Scholarly article on topic 'Abstracts of Invited Lectures'

Abstracts of Invited Lectures Academic research paper on "Clinical medicine"

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Asia-Pacific Psychiatry
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Academic research paper on topic "Abstracts of Invited Lectures"


PSYCHIATRY SrVi VS Racifb Rm College of Psychiatrists

The 15th Pacific Rim College of Psychiatrists

Scientific Meeting

Abstracts of Invited Lectures

KL Keynote Lecture......................................................................................................................... 2

PL Plenary Lecture.......................................................................................................................... 4

S Symposium................................................................................................................................ 7

C Case Conference....................................................................................................................... 60

W Workshop................................................................................................................................... 62

Keynote Lecture

Academic psychiatry across the pond - Challenges and opportunities for PRCP

Ee Heok Kua

Department of Psychological Medicine, National University of Singapore, Singapore

Academic psychiatry has a pivotal role in the development of national mental health programmes especially in education and training of human resource, and in planning and evaluation of services. There is cautious optimism that the economic growth around the Pacific-rim will stir the rise of academic psychiatry. However, the challenges in the region are phenomenal - many mental health services in Asia and South America are without psychiatrists and there is a paucity of training facilities and a dearth of trainers (Kua, 2010). Training seminars in Asia have been conducted periodically by regional psychiatric associations and pharmaceutical companies. About eight years ago, some psychiatrists from Asian and Australia banded together to form a Teachers of Psychiatry (TOP) club with a tag line, 'psychiatry sans frontier'. Primary care psychiatry training is the focus of the educational programmes. Two years ago, PRCP under Professor Fumitaka Noda embarked on a similar project in Cambodia. Collaboration among psychiatrists around the Pacific-rim can harness the limited expertise to promote academic excellence. One such endeavour is the formation of a consortium to study psychotropic prescription in Korea, China, Taiwan, Hong Kong, Japan, Malaysia, Thailand, India and Singapore. This consortium initiated 10 years ago as 'Research in East Asia on Psychotropics' or REAP, has published many papers in scientific journals and provided invaluable data (Chong et al, 2010). Recently, there are workshops organised for leadership training of young psychiatrists

(Sartorius, 2009). Many PRCP professors from around the Pacific Rim are actively involved in the development of academic psychiatry in Asia in 4 areas:

1. As visiting professors to Asian universities to conduct training courses

2. As mentors for young Asian psychiatrists sent to overseas universities

3. In organizing regular teachers of psychiatry (TOP) meetings

4. In cross-national research, e.g. dementia in Chinese (Feng et al, 2011)

PRCP has planned workshops on evaluation of clinical service, education and research. This is a major step to promote quality in academic psychiatry and clinical practice outcome in an era where patient care and service delivery demand more openness and transparency. Starting in Shanghai in October 2011, it is hoped that such training workshops can be held in other countries. Interest in academic psychiatry is nurtured during traineeship and a paper by Tor et al (2009) discussed some issues in the training of future psychiatrists.


1. Chong MY, Tan CH, Shinfuku N, et al (2010) Prescribing antipsychotic drugs for inpatients with schizophrenia in Asia: Comparison of REAP-2001 and REAP-2004 studies. Asia-Pacific Psychiatry 2: 77-84.

2. Feng L, Chiu H, Chong M-Y, Yu X, Kua E-H (2011) Dementia in Chinese populations: Current data and future research. Asia-Pacific Psychiatry 3: 109-114.

3. Kua EH (2010) Psychiatric service with no psychiatrist. Asia-Pacific Psychiatry 2: 117-118.

4. Sartorius N (2009) Leadership. International Psychiatry 6: 1.

5. Tor PC, Ng TP, et al (2009) Qualities of a good psychiatrist. Asia-Pacific Psychiatry 1: 9-14.

Beyond differences, towards harmony, and for oneness

Min-Soo Lee

Department of Psychiatry, Korea University College of Medicine, Korea

It is now the third time that the Pacific Rim College of Psychiatrists (PRCP) is taking place in Korea. PRCP 2012 will provide a formal setting for communication among our members, an opportunity for the presentations of scientific papers, discussions on important issues in psychiatry, and consideration of the variety of clinical, social, political and ethical issues in the Asia-Pacific. It will open doors for more opportunities for many professionals to form constructive communication and to achieve the balance between basic studies and clinical applications. It will help to close gaps between the Asia-Pacific Countries by supporting training and educational activities for young psychiatrists and holding symposiums of a diverse range of issues on psychiatry. It will

also be a chance of encounter and interaction among professionals from many countries. On this occasion we can advance 'Beyond Differences, Towards Harmony, and For Oneness.' PRCP 2012 will promote better understanding of mental illness in the community. There has been stigma associated with mental illness and prejudice shown towards people with mental illness and their families. I would like to point out the direction PRCP should pursue. As a psychiatrist I have treated a lot of patients with mental health problems and their families. In addition, I have engaged in the clinical study of pharmacoge-nomics all my life, for the purpose of choosing the most appropriate medication and dose titration regimen for individual patients. I believe that pharmacogenomics can help psychiatric patients recover from mental illness more safely and come back to normal life more rapidly. I hope PRCP will contribute to the elimination of inappropriate discrimination on the ground of mental illness against people with mental illness and their families. That is the responsibility of PRCP to achieve the goal of 'Beyond Differences, Towards Harmony, and For Oneness'.

Plenary Lecture

Seven anniversaries

Norman Sartorius

Department of Psychiatry, Association for the Improvement of Mental Health Programs, Switzerland

The past seventy years have witnessed major changes in the field of psychiatry. Although considered as being of determinant importance in this process the discovery of effective treatments was just one of the many factors that have changed the practice of psychiatry and its theories. Other developments had just as much if not more influence on the transformation of psychiatry. They include the changes of the social context, the new economic order, globalization, changes of value systems in many societies, massive migration, demographic changes and advances of the rest of medicine. The presentation will recall the changes of psychiatry during the past six decades and consider reasons that have led to these changes. It will also identify new challenges - identifiable already now - that will face psychiatry in the near future.

Is psychiatry universal across the world?: Possibility of culture-based psychiatry in Asia and Asian-pacific

Fumitaka Noda

Department of Human Life and Environment, Taisho University, Japan

There have been old but new discussions on the topic 'Is depression in East and West same?' or 'Is ICD or DSM fully applicable across cultures?' Biomedicine is trying to find universality of psychiatric illness from various points of view. If psychiatric disease is proved to be a pure physical disease like cancer and treatment modalities are established in that regard, then can every problem be solved? This direction will lead psychiatrists in the world to treat patient in scientific ways which will produce more medicine-oriented treatment. However, purely scientific approach tends to ignore sociocultural elements of disease. According to Arthur Kleinman, disease which is described in patients narrative is an 'illness' which contains a lot of sociocultural elements. In everyday practice of psychiatry, we hear a lot of illness narratives, which do not necessary fit to the diagnostic criteria. ICD or DSM tries to exclude those ambiguous phenomena by coining them as 'culture-bound'. However, we clearly know that representation of depression is different in the USA, Japan and Korea. If you know more about the culture and the sociocultural background of patients, it is for sure that treatment will be much easier. I am concerned that this active interest of 'evidence-based psychiatry' tends to seek only the scientific entity of disease and to ignore the actual 'illness'. In this lecture I would like to suggest psychiatry which puts more emphasis on culture.

Integrated neuroscience and culture in mental health promotion: A practice of neuroscience in the general public

Hai-Gwo Hwu

Department of Psychiatry, National Taiwan University, Taiwan

The matter of mental health is a way of daily life with a realistic value of surviving. The major determinants of mental health are the Brain, the Living Culture, and the Psychological Mechanisms. The brain is the tool for successfully managing the dynamic environmental events for satisfactory daily life and for sustainability. Neuro-scientific knowledge substantiated that human nature comprises of (1) self-survival, (2) empathetic understanding of others, and (3) social-ethical value with corresponding brain parts of limbic system, mirror neurons regions, and orbitofrontal region, respectively. The evolutionary model of individual development can be interpreted as the changes in neuron circuitries among the brain regions of human nature, based on neural plasticity induced by living experiences. Stressful living experiences can be of value for cultivating mental health, and can be an evil for initiating mental illness on the other side of the mental health story. The domains of mental health include (1) brain health, (2) psychological health, and (3) self-health. The metal health promotion, based on the neuroscientific knowledge, include the following public education: (1) Understanding the structure and function of the brain, (2) Awareness of the limitation of brain-power in daily life, (3) Operational ways of brain-protection, (4) Operational ways of establishing skills to abolishing worries in daily life, (5) Operational ways of creating life experiences of well-being. The program of this New Era of Mental Health Promotion, i.e. A Practice of Neuroscience in the General Public, in Taiwan will be demonstrated for the reference in the Pacific Rim Countries.

Partnerships for better mental health worldwide and across the Pacific Rim

Helen Herrman

Department of Centre for Youth Mental Health, University of Melbourne, Australia

Achieving adequate support for mental health in any country requires a unified approach. Service users and carers worldwide have the regular experience of stigma and discrimination, poor access to care, and treatment under conditions that fail to give respect and dignity. Psychiatrists in a range of countries recognise the need to work together to improve the situation for all concerned, and governments and professional groups increasingly support the inclusion of service users and carers in decisions about treatment and rehabilitation, service development, research and policy. Building on work in several countries, a World Psychiatric Association (WPA) taskforce recently developed recommendations for the international mental health community on best practices in working together between service users, family carers and professionals. The recommendations begin with respect for human rights as the basis for successful partnerships. Other recommendations include: clinical care is best done in collaboration between user, carers and clinicians; as are education, research and quality improvement. In 2011, a paragraph based on the recommendations was added to the Madrid Declaration, WPA's fundamental ethical guidelines for psychiatric practice. Each country will need specific guidelines and projects to apply these recommendations and contribute to worldwide learning. There are major opportunities for countries on the Pacific Rim to cooperate in project development and evaluation.

In the era of neuroscience progress and health reform, what psychiatrist should do?

Xin Yu

Department of Institute of Mental Health, Peking University, China

When Freud brought psychodynamic into psychiatry he thought he could make psychiatry more 'scientific'. However, psychodynamic became the media's darling and psychiatry seemed to the public more mysterious and divertive particularly under the exotic word such as ego or libido. With the advances of Neuropsychopharmacol-ogy, psychiatry had a chance to re-enter the medicine: they prescribe medications like other physicians. But psychiatrists are also blamed for 'labeling patients by various medications'. The introduction of a number of psychotropic drugs in 1960's also made a great transition on psychiatric practice: the hospital based psychiatric service gradually shifted to the community. The shift probably increased the coverage of mental health service but it also made psychiatry deeply involve in social, legal, and political debate. Psychiatrists are enthusiastic at playing the role as social advocates or even activists more than any other medical professionals. Psychiatry once again became the alternative of medicine. 'The decade of brain' and 'the decade of psychiatric disorders' depict the promising future of psychiatry. Unfortunately the pacemakers of this round are neuroscientists: they are focusing on molecules, cells, or rats, some of them have license of psychiatry, but they are now 'happily' freed from the clinical work by their research grants. The general psychiatrists tolerate even encourage the huge investment to neuroscience studies since they are so eager to practice like their counterpart cardiologists who are busy in putting stents into hearts. To the contrary of the great expectation, the implementation of products of neuroscientific research is far from satisfactory. The development of new diagnostic criteria seems like a desperate last fight to protect the territory of psychiatry. It is time that policy makers and consumers, clinicians and researchers made a dialogue to discuss the future of psychiatry. No matter what, the increasing need of mental health service has to be dealt with properly and promptly.

Prevention and early intervention against Alzheimer's disease

Masatoshi Takeda

Department of Psychiatry, Osaka University Graduate School of Medicine, Japan

Experience of donepezil, galantamine, rivastigmine and memantin has now demonstrated limited clinical usefulness to most of Alzheimer patients, because the patients may show the steady cognitive decline below the baseline after one year continuous use of these symptomatic drugs. Disease-modifying drugs to slow down or suppress the pathological process of the disease are highly expected. The development of disease-modifying drugs, however, has not been successful despite of the continuing endeavor in these 20 years. May compounds, including gamma-secretase inhibitors, gamma-secretase modulators, and BACE inhibitors, all failed to produce good results in clinical trials. The results of the clinical trials of immunotherapy for Alzheimer's disease will be disclosed soon. Considering these situations, there is a pessimism concerning the development of disease-modifying drugs under the present system of the clinical trial. New style of clinical trials of disease-modifying drug for Alzheimer's disease is proposed and discussed, in which the reduction of the conversion rate from MCI to dementia, or even from preclinical stage to MCI could be used as the primary outcome of the clinical trials. Establishment of biomarkers for early detection of possible patients is necessary and our data of APLP1 and APLP2 peptides will be discussed as the surrogate marker for pathological gamma-secretase activity.

Symposium 1

Dementia and Depression

Dementia, depression and Parkinson's disease

Kiyoshi Maeda

Department of Rehabilitation Medicine, Kobegakuin University School of Rehabilitation, Japan

Introduction: Several reports suggest a higher morbidity of depression in patients with dementia with Lewy bodies (DLB) than in patients with Alzheimer's disease (AD). However, these results have not been duplicated consistently. The psychiatric symptoms of dementia, including depression, are important for its diagnosis and management. Thus, the aim of the present study was to clarify the characteristics of the depressive symptoms in DLB compared with AD using the Geriatric Depression Scale (GDS). Several reports suggest a higher morbidity of depression in patients with dementia with Lewy bodies (DLB) than in patients with Alzheimer's disease (AD). However, these results have not been duplicated consistently. The psychiatric symptoms of dementia, including depression, are important for its diagnosis and management. Thus, the aim of the present study was to clarify the characteristics of the depressive symptoms in DLB compared with AD using the Geriatric Depression Scale (GDS).

Methods: We examined the GDS score for 86 patients with probable DLB (based on the Consensus Criteria for the clinical diagnosis of DLB) and 86 patients with probable AD (based on criteria of the National Institute for Neurological and Communicative Disorders and Stroke-Alzheimer's Disease and Related Disorders Association), who were matched according to age, sex, education, and Mini-Mental State Examination (MMSE) scores. We also examined correlations between GDS scores and age, sex, or MMSE scores in both groups. Correlations between GDS scores and metaiodobenzylguanidine (MIBG) scintigraphy were examined in patients with DLB. To characterize the GDS in DLB, its profile was examined using factor structures.

