Significant outcomes
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∙ Analysis of the data from 1122 patients with depressive disorders in the Research on Asian Psychotropic Prescription Patterns for Antidepressants (REAP-AD) study, showed that the rates of suicidal thoughts/acts of patients with depressive disorders in 10 Asian countries/areas varied from 12.8% in Japan to 36.3% in China.
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∙ Patients with suicidal thoughts/acts presented more persistent loss of interest, fatigue, insomnia, poor concentration, low self-confidence, poor appetite, guilt/self-blame, and use of mood stabilisers than those without suicidal thoughts/acts.
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∙ In Asian patients with depressive disorders, suicidal thoughts/acts can indicate greater severity of depression, and are associated with a poorer response to antidepressants and an increased burden of illness
Limitations
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∙ Generalisation and extrapolation of our findings should be limited since the REAP-AD study was not designed as an epidemiological study.
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∙ We did not distinguish between suicidal thoughts and acts.
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∙ Comorbid personality problems and emotional disorders can contribute to the use of mood stabilisers by depressed patients with suicidal thoughts/acts but these conditions were not evaluated in our study.
Introduction
Major depressive disorder (MDD) is closely associated with suicide and/or suicide attempts (Reference Jeon1). Several factors, such as type-D personality and alcoholism, have been proposed as intervening variables linking suicidality and MDD (Reference Park, Ko, Lee, Lee and Kim2,Reference Vijayakumar and Rajkumar3). The Suicide Prevention Resource Guide of the Massachusetts Government has described the evidence for a close relationship between suicide and depression as follows: (i) an increased risk of suicide has been reported in 50% of patients with depressive disorders; (ii) about 60% of patients who commit suicide suffer previously from depressive disorders; (iii) the risk of suicide in patients with depressive disorders is about 20-fold greater than in the general population; and (iv) patients with multiple episodes of depressive disorder are at greater risk of suicide than those with one episode (Reference Baek, Park and An4). In addition, in the Australian National Survey of Mental Health and Wellbeing, death and suicidal thoughts, among depressive symptom profiles, were regarded as reflecting the severe end of the depression continuum (Reference Carragher, Mewton, Slade and Teesson5). In a comparison of symptom profiles between Korean and American outpatients with MDD, it was found that suicidal ideation/gesture and hypochondriasis were more common in Koreans than in Americans, whereas depressive mood and feelings of guilt were more common in Americans (Reference Jeon, Walker and Inamori6). Suicide deaths in most countries were found to be more frequent in men than women, whereas those in China were found to more frequent in women rather men since suicidal behaviours of women in China were associated with low status and negative life-events (Reference Cantor and Neulinger7,Reference Han, Ogrozniczuk and Oliffe8)
Aims of the study
The Research on Asian Psychotropic Prescription Patterns for Antidepressants (REAP-AD) study has provided data on the general and clinical characteristics and patterns of psychotropic drug use in patients with depressive disorders in 10 Asian countries/areas: China, Hong Kong, India, Indonesia, Japan, Korea, Malaysia, Singapore, Taiwan, and Thailand. The study is the largest international survey of antidepressant use in Asian regions and partially reflects the overall trend of depressive symptom profiles and patterns of psychotropic drug use, although it was limited to the aspects covered by an epidemiological study (Reference Shinfuku9–Reference Park, Shinfuku, Maramis, Lee and Park14). Using data from the REAP-AD study, we aimed to (i) present international differences in rates of suicidal thoughts/acts, and (ii) identify the clinical correlates of suicidal thoughts (including other depressive symptom profiles and patterns of psychotropic drug use).
Materials and methods
Study overview
In the REAP-AD study (Reference Shinfuku9–Reference Park, Shinfuku, Maramis, Lee and Park14), 2470 patients who had used antidepressants were enroled in 40 psychiatric centres in 10 Asian countries/areas during the period March–June 2013; patients in departments of medicine or surgery were excluded. The 2470 patients comprised 350 Chinese, 81 Hong Kongers, 309 Indians, 269 Indonesians, 246 Japanese, 259 Koreans, 311 Malaysians, 135 Singaporeans, 199 Taiwanese, and 311 Thais. The 40 survey centres consisted of four in China, one in Hong Kong, five in India, four in Indonesia, five in Japan, four in Korea, six in Malaysia, two in Singapore, four in Taiwan, and five in Thailand. The institutional review boards of the survey centres approved the study procedures and the informed consent forms. A consensus conference was held before the start of the study to guarantee consistency of data collection and diagnosis between centres. All demographic and clinical variables of the patients were collected by research coordinators or clinical psychiatrists at the survey centres.
