Papers by Phern-Chern Tor
Schizophrenia Research, Oct 31, 2023
Personality and Individual Differences, Nov 1, 2023
PubMed, Sep 1, 2008
Suicide is a common and preventable event that is often reported by the media when there are sens... more Suicide is a common and preventable event that is often reported by the media when there are sensationalistic elements or if the suicide involves a celebrity. Media reports of suicide can induce a copycat or "Werther effect". There is increasing evidence that sensationalistic reporting of suicides has a direct effect on increasing suicide rates. Responsible reporting guidelines drawn up in consultation with media professionals have been shown to improve reporting of suicides. Local reporting on suicides tends to be sensationalistic but also has a strong educational slant. The media should educate both the public and the medical professional about their role in suicide prevention.
Brain Sciences, Dec 22, 2023
This article is an open access article distributed under the terms and conditions of the Creative... more This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY
Neuromodulation, Jun 1, 2018
Dip(Psychotherapy) † Background: Compared to electroconvulsive therapy (ECT), the cost-effectiven... more Dip(Psychotherapy) † Background: Compared to electroconvulsive therapy (ECT), the cost-effectiveness of repetitive transcranial magnetic stimulation (rTMS) in the management of treatment-resistant depression (TRD) remains unclear. Objective/Hypothesis: This study evaluated the cost-effectiveness of rTMS vs. ECT for TRD from Singapore societal perspective. Methods: We constructed a Markov model to project the cost and benefit of rTMS compared with ECT over one year in patients with TRD. The relative treatment effects between rTMS and ECT were obtained from meta-analyses of published trials. The effectiveness and quality of life data for patients using ECT, resource use for TRD and their associated costs were derived from the national tertiary mental institution in Singapore. Results: At one year, rTMS was cost-effective relative to ECT. The incremental cost-effectiveness ratio (ICER) associated with ECT was Singapore dollars (SGD) 311,024 per quality-adjusted life-year (QALY) gained. This exceeded the willingness-to-pay threshold of SGD 70,000 per QALY gained. A similar trend was observed for ICER per remission achieved (i.e., SGD 143,811 per remission achieved with ECT). In the subgroup analysis, rTMS was found to be less costly and more effective than ECT in nonpsychotic depressive patients. In the scenario analysis, ECT employed as an ambulatory service yielded a much smaller ICER (i.e., SGD 78,819 per QALY gained) compared to the standard inpatient setting. Conclusions: rTMS was a cost-effective treatment compared to ECT in TRD over one year. The cost-effectiveness of rTMS was attenuated when ECT was used in the outpatient setting.
Asia-pacific Psychiatry, Oct 1, 2009
Asean Journal of Psychiatry, 2021
Aim: To examine the trend of youth depression diagnosed in a healthcare group in Singapore over a... more Aim: To examine the trend of youth depression diagnosed in a healthcare group in Singapore over a 6-year period. Methods: This is a retrospective analysis of the medical records of patients who had been diagnosed with depression from Jan 2013 to Dec 2018 in a healthcare group in Singapore. The yearly trend of depression diagnosis among the youths (10-24 years of age) was compared with adults (25-64 years of age) and the elderly (≥ 65 years of age). The mean age at diagnosis, distribution of gender, ethnicity and clinical care settings among the subgroup of youth patients were compared across the years using analysis of variance or Pearson's chi-square test. Results: A total of 4701 youths, 15243 adults and 6908 elderly patients were included in the analysis. Between 2013 and 2018, the rise in depression diagnosis in the youth was greater than in the adult and elderly populations, and the mean age at diagnosis decreased from 49.7 ± 0.3 (mean ± SE) years in 2013 to 39.6 ± 0.3 years in 2018. Among the youths, more females had been diagnosed with depression than males and females displayed a larger increase in diagnosis of depression. There was also a larger increase in the diagnosis of depression in primary care compared to emergency departments, outpatient specialist clinics and in-hospital wards. Conclusion: Youth depression is a major health problem in Singapore. There is a need for the expansion of resources in a variety of avenues for depressed youths to seek help.