Results: Scores for DLB patients were twice as high on the GDS as those for AD patients. There was no correlation between GDS score and age, sex, or MMSE scores in either group. Furthermore, there was no correlation between the results of MIBG scintigraphy and GDS scores in the DLB group. Using factor structures,

the depression symptom profile of these diseases suggested that depression-specific symptoms, such as mood, worry, or future outlook, were more frequent in the DLB group than non-specific symptoms, such as lack of energy, decreased concentration, or apathy. Conclusions: The data suggest that depressive symptoms are highly specific symptoms of DLB, independent of other features of this disorder. The GDS could be used as a subsidiary tool in differentiating DLB from AD and is more useful than clinical observations of depression

Treatment strategy of BPSD in Korean dementia patients

Byung Hoon Oh

Department of Psychiatry, Severance Mental Health Hospital, Yonsei University, Korea

Dementia is the most disabling neuropsychiatric disorder of elderly population. Proper management of dementia, five domain must be considered such as 'cognitive, BPSD, ADL, family and legal aspects'. Especially, early detection and proper treatment of BPSD is essential for the maintaining quality of life in elderly dementia patients and their family members. Recognition and treatment of BPSD offer the best chance for alleviating patients suffering, reducing the family burden and lowing societal costs. BPSD are a distinct entity that can be differentiated from other late-life psychopathology. The etiology of BPSD is multifactorial, and the possible biopsychosocial contributing factors is elucidated. BPSD characteristics are different according to dementia type and disease severity. The prevalence of BPSD had positive correlation with decreased cognitive function and apathy, agitation, anxiety, depression, aberrant motor behavior in order by K-NPI subscale. The BPSD characteristics according to dementia severity were depression/dysphoria in mild stage; agitation/aggression in moderate stage; aberrant motor behavior/apathy in severe stage. Also BPSD is divided by four important issues such as 'delusions and hallucinations', 'depression and anxiety', 'agitation and aggression', and 'hypersexuality in dementia. Hypersexual behaviors became an immense burden for caregivers. ' Non-pharmacological treatment, various psychosocial interventions must be considered both for dementia patients, family members, and other caregivers. And atypical neuroleptics demonstrated highly useful and well tolerated drugs for the proper management of BPSD. Five step to control behavioral and psychological symptoms of dementia (BPSD) complications will be

summarized 'characterize target symptoms, identify medical causes, psychiatric evaluation, employ non-pharmacologic treatment first and use medication if necessary'.

Reliability and validity of Chinese version of AD8

Association of serotonin transporter with depression in Alzheimer's disease

Ming-Chyi Pai

Department of Neurology and Alzheimer's Disease Center, College of Medicine, National Cheng Kung University, Taiwan

Background: Depression is one of the most frequent psychiatric disturbances in Alzheimer's disease (AD). With a newly synthesized compound, we investigated the role of serotonin transporter (SERT) availability in AD patients with depression.

Methods: We studied 32 AD patients: 6 with major depressive disorder (AD-D), and 15 cognitively healthy controls (HC). Each participant was evaluated using single photon emission computed tomography (SPECT) five hours after an injection of 185 MBq I-123 2- ([2- ([dimethylamino]methyl)phenyl] thio) ([ 1231] ADAM), magnetic resonance imaging, and neurobehav-ioral tests: Mini-Mental State Examination (MMSE), Cognitive Abilities Screening Instrument (CASI), Neuropsychiatry Inventory (NPI), and Hamilton Rating Scale for Depression (HAM-D). The SERT availability was measured using the midbrain/cerebellum ratio (M/C ratio). Outcome measurements were SERT availability and neurobehavioral scores.

Findings: AD patients had a lower M/C ratio (2.3 ± 0.3 vs. 2.7 ± 0.3; p = 0.000) and a higher HAM-D score (8.3 ± 6.1 vs. 4.5 ± 2.1; p = 0.04) compared with HC. Furthermore, AD-D patients had a lower M/C ratio than AD patients without depression (2.0 ± 0.3 vs. 2.3 ± 0.2; p = 0.04). In AD group, the M/C ratio correlated with the HAM-D (r = -0.50; p = 0.004), but not with the MMSE, CASI, or NPI.

Interpretation: [123I]ADAM SPECT provides an in vivo approach for understanding the association of the serotonin system with depression and AD. The findings also suggest that SERT was involved in the pathogenesis of depression in AD patients: the higher the depression scores, the lower the central SERT availability. Funding: This study was supported by a mutual fund from the National Science Council and the Atomic Energy Council, Taiwan (94WFA0900209).

Tao Li

Department of Psychiatry, Peking University Institute of Mental Health, China

Objective: To establish the validity and reliability of the Chinese version of AD8, and to explore the discriminative properties of AD8 in differentiating dementia and normal controls.

Methods: 240 subjects were recruited, including 75 cognitively intact subjects and 165 patients with dementia. All subjects were administered with Chinese version of AD8, Clinical Dementia Rating (CDR), Mini-Mental State Examination (MMSE), and Clock Drawing Test (CDT). AD8 was re-administered to 158 subjects after one month.

Results: (1) The Cronbach alpha for Chinese version of AD8 was 0.78. The ICC of test-retest reliability was 0.96 (p < 0.01). (2) The correlation coefficients between each item of AD8 ranged from 0.36 to 0.69 (p < 0.01). Chinese version of AD8 total scores were strongly positively correlated with CDR global score (r = 0.82, p < 0.01), and CDR-SB (r = 0.80, p < 0.01), and negatively correlated with the total score of MMSE (r = -0.75, p < 0.01) and CDT (r = -0.53, p < 0.01). (3) For discrimination between subjects of CDR = 0 and CDR > 0.5 (dementia patients), the AUC was 0.93. Using a cutoff of 2 or greater on Chinese version of AD8 to discriminate dementia, the sensitivity was 93.9%, and specificity was 76.0%. Concerning the discrimination between cogni-tively intact (CDR = 0) and very mild dementia subjects (CDR = 0.5), the AUC was 0.86. Using a cutoff of 2 or greater, the sensitivity of Chinese version of AD8 was 85.9%, and the specificity was 76.0%. Conclusion: Chinese version of AD8 is a brief and sensitive screening measure with good validity and reliability. Cutoff of 2 might be useful in detecting early stage of cognitive impairment.

Symposium 2

ADHD-Child to Adult/Women & Men

ADHD: Discussed features and new clinical riddles

Sam Tyano

Department of Psychiatry, Tel Aviv University School of Medicine, Israel

ADHD is a common disorder, existing in all age groups, 6-10% of child and adolescent population and 4-6% of adults. It is getting a lot of attention from several fields of research, and is frequently discussed and studied in many scientific meetings. Hence, we would like to present a course that will last 3 hours, during which we will discuss some of the most important issues today:

1. ADHD etiology, mainly the genetic studies

2. Structural and functional features of ADHD as shown by imaging studies, neuro-cognitive studies, etc.

3. The clinical picture of ADHD in all age groups, including the 'extreme' age groups, i.e. infants and adults

4. The high comorbidity load related to ADHD, its relationship with other chronic disabling disorders such as PDD and psychotic disorders, and its organic comorbidities such as Dysregulation of biological rhythms

5. The dynamic aspects of living with ADHD

Current practice for the treatment of children with ADHD in Korea

Dong-Hyun Ahn

Department of Psychiatry, Hanyang University College of Medicine, Korea

ADHD becomes the major problem in psychiatric practice throughout the world since 1990s. The current practice pattern for the treatment of children with ADHD will be reviewed in Korea. We surveyed 76 child and adolescent psychiatrists on the current practice pattern for the treatment of children with ADHD. Additionally we reviewed statistical data on ADHD treatment and published articles in Korea. In according to the National Health Insurance Statistic Data on the ADHD treatment, the number of persons who were treated for ADHD is

increased from 18,967 in 2003 to 64,066 in 2009 (237.8%). Especially the number of adults above 20 years-old is increased 7.5 times from 2003 to 2009. This is the first survey the current practice pattern for the treatment of child and adolescent with ADHD in Korea. ADHD and related other disruptive behavior disorders (46.6%) were the most commonly treated disorder in child and adolescent clinical practice, followed by mood and anxiety disorders (21.8%), mental retardation and developmental disorders (14.2%), other disorders including tic and Tourette disorder, psychotic, adjustment, organic, and substance disorders (11.8%), and sleep, elimination, and eating disorders (6.0%). More than 90% of children with ADHD were prescribed medication to school age and adolescents compared with 45.3% to preschool children. Parental psychoeducation or parental training was done to all age groups. The portion of social skills training (SST) and play therapy prescription in school age were 77.3% and 56.0%, which decreased to 37.3% and 12.0% in adolescents. Cognitive-behavioral therapy (CBT) was constantly conducted from school age (49.3%) through adolescence (45.3%).

ADHD and social cognition

Dongwon Shin

Department of Psychiatry, Kangbuk Samsung Medical Center, Korea

Many patients with attention deficit/hyperactivity disorder (ADHD) have impairment in social functioning. Impulsivity, hyperactivity and inattention are likely affect adequate tuning of social behavior. Furthermore, oppositional defiant disorder, conduct disorder (CD) which are commonly associated with ADHD are important indicators of social impairment. Several behavioral elements are closely related to the social dysfunction of children with ADHD. Aggressive and negative nature of interactions tends to be associated with rule violation, hostile and controlling behavior. These behaviors may form a direct threat to other children, and result in negative peer nominations. The second element refers to restless and intrusive behaviors that are often inappropriate in the given context. These behaviors may also be related to the peer rejection. Inattention manifests itself in social situation by not listening, being distracted and having trouble switching roles. Predominantly inattentive type of ADHD tends to be dreamier, passive and slow in their behaviors. Results from theory of mind and facial emotion recognition tasks show that children with ADHD are lack of

awareness of the feeling of others. Children with ADHD fail in some tests of ToM and display impairments involving emotion, face and prosody perception, and reduced empathy. Social dysfunction may be of crucial importance for the prognosis of children with ADHD on both short and long-term. Social dysfunction predicted later CD and substance abuse after controlling of baseline mood, aggressive behavior and attention problems. Medication-induced reduction of symptoms was the strongest mediator of social skills improvement. Improvement of social cognitive skills and more effective parenting may be helpful. But, research data show inconsistent findings. Optimal treatment strategies for treating social problems in children with ADHD need further development.

Searching for cognitive endophenotypes for attention deficit hyperactivity disorder

Chi-Yung Shang

Department of Psychiatry, National Taiwan University Hospital, Taiwan

Attention deficit hyperactivity disorder (ADHD) is a common, early-onset, impairing, clinically and genetically heterogeneous neuropsychiatry disorder. The endo-phenotype approach has been proposed to reduce the complexity of the phenotype and its potential genetic heterogeneity and to increase linkage or association signals because the endophenotype is proximal to gene products and has the potential to target the possible pathophysiological deficits that combine to create the overall conditions of ADHD. Two of the most striking neuropsychological impairments in ADHD are in executive function and memory. Our recent work showed that the adolescents with ADHD and the unaffected siblings had a significantly shorter backward digit span, more extra-dimensional shift errors, shorter spatial span length, more total errors and poorer strategy use. In addition, the unaffected siblings occupied an intermediate position between ADHD probands and controls in the visual memory tasks. Our findings identified executive function and visual memory as useful endophenotypes for ADHD.

Symposium 3

Pacific Mental Health Acts and its Footsteps

New mental health acts in Australia and their effect on psychiatric care

Philip Morris

Department of Psychiatry, Distinguished Fellow and member of the Board of Directors of PRCP, Australia

Prof Morris will present a paper on the liberalisation of state mental health Acts across Australia around the turn of the 21st century. He will review the strengths and weaknesses of these new mental health Acts. The intended and unintended consequences of implementing these Acts will be described. The contribution of the effects of these mental health Acts to the crisis in Australian mental health services will be explored in this paper.

History of mental health legislature in Japan

Tsuyoshi Akiyama

Department of Psychiatry, NTT Medical Center Tokyo, Japan

The earliest reference to mental health in Japanese legislature was about penalty reduction for the crimes committed by mental insane in Taiho legal codes in AD 702. While this concept of penalty reduction continued in the legislature till Meiji era, the treatment systems were not developed. The first modern legislature was promulgated in 1900 as Custody and Care Law for Mentally Insane, in which psychiatric beds were put under the control of police. In 1919 Psychiatric Hospital Law was issued but did not succeed in promoting care quality. In 1950 Mental Hygiene Law was issued and prohibited home custody of psychiatric patients. In 1984, Utsunomiya hospital case, in which two psychiatric patients were killed by nurses, occurred and Japanese government received strong criticism from WHO. In 1987 Mental Hygiene Law was amended as Mental Health Law to protect the rights of patients. In 1995 Mental Health Law was further amended as Mental Health & Welfare Law to integrate welfare supports to psychiatric patients. Recently in order to ratify the International Covenant on Civil and

Political Rights, the Ministry of Health and Labour and Welfare inaugurated a study group. It is probable that Medical Protect Admission, which is implemented involuntarily with a designated family member's consent, will be abolished in the future. Thus the legislature has been revised and amended in Japan. However, the issue is how we realize a system to implement the spirits of legislature in psychiatric practice of real life.

Human rights and mental health legislation: Its effects on mental health services

Tae-Yeon Hwang

Department of Psychiatry, Yong-in Mental Hospital, Korea

In 2006, WHO declared Human Rights of Mentally Ill People is one of four most urgent issues in Mental Health all over the world. MI Principles adopted by General Assembly of UN on December 17, 1991, but still we witness violations of human rights of mentally ill people in the institution, facilities and anywhere in our society. National Human Rights Commission (NHRC) of Korea was established in 2001 and it has visited investigated many mental health facilities and hearing appeals from many consumers and families regarding violation of their basic rights to being treated as such persons, treated with humanity and respect for the inherent dignity of the human person. In 2009, NHRC published 'National Report for Protection and Promotion of Human Rights of Mentally Disabled' through special committee and research team for this project. Chapter 1 described 'the establishment of proper process of admission and discharge of the mentally ill patients'. Chapter 2 described 'improvement of human rights of the patients and quality of care of the facilities'. Chapter 3 described 'community-based treatment and rehabilitation of mentally disabled'. Chapter 4 described 'eradication of stigma and discrimination of mentally disabled'. This report contributed so much for the mental health services pattern in inpatients facilities. Involuntary admission was decreased and voluntary admission was increased. Direct appeal from the inpatients called visit and investigation by NHRC and they regain their human rights to treat properly. Evaluation and monitoring system was started for the quality of care and illegal asylum was closed. This report also contributed to the amendment of mental health act that mandatory human rights education for mental health staff was started, public mental health emergency intervention

system was established, community mental health services were expanded with anti-stigma campaign and prevention of human rights violation of mentally ill people.

The issues of mental health amendment in Korea

Myung-Soo Lee

Yong-in Mental Hospital, Seoul Mental Health Center, Korea

Korean Mental Health Act was enacted in 1995 and was revised 4 times in 1997, 2000, 2004 and 2008. There were some kinds of amendment issues such as re-categorization of social rehabilitation facilities, introduce the concept of community mental health enter, strengthening human right in the institutions and so on. However, the major revision issues were related to the mechanism of admission and discharge. The Act continuously tried to make it difficult of involuntary admission by carers through intensifying the carers' eligibility and the process. The Act also tried to strengthen the function of mental health review board by transferring the power to the local government from regional government. Through the transfer, we could expect that the review board could act more assertively by enhanced accessibility. Recently the government, professionals and some of consumers agreed to confine he concept of mental illness to seriously disabled person. The purpose of this amendment is to 'protect' other common mental disorder patients from the social stigma and discrimination, for example, rejection from the private insurance companies. Of course, this issue might bring other problems and some professionals and consumers still defying this opinion. The future mental health Act of Korea should consider several things to improve mental health system and mental health status of Korean people. Firstly, the Act should be followed by appropriate budget to make the system real. Simple announcement never settle the key mental health problems such as deinstitutionaliza-tion. Secondly, the Act should have mechanism to decrease the barrier for mental health promotion and rehabilitation. For example, to solve the dead-zone of welfare for psychiatric disabilities by negotiating with Disabilities Act.

o n Symposium 4

2 t Understanding and Recent Strategies on

5 d Internet Addiction: An International

T e Perspective

s S 4-1

Internet addiction: Why we become addicted to the Internet?