Study subjects
A sub-sample of patients in the REAP-AD study served as the subjects of our study. Inclusion criteria were as follows: (i) diagnosis of depressive episode (F32) or recurrent depressive episode (F33), made by clinical psychiatrists and based on the International Classification of Diseases and Related Health Problems, 10th revision (ICD-10) (15) and (ii) age ≥18 and ≤80 years. Exclusion criteria were: (i) comorbid diagnosis of organic mental disorders, schizophrenia, bipolar disorders, or intellectual developmental disorders and (ii) comorbid seizure disorders and other neurological diseases. Finally, a total of 1122 patients with depressive disorders were enroled.
Baseline characteristics
The 10 Asian countries/areas were grouped on the basis of geographic region and income level. Using the United Nations classification, China, Hong Kong, Japan, Korea, and Taiwan were defined as East Asia; Indonesia, Malaysia, Singapore, and Thailand as South-East Asia; and India as South Asia (Reference Chee, Tripathi and Avasthi10,Reference Chee, Tripathi and Avasthi11). Using the World Bank income designation, Hong Kong, Japan, Korea, Singapore, and Taiwan were defined as high-income countries/areas; China, Malaysia, and Thailand as upper-middle income countries/areas; and India and Indonesia as lower-middle income countries/areas (Reference Chee, Tripathi and Avasthi10,Reference Chee, Tripathi and Avasthi11). These groups were transformed to dummy variables as follows: geographic region grouping (East Asia and South/South-East Asia) and income level grouping (high-income countries and upper- and lower-middle income countries/areas).
Suicidal thoughts/acts and other depressive symptom profiles
Suicidal thoughts/acts and other depressive symptom profiles (persistent sadness, loss of interest, fatigue, insomnia, poor concentration, low self-confidence, poor appetite, agitation/retardation, and guilt/self-blame) were evaluated using the 10 depressive symptoms listed in the National Institute for Health and Clinical Excellence guidelines for depressive disorders (16). The degree of depression was defined by the number of symptoms: <4 indicated subthreshold depression, 4 indicated mild depression, 5 or 6 indicated moderate depression, and >6 indicated severe depression.
Anxiety and somatic, psychotic, and other mental symptoms were evaluated. Comorbid psychiatric disorders, including mental and behavioural disorders caused by psychoactive substance abuse (F1) and neurotic, stress-related, and somatoform disorders (F4), were also assessed. Comorbid physical diseases, including chronic obstructive pulmonary disease, rheumatic disease, peptic ulcer disease, mild liver disease, diabetes mellitus, renal disease, moderate to severe liver disease, malignancy, AIDS/HIV, and other medical illnesses were also evaluated.
Patterns of psychotropic drug use
Based on the Anatomical Therapeutic Chemical Classification index of the World Health Organization Collaborating Center for Drug Statistics Methodology, selective serotonin reuptake inhibitors, serotonin and norepinephrine reuptake inhibitors, norepinephrine and dopamine reuptake inhibitors, mixed noradrenergic-serotonergic antidepressants, selective norepinephrine reuptake inhibitors and serotonin receptor antagonists were considered newer antidepressants; tricyclic antidepressants and monoamine oxidase inhibitors (both irreversible and reversible) were considered older antidepressants (Reference Chee, Tripathi and Avasthi10,Reference Chee, Tripathi and Avasthi11). In relation to the introduction of clozapine, antipsychotics were divided into first- and second-generation (Reference Park, Lee, Kang and Lee17).
Statistical analysis
International differences in rates of suicidal thoughts/acts among the patients were evaluated using the χ2 test. General and clinical characteristics and patterns of psychotropic drug use were compared in patients with and without suicidal thoughts/acts using independent t-tests for continuous variables and χ2 tests for discrete variables. Logistic regression analysis for discrete variables controlled for the potential effects of covariates. To reduce the family wise error rate in multiple comparisons, statistical significance was set at p<0.01 (two-tailed) for all tests. SPSS 21 for Windows (SPSS Inc., Chicago, IL, USA) was used for all the statistical analyses.