PubMed, 2010
To the Editor: The provision of mental health care around the world is uneven and insufficient.1 ... more To the Editor: The provision of mental health care around the world is uneven and insufficient.1 The solution is generally agreed to be a systems approach that would shift responsibility for diagnosis and initial management of psychiatric cases from specialist mental health providers to general practitioners (GPs), with only complex cases being referred to mental health specialists.2 In Singapore, the close relationship between primary care doctors and psychiatrists is especially important because the primary care doctors manage the bulk of mental health problems in the country. However, in this new partnership, it is not clear what GPs expect of mental health specialists in Singapore and if mental health specialists share these expectations. We sought to answer this question by comparing the opinions of GPs and psychiatrists on the qualities of a good Singaporean psychiatrist. Method. Details of the original study methodology have been previously published.3 In summary, a focus group of senior psychiatrists developed a survey with 40 qualities, and this was sent to all Singaporean psychiatrists. Factor analysis of the qualities delineated 4 themes in descending importance (professional, personal values, relationship, academic-executive) for a good Singaporean psychiatrist. A voluntary, anonymous study using the same survey form was subsequently conducted for all GPs in a government polyclinic group that covered half of Singapore's population (approximately 2 million people). The survey form asked participants to rate each quality on a Likert scale. All analyses were done using Statistical Package for the Social Sciences (SPSS) version 14 (SPSS, Inc, Chicago, Illinois). The relative ranking of the themes for GPs was evaluated using Friedman's χ2 test. Comparisons between psychiatrists and GPs were performed using multiple independent t tests. Two-tailed tests of significance were used and statistical significance was set at P < .05. Results. A total of 107 (of 168) GPs participated in the survey, giving a response rate of 63.7%. In contrast with psychiatrists, GPs ranked personal values as the most important theme, followed by professional, relationship, and academic-executive themes. GPs rated the professional theme significantly lower than psychiatrists (P = .047, t = 2.00, df = 171.6). Thirteen of 40 individual qualities were scored significantly differently. GPs rated 3 qualities higher than psychiatrists (provides effective explanations/discusses values and attitudes/challenges junior staff, stretches their abilities, actively involves them). The 10 remaining qualities were ranked higher by psychiatrists, with the majority from the professional and academic-executive themes. Our survey showed that psychiatrists and GPs have different views on what the qualities of a good psychiatrist are. GPs in Singapore understandably valued psychiatrists that could communicate well, were open about their approach toward cases, and were able to enhance the GPs’ ability to manage psychiatric patients. This is very much in line with findings in the West,4 where the psychiatrist (as opposed to the multidisciplinary team) is still seen as the access point to specialist knowledge. However, psychiatrists in Singapore do not seem to share the same priorities, possibly because of the low referral rate by GPs to psychiatrists.5 (Patients can access specialist services without a GP referral.) This in turn could be related to the lack of a consultation-liaison relationship between mental health services and primary care services in Asia.6 Equally interesting is the lack of emphasis by GPs on technical skills of psychiatrists, as seen by the significantly lower ratings for the professional theme. It is possible that GPs feel that psychiatry is unscientific7 and that the “technical” skills do not matter very much in the management of psychiatric patients. This is a new finding and will require further research. In conclusion, there is a disconnect between the expectations of psychiatrists by GPs and what psychiatrists themselves feel is important for Singaporean psychiatrists. It is important to resolve this disparity by either changing the way our psychiatrists are trained or reviewing the expectations of GPs for psychiatry to progress in Singapore.
Annals Academy of Medicine Singapore, Sep 15, 2008
PubMed, Apr 1, 2007
Late-onset bipolar disorder is rare and can be precipitated by organic brain disorders. While the... more Late-onset bipolar disorder is rare and can be precipitated by organic brain disorders. While the association between hyperthyroidism and mania is well described, mania or hypomania precipitated by hypothyroidism is rare. The authors present late-onset bipolar disorder in a 72-year-old woman presenting with mania and psychosis, which appear to have been precipitated by autoimmune hypothyroidism. This case shows the importance of ascertaining the thyroid status in patients with mood and psychotic disorders, especially in elderly patients and in patients lacking prominent signs of thyroid disease.
Journal of Affective Disorders, Apr 1, 2020
Background: : Electroconvulsive therapy (ECT) is an effective treatment for severe mental illness... more Background: : Electroconvulsive therapy (ECT) is an effective treatment for severe mental illness but access is limited for patients lacking consent capacity. We aimed to compare the symptomatic, cognitive, quality of life (QOL) and functional outcomes of patients with and without capacity receiving ECT for schizophrenia, depression or mania. Methods: : Patients prescribed ECT in a single center had their clinical outcomes pre and post ECT compared with repeated measures ANOVAs. Differences in demographic, clinical characteristics and ECT treatment between the group lacking and having capacity were examined using independent t-tests for continuous variables and chi-squared tests for categorical variables. Results: : 75.1% of 175 patients lacked capacity. The group lacking capacity had overall poorer cognitive and global functioning pre ECT but higher QOL. Objective psychiatric symptom ratings after ECT improved similarly between groups. Mood, cognition, QOL and function improved in both groups, with more improvement in mood and function in the group lacking capacity and a trend towards greater cognitive improvement (p = 0.051). Limitations: : Subgroup analysis by diagnosis was not done due to smaller sample sizes in each group. Cognition was assessed with a general screening instrument not a full neuropsychological assessment. Conclusions: : ECT is a safe and effective treatment for schizophrenia, bipolar mania and depression, and may provide similar or greater benefits in patients lacking capacity to consent, compared to those with capacity. These results support the provision of a framework for substitute decision making in the patients' best interests for ECT in patients unable to provide their own consent.