Sam-Wook Choi

Department of Psychiatry, Eulji University Hospital, Korea

The Internet has become all pervasive in the lives of modern people. Especially for youth, excessive Internet use is considered as one of the most negative aspects of online activities. Several studies suggest possible links between Internet addiction and negative health consequences such as depression, ADHD, daytime sleepiness, problematic alcohol use, or negative effect on academics and family relations. Interactive communication applications such as online games, chat rooms and instant messaging have most commonly been associated with Internet addiction among youth. Although a number of studies have indicated that Internet addiction is a mental health problem, and as with most addictions, several studies based on a range of biopsychosocial theories have been proposed to explain Internet addiction, the underlying mechanisms of Internet addiction are still unclear. Among those studies, individuals with Internet addiction scored high on self-report measures of impulsivity, sensation-seeking and generally high on measures of harm avoidance. Diminished activity of the ventral medial prefrontal cortex has been associated with impulsive decision making in risk-reward assessments. Game cue-associated brain activation in Internet gaming addicts occurred in the same brain regions (orbitofrontal, dorso-lateral prefrontal, anterior cingulate, nucleus accumbens) as with drug cue-associated brain activation in drug addicts. In addition, individuals with Internet addiction showed reduced levels of dopamine D2 receptor availability in subdivisions of the striatum. Future research is needed to bring our knowledge of Internet addiction to the level of that for substance addiction, especially in the domains of neurobiology and treatment.

Recent strategies for the treatment of Internet addiction in Germany

Manfred Beutel

Department of Psychiatry, University Medicine Mainz, Germany

Purpose: Since its foundation in 2008 the Mainz outpatient clinic for behavioral addiction as the first clinic in Germany has served about 500 online and gambling addicted patients. According to our recent, statewide representative survey, out of 4,000 German students (aged 12-18 years), 3.3% fulfill the criteria of addictive Internet use, and another 12.5% show problematic online behavior. In order to provide evidence-based treatments for the large number of Internet addicted patients we have devised and tested a specific intervention. Materials and methods: A cognitive-behavioral treatment manual, pretested in an open trial, is now tested in a randomized controlled trial (RCT). Short-term Treatment for Computer game and Internet Addiction (STICA) consists of 15 group (100 min, each) and 8 individual sessions (50 min) over a period of four months. The early phase (group sessions 1-3) focuses on patient education and motivation, the middle phase (4-13) includes behavioral analysis and building functional Internet use, social skills, problem solving, exposition and alternative activities. Treatment is concluded by relapse prevention (14-15).

Results: In an open trial, 33 patients (male, mean age 26.1; range: 18-47 years) were treated according to STICA. Based on an intent-to-treat analysis, the primary endpoint of normalized online behavior (as measured by a specific and valid self-report questionnaire, AICA-S) was reached by 68%. Concerning expert rating (AICA-C), online addiction was significantly reduced (effect size was 1.62), and so were leisure-time computer use (1.09) and distress (0.44). In the first multisite RCT to date with 192 patients with online addiction (funding: DFG), STICA is compared to a wait-list control group; patients are followed over 6 months. Treatments are videotaped and rated for therapist competence and adherence.

Conclusion: Based on pilot data, STICA as a promising treatment will be illustrated by videotaped clinical cases. Strategies and experiences in the ongoing RCT will be discussed.

Recent strategies for the treatment of Internet addiction in Taiwan

Chih-Hung Ko

Department of Psychiatry, Kaohsiung Medical University, Taiwan

Internet use disorder is newly defined by the DSMV in May, 2012. The prevalence in Taiwan is about 15-20% in adolescents and 10-15% in college students according to the massive evaluation of Chen Internet Addiction Scale at 2006 and 2009. The Internet use disorder is an important behavior problem in Taiwan. We have developed a specific clinic for Internet use disorder at Kaohsiung Municipal Hsiao-Kang Hospital. According to the previous studies for Internet use disorder in Taiwan, the Internet use disorder is comorbid with ADHD, depression, hostility, social phobia, or substance use disorder. Further, high novelty seeking, high harm avoidance, low reward dependence, high behavior activation, and high behavior inhibition were reported to be the characteristics of subjects with Internet use disorder. The associated psychosocial factors include stress, family support, frustration intolerance, self-esteem, impulsivity, and life quality. Based on these findings, we developed a protocol for Internet use disorder to integrate the bio-psycho-social intervention of Internet use disorder. We recruited psychiatrist, psychologist, social worker, and counseling teacher in school to provide intervention for students with Internet use disorder and their parents. The primary goal of the intervention is to redirect the motivation system to the real world. The psychiatrist should confirm the diagnosis and comorbidity of Internet use disorder and determine the treatment schedule. The psychologist needs to assess the characteristics of the patient and determine the protocol of cognitive behavior therapy. The social worker has to provide environment intervention and parental skill counseling to the parents. Lastly, the course and prognosis in the treatment should be monitored to revise the treatment plan.

addiction treatment currently. This short paper presents a few recent reports on Internet addiction treatment. Some drugs were tried for Internet addiction but no definite evidence emerged supporting the use of any drug. But much new information about SSRI, bupropion, naltrexone and methylphenidate in the treatment of Internet addiction became available. Many psychosocial approaches were also tried for patients with Internet addiction, including cognitive behavioral therapy, reality therapy, solution focused therapy, family intervention, and camping schools targeted for adolescents and adult addicts. But systematic meta-analysis showed many limitations of the different approaches and research. Although the approaches were not complete failures, many difficult problems arose from the start-up of therapy. In the future more precise and scientific definitions relating to Internet addiction, development of concepts and the establishment of criteria for therapy of Internet addiction will be formulated. Key Word: Internet addiction, Treatment, Biological therapy, Psychosocial approach, Meta-analysis.

Symposium 5

Pain in Psychiatry

Treatment of chronic pain in psychiatry

Chay-Hoon Tan

Department of Pharmacology and Psychological Medicine, National University of Singapore, Singapore

Chronic pain is difficult to treat. It often precedes or exacerbates mood and sleep disturbances. Depression and insomnia further amplifies the pain experience. The vicious cycle of depression, insomnia and pain continues. Patients with chronic pain are referred by various health care specialists to psychiatrists for treatment as a last resort. How do we treat these patients? The aim of this talk is a case-based discussion on evidence-based treatment of chronic pain.

Treatment of Internet gaming addiction

Hyunsoo Kim

Department of Psychiatry, Myongji Hospital, Korea

Internet addiction treatment is a new area of paradigm and concept. Many disputes and controversies exist, and there are no apparent guidelines or consensus about Internet

Resilience as a possible moderator for the relationship between pain and depression in patients with spinal cord injury

Jung-Ah Min

Department of Psychiatry, The Catholic University of Korea, Seoul St. Mary's Hospital, Korea

Purpose: Spinal cord injury (SCI) is one of the most disastrous injuries. Indeed, SCI patients suffer from mental health problems, most commonly depression and anxiety, which may contribute a high-risk for disability and reduced quality of life in these patients. Chronic pain after SCI was reported to be one of the contributing factors to higher depression. On the other hand, the buffering effect of resilience on depression in SCI patients and the role of resilience in adaptation to chronic pain have been suggested. In this study, we attempted to identify the moderating role of resilience in that chronic pain contributes to depressive symptoms among community dwelling SCI patients.

Methods: Community dwelling SCI patients (n = 37) were consecutively recruited at admission for yearly health examination. Participants completed the depression subscale of Hospital Anxiety and Depression Scale (HADS), Connor-Davidson Resilience Scale (CDRS), Visual Analog Scale (VAS) for pain to assess depression, resilience, and subjective pain severity. Demographic and medical data were elicited from patients and hospital chart. After univariate analyses, hierarchical linear regression analysis with depressive symptoms as the dependent variable was performed to identify the independent effect of pain to depression and the moderating role of resilience.

Results: Moderate to extremely severe pain and unemployment were associated with higher depression (p = 0.001 and 0.013, respectively). Resilience was negatively correlated with depression (r = -0.615, p < 0.001). In regression model after controlling for employment status, pain severity was significant independent predictor for depression (P = 0.55, p = 0.001). After entering resilience into this model, resilience was also significant predictor for depression (P = -0.39, p = 0.026). In addition, impact of pain severity on depression was decreased to 0.42 and change of explained variance of this model was significantly increased.

Conclusion: As expected, chronic pain contributed to higher depression in SCI patients. In addition, we found

that low resilience was an additional contributor to depression whereas high resilience reduced the impact of pain to depression. Therefore, resilience might provide the target for psychosocial intervention in SCI patients with chronic pain.

Can education change nursing attitudes of Japanese nursing personnel toward patients who have attempted suicide?

Yasuhiro Kishi

Department of Psychiatry, Nippon Medical School Musashikosugi Hospital, Japan

In Japan, suicide is a major cause of death. Many studies have shown that a history of suicide attempts and/or repetition of deliberate self-harm increases the risk of suicidal behavior over both the short and long term, suggesting that specific suicide prevention strategies should be targeted for this group. Suicide attempts are frequently encountered by emergency department nurses. Such encounters can potentially provide a foundation for secondary suicide prevention, with emergency room nurses playing a key role. Our research shows that the nurses who worked at emergency care/intensive care unit were less likely to understand suicidal patients, and were less inclined to be sympathetic and verbally interact with suicidal patients concerning their problems. This negative attitude could lead to a decreased quality of care for suicidal patients together with a missed opportunity for preventive influences. This attitude could cause further emotional 'pain' for suicidal patients. Following the introduction of the Basic Suicide Prevention Law in 2006, a project providing a training workshop on caring for suicide attempters was started by the Ministry of Health, Labour and Welfare in 2008 and is ongoing. The 1-day workshop primarily targets medical staff in emergency units and involves lectures and case studies. A total of 139 emergency nurses attended the workshops in 2010. The attitudes changes were measured by the Understanding Suicidal Patients scale-Japanese version. Among those 52 nurses completed the questionnaires before the workshop and at one month after the workshop. General understanding and willingness to nurse increased significantly. The results suggest that it may be possible to enhance attitudes to attempted suicide patients

among emergency care nursing personnel. More medical staffs who work for suicide attempters are expected to participate in the training workshop in the future and the workshop content will need to be more tailored, in-depth training may be required.

Complex pain management in psychiatry

Soma Ganesan

Department of Psychiatry, Vancouver General Hospital, Canada

Although pain management medical services are regarded as a specialty of anesthesia, the research literature has pointed to a greater need for a multi-disciplinary approach. This presentation will provide an overview of the importance of psychiatric triage and treatment in the management of chronic pain. It will present the restructured Complex Pain Clinic at Vancouver General Hospital as one potential model. The presentation will highlight the clinical pathway, assessments and treatment services provided to patients. The importance of a multi-disciplinary approach that emphasizes the substantial psychological conditions as well as psychiatric and co-morbid conditions that patients encounter will be discussed.

to take therapeutic measures in treating its individual components. Metformin an oral hypoglycemic agent has been proven to be efficacious in treating weight gain component of the metabolic syndrome. Fibromyalgia is a condition where chronic widespread pain in the muscles and joints of the body is accompanied by fatigue, difficulty sleeping and depression. The condition affects more women than men. Naltrexone is an opioid antagonist that inhibits or accelerates cell proliferation in vivo when utilized in a low (LDN) or high (HDN) dose, respectively. LDN upregulates OGF (opioid growth factor) and OGFr (opioid growth factor receptor) and this seems to be responsible for the beneficial effect of LDN in fibromyalgia.

Methods: Two retrospective chart reviews studies of patients presenting to a rural outpatient clinic West Kern Mental Health identified patients receiving Metformin for weight control of metabolic syndrome and LDN for patients that had comorbid depression with fibromyalgia or rheumatoid arthritis.

Results: All patients receiving Metformin experienced a certain degree of weight loss and almost 80% of patients receiving LDN obtained a Clinical Global Impression Scale (CGI) of Much (MI) or Very Much Improved (VMI).

Conclusions: Metformin has the potential to decrease psychotropic induced weight gain. The LDN potential use in pain syndromes accompanying depression needs to be explored in more rigorous research.

Symposium 6

Treating Comorbidities in Patients with Mood Disorders

Overview & introduction

Tai Pyung Yoo

Department of Psychiatry, UCLA Kern Medical Center, U.S.A.

Purpose: The significance of the following two studies is twofold: 1. there is evidence that people with mental disorders are more likely to suffer from several other comorbid medical conditions; two most frequent such conditions are the metabolic syndrome and fibromyalgia. 2. Ethnic minorities are less likely to seek mental health care and thus any efforts to improve their awareness of mental illness with medical comorbidities will ease their suffering. Metabolic syndrome can significantly contribute to morbidity and mortality. It is certainly necessary

Efficacy of low dose naltrexone for patients that suffer from comorbid depressive illness

Gabriela Obrocea

Department of Psychiatry, UCLA Kern Medical Center, U.S.A.

Purpose: Naltrexone, an opioid antagonist at low dose (4.5 mg per day) helps in reducing the production of proinflammatory cytokines by suppressing the microglial cells in the CNS. This study is a retrospective chart review meant to investigate the efficacy of low dose naltrexone (LDN) for the treatment of patients with co-morbid depression and collagen disease. Materials and method: A retrospective chart review of patients presenting to a rural clinic (Wasco Mental Health) identified five patients receiving LDN from October 2008 to present. The outcome measure was the clinical global impression scale (CGI).

Results: Five patients received at least one month of LDN. All patients were females with age ranging from 47 to 63, one Hispanic ethnicity, and four Caucasian. Two had a diagnosis of Major Depressive Disorder, two had Bipolar Type II and one had Bipolar Type I. Two patients with fibromyalgia only had minimal improvement. One patient with lumbar discopathy had no improvement. One patient with Lupus responded with much improved with liquid LDN; another patient with both Lupus and Fibro-myalgia had a very much improved response on LDN capsule.

Conclusion: At week 4, 80% of patients experienced a certain degree of improvement with LDN. The use of LDN for osteoarthritis and lumbar discopathy in our study did not give a robust benefit. In addition, the use of liquid LDN appeared to be less effective as the capsule form. Prospective studies randomized using LDN and current practice guidelines for treatment of RA and fibromyalgia must be considered.

received Metformin, which was started at 500 mg daily and increased to 1-2 gr/day. The weight loss ranged from 10 to 69 pounds in 10 to 18 months of treatment. One patient experienced gastrointestinal disturbance at the higher dose 2 gr, and dose was reduced to 1 gr/day. Conclusion: Metformin has potential to decrease psychotropic induced weight gain. Metformin may also have a positive effect on metabolic parameters such as waist circumference, fasting blood glucose levels and triglycerides. Further research involving large scale trials that evaluate weight loss as primary outcome is necessary to firmly establish the role of metformin in this population.

Comorbid anxiety disorders in major depression: Considering neuroimaging perspectives

Metformin for weight control in psychiatric patients

Conrado Sevilla

Department of Psychiatry, UCLA Kern Medical Center, U.S.A.