Results
Country/area differences in rates of suicidal thoughts/acts
The overall rate of suicidal thoughts/acts in the 1122 patients was 23.1%. The rates for individual countries/areas varied from 12.8% in Japan to 36.3% in China (Fig. 1a). The geographic regions are ranked in order of the rate of suicidal thoughts/acts in Fig. 1b: Eastern Asia, 24.9%; Southern Asia, 23.0%; and South-Eastern Asia, 20.2%. Country/area income levels are ranked in order of rate of suicidal thoughts/acts in Fig. 1c: upper-middle income countries/areas, 28.2%; high-income countries/areas, 19.4%; and lower-middle income countries/areas, 19.2%.
Fig. 1 Rates of suicidal thoughts/acts among 1122 depressed patients in 10 Asian countries/areas.
† Defined by United Nations classification: Eastern Asia (China, Hong Kong, Japan, Korea and Taiwan), Southern Asia (India) and South-Eastern Asia (Indonesia, Malaysia, Singapore and Thailand).
‡ Defined by World Bank designation: High income countries/areas (Hong Kong, Japan, Korea, Singapore and Taiwan), upper middle income countries/areas (China, Malaysia and Thailand) and lower middle income countries/areas (India and Indonesia).
Baseline characteristics of patients with and without suicidal thoughts/acts
Patients with suicidal thoughts/acts were more often treated in public settings (χ2=14.97, p<0.001) and enroled as inpatients (χ2=83.62, p<0.001) than those without suicidal thoughts/acts (Table 1). Although the differences were not significant, those with suicidal thoughts/acts tended to be younger (t=−2.05, p=0.04) and from high-income countries (χ2=5.08, p=0.02). There were no significant differences by sex (χ2=2.95, p=0.09), geographic region (χ2=2.51, p=0.11) or diagnosis (χ2=0.16, p=0.69) between patients with and without suicidal thoughts/acts, although previous studies have reported that sex and geographic region were potential contributors to suicidal behaviours in depressive disorders (Reference Vijayakumar and Rajkumar3,Reference Cantor and Neulinger7,Reference Takei and Nakamura18–Reference Bagalkot, Park and Kim20). Thus, using a conservative method, age, sex, treatment setting, and enrolment setting were defined as the covariates in the following statistical analyses.
Table 1 General characteristics of depressed patients with and without suicidal thoughts/acts in 10 Asian countries/areas
* Adjusted for the effects of age, sex, treatment setting, and enrolment setting.
§Defined by World Bank designation: High income countries/areas (Hong Kong, Japan, Korea, Singapore and Taiwan), upper middle income countries/areas (China, Malaysia and Thailand) and lower middle income countries/areas (India and Indonesia).
Other depressive symptom profiles of patients with and without suicidal thoughts/acts
After adjusting the effects of the covariates, patients with suicidal thoughts/acts presented significantly more persistent sadness (adjusted odds ratio [aOR]=2.64, p<0.001), loss of interest (aOR=2.33, p<0.001), fatigue (aOR=1.58, p<0.001), insomnia (aOR=1.74, p<0.001), poor concentration (aOR=1.88, p<0.001), low self-confidence (aOR=1.78, p<0.001), poor appetite (aOR=2.27, p<0.001) and guilt/self-blame (aOR=3.03, p<0.001) than those without suicidal thoughts/acts; the exception was agitation/retardation (aOR=1.18, p=0.36) (Table 2). In terms of degree of depression, taking subthreshold depression as the reference category, patients with suicidal thoughts/acts were characterised by higher rates of moderate (aOR=6.34, p<0.001) and severe (aOR=16.60, p<0.001) depression and by a low rate of mild depression (aOR=0.60, p<0.001).
Table 2 Depressive symptom profiles and clinical characteristics of depressed patients with and without suicidal thoughts/acts in 10 Asian countries/areas
* Adjusted for the effects of age, sex, treatment setting, and enrolment setting.
† Multinominal logistic regression analysis with subthreshold depression as reference category.
