviour by parents and teachers alike. Even after diagnosis, parents and teachers often require plenty of education and convincing before realising that the symptoms are not wilful or deliberate in nature. It is normal for kids to have naughty behaviour here and there. However, ADHD symptoms are pervasive, meaning that the child is constantly inattentive, hyperactive and impulsive in most situations. Unlike in naughty behaviour, these symptoms lead to long term difficulties academically in school and in other aspects of the child's life.

- How is ADHD treated? How safe is it for children to take medication for ADHD long-term?

ADHD can be treated with medications. Currently, two main types of medications are available, stimulants and norepinephrine uptake inhibitors. They help ADHD by  increasing the level of neurotransmitters (chemical messengers) in the brain called dopamine and norepinephrine. Behavioural modifications and therapy are also useful treatments and are always given alongside medications.

Latest studies showed that medications are safe and effective for long term ADHD treatment when taken under the supervision of a psychiatrist and earlier fear of untoward heart problems are unfounded. However when under treatment, the psychiatrist will continue to monitor for any possible side effects that may occur and will make the necessary adjustments when needed.

- How can parents of ADHD children cope and what can they do to help their child?

First and foremost, parents will need to be educated about that ADHD  is not unlike any other medical problems and ADHD children are not lazy, naughty or being wilful. As such, what parents need to do is not be punitive but to approach the symptoms with patience and compassion and to assist the child with managing his or her symptoms. Parents should consult their child's psychiatrist in learning about the specific approaches they can adopt. These will usually include setting up firm and consistent boundaries and routines for the child, rewarding and encouraging positive behaviour and meting out the appropriate consequences for bad behaviour. Adjustment to communication styles are important. Parents need to catch their child's attention before speaking to them rather than just yelling at them. Use as little words as possible as the ADHD child has poor attentional span and will not be able to follow long instructions.

Postpartum Depression

In a study published in March this year in  JAMA Psychiatry,  1,396 of 10,000 mothers screened positively for postpartum depression on the Edinburgh Postnatal Depression Scale (EPDS). This study sponsored by the publicly funded National Institute of Mental Health in the US shows that depression after childbirth is a significant problem. Unfortunately, postpartum depression remains underidentified and undertreated. Some of the following are common myths about Postpartum Depression.

Postpartum Depression (PPD) is the same as baby blues.

Unlike baby blues that goes away after a few days, postpartum depression lasts for weeks to months. The symptoms of PPD is the same as for a Major Depressive Episode. 

PDD is normal and ok to be sad after having a baby.

Whilst changes in mood may be normal after birth, if they are prolonged or are affecting your ability to care for your child, you should seek medical attention. If left treated, PDD can lead to:

1) Inconsistent and poor childcare
2) Avoidant or venting type of coping strategies with child
3) Insecure attachment between mother and child (may result in anxiety and depression of the child in later life)
4) Risk and danger if mother becomes agitated or suicidal with depression

PDD occurs right after birth.

It can occur right after birth or even up to a year later. Most of the time it occurs within three months.

Treatment for PDD will prevent me from breastfeeding and harm my baby.

Effective treatment is available for PDD. Antidepressants safe for pregnancy can be used to treat PDD after the risks and benefits have been discussed. Psychological therapy with techniques such as CBT is also useful.

It is unfortunate that PDD often goes unrecognised leading to tragedies such as these. Seek help today as PDD  can be treated!

The Myths About Antidepressants

Antidepressants are the mainstay of treatment for clinical depression and anxiety disorders.  These medications are effective and safe for the general population. However, many remain skeptical about antidepressant treatment and many myths remains.

1. I will become reliant on antidepressants and be addicted.

This is one of the main concern that my patients have when they have to be started on an antidepressant medication. It is important to realise that unlike sleeping pills, it is not possible to be addicted to antidepressants. Antidepressants do not cause tolerance or cravings like street drugs do. The fact that there are no street values with antidepressants attest to the fact that they are not addictive. However, if a patient is on high doses of antidepressants for a long time, it is best for him or her to seek the advice of the psychiatrist and not stop medication abruptly as this can cause "discontinuation syndrome". Discontinuation syndrome can lead to physical discomfort and can be completely avoided by weaning off the medication slowly in a few weeks.

2. My condition will become worse that when it started if I stop the medications.

Your condition will not worsen or rebound simply because you stop your medication. Antidepressants treats your depression or anxiety and also protects you from future episodes. If you stop the medication, it is like you taking off your armour. You will be vulnerable to depression or anxiety again.

3. Antidepressants have terrible side effects.

Newer classes of antidepressants like SSRIs are currently the mainstay of treatment. Unlike older antidepressants, these newer medications are well tolerated. At times, side effects can still occur to the minority of people. Known side effects include weight gain, sedation and rarely sexual dysfunction. These side effects are reversible and if any these side effects arises, you must inform your doctor who will switch you to another medication.