Purpose: There is evidence that metabolic disturbances occur with the use of psychotropic medications. Patients with chronic mental illness are at higher risk for developing metabolic syndrome or its individual components due to a complexity of factors. Weight gain seen in metabolic syndrome can lead to decreased adherence to treatment and therefore increased risk of relapse; in addition, there is increased risk of diabetes and cardiovascular disease. Metformin may attenuate the weight gain and/or induce weight loss in patients with schizophrenia, bipolar disorder, and psychotic depression. Materials and method: A retrospective chart review of patients presenting to a rural outpatient psychiatric clinic Wasco mental Health, identified 5 patients receiving Metformin (500-2000 mg/day) as an add-on for control of weight or metabolic syndrome. The outcome measure was weight measurement. Results: Data was collected from 5 patients. All patients were female gender, with ages ranging from 36 y/o to 61 y/o; diagnoses were as follows: one had schizophrenia, one had major depressive disorder with psychotic features, and three had bipolar disorder (two with bipolar 1 and one with bipolar II). All patients

Borah Kim

Department of Psychiatry, CHA University, CHA Bundang Medical Center, Korea

Depression is heterogeneous and highly comorbid with other psychiatric disorders. Above all, comorbid mood and anxiety disorders are commonly seen in clinical practice. It has been demonstrated that comorbid syndromes of depression and anxiety are associated with increased symptom severity, chronicity, and greater functional impairment, along with a decreased response to antidepressant monotherapy and a higher incidence of suicide. Although various studies on comorbid mood and anxiety disorders had been reported before, studies with neuroimaging perspectives have recently emerged. The search for the comorbid depression and anxiety disorders was accomplished by PubMed for clinical and neuroim-aging papers published between 1990 and 2012 with the following search terms: depression, anxiety, and MRI. Contemporary MRI studies in psychiatric disorders are beginning to address the concept that mood and anxiety symptoms are likely to arise from disruptions of the normal function of large distributed neural networks. To date, there is evidence of abnormalities in prefrontal and limbic-paralimbic cortex involved in both mood and anxiety. However, it is unclear to what extent those findings are disorder specific and/or reflect common etio-logic and vulnerability factors that result in common pathophysiological profiles that span mood and anxiety disorders. Although much more data are needed, there is growing recognition of the urgent requirement for better

understanding of these comorbidities. It would be recommended that careful attention be given to correctly identifying anxiety comorbidities in patients with mood disorders.

Symposium 7

Psychiatric Education

Guidelines for psychiatric education for medical students and residents

Allan Tasman

Department of Psychiatry, University of Louisville, U.S.A.

In the last decade, the field of psychiatry has been marked by tremendous advances in the knowledge base and in development of new therapeutic interventions. The need to incorporate information about the knowledge and skills necessary to clinically utilize these advances has had a substantial effect on the content of psychiatric training programs for both medical students and residents. In addition, changes in teaching approaches and teaching technologies have also greatly influenced psychiatric education. For example, the increasingly widespread use of competency based approaches to both education and evaluation were not even in early stages of implementation a decade ago. When the author of this presentation, Professor Allan Tasman, was Secretary for Education of the World Psychiatric Association (WPA), he coordinated in 2009-11 the development of global guidelines for psychiatric education for the World Psychiatric Association. This presentation will provide a brief overview of the official WPA recommendations for psychiatric education programs, at both the medical student and residency training levels, focusing on both the content of educational programs, and changes in the overall themes of psychiatric education such as competency focused education and evaluation. In addition, discussion of use of modern electronic technologies, new evaluation methods, and the need to modify curricula for local needs will also be discussed. Attention to cultural competency and to training in high or low resource geographic areas will also be addressed.

Psychiatric education and resident training in Korea

Jin Kyung Park

Department of Psychiatry, Kyung Hee University Hospital at Gangdong, Korea

In Korea, medical students take two years' premedical course or four years' master course, and then four years' regular medical course. On the third and fourth year of the regular medical course, there are lectures and clinical education of psychiatry. After one year of internship, all applicants to psychiatric resident must take the entrance examination including written test, oral test, and internship grade. In recent years, competition for psychiatric resident is very high. There are about 150 new psychiatric residents per year. Psychiatric resident training course takes four years in Korea. The curriculums are designed by the Korean NeuroPsychiatric Association (KNPA) and the training institutions must receive inspection from KNPA every year. In order to be a medical specialist in psychiatry, they must write one or more original article as the first author and take two more in-training examinations for estimation of resident's performance. Psychiatric residents are qualified for board examination at the end of the fourth year in the training course. The examination is composed of three types of tests (written, video, and psychotherapy supervision) and around 90% of the applicants pass.

Psychotherapy training in the Korean academy of psychotherapists: The significance and implications of the Korean empathic culture

Hyo-Deog Rim

Department of Psychiatry, Kyungpook National University School of Medicine, Korea

Since the theory of western psychotherapy was first introduced to Korea in the 1930s, there were many obstacles in the process of the assimilation of western ideas into Korean culture. Back then, several psychotherapists were pessimistic in practicing psychotherapy with a negative viewpoint that the Korean culture and its personality were not suitable for psychotherapy. Overcoming this prevailing pessimism, Rhee has consistently argued that this pessimism was a neurotic phenomenon resulting

from the cultural element of defeatism and incomplete understandings of Western psychotherapy. In the early 1960s he stressed the similarity between western psychotherapy and eastern Tao and that Tao is the supreme form of psychotherapy. The first insight Rhee gained from examining the assimilation process was that Korea has Tao oriented culture, as we know in the spirit of the national foundation in Korea, which is 'Hong Ik In Gan Jung Sin' < the spirit of devotion to the welfare of mankind through harmony with heaven (nature or the universe) by the practice of Tao > , and due to its humanistic, psychotherapeutic characteristics and a strong tendency to harmonize and empathize emotionally, Korean culture is more suitable for psychotherapy practice and training viewed from the principles of western psychoanalytic theories. Founded on the penetrating insight, Rhee's relentless effort to gradually resolve this pessimism was a success - presently this issue is no longer contestable. The current status of psychotherapy practice and training in Korea has two directional modes. One is imitating the foreign school's institutional style and to apply it to Korea. The other unique direction is rediscovering traditional Korean culture originating from Tao through studying western psychotherapy literature and Eastern Tao classics. This is led by Rhee in activities of KAP and is bringing about more comprehensive understandings of western psychotherapy in depth and more effective psychotherapeutic treatments. Recently, Rhee declared Taopsychotherapy as the fusion of Tao and western psychoanalysis and psychotherapies (Daseins-analysis, Existential analysis, Client-centered therapy, Transpersonal psychotherapy and Spiritual theological psychotherapy). The Korean Taopsychotherapy Institute for further development of systematic investigation and education is to be established by Rhee and his protégés. The late Edwin Reischauer predicted in early 1970's that in the 21st century a new civilization in the North East Asia will emerge for the first time in 5000 years of human history. Rhee has posited, 'the civilization is the fusion of the North East Asian tradition and western science. Although the western psychotherapy cannot be said as science, this fusion of western psychotherapy and Tao, which is the essence of North East Asian tradition, could be the forerunner of this new civilization predicted by Reischauer.'

Symposium 8

Biology of Schizophrenia

Detection of schizophrenia patients with severe symptoms using exploratory eye movement test - Simplification of heterogeneity of schizophrenia

Takuya Kojima

Department of Psychiatry, Ohmiya-Kosei Hospital, Japan

Schizophrenia patients diagnosed clinically using DSM-IV or ICD-10 are supposed to be heterogeneous in their causes. A new biological marker is desired which is capable to be specific to schizophrenia and to diagnose a limited group of schizophrenia objectively. The exploratory eye movement test involves the monitoring of eye movements while subjects freely view geometric figures. In the first study1), we performed the discriminant analysis between schizophrenia patients and non-schizophrenia subjects on a large sample using the EEM test data. EEM performances were recorded in 251 schizophrenia patients and 389 non-schizophrenia subjects. We measured four parameters: number of eye fixations (NEF), total eye scanning length (TESL), mean eye scanning length (MESL) and responsive search score (RSS). The stepwise regression analysis selected the TESL and the RSS as the valid parameters for discriminating between schizophrenia patients and non-schizophrenia subjects. In the discriminant analysis using RSS and TESL as prediction parameters, 184 of the 251 clinically diagnosed schizophrenia patients were discriminated as having schizophrenia (sensitivity 73.3%); and 308 of the 389 clinically diagnosed non-schizophrenia subjects were discriminated as non-schizophrenic (specificity 79.2%). The second study2) was to investigate the characteristics of schizophrenia patients who were identified as having schizophrenia on EEM discriminant analysis (SPDSE) (73.3%) or schizophrenia patients who were identified not having schizophrenia on EEM discriminant analysis (SPDNSE) (26.7%). As for the symptomatic features, a factor analysis of the Brief Psychiatric Rating Scale (BPRS) rating from schizophrenia subjects was carried out. Five factors were found for schizophrenia symptoms: excitement/hostility; negative symptoms; depression/anxiety; positive symptoms; and disorganization. SPDSE had significantly higher factor scores for excitement/hostility, negative symptoms and disorganization than SPDSE. Furthermore, the BPRS total score

for the SPDSE was significantly higher than that for the SPDNSE. SPDSE may be a disease subtype of schizophrenia with severe symptoms which may be the core type of schizophrenia.


1. Masahiro Suzuki, Sakae Takahashi, Eisuke Matsu-shima et al: European Archives of Psychiatry and Clinical Neuroscience 259; 186-194, 2009.

2. Masahiro Suzuki, Sakae Takahashi, Eisuke Matsu-shima et al: Psychiatry and Clinical Neurosciences 66:187-194, 2012.

Metabolic syndrome in schizophrenic patients in Thailand and other Asian countries

Pichet Udomratn

Department of Psychiatry, Prince of Songkla University, Thailand

The prevalence of metabolic syndrome (MetS) among psychiatric patients has been reported to be high in the West especially in schizophrenic patients receiving antipsychotic medications with a range of 19.4% to 54.0%. Prospective data in Asia show that MetS not only increases the risk of coronary artery disease but also cerebrovascular disease. However, few papers on MetS in schizophrenic patients have been reported from Thailand and other Asian countries. Therefore, the objectives of this presentation were to review the rate of MetS in schizophrenic patients receiving antipsychotics and to find the associated factors of MetS in Asian patients. It was found that the prevalence rate of MetS in Thai patients varied from 15.4% to 23.9% by the IDF criteria and it was higher, between 20.5% to 30.5%, by the updated ATP III criteria. In Taiwan, the prevalence rate of MetS was 28.4% and 34.9% by the IDF and the updated ATP III criteria, respectively. While in Korea, the prevalence rate was 31.7% in schizophrenic patients receiving a monotherapy with aripiprazole, olanzapine or risperidone. The prevalence rate of MetS in India was the highest at 43.6% by the IDF criteria and 44.5% by the modified ATP III criteria. Studies from Thailand and India have found that females were more likely to develop MetS than males. A logistic regression analysis in a Korean study found that age and sex, but not the type of antipsychotic, were significantly related to the prevalence of MetS. In conclusion, about one-fifth to one-third of East Asian or South Asian patients with schizophrenia

who receive antipsychotics have MetS. Perhaps the updated ATP III criteria are more appropriate to identify metabolically abnormal but non-obese individuals in Asian patients. These findings confirm the importance of regular metabolic monitoring as an essential component of antipsychotic treatment in schizophrenic patients in Asia.

Antipsychotic polypharmacy in patients with schizophrenia

Chan-Hyung Kim

Department of Psychiatry, Yonsei University College of Medicine, Korea

Although most treatment guidelines recommend mono-therapy in schizophrenia, the combined use of multiple psychotropic agents is very common in real clinical world, especially in treatment refractory patients. In general, polypharmacy intends to address different aspects of treatment resistance, most importantly in sufficient response of psychotic positive and negative symptoms, but also cognitive disturbances, affective comorbidity, obsessive-compulsive syndromes and side-effects of antipsychotic drugs. Generally, research data on combination therapy in schizophrenia are rare and further randomized controlled trials, naturalistic trials and head-to-head-trials are necessary. Limited evidence supports a combination of antipsychotics and antidepres-sants for negative symptoms and comorbid major depressive episodes. The combination of lithium and mood stabilizers lacks compelling evidence, but might be beneficial for specific subgroups. For treatment-resistant cognitive symptoms, antipsychotic medication should be combined with cognitive enhancers, as no pharmacological add-on strategy has gained convincing evidence so far. Treatment-emergent psychotic symptoms under clo-zapine treatment might be useful from adding a second atypical agent. In this session, I will summarize the results of the randomized controlled trials of combination therapy versus monotherapy in schizophrenia and to discuss possible implications and rationale of these results.

0= S 8-4

5 d Genetic issues of schizophrenia

hc Jung Jin Kim

Department of Psychiatry, The Catholic University of Korea, School of s Medicine, Korea

Schizophrenia is a major psychiatric disorder with heri-tability. Enormous efforts towards understanding patho-physiologic mechanism of schizophrenia have been undertaken. Genetic research has been the major field of research for schizophrenia. However, despite considerable investigation, little is known for certain etiology of schizophrenia. Through association and linkage studies, many kinds of genes and location have been published as plausible findings for schizophrenia. However, few of them are replicated in succeeding studies. With technical improvement in genetics, genome-wide association studies and structural variation studies with high throughput sequencing analysis has been undertaken. Several regions and variations were noticed as true loci. However, the results were not consistent and the statistical power was not sufficient. There are some reasons for that fail and frustration of genetic research of schizophrenia. Schizophrenia is complex traits with polygenicity. It has phenotypic uncertainty. It has no Mendelian forms of heritance. There are unknown genetic blow over development, gene-gene interaction and gene-environmental interaction with epigenetic modification. Some candidate genes are overlapped with other psychiatric diseases. Though there have been disappointing results of genetic study of schizophrenia, it is too hasty to assume that genetic research of schizophrenia has been failed. Recently, a considerable number of new findings have been discovered and replicated. With more technical advances of genetic investigation, more hidden genetic variation could be revealed. With larger sample sizes and multiple meta-analyses, genome-wide association could yield new findings. Novel and precise statistical analysis including clinical variables and other pathophysiologic findings like neuroimaging and immunology of schizophrenia is needed.

Symposium 9

New Perspectives of Psychosurgery S 9-1

Psychosurgical treatment of schizophrenia with malignant OCD: Two case report

Tae Kyung Lee

Department of Psychiatry, Seoul National Hospital, Korea

Today's psychological intervention is performed to alleviate mental disorders such as major depression, bipolar, or obsessive-compulsive disorder (OCD), which have not responded to non-surgical psychiatric therapies. However, the role of psychosurgery for the treatment of schizophrenia is still controversial. The controversy over the efficacy of psychosurgery in schizophrenia comes from the fact that the broad range symptoms of schizophrenia represent that they are associated with diverse area of the brain and psychosurgery, which is disrupting a connection of certain brain circuits, could not control whole symptoms of schizophrenia. On the contrary, the efficacy of psychosurgery on OCD is widely supported. Interestingly, schizophrenia and OCD co-occur with one another at a higher rate than would be expected in the general population. The effect that OCD has on the clinical outcome of schizophrenia appears to have a negative impact on the individual sufferer. Because of the widespread acceptance psychosurgery for some highly selected cases of medically intractable OCD, we believed that psychosurgery might be beneficial for ameliorating symptoms in a patient with schizophrenia and obsessive compulsive symptoms. Here, we applied psychosurgical treatment to schizophrenic patients who had malignant OCD symptoms. After psychosurgical operations, their psychiatric symptoms have been significantly improved with decrease of medication. Through our experience, we suggest that psychosurgery could be considered as part of an entire treatment including appropriate psychiatric rehabilitation.