In addition, those with suicidal thoughts/acts tended to show a higher rate of comorbid physical disease (aOR=1.47, p=0.02), although the difference was not significant. There were no significant differences between patients with and without suicidal thoughts/acts in relation to other symptom profiles (aOR=0.95, p=0.99), including anxiety symptoms (aOR=0.49, p=0.21), somatic symptoms (aOR=1.39, p=0.56), and psychotic symptoms (aOR=1.61, p=0.40), no differences in comorbid psychiatric disorders including substance abuse (aOR=0.74, p=0.60), and anxiety and somatoform disorders (aOR=1.67, p=0.07).
Patterns of psychotropic drug use in patients with and without suicidal thoughts/acts
After adjusting the effects of the covariates, it was found that patients with suicidal thoughts/acts were more frequently prescribed mood stabilisers than those without suicidal thoughts/acts (aOR=1.78, p<0.001). In addition, those with suicidal thoughts/acts tended to be prescribed more combination antidepressant treatments (aOR=1.44, p=0.03) and antiparkinson medication (aOR=0.50, p=0.05), although the differences were not significant. There were no significant differences in use of newer antidepressants (aOR=0.95, p=0.76), any antipsychotics (aOR=0.99, p=0.93), first-generation antipsychotics (aOR=0.82, p=0.43), second-generation antipsychotics (aOR=0.99, p=0.93), anxiolytics (aOR=0.94, p=0.69), and hypnotics (aOR=0.84, p=0.44) (Table 3).
Table 3 Patterns of psychotropic drug use of depressed patients with and without suicidal thoughts/acts in 10 Asian countries/areas
* Adjusted for the effects of age, sex, geographic region, income level of country/area, treatment setting, and enrolment setting.
Discussion
To our knowledge, variation in rates of suicidal behaviour among Asian countries/areas has rarely been reported in the past. In addition, depressed patients with suicidal thought/acts presented more additional depressive symptoms including persistent sadness, fatigue, insomnia, loss of interest, poor concentration, low self-confidence, poor appetite, and guilt/self-blame. They were also more often prescribed mood stabilisers than those without suicidal thoughts/acts.
A previous study found that unemployed status was associated with high suicidality in MDD patients in six Asian countries/areas (China, Korea, Malaysia, Singapore, Thailand, and Taiwan) (Reference Lim, Lee and Hatim21). In addition, a community-based study showed that the subjective sense of economic status can be an important contributory factor for depression and psychosocial impairment in elderly people in three Asian countries/areas (Japan, Korea, and Taiwan) (Reference Imai, Chen and Fujutomi22). A preponderance of women over men for suicides may be a phenomenon limited to China. Women in rural areas of China suffer greater suicidal risks than women in urban regions (Reference Pearson and Liu23). In addition, the suicide rate among the Chinese elderly is the highest in the world and, more specifically, their risk is higher in Northern China and in rural areas (Reference Dong, Chang, Zeng and Simon24).
In our study, the relatively high rate of suicidal thoughts/acts in depressed patients in Malaysia is striking, because the prevalence of suicidal ideation in Malaysian people has previously been found to be relatively low and Malaysian law has defined attempted suicide as a crime (Reference Morris and Maniam25,Reference Aishvarya, Maniam, Sidi and Oei26). It can be speculated that, despite suppression by social regulation, suicidal ideation and/or intent may be overtly presented by depressed patients in Malaysia. Differences in suicidal behaviour in geographic regions can reflect variations in ethnic groups, cultures, and religions. In addition, colonialism, globalisation, industrialisation, and urbanisation have continuously affected religious affiliations and other cultural contexts in Asia (Reference Tseng27). Among the geographic factors, religious affiliation has been proposed as the strongest cultural influence on suicidal behaviours (Reference O’Reilly and Rosato28). There have been many different religions in Asia: roughly speaking, Confucianism and Buddhism have been predominant in East Asia; Islam, Buddhism, and Hinduism in South-East Asia; and Hinduism and Islam in South Asia. More specifically in East Asia, Christianity (Protestantism and Catholicism) has been also predominant in Korea and Shintoism in Japan, and some religious activities have been prohibited under regulation of the communist government in mainland China. Paradoxically, Confucianism and Buddhism have reduced suicidal ideation but lead to a greater stigma for suicidal survivors (Reference Han, Ogrozniczuk and Oliffe8). Religious affiliations were not addressed in our analysis, but heterogeneity of religious affiliations in the different geographic regions of Asia might have contributed to the observed lack of significant differences in the rates of suicidal thoughts/acts. Further study is needed on the association between religious affiliations and suicidal thoughts/acts in depressed patients in the Asian region.