Primary care companion to the Journal of clinical psychiatry, Jul 1, 2010
Methods: The present study consisted of two steps. First, a focus group of six senior psychiatris... more Methods: The present study consisted of two steps. First, a focus group of six senior psychiatrists was conducted to obtain a list of positive qualities of a psychiatrist. Second, an anonymous survey was sent to all psychiatry trainees and psychiatrists in Singapore to ...
MedEdPublish, 2016
Introduction Singapore had an apprentice style medical specialization training program until 2010... more Introduction Singapore had an apprentice style medical specialization training program until 2010 when it adopted an ACGME certified residency training program. A recent survey showed Singapore psychiatry residents rating their educational environment worse than non-residency psychiatry trainees. To confirm these findings we repeated a 2008 survey of perceived importance and adequacy of 11 aspects of psychiatric training among psychiatry trainees in Singapore. Methods We sent out an electronic survey to all psychiatry trainees in Singapore (residents and non-residents) to rate their perceived importance and adequacy on 11 aspects of psychiatric training on a 5 point Likert scale. Results were analyzed with paired or independent t-test analysis as appropriate with p-values at 0.05. Results The survey was conducted from Apr to Aug 2013 with a response rate of 57.9% (N=44). The perceived adequacy of training was significantly better in 2013 than 2008 with 6 of 11 aspects of training rated higher in 2013. Residents had higher ratings in 16 of 19 significant between group differences of perceived adequacy of training. Conclusions A competency based style residency program has resulted in improved perceived adequacy of psychiatric training compared to an apprentice style program. Further research to assess objective adequacy of psychiatric training under the residency program is recommended.
Journal of Psychiatric Research, 2022
Although highly effective, electroconvulsive therapy (ECT) often produces cognitive side effects ... more Although highly effective, electroconvulsive therapy (ECT) often produces cognitive side effects which can be a barrier for patients. Monitoring cognitive side effects during the acute course is therefore recommended to identify patients at increased risk for adverse outcomes. The Brief ECT Cognitive Screen (BECS) is a brief instrument designed to measure emerging cognitive side effects from ECT. The aim of this study was to examine the clinical utility of the BECS for predicting adverse cognitive outcomes in real world clinic settings. The study included data collated from four participating sites in the Clinical Alliance for ECT and Related treatments (CARE) network. The BECS was administered at pre ECT and post 3 or 4 ECT. The primary outcome was a ≥4 point decrease on the Montreal Cognitive Assessment (MoCA) from pretreatment to post ECT. Logistic multiple regression analyses examined the BECS and other relevant clinical and demographic and treatment factors as predictors. The final analysis included 623 patients with diverse indications for ECT including 53.6% with major depression and 33.7% with schizophrenia or schizoaffective disorder. A higher total score on the BECS significantly predicted decline in Total Scores on the MoCA [B = 0.25 (0.08), p = 0.003], though not decline in MoCA Delayed Recall scores (p > 0.1). Other significant predictors included higher pretreatment MoCA Total Scores and female gender for verbal anterograde memory decline. This study confirmed that the BECS has clinical utility for identifying patients with both reduced and increased risk for adverse cognitive outcomes from ECT.
Journal of Affective Disorders, Apr 1, 2021
AIM To examine the association of the anaesthesia to ECT stimulus TI (anaesthesia-ECT TI) with ef... more AIM To examine the association of the anaesthesia to ECT stimulus TI (anaesthesia-ECT TI) with efficacy and cognitive outcomes after ECT treatment. METHODS Retrospective cohort study of 690 patients who received ECT from July 2017 till December 2019. Generalized linear regression was utilized to analyse the association of mean anaesthesia-ECT TI (from session 2 to session 6 ECT treatment) with Clinical Global Impression-Severity scale (CGI-S) scores and Montreal Cognitive Assessment (MoCA) score after 6 ECT treatments, and with EEG quality during the treatments (post ictal suppression scores). RESULTS The averaged TI was 106.6±20.2 (mean±SD) seconds. There was significant improvement of overall CGI-S score after ECT treatment (3.3±1.0) vs pre-ECT treatment (5.0±0.8, p<0.001) while there was no significant change of MoCA score over the course of 6 ECT (p>0.05). The anaesthesia-ECT TI had no association with post-ECT CGI-S while longer anaesthesia-ECT TI was associated with poorer post-ECT MoCA scores [adjusted β, -0.056; 95% CI (-0.099, -0.013), p=0.011] and better EEG quality score [adjusted β (0.001), 95% CI (0, 0.002), p=0.011]. CONCLUSION Longer TI between anaesthesia and ECT stimulus administration resulted in higher seizure quality, suggesting more effective stimulation. This was associated with more cognitive impairment but not higher efficacy. The assessment of outcomes after only 6 ECT limited the ability to fully explore associations between the TI and clinical outcomes. This was a retrospective analysis of clinical data from a real-world treatment setting. A controlled study would provide greater potential to fully explore the association between TI and clinical outcomes.