Surgical management of psychiatric disease: Literature review and National Seoul Hospital - Asian Medical Center experience in Korea

Jung Kyo Lee

Department of Neurosurgery, Asan Medical Center, Korea

Many patients with severe and intractable psychiatric illness fail modern all conventional treatments and remain severely disabled. Therefore, it would be reasonable to consider surgical options. The treatment of psychiatric disorders using stereotactic lesions has existed for the greater part of the past century and has showed a great range in the effectiveness of lesioning as a treatment option. Recently, less invasive therapeutic surgeries such as DBS and radiosurgery were introduced in mainly intractable OCD and depression. The authors have operated 13 cases (12 anterior capsulotomies, 1 cingulotomy) among 12 patients since January 2011. Surgical candidates were schizophrenia with OCD/OCS - 5 patients, Schizophrenia with auditory hallucination and aggressiveness - 3 patients, Bipolar disorder with OCS - 1 patient, OCD - 1 patient, and autism with aggressiveness - 2 patients. One patient who was referred from another hospital was lost in long-term follow. Ten patients among 11 patients (91%) were improved after operation. A failed case was schizophrenia with auditory hallucination and aggressiveness. There were no surgical complications and no cognitive impairment. Conclusion; Surgical option should be considered in intractable psychiatric disease. Selective patient in intractable schizophrenia could be good candidate of surgical option.

Method: Twenty cases with severe chronic schizophrenia underwent bilateral capsulotomies. The target of the lesion was located at anterior limb of internal capsule and determined under high resolution MRI directly. Thermo lesions were made by radiofTequency with 80°C, 60 seconds. Clinical global impression (CGI), positive and negative symptom scale (PANSS), personal and social performance (PSP) were evaluated by psychiatrists pre-operative and post-operative respectively. Results: 100 patients have been followed from 2 to 5 years. With CGI evaluation, 5 of 100 patients had symptom free without any medical therapy, 7 patients had symptom free but still need anti-psychiatric drug therapy, 36 patients experienced significant improvement, 38 patients with improved, 26 patients with mild change or no effect. PANSS positive symptom scores decreased from 26.65 ± 4.85 (mean ± SEM) at preoperative to 7.45 ± 8.59 (postoperative); PANSS negative symptom scores decreased from 21.65 ± 7.19 (preoperative) to 10.7 ± 8.71 (postoperative). BPRS scores decreased from 44.97 ± 9.36 (preoperative) to 14.75 ± 13.21 (postoperative). There was no mortality and severe complications in all of these patients. 2 patients suffered mild memory deficit and 2 cases had immature personality change and these side effects recovered in 6 months. Conclusion: MRI guided Bilateral capsulotomy is very effective therapy for those severe chronic schizophrenia patients. It not only relieves most symptoms of schizophrenia, but also improve the personal and social function of patients. Compare with negative symptoms of schizophrenia, capsulotomy is more effective to improve positive symptoms.

Symposium 10

Rising Issues in Pacific Rim Countries

MRI guided bilateral capsulotomy for chronic and refractory schizophrenia

Bomin Sun

Department of Neurosurgery, Shanghai Jiao Tong University Rui Jin Hospital, China

Objective: Many of schizophrenia patients are refractory to anti-psychiatric drugs and other treatments, there is demand alternative therapy for those patients. We studied long term follow-up results of bilateral capsu-lotomy in patients with chronic, severe, noninvasive treatment resistant schizophrenia.

S 10-1

Cultural competence and diversity standards in the United States

Francis Lu

Department of Psychiatry, University of California, Davis, U.S.A.

This presentation will review the new developments in cultural competence and diversity standards in the United States. Specific standards will include the LCME accreditation standards for medical schools; the Joint Commission standards for hospitals and health care organizations concerning communication, cultural competence, and

patient- and family-centered care; and the Department of Health and Human Services Office of Minority Health Cultural and Linguistic Appropriate Standards for Health and Healthcare Organizations. While these standards have important applications for departments of psychiatry in the United States, they may be of interest to departments of psychiatry of increasingly diverse Pacific Rim countries.

These social changes could influence mentality of people in general and especially of younger generation.

S 10-3

Current mental health situation in Cambodia

S 10-2

New type of depression and role of psychiatrist in Japan

Shimpei Inoue

Department of Psychiatry, Kochi Medical School, Japan

The International Consortium of Psychiatric Epidemiology Surveys showed that lifetime prevalence rates ranged from approximately 3 percent in Japan to 16.9 percent in the United States, with most countries falling somewhere between 8 to 12 percent. However, more and more patients with mood disorders have received treatment; the Ministry of Health and Welfare reported that the number of patients with mood disorders surpassed one million in 2008. Last year, the Government designated mental disorders as one of the five diseases. They were specified for the purpose of promoting national health by offering extensive and continuing services. It is now compulsory for local government to provide comprehensive health services for those with mental disorders. One reason for the increase of patients with mood disorders is said to be new a type of depression. After 1970s, several ideas have been proposed to explain recent changes of clinical expression of depressive disorders. Among them, Tarumi suggested a dysthymic type of depression; as contrasted with melancholic type, it is characterized by mild but chronic nature. Scarce guilty conscience, avoidant social behavior, negative attitude to being loyal employer, and self-confidence vaguely believing to do anything are another features. New type of depression is prevailing, especially in urban areas and it is a challenge to psychiatric treatment. The author would like to speculate background against which new type of depression have emerged. After rapid economic growth during latter half of the twentieth century, Japan has experienced long stagnation as well as fundamental social changes; the abandonment of lifetime employment, the wage system based on one's merits and so on. In other words, people more likely rely on their talent and social skills instead of being dependent on organizations.

Savuon Kim

Department of Psychiatry, Mental Health Association of Cambodia, Cambodia

Cambodia had been three decades of war, genocide, and civil political unrest. From 1975-1979, 1.7 Million of people were killed, all economic and health facilities were destroyed by the Khmer Rouge regime. Consequences led to increased psychological disorders, social mistrust, breaks in psychological development and parenting skills, and loss of human resources in mental health, although high levels of resiliency among population. 1979-1996, mental patients have been brought to see traditional healers who involve a range of professionals, such as, monks, and fortune tellers, and includes a range of treatments: reading of fortunes, speaking to spirits through medium, cupping or coining, herbal remedies, making offerings to spirits, or meditative prayer.. Currently; 41 psychiatrists, 45 psychiatric nurses and nearly 275 general practitioners have undergone 3 month courses in primary care psychiatry. Mental health services delivery has been integrated into the general health care system. There are 6,1% of Referral Hospitals (n = 82) provide mental health services led by psychiatrists. 52.4% of Referral Hospitals (n = 82) and 1.8% of Health Centers (n = 1004) provide Primary Mental Health care led by General Practitioners and Psychiatric nurses while only one referral hospital provides child mental health services led by foreign child psychiatrist. In 2011, 15,545 new cases and 80,000 follow up cases consulted at mental services. Children, women, rural populations, persons with disabilities, and persons with substance abuse are still lacking in mental health care. This conclude to expand services to rural areas, as well as at-risk demographics to address gaps in treatment across Cambodia and increase training and education of community leaders and mental health professionals in those areas to reduce burden of mental diseases through early detection, prevention, treatment and rehabilitation.

S 10-4

Changing diagnostic concepts and treatment strategies for mood disorders in Taiwan: Evidence based study

Tung-Ping Su

Department of Psychiatry, National Yang-Ming University, Veterans General Hospital, Taiwan

Over the years, the term of depression was vague and unclear. People in Taiwan often called as neurasthenia or sought doctor's help due to somatic symptoms. Since early 1980s, prevalence of depression was first identified through an epidemiological survey as 1.1% using DIS tool. Another study used nationally representative sample still revealed lower lifetime prevalence (1.2%) (Liao & Lee, 2011). However, suicide rate was gradually increased from 6.9 to 19.3/100,000 (1994 to 2006), indicating the hidden increasing depression over the past decade. The other evidence also support the rising awareness of depression in Taiwan by increasing the prescription of antidepressants 2.5 fold in 2009, vs. 2000 and the ratio of psychiatric vs. non-psychiatric visits for patients with antidepressants use was doubled from 0.7 in 2000 to 1.5 in 2009. Since 2003, the diagnosis of bipolar disorder has been increased from 0.19% to 0.283% in 2007, according to the database of National Health Insurance (NHI), in which 99% of Taiwanese people were insured. About 10-11% of patients with unipolar depression changed to bipolar disorder diagnosis every three years. It was fascinated to see that the group of refractory depression was found 25% changing rate. This is the first time using a large-scale longitudinal cohort study to document the switching diagnosis phenomenon and suggests that there might exist a spectrum affective disorder, instead of two distinct mood disorder entities (Li and Su, 2012). Using imaging techniques such as PET-FDG and MRI, we found the brain image of treatment refractory depression is very similar to bipolar disorders. So did the neurocog-nitive assessments, further confirming the concept of affective spectrum disorders. Besides novel antidepressants, development of neuromodulation (rTMS, DBS) to regulate the neural circuits also provides new strategies to help diminish the rate of depression and suicide.

Symposium 11

Rework Program; Japanese Innovative Treatment for Mood Disorder

S 11-1

Concept of return-to-work program and its significance

Tsuyoshi Akiyama

Department of Neuropsychiatry, NTT Medical Center Tokyo, Japan

The aim of this presentation is to introduce the concept of the Rework Program (return-to-work program), a type of high-level rehabilitation program developed in Japan. This program was first developed in 1997 at NTT Medical Center Tokyo to help company employee patients to return to high demand work without relapses. In 2005, Yoshio Igarashi modified the program into a full-day day treatment model. In 2008, 26 facilities jointly founded the Depression Rework Research Association. As of 27 July, 2012, more than 140 facilities in Japan provide Rework Program to company employee patients who try to return to work after extensive absence due to mental illness. This program needs to help patients regain work skills, concentration and stamina. More importantly it must address the identity issue. The company employees who develop mental illness under work stress do not refuse high work load when requested. In other words they have 'hard worker' identity. If the worker returns to work with this identity unmodified, relapse may happen sooner or later. Therefore, this program should help the workers to develop a new Rework Identity so that they can exert work capacity, while carefully monitoring their health condition. If these program succeed in helping people with mental illness to return to work without relapses and to contribute to the workplace as equal partner of colleagues, this can lead to de-stigmatization against mental illness at workplace.

S 11-2

Rework program for employees with mood disorders; Methodology and contents

Hideaki Arima

Department of Psychiatry, Shinagawa-Ekimae Mental Clinic, Japan

In Japan, the number of patients who suffer from mood disorder is getting higher these days. The patient survey

which is undertaken in every 3 years reported that there are about 1.1 million patients with mood disorder in 2008 and the number is 2.4 times higher than that in 1996. According to another research, the companies with employees who are absent from their jobs for over a month due to mental health problems is 7.6%. Furthermore, it is reported these are not a few employees with depression who relapse after they return to work. Because of the social situation, the Depression Rework Research Association was founded in 2008 in Japan. This association consists of 127 health organizations as of May 2012, which includes psychiatric hospitals, psychiatric department in general hospitals and psychiatric clinics. The main characteristics of Japanese re-work program are; the target patient is limited within mood disorder, the program is delivered in groups, and gives psycho-social education with the component of rehabilitation. We consider from our experience that re-work program involves a number of advantages for the treatment of depressive patients, such as those positive results from positive effectiveness, the improvement in quality of care perceived by patients, which frequently results in improved therapeutic alliance and pharmacological adherence and helps them feel that they have an active part to play in their treatment. In order to prove that the re-work program reduces the number of relapse and repeated sickness leave, the national research has been undertaken for 3 years. This is a clinical control study that includes a large sample, a prospective design, an adequate control group, randomized assignment of groups and a long-term follow-up of patients. The symposium introduces the return-to-work system for employees with mood disorder in Japan and provides curious discussion about the activities.

S 11-3

Implementation for return-to-work approach at work-site for employees with mood disorders

Yuka Kobayashi

Department of Safety and Health Administration Control Center, Honda Motor Co., Ltd., Japan

In Japan, nearly all companies have a sick-leave system for certain periods of time whenever necessary, so that their employees could concentrate on their required medical treatment. Japanese companies are also requested to get ready for such employees' recovery and re-adaptation. In 2004, the Japanese ministry has established a guideline to support the employees returning to

work. According to study reported in 2007, 100% of the large offices (more than 5,000 employees) and 69% of the medium-sized offices (1,000-4,999 employees) had set a program, however, the smaller offices (less than 1,000 employees) tended to have difficulties in starting the program, which has made the total ratio (in establishing some kind of program) decrease to 6%. The guideline recommends the following procedure to the company: 1) making sure that the employee is regularly contacted by his/her office during the sick leave; 2) letting the employee given appropriate supports by a medical institute or a specialist before his/her return; 3) making sure that the employee gets well-followed-up after his/her return. Following these recommendations will enable office workers to recover faster, and therefore to return to work at the most appropriate time, which may lead to the prevention of the relapse of his/her illness. The procedure ultimately contributes to the retention of labor force. Actually, the occupational health professionals support workers of Honda Motor Company by checking their immediate working environments and by making environmental adjustment appropriate for workers with problems if necessary. Also, they collaborate with the well-established return-to-work program conducted in the hospital. In this symposium, I will firstly introduce you a return-to-work program that I get involved in Honda, and secondly, the differences of programs in the company and the hospital would be made clear. Finally, I will present the way how the company and the hospital can collaborate to facilitate the workers' re-adjustment.

S 11-4

Mental health activities based on practice guideline in the Netherlands

Jiro Moriguchi

Department of Occupational Health Promotion, Kyoto Industrial Health Association, Japan

In the Netherlands, workers have to visit an occupational physician (OP) for return-to-work purposes when they are on sick-leave. Therefore, OPs play a central role in the treatment of workers with common mental health problems. Dutch practice guideline for OPs dealing with mental health disorder at work had been completed by the Netherlands Society of Occupational Medicine in 2000, and was updated in 2007. The guideline concentrates on the diagnosis of common mental disorders (adjustment disorders, anxiety disorders and depression) and effective strategies for client guidance and therapy. The effects of an intervention based on the guideline

among Dutch employees who were absent due to mental health disorders were evaluated in several studies. Klink et al. have reported that mean sickness absence duration among the employees who were treated in accordance with the practice guideline was significantly shorter than that of the employees not treated in accordance with the guideline (49 days vs. 70 days). It has been reported that better guideline adherence showed a statistically significant association with a shorter time to return to work as well. Thanks to the strenuous effort by Dutch researchers, many articles on effect of the guideline have been published. Some of these results are shown in a website (Psychisch & Werk; The website includes a lot of useful information based on scientific evidence and several downloadable tools. The number of visits reaches 4000 per month (in 2011). This website might make OPs and other experts in occupational health more professionalized and influential. However, skills of OPs in using guidelines efficiently and in finding evidences of specific problems are not sufficient yet. Moreover, some of OPs are not affirmative enough to apply such guidelines. Therefore, further efforts would be necessary for increasing the acceptance of the guidelines and training professionals in their use.

incidence of mood disorders including major depression. However, comprehensive intervention including Return To Work (RTW) program is yet to be disseminated. In Korea, more and more companies and public organizations have been adopting various types of employee assistance programs (EAPs) to help workers with distress. Some conglomerates are hiring dozens of board-certified psychiatrists and hundreds of psychologists to their large-sized factories/urban locations to help employees with mental health problems. The presenter myself has been working with some large-sized banks and other companies to diagnose and treat workers with mood disorders and to help managers in the human resources (HR) department to take care of the administrative things, such as medical leave and job relocation, for the workers. For now, individual effort to reintegrate depressed workers to their workplace is much more popular than group-based RTW program in Korea. In terms of group-based RTW, Ministry of Labor and Welfare has been providing group psychological rehabilitation programs to help patients with occupational 'physical' injury (not for depression) to reduce stress and anxiety and restore mental strength.

