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This study examines the experiences of patients in treatment with psychodynamic psychiatrists on an intermittent basis following an initial brief period of intensive psychotherapy and stabilization. Patients with non-psychotic disorders who received intermittent treatment answered a web-based questionnaire describing the usefulness of various supportive, cognitive-behavioral, and psychodynamic interventions. Forty-eight out of 58 patients invited to participate completed the survey (83% response rate). The majority (75%) of respondents welcomed the intermittent treatment frame. Therapeutic factors deemed to be most helpful included supportive interventions such as ability to relate to the clinician, ability of clinician to listen empathically, and feeling supported by a non-judgemental therapist when talking about private matters. The majority of respondents also endorsed as highly beneficial various cognitive-behavioral interventions such as understanding how thinking patterns impact behavior and feelings and discussing alternative coping skills. Also highly rated were psychodynamic interventions, including understanding how the present is modeled from past experiences and expression and regulation of affect. In the open-ended qualitative feedback, therapeutic factors including collaboration, forming an alliance, and empathic attunement emerged as important. Our preliminary findings suggest that the intermittent psychodynamic treatment frame is well received by patients. Patients welcome integration of different psychotherapeutic approaches to individualize treatment. The common factors in psychotherapy are important patient-reported therapeutic factors in the intermittent treatment approach.

Community psychiatry focuses on the delivery of a coordinated programme of mental healthcare to a specified population. Mental illness is prevalent and a significant cause of morbidity in Singapore. In line with Singapore’s drive toward right siting of care, community psychiatry will play a pivotal role in providing timely access to effective and affordable mental healthcare in the community. This paper provides an overview of the community mental health ecosystem and range of services that seek to integrate mental and physical healthcare with social and community support in Singapore. We discuss systemic challenges such as financing issues and patient confidentiality in relation to the important role primary care physicians play in enhancing community mental health. Finally, we propose solutions and future directions to develop an effective and sustainable ecosystem for community mental health in Singapore.

Psychotherapy provides substantial benefits for patients with medical illness. Western‐based psychotherapies are commonly practiced by consultation‐liaison psychiatrists in Asia. Although such interventions benefit Asian patients, they are limited by their cultural applicability. Sociocultural factors shape the meaning, expression, and treatment of medical illnesses. In helping patients with medical problems, it is imperative that psychiatrists be mindful of the value of culture in their clinical work. The concept of the self, religion, spirituality, adaptation, coping, and defense mechanisms are all culturally determined. This article discusses how these concepts impact the practice of psychotherapy in the Asian consultation‐liaison psychiatry setting. Currently, there is a dearth of systematic research about this subject matter. Most studies describe the application of Western‐based psychotherapies for patients with medical illness with little input as to cultural modifications or implications of such interventions. The authors of this article identify culturally consonant psychotherapeutic techniques in the Asian consultation‐liaison psychiatry context. Furthermore, they also propose general guidelines in the cultural adaptation of psychotherapy interventions or development of indigenous psychotherapies.

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Background: In addition to increased cardiovascular risk, patients with primary aldosteronism (PA) also suffer from impaired health–related quality of life (HRQoL) and psychological symptoms. We assessed for changes in HRQoL and depressive symptoms in a cohort of Asian patients with PA, after surgical and medical therapy. Methods: 34 patients with PA were prospectively recruited and completed questionnaires from 2017 to 2020. HRQoL was assessed using RAND–36 and EQ–5D–3L, and depressive symptoms were assessed using Beck Depression Inventory (BDI–II) at baseline, 6 months, and 1 year post–treatment. Results: At 1 year post–treatment, significant improvement was observed in both physical and mental summative scores of RAND–36, +3.65, P=0.023, and +3.41, P=0.033, respectively, as well as four subscale domains (physical functioning, bodily pain, role emotional and mental health). Significant improvement was also seen in EQ–5D dimension of anxiety/depression at 1 year post–treatment. Patients treated with surgery (N=21) had significant improvement in EQ–5D index score post–treatment, and better EQ–5D outcomes compared to medical group (N=13) at 1 year post–treatment. 37.9%, 41.6% and 58.6% of patients had symptoms in the cognitive, affective and somatic domains of BDI–II respectively. There was significant improvement in the affective domain of BDI–II at 1 year post–treatment. Conclusion: Both surgical and medical therapy improve HRQoL and psychological symptoms in patients with PA, with surgery providing better outcomes. This highlights the importance of early diagnosis, accurate subtyping and appropriate treatment of PA.

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Abstract:Background:Antidepressant-induced hyponatremia/syndrome of inappropriate antidiuretic hormone (SIADH) can cause significant morbidity and mortality. Antidiuretic hormone release due to stimulation of central serotonin 5HT1C, 5HT2 and α-1 adrenergic receptors is thought to cause this adverse effect (Spigset, 1995). Evidence on which antidepressants are more likely to cause hyponatremia is inconsistent (Coupland, 2011; Leth-Moller, 2016). Owing to its uncommon use, there is limited and conflicting data on the risk of hyponatremia with Moclobemide, a reversible inhibitor of monoamine oxidase A (Mercier, 1997; Mazhar, 2019). There are few reports of hyponatremia induced by multiple antidepressant classes in the same patient.Objective:To add to the literature on risk of hyponatremia with Moclobemide and other antidepressants.Methods:We report a case of hyponatremia sequentially induced by multiple different antidepressant classes who was treated with Moclobemide with no recurrence of hyponatremia. We review existing literature on antidepressant-induced hyponatremia.Results:A 67-year-old man with a history of hypertension, dyslipidemia and gout was first diagnosed with major depressive disorder at age 50 after presenting with pervasive depressed mood, anhedonia, insomnia, poor concentration and feelings of worthlessness. Investigations found no medical causes of depression. His depression remitted on Venlafaxine 75mg/day with no hyponatremia induced. During a second depressive episode 4 years later, his serum sodium (Na) dropped from a normal baseline to 122mmol/L after Venlafaxine was restarted. He appeared euvolemic on physical examination. Investigations found no other causes of hyponatremia and were consistent with SIADH, which was attributed to Venlafaxine. His depression later remitted on Mirtazapine 30mg/day with no hyponatremia induced. During his third depressive episode at age 67, he developed hyponatremia (serum Na 123mmol/L) a week after restarting Mirtazapine. His clinical picture was consistent with SIADH. He later developed hyponatremia after initiating the following antidepressants sequentially: Fluvoxamine, Agomelatine, Nortriptyline, Bupropion. Hyponatremia resolved with fluid restriction and cessation of the implicated antidepressant each time before the next was initiated. He eventually tolerated Moclobemide 300mg/day with no recurrence of hyponatremia.Conclusions:Agomelatine, Nortriptyline and Bupropion are reported to have a low risk of hyponatremia but were implicated in this case. Venlafaxine and Mirtazapine did not cause hyponatremia when first taken but were implicated when restarted after a period of cessation, underscoring the idiosyncratic nature of antidepressant-induced hyponatremia. Moclobemide can be considered for depressed patients with recurrent antidepressant-induced hyponatremia. Serum Na should be regularly monitored in patients taking antidepressants who are at high risk of hyponatremia.