Psychiatry and Clinical Neurosciences, Sep 5, 2020
Acknowledgments This work was supported in part by a JSPS KAKENHI Grant (19K10328) to Professor T... more Acknowledgments This work was supported in part by a JSPS KAKENHI Grant (19K10328) to Professor Toyofuku. The study protocol was approved by the Ethical Committee of Tokyo Medical and Dental University (D2013-005) and conformed to the provisions of the Declaration of Helsinki. Both patients had been informed about the possibility of their data being used for study purposes at their first visit and had provided written informed consent.
Academic Psychiatry, 2010
Journal of Ect, Mar 1, 2019
Objective: Electroconvulsive therapy (ECT) is an effective treatment in mania. However, there is ... more Objective: Electroconvulsive therapy (ECT) is an effective treatment in mania. However, there is little evidence regarding the use of ultrabrief right unilateral (RUL-UB) ECT in treatment of acute manic episodes. The aim of this study was to report on the effectiveness and cognitive profile of ECT in bipolar mania, including a sample who received RUL-UB ECT. Methods: This naturalistic study retrospectively collected data in 33 patients who received ECT with concurrent antipsychotics for mania between October 1, 2014, and July 30, 2016. Electroconvulsive therapy was given using RUL-UB, brief-pulse right unilateral, or brief-pulse bitemporal approaches, dosed according to the patient's seizure threshold. The Brief Psychiatric Rating Scale (BPRS), Young Mania Rating Scale (YMRS) score, and the Montreal Cognitive Assessment (MoCA) were administered to patients before and after the ECT course. Results: For the whole sample, there was a significant improvement in BPRS (total score and manic subscale), YMRS, and MoCA total scores across the ECT treatment course. The overall BPRS response rate was 84%, and mean scores decreased from 42.1 (SD, 12.0) to 26.0 (SD, 4.0). The 13 patients who received RUL-UB ECT also showed significant improvement in BPRS, YMRS, and MoCA scores over the treatment course. Conclusions: Electroconvulsive therapy in general and also specifically RUL-UB ECT were effective in treating mania and also led to global cognitive improvement.
Journal of Ect, Apr 1, 2020
Background China confirmed person to person transmission of a novel coronavirus (now named SARS-C... more Background China confirmed person to person transmission of a novel coronavirus (now named SARS-CoV-2) on 21 st Jan 2020 1 with more than 200 cases and 4 deaths. The World Health Organization (WHO) declared the COVID-19 outbreak as one of international concern on 30 th Jan 2020 2. By 11 th Mar 2020 the WHO Director-General declared the COVID-19 outbreak a pandemic with 118,00 cases in 114 countries and 4291 deaths 3. COVID-19 is currently understood as a droplet spread illness with a reproduction number of approximately 2.2 4 , transmitted via respiratory droplets, contact, fomites and fecal-oral routes 5,6 and with high lethality (3.4%) 7. Many more patients with COVID-19 than SARS (Severe Acute Respiratory Syndrome) 8 have mild symptoms that contribute to spread as these patients are not picked up by current screening mechanisms 9. The current outbreak is expected to last at least till the end of 2020 10 with the possibility of a second deadlier wave several months after the current outbreak like the 1918 Spanish Flu 11. There is no known specific treatment or vaccine. Challenges Facing ECT during COVID-19 This situation poses significant challenges for ECT services around the world. ECT is an essential psychiatric service that provides lifesaving treatment for severe mental illnesses like depression and catatonia if given in a timely fashion 12,13 and for which there is no viable alternative. However, ECT service is often not prioritized in hospitals 14 and may be stopped if anaesthesia resources are limited. This occurred at the beginning of the COVID-19 situation in a general hospital in Singapore, resulting in an acute ECT course stopping halfway for a patient
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Papers by Phern-Chern Tor