S 11-5

Current status of occupational mental health in Korean corporations and their efforts to develop return-to-work activities

Jong Min Woo

Department of Psychiatry, Inje University Seoul Paik Hospital, Korea

Korean companies and organizations have been suffering from ever increasing number of committing suicide and

Symposium 12

Addictive Brain in Biological Perspective S 12-1

Intravenous neural stem cell transplantation: A new strategy for facilitation of neural network recovery in fetal alcohol spectrum disorder model rats

Toshikazu Saito

Department of Psychiatry, Sapporo Medical University, School of Medicine, Japan

Recent clinical neuroimaging studies have revealed a possible relationship between morphological brain changes and the manifestation of psychiatric disorders such as depression, schizophrenia, and alcohol-induced brain damage. Although its biological mechanism is still unclear, the emerging evidence suggests that the alteration of neurogenesis is the key factor for those brain changes in psychiatric disorders. In our previous work, we analyzed the mechanism of neural network disruption by ethanol using cultured cells, and found a specific suppression by ethanol on neural stem cell (NSC) differentiation. While, we also demonstrated that antidepressants, mood stabilizers and atypical antipsychotics stimulate NSC differentiation which was inhibited by ethanol. In the present work, we have demonstrated the usefulness of intravenous transplantation of NSCs to fetal alcohol spectrum disorder (FASD) model rat and proposed the possibility of regenerative therapy for patients with neu-robehavioral deficits of FASD. We have shown the potential migration of transplanted NSCs into the brain by visualizing a fluorescent cell marker and radioisotope, and suggested the recovery of behavioral abnormalities observed in FASD model rats, such as anxiety-like behaviors, memory/cognitive function, and social interaction. We further assessed the characteristics of transplanted cells in the brain and found its GABAergic cell differentiation in the amygdale and anterior cingulated cortex in the model rat. In these regions, the numbers of parvalbumin positive cells were increased by NCS transplantation those were decreased in FASD model rat. Moreover, in the amygdala and anterior cingulate cortex, intravenous NSC transplantation appeared to regenerate expression of post-synaptic density protein 95 (PSD95) in FASD rats. These results indicate that intravenous NSC transplantation might have potential to become a therapeutic intervention for FASD patients.

S 12-2

Genetic analysis of alcohol use disorders in a Tibet population

Tao Li

Department of Psychiatry, Mental Health Center, West China Hospital, Sichuan University, China

Associations between alcohol use disorders and polymorphisms of genes influencing ethanol metabolism have been widely reported, but gene-gene and gene-sex interaction studies have rarely been examined. Using a set of samples collected during an epidemiological study of alcohol use disorders in a Tibetan population in China, we performed a case-control study to investigate the relationship between the functional polymorphisms of genes influencing ethanol metabolism and alcohol use disorders in this population. The sample included 383 individuals with an AUDIT score >10 and 350 control subjects with the AUDIT score <5. All participants were genotyped for polymorphisms of ALDH2*1/*2, ADH2*1/*2 and CYP2E1*c1/c2*. Data were analyzed employing an integrated strategy using MDR, SPSS and UNPHASED software. The MDR analysis showed that the four-factor model including ADH1B*1/*2, ALDH2*1/*2 and CYP2E1*c1/*c2 polymorphisms, and sex was the most accurate model associated with alcohol use disorders with the highest OR 3.299. It also revealed that CYP2E1 *c1/*c2 polymorphism interacted significantly with sex, and the combination of CYP2E1 and sex interact moderately with the combination ofADH1B*1/*2 and ALDH2*1/*2. Independent analysis confirmed that both ADH2*2 and ALHD2*2 allele were significantly negatively associated with alcohol use disorders in both males and females (OR: 0.441 for ADH2*2 and 0.137 for ALHD2*2). CYP2E1*c2 was significantly positively associated with alcohol use disorders only in males homozygotic for ALDH2*1 and AHD2*1 (OR: 2.585). Cumulative association analysis showed the number of protective alleles and genotypes were negatively associated with alcohol use disorders. In conclusion, ALDH2*2 and ADH1B*2 alleles were not only independently negatively associated with alcohol use disorders but also demonstrated cumulative dosage effects in this population. However the positive association between CYP2E1*c2 allele and alcohol use disorders might only exist in males homozygotic for ALDH2*1 and AHD2*1.

S 12-3

Cognitive functioning and aggressiveness related to Internet addiction in Korea

Dai Jin Kim

Department of Psychiatry, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Korea

The relationship between Internet addiction and psychiatric symptoms has been suggested by several studies. There are the relatively large number of evidence for relationship between Internet addiction and substance use disorders, ADHD, depression, social anxiety and aggression. However, few studies have examined the differences in cognitive functioning and aggression between persons addicted to the Internet and persons not addicted. Our group screened 642 middle and high school students for Internet addiction and compared 59 Internet-addicted students with 43 non-addicted students using an IQ test. The Internet-addicted group had comprehension subitem scores that were significantly lower than those of the non-addicted group. As the comprehension item reflects ethical judgment and reality testing, there may be a relationship between Internet addiction and weak social intelligence. Earlier onset of Internet addiction and longer addiction duration were associated with lower participant performance in areas related to attention. As this study is a cross-sectional study, it is not clear whether the persons who display weak cognitive functioning are susceptible to Internet addiction or if Internet addiction causes cognitive problems. However, as brain development remains active during adolescence, the possibility that Internet addiction adversely affects the cognitive functioning of adolescents cannot be ruled out. Several studies have reported that the Internet addiction was strongly associated with aggression. However these previous studies could not confirm the above hypothesis. Therefore we have analyzed several papers about the relationship between Internet addiction and aggression. And we have a plan of clinical study to support the hypothesis about the relationship between Internet addiction and aggression. And I will present psychosocial intervention including CBT and MET with internet addicted patients and treatment network in Korea.

S 12-4

Temperament and 2D:4D digit ratio in internet over-using adolescents

Sang-Kyu Lee

Department of Psychiatry, Hallym University Chuncheon Medical Center, Korea

Although it is well known that Internet over-using behavior is a serious psychological or social issue, Internet addiction is still a much debated topic to include Internet Addiction Disorder a formal diagnosis in DSM-V One of that reasons has not been enough of biological evidence of internet over-using behavior as real diseases entity. The ratio of the digit lengths of the 2nd and 4th finger (2D:4D) has been suggested that reliable peripheral biomarker for clinical diagnosis of alcohol dependence, ADHD, and developmental disorder. Considerable evidence reports that prenatal testosterone affects behavioral traits, cerebral lateralization, temperament character, addictive disorder and digit length patterns. So, we hypothesized that low 2D:4D ratio is prevalent in male internet over-using adolescents and it would be one bio-marker of internet addiction. To look at it clear, we had surveyed for 700 middle school students in Korea. This lecture will be presented about the result of our study for correlation the digit length ratios, character and temperament patterns with Internet over-using behavior in Korean adolescents.

Symposium 13

Diversity of Depressive Symptoms among Asians

S 13-1

Differences in psychiatric symptoms among Asian patients with depression: A multi-country cross-sectional study

Manit Srisurapanont

Department of Psychiatry, Chiang Mai University, Thailand

Controversy exists as to whether different Asian populations differ in terms of symptomatic and clinical features of depression. To address this issue, we compared five groups of patients with major depressive disorder (MDD) based on country of residence: China, Korea, Malaysia/ Singapore, Taiwan, and Thailand. Consecutive consenting

adults (ages 18-65) who met DSM-IV criteria for non-psychotic MDD - based on the Mini International Neuro-psychiatric Interview (MINI) - and were free of psychotropic medication were evaluated in a cross-sectional study. Depressive symptoms were evaluated using the 10-item Montgomery-Asberg Depression Rating Scale (MADRS) and the 13-item depression subscale of the Symptoms Checklist 90-Revised (SCL-90-R). In addition, the 10-item SCL-90-R Anxiety Subscale and the 9-item Fatigue Severity Scale (FSS) were completed. Analyses of covariance were conducted adjusting for con-founders: age, completion of secondary education, marital status, work status, religion, index episode duration, and depressive severity. Six MADRS symptoms differentiated these five groups, the most prominent being 'lassitude' and 'inner tension'. Twelve SCL-90-R depression items also differentiated the groups as did 9 SCL-90-R Anxiety Subscale items and 8 FSS items. However, none of those statistically significant differences were clinically meaningful in that none of the effect sizes for any of these items exceeded 0.15. MDD is more similar than different among outpatients in these diverse Asian countries. The between-country differences, while present and not due to chance, are small enough to enable the use of common clinician and self-report rating scales in studies involving Asians with MDD from various ethnic backgrounds.

MDD were eligible for analysis. 125 (22.9%) were early-onset (age at first onset less than 25 years old), and 421 (77.0%) were late-onset (age at first onset were 25 year old or more). The disease severity had no significant different between two groups. But patients of earlier onset had higher score in the items concentration difficulties and suicidal thoughts, while the patients of later onset had higher score in item of reduced sleep. Some items of SCL-90R, FSS, and SF-36 also had some different between these two groups. Even though after concerning the demographic data, the difference of MADRS items, FSS and SF-36 were not so significant between these two groups. While the difference for Social function (SDS score) was still different significantly. Our results show that there may exist clinically meaningful differences between child and adult onset MDD. The further study is needed to clarify the environmental and neurobiological factors contributing to the difference.

S 13-3

Stigma, beliefs and help seeking in Asians with depression

Hong Choon Chua

Department of Psychiatry, Institute of Mental Health, Singapore

S 13-2

The clinical features of early-onset versus late-onset depression in Asia: Result of a large prospective, cross-sectional study

Tianmei Si

Department of Psychiatry, Peking University, China

Major depression (MDD) is a quite debilitating disease. The existence of MDD in children and adolescents was controversial before the late 1970s. Research over the past 2 decades has clearly demonstrated that children and adolescence are capable of experiencing episodes of MDD. An early age of onset of MDD has been associated with increased familial burden and a high risk of recurrence into adulthood, impairment of psychosocial functioning, and suicide. Over the past few years, a group of psychiatrists in Asia countries have collaborated, mainly aimed to find the clinical features of depression in Asians. One of aim in this study is to use The Study on Aspects of Asian Depression (SAAD) database to identify specific clinical features of early-onset versus late-onset depression in Asia. A total of 546 patients with

The Modified Explanatory Model Interview Catalogue (mEMIC) was used to evaluate individuals with symptoms of depression from several Asian ethnic backgrounds. This lecture describes how Asians with depression experience and respond to their condition -through the domains of perceived stigma, causal attribution and subsequent help seeking behaviour. The findings provide an insight on how Asians perceive and understand depression, and may be used to improve public education on depression and to encourage more individuals to seek appropriate treatment.

S 13-4

Suicidality and depressive disorder among Asians

Jin Pyo Hong

Department of Psychiatry, Asan Medical Center, Korea

Suicide in Asian countries accounts for approximately sixty percent of all suicide in the world. Population based community study showed that prevalence of depressive

disorder in Asian countries seemed to be lower than those of western countries. Psychological autopsy study in Asia showed that 68-97% of suicide completers had diagnosable psychiatric disorders, however less than 40% of suicide received the diagnosis of depressive disorder. There is a suggestion that the association between depression and suicide is less pronounced in Asia. Suicidal ideation and suicide attempts among depressive patients in Asian countries will be reviewed. The characteristics of patients with depressive disorder who showed suicid-ality will be presented.

by deviant human phenomena only for the purpose of producing medical relief to alleviate human suffering. I will baptize it by a term unused in contemporary literature in order to sever any connection/relations to what has already been philosophized for the mind/psyche and willfully exclude any preexisting assumptions about it. Let me highlight the importance of this issue and cover in detail in my talk.

S 14-2

Symposium 14

Asia-Pacific Culture Related Syndromes

The relevancy of Culture-Bound Syndrome Diagnosis in an Asian immigrants/ refugees focused mental health program in America

S 14-1

Utilitarian concept of mental health

Thirunavukarasu Manickam

Department of Psychiatry, World Psychiatric Association, Indian Psychiatric Society, India

Even though we bask in the glory of unprecedented and unparalleled growth in our understanding and knowledge of the world around us, let us not forget that there are some important questions remain unanswered embarrassingly. Most conspicuous is one like Mind and Mental Health. Psychiatrists have brazenly avoided or ignored this question due to lack of enthusiasm. Our willful indifference and tactical retreat from this tough question is not helping us one bit. We are telling that any definition of Mind or Mental health is not even a possibility, let alone plausibility. In teaching psychiatry for all the available definition and description are minimally beneficial in education. It allows personal bias to creep in leading to exploitation of the field by ideologists operating through non medical objectives. Is it possible to identify sanity form insanity. Psychiatrists conclude by continually asking themselves if the patients have schizophrenia or depression, thereby arriving at a diagnosis. The line of thinking is rooted in identifying mental illness. Absence of mental illness does not mean presence of mental health. The line of thinking must be rooted in identifying mental health and not mental illness. Hence, it is critically important that clinical evaluation, training and education in Psychiatry should start with mental health, moving to mental illness and not the other way around. I am trying to conceptualize the part of the human self that is the subject of interest in scientific study triggered

Paul Leung

Department of Psychiatry, Oregon Health & Science University, U.S.A.

The author has been working in community mental health programs serving the Asian immigrants and refugees in Portland, Oregon for the past 30 plus years. In preparing for this presentation he has reviewed the history of treatment for the Asian patients with long-term colleagues in the programs who, together, representing more than 100 years of clinical experiences. Of the commonly known culture-bound syndromes specifically associated with Asian populations, several stood out as had been presented among Asian patients they had treated. This includes Shenjing Shuairuo (neurasthenia) & Shen Kui (weak kidney) among Chinese. There were also several possible cases of Hmong Sudden Death Syndrome did come to the attention of clinicians in the early and mid-80's but none really been proved. The author also touch on the Eating Disorder which is mostly thought of existing within a Western cultural context but now shoeing up more and more among young Asian females born or raised in America.

S 14-3

Culture bound syndrome; A Malaysian experience

Hussain Habil

Department of Psychiatry, Director UMCAS, Malaysia

Malaysia is multiethnic, multi religious and multiculture nation. The Malays were the majority and followed by Chinese and Indian. This could explain why we saw

° _ many different type of culture bound syndrome. Among t < them were latah, Amok, Kuru and translike states. What 6<d is particular about these conditions, it was rarely cross ( _ culture. Even though all these races were staying side by i c side but they rarely share the same culture bound sync drome. For example, Latah and Amok were mainly s reported among the Malays while translike state and kuru were more prevalent among the Chinese. Of late there was 'destabilization' of culture bound syndrome in Malaysia. Less cases were reported and in fact some was disappearing. This could be due to increase urbanization process and it could be due to other form of social control. For example, the feeling of shame and less attention to those who perform could lead to changes of perception to the condition. In the case of Amok the intolerance toward the behavior and making the act as illegal has tremendously brought down the case to negligible.