In our study, with the exception of agitation/retardation, other depressive symptom profiles were significantly more common in patients with suicidal thoughts/acts than those without. In terms of degree of depression, those with suicidal thoughts/acts had more moderate and severe depression and less mild depression than those without suicidal thoughts/acts. These findings are partly consistent with previous findings in Asian regions: for example, in Koreans, despite 12-week antidepressant treatment, suicidal ideation persisted significantly in patients with moderate to severe depression (Reference Seo, Jung and Jeong29); in Han Chinese women, recurrent MDD patients with suicidality presented more MDD symptoms and more melancholia (Reference Zhu, Zhang and Shi30); and in Japanese patients, suicidal ideation was associated with moderate to severe depression (Reference Ando, Kasai, Matamura, Hasegawa, Hirakawa and Asukai31). In addition, reduced projections to the orbitofrontal cortex and thalamus have been considered distinctive neural correlates of depressed patients with a history of suicidal attempts (Reference Jia, Wang, Huang and Kuang32). On the basis of neurobiological underpinnings, suicidal thoughts/acts can reflect a greater severity of depressive disorder in Asians, despite the cultural variations in presenting depressive symptom profiles.
With regard to psychotropic medication, adjunctive use of mood stabilisers in our study was more common in patients with suicidal thoughts/acts than in those without. These findings can be partly explained by the anti-suicidal properties of lithium and other mood stabilisers (Reference Malhi, Tanious, Das and Berk33). Hantouche et al. (Reference Hantouche, Akiskal and Lancrenon34) have shown that, in terms of mood stabiliser augmentation in patients with unipolar MDD, poor responders present higher levels of suicidal thoughts than good responders. Adjunctive use of mood stabilisers has been associated with prolongation of length of hospital stay in patients with late-onset depression (Reference Mastumoto, Kobayashi and Kato35). Thus, it can be speculated that depressed patients with suicidal thoughts/acts are associated with poorer response to one or more antidepressants and poorer prognosis. There were no differences in the use of other psychotropic drugs between those with and without suicidal thoughts/acts in our findings. Nevertheless, a previous study showed that pharmacotherapy and interpersonal psychotherapy can reduce suicidal ideation in depressed patients (Reference Weitz, Hollon, Kerkhof and Cuijpers36). These subtle discrepancies cannot be simply explained and may be associated with the possibility that non-biological factors can shape patterns of psychotropic medication prescription.
There are several limitations to our study. First, generalisation or extrapolation of our findings must be limited, because the REAP-AD study was not designed as a form of epidemiological study. Second, data on religious affiliation and other sociodemographic characteristics were not collected; therefore, the country-wise differences in rates of suicidal behaviour have limited value. Third, data on psychosocial approaches to suicidality and depression were not collected; thus, psychiatric treatments associated with suicidal thoughts/acts are only partly understood. Fourth, the design of the REAP-AD study was not longitudinal but cross-sectional. Fifth, we did not distinguish between suicidal thoughts and acts. Sixth, comorbid personality problems and emotional disorders can contribute to the use of mood stabilisers by depressed patients with suicidal thoughts/acts but these conditions were not evaluated in our study. Seventh, differences in cultural background, economic status, and other confounding factors may contribute to the relationships between depressive symptom profiles and suicidal thoughts/acts and between patterns of psychotropic drug use and suicidal thought/acts. In addition, genetic influences on the pharmacokinetics of psychopathology, and non-biological factors shaped mainly by culture, may contribute to patterns of psychotropic drug use (Reference Yu, Liu and Lin37).
Despite its limitations, our study has the strength of exploring the variation and clinical correlates of suicidal thoughts/acts in depressed patients in 10 Asian countries/areas. It can be concluded that, in Asian patients with depressive disorders, suicidal thoughts/acts can indicate greater severity of depression, and are associated with a poorer response to antidepressants and an increased burden of illness. Proactive screening and treatment for suicidal thoughts/acts is recommended in Asians with depressive disorders.