4. My brain will be affected by the medications!

Sometimes patients worry that they will be "changed" by the medications and their brain will become different. Antidepressants normalises the neurotransmitters in your brain  and this in turn makes your mood normal again. Antidepressants are not "happy"pills. They help by making you cope better so that you can solve the problems you have in life and it is up to you to find new meaning and happiness.

5. I'll have to take medications forever!

Many patients are afraid that once they are on medications, they cannot come off it. Majority of patients will become better once they have been treated and will come off medications. Some patients who have multiple episodes of mood or anxiety problems and may decide to stay on the medications long term. Your doctor will discuss with you the pros and cons of taking medications and how long you will require them. Ultimately, you have the choice of whether to take medications and the choice to stop them.

The Top Five Regrets of the Dying

Bronnie Ware is a palliative nurse who has been seeing dying patients. From her experience, she observed five common themes that often resurfaced with regards to the regrets of people who were dying.

1. I wish I'd had the courage to live a life true to myself, not the life others expected of me.
2. I wish I didn't work so hard.
3. I wish I'd had the courage to express my feelings.
4. I wish I had stayed in touch with my friends.
5. I wish that I had let myself be happier.

In essence, the dying often wished that they have lead a more meaningful and fulfilling life. That they have been more true to themselves and in touch of their feelings. They wished they had spent more time with family, friends and with the things they like to do instead of just their work. Such reflections are not new. Kubler Ross in her work about the grief of dying had often alluded to these.

Sadly, our society continues to overemphasize academic and occupational achievements. Family and other social aspects of life are often neglected.

If your time is ending, will you have any regrets?

Most adolescent suicidal behavior preceded by mental health treatment

A recent research(1) showed that the lifetime prevalence of suicide ideation among adolescents was 12.1%, suicide plans 4%, and suicide attempts 4.1%. One-third of adolescents with suicidal ideation went on to develop a suicide plan and 33.9% made an attempt. Most adolescents (88.4%) who transitioned from planning suicide to attempting suicide did so within a year.

Most adolescents who had suicidal ideation (89.3%) and attempted suicide (96.1%) met lifetime criteria for at least one DSM-IV mental disorder, which included major depressive disorder, specific phobia, oppositional defiant disorder, substance abuse, intermittent explosive disorder and conduct disorder. Most disorders significantly predicted suicidal behaviors, and the prevalence of mental disorders generally increased with the increasing severity of suicidal behaviors.

From this study, we can see that it is important to identify and provide early treatment for these troubled youths. Unlike physical illnesses, parents tend to ignore mental health issues and to believe that such problems will go away by themselves. Otherwise, they may feel that seeking help from a mental health professional is too stigmatising and may do more harm to their children.

Such ignorance, often lead to delay in seeking treatment and may result in the youths and parents defaulting follow-ups. Today, suicidal behaviors are among the leading causes of death in Singapore and worldwide, especially among adolescents and young adults. Seek help early and contact a psychiatric clinic in Singapore.

(1) Prevalence, Correlates, and Treatment of Lifetime Suicidal Behavior Among Adolescents Results From the National Comorbidity Survey Replication Adolescent Supplement  
Matthew K. Nock, PhD; Jennifer Greif Green, PhD; Irving Hwang, MA; Katie A. McLaughlin, PhD; Nancy A. Sampson, BA; Alan M. Zaslavsky, PhD; Ronald C. Kessler, PhD
JAMA Psychiatry. 2013;():1-11. doi:10.1001/2013.jamapsychiatry.55

A Study on Empathy

Empathy is an innate quality in humans. It ensures that we have the ability to feel for one another and this further promotes kindness and co-operation. The more people are alike, the more they identify with one another. In fact, it has been found that if you did not identify with a victim of  any kind of trauma, you are unlikely to be vicariously traumatised. This may be protective for rescue workers in major disasters or healthcare personnels dealing with patients with PTSD.

In this interesting study on empathy in rats. Watch the video!

Adult ADHD: Simply a Myth?

There has been many research done on adult ADHD which have shown that many adults continue to be affected with ADHD symptoms. Despite this, many still think of ADHD as an illness affecting only children. There is a lack of understanding about adult ADHD both in healthcare professionals as well as the public in general.

In this paper written by doctors from the Institute of Mental Health (IMH), Woodbridge Hospital, Singapore, it is estimated that 5.29% of people may have ADHD. Only 10% will recover fully such that the symptoms no longer affect their lives in any way. This means that in Singapore, 265,000 people have ADHD and about 240,000 people will have ADHD symptoms into adulthood!