S 14-4

Hwa-byung and Korean culture

Sung Kil Min

Department of Psychiatry, Seoul Metropolitan Eunpyeong Hospital, Korea

A culture-related syndrome can be considered as a gene (key, which is better) for understanding corresponding culture. In Korea, hwa-byung (HB), meaning anger (fire) disease, is a meaningful cultural heritage for integrative understanding traditional and current culture of Korea. Etiological affect related to HB, which is known to be anger, feeling of unfairness, and haan (Korean traditional culture-related pathos of embitterment), has been related not only to personal suffering including 'reactive' depression, somatization symptoms, suicide, or persecutory feeling in Koreans but to social phenomena including rapid economic growth, democratization process and violence of Korean society. HB is known to develop from suppression anger not to jeopardize social harmony. Suppression of affects has been a virtue in traditional culture of familial collectivism, ancient philosophy of han (oneness), or Confucianism in Korea. HB, a psychiatric syndrome, and haan, a normal sentiment, are basically common in which they are suppressed and 'accumulated' anger reactive to victimization or loss-separation. Traditional ways to treat HB or to dissolve haan have been traditional Asian medicine and shamanism, and are suggesting us new methods to treat anger syndrome. Anger-related syndrome may be found in other cultures. Unfortunately DSM-V does not include anger disorder.

The relationship between sad mood and depression or between pleasure and mania can be applied to anger and anger disorder. Having anger disorder in classification of mental disorders can lead to early detection and early treatment of anger disorder, and may prevent other mental disorders and anger-related physical disorders such as cardiovascular diseases as well.

Symposium 15

Taopsychotherapy and Global Psychotherapy

S 15-1

Psychotherapy East and West: Paradigms and parallels

Allan Tasman

Department of Psychiatry, University of Louisville School of Medicine, U.S.A.

Both Eastern and Western cultures have long and rich histories of scholarship which address the basic nature of man and of mental processes and functions. This body of thought has been accompanied by attempts to understand psychological and interpersonal approaches to the alleviation of emotional suffering. To a great extent, the nature of the approaches reflects the cultural milieu in which they were developed. Western societies have historically, and still at present, emphasize the role of the autonomously functioning individual. The focus of the psychoanalytic approaches developed by Freud and others at the start of the 20th century use as a framework for understanding mental processes the struggles of the individual in reconciling biological urges with social constraints and personal moral values. To some degree, all modern Western psychotherapeutic methods, including cognitive, behavioral, and interpersonal therapies, were developed within this framework. Eastern cultures, with a greater emphasis on the individual as a member of a family unit and a larger social unit, have developed different frameworks for understanding and intervention. Over the last 30 years, however, with a growth in understanding of Eastern philosophies and cultures in the West, new perspectives have begun to emerge. This presentation reviews the historical antecedents to presently used psychotherapeutic approaches, and discusses how future gains in both our understanding and in our approaches to treatment will benefit from increased interaction of Eastern and Western perspectives.

S 15-2

Phenomenological focus on affect: Taopsychotherapy and intensive short-term dynamic psychotherapy

Erik Craig

Department of Psychotherapy, Private Practice, U.S.A.

All forms of depth psychotherapy purport to emphasize the emotional basis of patients' difficulties in living. In practice, however, concepts, theories, and anamnesis often override, cover up, and even derail attention to the crucial role of intense emotion in patients' lives. The purpose of this presentation is to discuss two approaches to psychotherapy that try to avoid these pitfalls by maintaining an intensive, disciplined, phenomenological focus on impulse or feeling. The presentation will show how these two approaches, Taopsychotherapy from the East and Intensive Short-Term Dynamic Psychotherapy (ISTDP) from the West, come at the problem in almost completely opposite ways and yet arrive at the same place, namely the immediate experience of what is called in Taopsychotherapy nuclear feelings and in ISTDP the core impulse/feeling. ISTDP aims at a phenomenological assault, through challenging blocking defenses against core impulses and feelings, monitoring the resulting anxiety, and then inviting the core impulses and feeling into the open where they can be expressed and understood. On the other hand, Taopsychotherapy seeks to 'penetrate' the defenses and phenomenologically expose or point to the impulse or feeling directly. These and other similarities and differences differences will be discussed and illustrated as a way of unfolding more effective ways of getting to the core dynamic of each patient's suffering and life problems in order to relieve symptoms and, eventually, bring about lasting character change.

S 15-3

Taopsychotherapy at the eyes of a

Chinese psychiatrist

Donggen Li

Department of Psychiatry, YanBian University Hospital, China

1. Fusion of East and West Culture. Theory and technique of Taopsychotherapy is not differentiation, analysis, objective conceptualization or theorization like in the West. It had found real facts of psychotherapy through subject-object congruent Tao thinking, and integrated

it with direction of Western psychotherapy development. Dr. RHEE Dongshick had mastered East and West culture, and Tao and Western Psychotherapy. He had integrated the essence of Western Psychotherapy development and 2500-5000 years old Chinese classic, Tao thinking. This is the acme of modern psychotherapy development, and is the first fusion of East and West culture.

2. Problem of Introduction into China. 'Tao' was not succeeded to and developed inside of China. Ten years of the Cultural Revolution especially had damaged Tao, and it's influence persists through generations. For a while after reformation and opening of China, influence of heresy such as Qigong spoiled millions to ten-millions of people. But since after establishment of China in 1949, there had been inductions such as : publication of basic theories of Freud; filial piety is taught at National high officials training Institute; the 3rd Chinese Psychoanalytic Congress was held in Shanghai this September - it's theme was Clinical Application of Current Psychoanalysis. Books read in China for clinical purpose are Sandler's 'The Patient and the Psychoanalyst' and Dr. Zhong YouBin's 'Chinese Psychoanalysis', and Dr. Lee Moo-Suk's 'Invitation to Psychoanalysis' which I had translated in Chinese. From now on Dr. RHEE's 'Introduction to Taopsychotherapy' would be published in China. And with permission of Dr. RHEE and support of members of the Korean Academy of Psychotherapists, we would like to build a Psychotherapy Research Center in China to spread Taopsychotherapy.

S 15-4

Global development of psychotherapy - An Asian perspective

Suk-Hun Kang

Department of Dr. Kang's Psychotherapy Center, Korea Institute of Psychotherapy, Korea

In this paper, the authors present an Asian perspective of the world-historical development of psychotherapy with an emphasis, first, on historical encounters between the Eastern Tao and Western psychotherapy and, second, on the Asian assimilation of Western psychotherapy, particularly in India, China Japan, and Korea. Finally, the authors will summarize the promises of Prof. Rhee Dongshick's Taopsychotherapy for the future development of global psychotherapy. The core aspects of Taopsychotherapy are 'Nuclear Feelings, purification of mind and compassion (empathy).'

Prof. Rhee does not use theory or technique but only points to the patient's mind, to nuclear feelings that, as he puts it underlie 'something stuck in the Chest.' Eliminating Nuclear Feelings in both the therapist and patient is sine qua non of Taopsychotherapy practice. Rhee claims that Taopsychotherapy can be applied both in East and West, all over the world as the essence of Western psychoanalysis and psychotherapy and the essence of Eastern Tao are precisely the same. Moreover, Rhee maintains that Taopsychotherapy will be the remedy for the theory- and technique-addicted Western psychotherapy.

Symposium 16

Sleep and Chronobiology

S 16-1

Residual symptoms in depression -Implications of sleep and circadian influences

Yun Kwok Wing

Department of Psychiatry, Chinese University of Hong Kong, Hong Kong

Major depressive disorder (MDD) is a debilitating illness that is often associated with significant impairment on psychosocial functioning, increased morbidity and mortality. Although the ultimate treatment goal is to have a sustained resolution of symptoms, a substantial portion of depressed patients continue to experience residual symptoms despite optimized antidepressant trials.1 Depending on study populations, measurements and duration of treatment, the prevalence rate of residual symptoms after antidepressant treatment varied from 15% to 90%. Residual depressive symptoms have been linked to significant psychosocial disability, increased health service utilization and a clinically prognostic significance in predicting relapse or recurrence. Among all symptoms, sleep disturbances represent one of the most common and distressing residual symptoms in depressed patients. In particular, residual insomnia was found to be present in 50% of depressed patients in psychiatric out-patients.2 It is associated with a worst clinical outcome, including higher rates of non-remission, increased risk of relapses and suicidality. Nightmare, another distressing nocturnal symptom, has also been found to be associated with poorer clinical outcome and increased suicidal risk.3 These sleep disturbances were found to be associated with impaired quality of life and suicidal ideation in

remitted MDD.4 On the other hand, increasing data suggested the importance of circadian rhythm disturbances in both the etiologies and management of MDD. Eve-ningness, a chronotype having a predisposition of initiating their activities later in the day, is found to have stronger association with depression, as compared to morningness. Our study among patients with MDD also found that eveningness is more prevalent in MDD, and is associated with more severe depressive symptoms and suicidality, even after controlling for co-morbid sleep disturbances.


1. Trivedi MH, Rush AJ, Wisniewski SR, Nierenberg AA, Warden D, Ritz L, et al. Evaluation of outcomes with citalopram for depression using measurement-based care in STAR*D: implications for clinical practice. Am J Psychiatry 2006;163:28-40.

2. Li SX, Lam SP, Yu MWM, Zhang J, Wing YK. Nocturnal sleep disturbances as a predictor of suicide attempts among psychiatric outpatients: a clinical, epidemiologic, prospective study. J Clin Psychiatry 2010;7:1440-1446.

3. Li SX, Lam SP, Chan JWY, Yu MWM, Zhang J, Wing YK. Clinical and psychosocial correlates of residual sleep disturbances in patients remitted from major depressive disorder - a 4-year naturalistic follow-up study. Sleep (in press).

4. Chan JWY, Lam SP, Li SX, Yu MWM, Wing YK. Sleep disturbances and chronotypes in major depressive disorder (submitted).

S 16-2

Genetic studies on seasonality in mood disorders

Heon-Jeong Lee

Department of Psychiatry, Korea University Anam Hospital, Korea

A circadian rhythm is a biological process that displays an endogenous and entrainable oscillation of about 24 hours. Seasonality (seasonal variation) can be regarded as the result of accumulated changes of circadian rhythm phase. There are many health problems associated with disturbances of circadian rhythm, such as seasonal affective disorder (SAD), delayed sleep phase syndrome (DSPS), and bipolar disorder (BP). BD is a category of mood disorders defined by the repeated depressed and manic/hypomanic episodes. Therefore, focusing on prominent seasonality can be a promising approach for

finding the circadian pathophysiology of BD. The author will present circadian dysregulation hypotheses on BP and supporting evidences by his own studies including phenomenology and genome-wide association study (GWAS).

S 16-3

Circadian rhythm sleep disorders in adolescents and chronotherapy

Yu-Shu Huang

Department of Psychiatry, Chang Gung Memorial Hospital and University, Taiwan

Approximately one fourth of all school-aged children and adolescents have sleep problems. Such as difficulty falling asleep, delay sleep phase (DSPD), parasomnia, sleep enuresis, sleep-disordered breathing (SDB) or periodic limb movement disorder (PLMD). DSPD is the most common Circadian Rhythm Sleep Disorder in adolescents and young adults. DSPD finally shall conflict the individual's normal school, school performance, learning problems, social problems, and lifestyle demands. Actually, it is often a chronic disorder and difficult to treat. Therefore, we will present the Chrono-therapy and light therapy for Circadian Rhythm Sleep Disorders in Adolescents.

S 16-4

Characteristics of Narcolepy in Korean

Hong-Beom Shin

Department of Psychiatry, Komoki sleep clinic, Korea

Narcolepsy is a disabling major sleep disorder which cause excessive daytime sleepiness in the patient. However narcolepsy is rare disease, we can encounter narcolepsy in psychiatry outpatient clinic. Clinical features of narcolepsy are different among ethnic groups. There are few clinical reports regarding clinical feature of Korean narcolepsy. So, sleep study results, major symptoms of narcolepsy, response to pharmacological treatment and compliance of treatment of the sleep study confirmed Korean narcolepsy are presented. These results are helpful in the understanding of narcolepsy patient in Korea and will be used in subsequent study.

Symposium 17

Genetics of Schizophrenia

S 17-1

Discordant fingerprint patterns among twins concordant and discordant for schizophrenia

Yuji Okazaki

Department of Psychiatry, Tokyo Metropolitan Matsuzawa Hospital, Japan

Fingerprints are considered as a possible marker of the brain development as the fingerprint is formed during 9-16 gestational weeks when significant growth and development of the brain, especially cerebral cortex, are also taking place. We reanalyzed fingerprints data of monozygotic (MZ) twins consisting of 31 pairs concordant and 18 pairs discordant for schizophrenia from Eiji Inouye's twin sample (1970), and 53 normal MZ twin pairs. Statistically significant difference was observed between the three groups, in lateral difference of fingerprint patterns (fluctuating asymmetry) that is a measure of poor developmental buffering capacity in the morphogenesis of ectodermal epithelium, showing larger difference in MZ twins concordant for schizophrenia than those in the other groups. These results indicated that MZ twins concordant for schizophrenia were poorly buffered from developmental noises or insults, and they were under more homozygous genotype than the MZ twins discordant for schizophrenia, being under rather heterozygous genotype, because positive correlation of fluctuating asymmetry of the structures in organisms with homozygous genotype has been revealed. These results suggested brain morphological abnormalities seen in some schizophrenics originated at least in early fetal period. Furthermore, these results suggested that heterogeneity of schizophrenia, different roles of genotype and environment for MZ concordant or discordant for schizophrenia.

S 17-2

Myelin-related abnormality of schizophrenia: Genetic, imaging and postmortem study

Norio Ozaki

Department of Psychiatry, Nagoya University Graduate School of Medicine, Japan

Schizophrenia with unclear etiology and pathophysiology is thought to be behavioral outcome of an aberration in neurodevelopmental processes. Recent findings have revealed the functional significance in neuronal circuitry of the white matter. White matter abnormalities are frequently associated with cognitive impairments including deficit of sustained attention, which is an important component of schizophrenia symptomatology. Genetic, brain imaging and postmortem brain studies have also implicated white matter abnormalities in schizophrenia as follows. Genetic studies have shown the association between oligodendrocyte/myelin genes and schizophrenia. Diffusion tensor imaging (DTI) used to investigate the microstructural properties of white matter, has shown low fractional anisotropy (FA) values in schizophrenia. Moreover, the expression levels of several myelin-related genes are decreased in postmortem brains obtained from patients with schizophrenia. Our genetic, imaging and postmortem studies of schizophrenia also have implicated myelin-related abnormality of this condition as follows.

1. Genetic study

Candidate gene analysis in terms of myelin-related genes including CNP, NRG1, OLIG2, PLP1, PTPRZ1, PTPRA, SOX10 and transferrin revealed significant association between PTPRA, SOX10 and schizophrenia.

2. Brain imaging study

FA value measured by DTI of the right cingulum correlated positively the score of continuous performance test (CPT), an index of sustained attention of which schizophrenic patients have deficit. In addition schizophrenic patients with protective allele in SOX 10 gene showed higher FA value and CPT score.