Acknowledgements
China: Dr. Hao Wei, Dr. Zhao Jing Ping, Dr. Xie Guang Ron, Dr. Wang Xiao Ping, Dr. Su Lin Yan, Dr. Luo Xue Rong, Dr. Li Ling Jiang, Dr. Jiang Wen Hui, Dr. Cao Yu Ping (Central South University); Dr. Li Tao (West China Hospital, Sichuan University); Dr. Zhu Min Jie, Dr. Xue Zhen Kang, Dr. Tian Tao, Dr. Cao Lan, Dr. Liu Cai Ping, Dr. Feng Qiang, Dr. Yao Jie, Dr. Yin Fei Yan, Dr. Ji Chen Feng, Dr. Jiang Wen Hui, Dr. Shi Dian Hong, Dr. Li Yuan Yuan, Dr. Qiu Mei Hui, Dr. Liu Qiong, Dr. Fan Qing Li, Dr. Li Hao Jie, Dr. Peng Yi Hua, Dr. Yu Mei Hong, Dr. Su Ning, Dr. Ni Kai Ji (Shanghai Jiaotong University, School of Medicine, Mental Health Center); Dr. Li Qian, Dr. Duan Yan Ping, Dr. Chen Chao (Peking University Institute of Mental Health). Taiwan: Mr. Hsin-Nan Lee (Kaohsiung Veterans General Hospital, Kaohsiung); Dr. Hong-Bin Huang (Tsyr-Huey Mental Hospital; Kaohsiung); Dr. Happy Kuy-lok Tan, Mr. Tia-Se Su (Department of Psychiatry, Tsao-Tun Psychiatric Center, Nan-Tou); Ms. Yi-Hsin Yang, (Kaohsiung Medical University, Kaohsiung); Dr. Shih-Ku Lin (Taipei City Hospital, Taipei); Dr. Kuan-Pin Su (China Medical University Hospital, Taichung); Dr. Tsung-Ming Hu (Yuli Veterans Hospital, Hualien). Hong Kong: Dr. Gabor S Ungvari, Dr. Tsang A, Dr. Arthur Lam, Dr. Cheng C, Dr. Wong C., Dr. Au CH, Dr. Kam I, Dr. Chung PW, Dr. Grace Leung, Dr. Tong KH, Dr. Cheung LK, Dr. Wong M, Dr. Hong MC, Dr. Chung PW, Dr. Tai W, Dr. Ko R, Dr. Wong Hoy An, Dr. Chan WT (Chinese University of Hong Kong, Hong Kong SAR, China). Japan: Dr. Senta Fujii (Department of Disasater Psychiatry, Fukushima Medical University); Dr. Nishimura Ryoji, Dr. Uchida Naoki, Dr. H Nagai, Dr. H Iida, Dr. K Kuroiwa, Dr. H Nawata, Dr. K Ogomori, Dr. M Fujioka, Dr. M Matsushita, Dr. T Yoshida, Dr. Y Nakano, Dr. R Yoshimura, Dr. N Eto (Department of Psychiatry, Faculty of Medicine, Fukuoka University); Dr. Shinji Shimodera, Dr. C Iwagawa Dr. H Fujita, Dr. K Kakeda, Dr. M Fuji, Dr. M Kawano, Dr. M Akamatsu, Dr. Y Suga, Dr. S Shimodera (Kochi Medical School Department of Neuropsychiatry); Dr. Sejima Kanako, Dr. Y Nishizima (Kyoto University Graduate School of Medicine); Dr. A Ichimiya, Dr. D Katsuki, Dr. H Sanematsu, Dr. K Motomura, Dr. K Yamane, Dr. R Tsuchimoto, Dr. S Nakanishi, Dr. S Sakaguchi, Dr. T Miura, Dr. J Sato, Dr. M Ogusu, Dr. N Kuwano, Dr. Y Tomiyama (Department of Neuropsychiatry, Graduate School of Medicine, Kyushu University); Dr. A Yabuki, Dr. H Hori, Dr. K Atake, Dr. J Nakamura, Dr. T Kubo, Dr. K Yamada, Dr. T Saitou, Dr. T Shinkai, Dr. M Yamana, (Department of Psychiatry, University of Occupational and Environmental Health); Dr. T Arai, Dr. Y Fujinaga, Dr. S Fukushima, Dr. J Fukuyama, Dr. H Kodoma, Dr. M Hirano, Dr. S Inomata, Dr. H Kamiya, Dr. N Nakagawa, Dr. Y Nishimura, Dr. T Sunami, Dr. S Miyashita, Dr. T Yoshimori, Dr. N Miyoshi (National Hospital Organization Hizen Psychiatric Center); Dr. H Kunitake, Dr. H