Based on this report, about 140,000 Singaporeans suffer from asthma. This is about 100,000 less than ADHD. Yet, it is not uncommon to hear of adults getting treatment for asthma whilst you will almost never hear adults getting treated for ADHD. In fact, many adult with ADHD today may have never been diagnosed in their childhood as the illness was poorly understood in this part of the world when they were children.

This can be due to the fact that the symptoms of adult ADHD is somewhat covert and hidden. As the child grows older, the hyperactivity symptoms (ie fidgeting,  running around, talking excessively) subsides. The adult can control their hyperactive symptoms much better. However, they continue to have inattentive symptoms like forgetfulness, poor time management and disorganisation. These symptoms can often be very disruptive. This is especially so students undergoing tertiary education where academic work can be fast paced and stressful. The ADHD mind may find itself unable to cope or manage in these times of stress where time allocation, organisation and prioritisation of work is critical.

Psycho-stimulant medications like methylphenidate is a very effective treatment for these symptoms. Other therapy such as behavioural modifications or cognitive behavioural therapy are helpful for the individuals suffering from adult ADHD.

Depression: Should I See A Doctor?

In life, it is not uncommon to be down and out especially if you have experienced an upsetting event. Clinical depression however, is a separate entity whereby the mood is low for more than two weeks accompanied by various other symptoms (see here). Clinical depression is a medical condition that requires treatment.

Why see a Doctor for Depression?

Many a times, people feel that they are strong enough to will themselves out of depression. Despite wanting to get away from everything, those with depression often soldier on with work and social commitments. In front of friends and family, they put up a strong front as if nothing is wrong. Sometimes in milder cases, the individual may recover shortly but in many cases, without help, the depression and ability to cope will worsen. This results in a vicious cycle.

Physical Assessment

In the assessment of depression, the doctor or psychiatrist will also perform a physical examination and sometimes blood tests to make sure that the low mood is not caused by medical problems such as hypothyroidism.

Suicide Assessment
The psychiatrist is also the most qualified person to perform a suicide assessment. If your friend of love one has depression, there is a risk that he or she may harbour suicide thoughts and may act on them in the future. A suicide risk assessment will help identify individuals at high risk of completing suicide so that immediate help and treatment can be performed.

Brain Changes in Depression
One cannot simply will away depression. It is not due to moral deficits or weakness in personality. It has a biological basis. In depression, actual structural changes of the brain occurs. Depression is associated with changes in metabolism and blood flow in the brain. Medication can protect the brain from these damages and potentially reverse these changes.

Treatment of Depression
Depression is very treatable. 70-85% of sufferers respond to medications. There really is no need to suffer the sleepless nights, endless guilt feelings and hopelessness. In addition to medication and psychological treatment, psychiatrist will advise their patients about practical steps to take to improve their mood. Watch this space for more advice about depression.

What is Psychiatry?

In Singapore, many people do not know what psychiatry is or what psychiatrists do. Even healthcare professionals sometimes get confused between psychiatrist and psychologist. Let me explain what Psychiatry is.

What is Psychiatry?

Psychiatry is a medical specialisation focusing on mental illnesses and disorders. Before Psychiatry, mental disorders were thought of as demonic possessions or character flaws. Sufferers were often locked up and kept away from society. In the 20th century, psychological treatments were discovered for these illnesses. The first medication for psychiatric disorders were discovered in the 1970s.

Who are Psychiatrists?

Psychiatrists are medical doctors who are trained and specialises in the field of psychiatry and psychology. As medical doctors, we are trained to identify and diagnose psychiatric and mental disorders. We can then prescribed the necessary treatment for our patients and these can be therapy, medications and even simple lifestyle changes.

When it comes to talk therapy, the role of psychiatrists, psychologists and counsellors may overlap. Depending on his training, the psychiatrist may decide to perform the talk therapy with the patients himself. Often, he may work with the psychologist or counsellor in his team to implement the therapy.

Psychiatrist vs Psychologist: Who to see?

If you suspect you or your love one has a psychiatric illness or condition, it will be best for you to seek help from a medical doctor. A good staring point may be your family physician or a psychiatrist. Many a times, medical conditions (eg. Hyperthyroidism) can masquerade as low mood, anxiety or poor sleep. You should see someone medically trained to make sure that the psychological condition is not due to a medical problem.

For this reason, in most Singapore public hospital, you will need to consult a psychiatrist before you can be referred to a psychologist or a counsellor for therapy. The psychiatrist is responsible for making the diagnosis and to decide on the treatment plans for you. Only a medically trained doctor can order blood tests or prescribe medications.

For the best outcomes in treatment, a multi-pronged biological-psychological and social approach is recommended. Hence, when considering private care treatment, it is important to remember that a psychiatrist is in the unique position to provide holistic and comprehensive care:

• Exclude other medical problems
• Diagnose your condition
• Prescribe the appropriate medication /  biological therapy
• Address psychological issues and perform psychological therapy
• Advise on lifestyle changes