Takei, Dr. H Tatebayshi, Dr. H Tateishi, Dr. J Maruo, Dr. T Kawashima, Dr. Y Haraguchi (Department of Psychiatry, Faculty of Medicine, Saga University); Dr. O Sakurai (Shinmoji Hospital). Singapore: Dr. Ee-Heok Kua, Dr. Jia-Yin Teng, Dr. Adrian Loh, Dr. Birit, Dr. Cecilia Kwok, Dr. Cornelia Chee, Dr. Cyrus Ho, Dr. Emily Ho, Dr. John Wong, Dr. Lai YM, Dr. Lui Yit Shiang, Dr. Roger Ho, Dr. Surej John, Dr. Tsoi Tung (National University Hospital, Singapore); Dr. Donovan Lim, Dr. Sandeep Raj Kala Naik, Dr. Tina Tan, Dr. Tsoi Wing Foo, Dr. Vincent John Magat Lu (Institute of Mental Health, Singapore). India: Dr. Dipesh Bhagabati (Department of Psychiatry, Gauhati Medical College and Hospital, Guwahati); Dr. Nilesh Shah (Department of Psychiatry, Lokmanya Tilak Municipal Medical College, Sion Mumbai). Thailand: Dr. Nopporn Tantirangsee (Songkhla Rajanagarindra Psychiatric Hospital); Dr. Pitchayawadee Theeramoke (Ramathibodi Hospital); Dr. Chawit Tunvirachaisakul (King Chulalongkorn Memorial Hospital); Dr. Sarosaporn Joowong (Suan Saranrom Psychiatric Hospital). Indonesia: Dr. Elmeyda Effendy (North Sumatra University, Medan); Dr. Hervita Diatry, (Indonesia University, Jakarta); Dr. Isa Multazam Nur, Dr. Agung Frijanto (Suharto Herjan Mental Hospital, Jakarta); Dr. Shelly Iskandar (Pajajaran University, Bandung); Dr. Carla Marchira (Gajah Mada University, Yogyakarta); Dr. Yuniar Sunarko (Radjiman Wediodiningrat State mental Hospital , Malang); Dr. Tini Sri P (Soryo mental Hospital, Central Java). Korea: Dr. Jong Il-Lee (Department of Psychiatry, Seoul National Hospital, Seoul), Dr. Daeyoung Oh (Department of Psychiatry, Hanyang University, Seoul). Malaysia: Dr. Chin Loi Fei (Department of Psychiatry & Mental Health, Tengku Ampuan Rahimah Hospital, Klang, Selangor); Dr. Rahima Dahlan (Department of Psychiatry & Mental Health, Kajang Hospital, Selangor); Dr. Mohd Fadzli Mohammad Isa (Department of Psychiatry & Mental Health, Sultan Abdul Halim Hospital, Kedah); Dr. Esther Gunaseli Ebenezer (Department of Psychiatry, Universiti Kuala Lumpur Royal College of Medicine, Perak); Dr. Norhayati Nordin (Mesra Hospital, Sabah).
Authors Contributions: All authors satisfied the International Committee of Medical Journal Editors (ICMJE) authorship criteria, which include substantial contributions to conception and design of, or acquisition of data or analysis and interpretation of data, drafting the article or revising it critically for important intellectual content, and final approval of the version to be published.
Financial Support
This research received no specific grant from any funding agency, commercial, or not-for-profit sectors.
Conflicts of Interest
None.
Ethical Standards
The authors assert that all procedures contributing to this work comply with the ethical standards of the relevant national and institutional committees on human experimentation and with the Helsinki Declaration of 1975, as revised in 2008.