3. Postmortem study

The impact of aging has a greater effect on the white matter in the superior temporal gyrus in schizophrenic subjects than in normal individuals. Moreover, PTPRA mRNA levels are reduced in post mortem dorsolateral prefrontal cortex of subjects with schizophrenia. These findings implicate strategies targeting myelin-related abnormality could provide novel entry points into the understanding of etiopathology of schizophrenia.

S 17-3

Phenotype mining in genetic studies of schizophrenia

Kyung Sue Hong

Department of Psychiatry, Sungkyunkwan University, Samsung Medical Center, Korea

Genomewide association studies have revealed several common variants associated with schizophrenia, but these explain only a small proportion of the phenotypic variance. Rare variants might explain the rest of the heri-tability. However, population-wide effects of rare variants are tiny, and thousands of polymorphisms are therefore implicated to explain the observed genetic variation. If this is the case, 'schizophrenia' cannot be a valid disease entity in genetics perspectives. The next challenge would be exploring new phenotypes. 'Phenom-ics', a large scale phenotyping for the full set of behavioral characteristics, has been proposed and initiated. This work demands multidisciplinary approaches including genomics, proteomics, systems biology, neuroscience, and behavioral science. Clinicians would play a pivotal role here through their phenotype-mining approaches in the clinical space. Phenotype-mining in psychiatry may need crossing syndromal boundaries of DSM or ICD. Reconstruction of symptom domains across wide range of disease entities may be needed. For most psychiatric disorders, major symptoms cover multiple behavioral dimensions, and these dimensions are overlapping among several diagnostic entities, suggesting various combinations of common pathophysiology. A core feature of this common pathophysiology would be more appropriate phenotype than DSM/ICD diagnostic categories. In addition, severe isolated symptoms that may have unique genetic basis have been overlooked in genetic studies pursuing current diagnostic systems. Endophenotype approaches also need to be done across multiple diagnostic categories. Deep re-phenotyping based on genotype data would be helpful. Another promising approach is searching common genetic underpinning for disease-based symptomatology and behavioral responses to psychotropic agents, i.e., incorporation of disease genetics and pharmacogenetics. From this perspective, this presentation aims at reviewing phenotype mining approaches that have been done in schizophrenia and psychiatric genetics, and at suggesting future directions for this field.

S 17-4

The gap between gene and behaviors in schizophrenic genetic studies - A neuroimaging perspective

Yen Kuang Yang

Department of Psychiatry, National Cheng Kung University Hospital, Taiwan

Schizophrenia is a highly heritable disorder, with approximately 70-80% of the variance attributable to genetic influences. As we known, thousands of common single nucleotide polymorphisms (SNPs), so called common and small effect, cumulatively could account about 30% of the underlying genetic risk of schizophrenia. Additionally, copy number variants (CNVs), so call rare but large effect, could explain about 30% of schizophrenic genetic loading. Although environmental factors are rarely sufficient to cause the onset of schizophrenia independently, but it was proposed that impact of environmental stress could act in synergy with the underlying genetic liability to cause schizophrenia. Epigenetic misregulation may be the main mechanism to mediate environmental impact. Currently, the neuroimaging techniques could provide more detailed insight of the intercorrelation among genome, brain and behaviors. The impacts of stress, substance, genome and environmental factors to brain in healthy/schizophrenic participants will be illuminated. Then, discussion on epigenetic, neurodevelopmental, and degenerative features of schizophrenia based on available information from epigenetic, epidemiology, neuroscience, and clinical research will be outlined.

Symposium 18

Comorbidity of Mental and Physical Disorders

S 18-1

Comorbidity of mental and physical disorders: A main challenge for medicine of the 21st century

Norman Sartorius

Department of Psychiatry, Association for the Improvement of Mental Health Programs, Switzerland

The epidemic growth of comorbidity of mental and physical disorders is gradually becoming recognized as a

major challenge to medicine of the 21st Century. There are a number of reasons for this development including the successes in prolonging the life of people with chronic physical illnesses, the changes of the demographic structure of communities, the increased prevalence of mental disorders and the changes of the life style - noticeable in most countries - and representing an important risk factor for many chronic diseases. The presentation will discuss the consequences of comorbidity and reflect on ways in which the challenge of comorbid-ity could be met by the health system, by society and by individuals.

S 18-2

Neural substrates of depression in diabetes

In Kyoon Lyoo

Department of Life and Pharmaceutical Sciences, Ewha Brain Institute, Ewha Womans University, Korea

Depression is common in patients with diabetes mellitus (DM). Underpinnings of the high comorbidity rate of these two conditions are not yet completely understood. Several health behaviors and common risk factors may explain the association between the two conditions to a certain degree. More recently, it has been suggested that there might be neural substrates of the association. In topological aspect, functional and structural deficits of the prefrontal area in patients with DM have been reported. The prefrontal area has been considered to be important for mood regulation. This suggests that, topo-logically, prefrontal cortical area and deficits therein could be one of the links between diabetes and depression. In the aspect of cerebral metabolism, disturbances of glutamate neurotransmission in the prefrontal area of the DM patients, which was greater in patients with poor glycemic control, were associated with depressive symptoms. Considering the glutamate hypothesis of depression and the finding that cerebral glucose catabolism is closely coupled to the glutamine-glutamate cycle altered glutamate system could be one of the biological links between diabetes and depression. Recent study showed that creatine monohydrate augmentation to a selective serotonin reuptake inhibitor for patients with depression boosted the improvement of depressive symptoms significantly faster than that of placebo augmentation treatment, implying the possibility that depression could be a disorder of cerebral metabolism in one aspect where diabetes share the similar pathophysiology of developing depressive mood. Continued research on the biological

underpinnings of depression in diabetes may further unveil the hidden link between the two conditions.

S 18-3

Physical and psychological health in type 2 diabetes

Juliana Chan

Department of Internal Medicine-Endocrine, The Chinese University of Hong Kong, Hong Kong

Diabetes is a classical example of chronic and complex disease due to abnormal energy metabolism with multiple causes and consequences. While insulin is the only hormone that lowers blood glucose, there are many stress hormones which can increase glucose and fatty acid levels to meet energy demands. Physical and mental stress can activate the hypothalamic pituitary adrenal axis, sympathetic nervous system and renin angiotensin aldosterone system which are interlinked to give rise to vascular, metabolic and renal manifestations. There is now growing evidence supporting the bidirectional association of diabetes and depression, although the underlying nature remains to be determined. While both conditions may share common etiologies or have causal effect on one another, their co-occurrence can aggravate one another to worsen both physical and psychological health. In Hong Kong, approximately 15-20% of type 2 diabetic patients attending hospital clinics have negative emotions including anxiety, stress and/or depression, in part due to poor treatment compliance and self care. These negative emotions are associated with suboptimal metabolic control, increased body weight and adverse clinical outcomes. While some of these patients may require formal intervention by psychiatrists or psychologists, our data suggest that an interdisciplinary, integrated and structured care program with features of communication of personalized risk profile, empowerment and decision support improved both physical and psychological health. Interestingly, in patients with negative emotions, peer support further reduced negative emotions, risk factor and hospitalizations. In conclusion, there is emerging evidence showing that cognitive, psychological and behavioral factors contribute to the predisposition, precipitation and perpetuation of diabetes and its co-morbidities. In diabetic subjects with negative emotions and/or suboptimal risk factor control, there is a need to systematically assess and improve their psychological and physical status using a multipronged strategy including education, empowerment and extended support.

S 18-4

Comorbidity of depression and dementia

Ee Heok Kua

Department of Psychological Medicine, National University of Singapore, Singapore

Recent epidemiological studies of elderly people have suggested an association between depression and dementia. Barnes et al (2012) reported that elderly people with late onset depression were more prone to Alzheimer's disease and vascular dementia (1). A study on mild cognitive impairment indicated that depressive symptoms among the elderly were associated with increased risk of dementia on follow-up (2). Two recent publications from the Singapore Longitudinal Ageing Study reported:

i. A greater rate of cognitive decline in men with depressive symptoms, especially in those with hypertension or vascular risk factors, and

ii. Presence of the APOE-e4 allele significantly increased the risk of cognitive decline in those elderly with depressive symptoms (3,4).

A naturalistic study of elderly patients seen at the Memory Clinic of the National University Hospital, Singapore, indicated that symptoms of depression were more common in those with moderate degree of dementia and those with vascular dementia.

Symposium 19

Current Research on Transcultural Psychiatry in Asia-Pacific

S 19-1

Transcultural psychiatry in Japan: Current trend and future possibilities

Fumitaka Noda

Department of Psychiatry, Taisho University, Japan

Modern transcultural psychiatry research in Japan originated in the 1950s and 1960s, amidst increasing study and awareness in Japan of what were seen as particularly 'Japanese' characteristics, such as Doi's psychology of amae. Later, Ogino and others elaborated the concepts of transcultural psychiatry in Japan. These movements culminated in the founding of the Japanese Society of Transcultural Psychiatry in 1993. Recent research themes

include the mental health of Japanese residing overseas, as well as the mental health of various groups of foreign residents and ethnic minorities in Japan. The author notes efforts related to application of the Japanese Morita and Naikan therapies to Western populations, as well as debate over the applicability of Western concepts to a Japanese population. Pathologies that appear to be found more often in Japan, including taijin kyofusho (relationship phobia) and social issues such as hikikomori (severe social withdrawal) are reviewed. The devastating earthquake and tsunami that occurred in eastern Japan on March 11, 2011, focused awareness on disaster mental health issues, and the author describes efforts to address the mental health needs of non-Japanese residents in the wake of the tragedy. Other topics for future study include the clinical characteristics of 'modern' depression and culturally competent approaches to clinical care.

S 19-2

The importance of cross-cultural research in the training of Asia-Pacific psychiatrists

Soma Ganesan

Department of Psychiatry, Vancouver General Hospital, Canada

Cultural, spiritual and ethnic diversity are becoming more prevalent throughout the countries of the Pacific and Asia. Yet this diversity is not always reflected in the clinical assessment, diagnosis and treatment of patients with mental health issues or disorders. The University of British Columbia's medical school and psychiatric residency program instructional model will be presented as an example of integrating research on cross-cultural psychiatry into clinical instruction. Research will be presented on the importance of direct and adjunct teaching about cross-cultural psychiatry and how it can affect medical and psychiatric treatment and assessment of patients. Recommendations from the Canadian Mental Health Commission will be highlighted.

S 19-3

Folk therapy in Taiwan

Te-Jen Lai

Department of Psychiatry, Chung Shan Medical University and Hospital, Taichung, Taiwan

It is commonly said 'Long illness makes the patient a doctor'. When people in Taiwan are sick, in addition to

Chinese medicine or modern western medicine, they will resort to a set of health care treatments against illness. It is a health care concept and folk therapy accumulated through a long-term combat against illnesses. In addition to the 2 systems of Chinese medicine and western medicine, it is a set of non-professional medical knowledge and behaviors developed by folks, closely connected to cultural traditions, and formed into a unique medical system.

In Taiwan, folk therapies are infused with Taoism, Buddhism, Confucianism, Shamanism and the religious beliefs held by aborigines for the diagnosis and treatment of illnesses. Different from general medicine (western medicine) or traditional Chinese medicine, somatic symptoms are not considered in folk therapies. Instead, it is believed that illnesses are caused by spiritual or supernatural phenomena.

These people equipped with medical techniques can be categorized into 2 kinds. One is the religious kind, including shaman (dang-gi), messenger (fu-ji), wang aunt, Taoist priest, doctor's wife, fortune-teller, soul-comforter, medical slip, medical slip interpreter, and etc. The other is the non-religious kind, including herbalist, bone setter, acupuncture doctor, fingersmith, massager, and breathing master.

S 19-4

Recent transcultural issues in Korea

Narei Hong

Department of Psychiatry, Hallym University Sacred Heart Hospital, Korea

Korea had been known as a homogeneous country, and Korean people had prided themselves in the unbroken 5,000-year-history of homogeneous population. This might have given Korean people pride and traditional energy; however it had made foreign people difficult to adjust in Korean society. Nowadays Korean society has been rapidly changing with the influx of foreigners coming to the nation, especially married immigrants and even North Korean defectors. So their transcultural issues have been serious problems in Korea. Also their psychiatric problems have come up for Korean psychiatrists. We interviewed married immigrant women from Vietnam and China, and North Korean defectors who lived in Gunpo-si, Gyeonggi-do, Korea for the mental health research projects in Gunpo community mental health center. For married immigrants, we evaluated 118 subjects with Beck Depression Inventory (BDI), Beck Anxiety Inventory (BAI), Scale for Suicide ideation

(SSI), Acculturative Stress Scale for International Student (ASSIS), Family Inventory of Life Events and Changes (FILE), Connor-Davidson Resilience Scale (CD-RISC) and Sheehan Disability Scale (SDS) in Vietnamese and Chinese language. For North Korean defectors (N = 56), we used BDI and BAI. Vietnamese married immigrant women complain of depression and anxiety less than Korean women. Chinese immigrant women had more depression and anxiety, and their psychiatric symptoms and acculturative stress correlated with high educational level of the couple and how to get married (a love marriage). More than 60% of Korean defectors had depressive symptoms and more than 50% of them had anxiety symptoms. And their symptoms had relation with financial and health problems, but not with defection process. Immigrants had their own psychiatric problems and the problems might have a bad influence on immigrants themselves and also Korean society. Korean psychiatrists need to concentrate on their specific issues.

Symposium 20

Brain Imaging in Psychiatry

S 20-1

Neurogenetic substrates for autistic social behavior

Hidenori Yamasue

Department of Psychiatry, Graduate school of Medicine, University of Tokyo, Japan

Difficulty in appropriate social and communicative behavior is the most prevalent and one of core symptoms of autism spectrum disorders (ASDs). Recent intensive research has focused on the neurobiological background of this difficulty. We employed multimodal magnetic resonance imaging (MRI) indices as intermediate pheno-types of this behavioral phenotype to reveal links with candidate genes for the autistic social difficulty. As MRI indices, functional MRI (fMRI), structural MRI, and MR-spectroscopy were examined in high-functioning adult males with ASDs. As candidate genes, we have much interest in oxytocin receptor genes (OXTR), since recent studies have repeatedly reported their associations with ASDs, especially their social aspects. Through our several studies, medial prefrontal, inferior frontal, insular cortices and amygdala have repeatedly been revealed as neural correlates of autistic social behavior by MRI mul-timodalities and their relationship to OXTR. I would like

to further talk about an integrative view to relate these findings to candidate biomarkers for developing new treatment of autistic social difficulty.

S 20-2

Structural neuroimaging in geriatric depression and Alzheimer's disease

Chang Uk Lee

Department of Psychiatry, Seoul St. Mary's Hospital, The Catholic University of Korea College of Medicine, Korea

Geriatric psychiatric disorders including Alzheimer's disease, mild cognitive impairments and geriatric depression consists of complex and heterogeneous cognitive functions and behaviors unlikely to be caused by a single brain lesion. However, there is evidence that abnormalities in specific brain structures and their interconnections confer vulnerability to the development of geriatric psychiatric disorders. Structural magnetic resonance imaging methods can be used to identify and quantify brain abnormalities predisposing to geriatric psychiatric disorders and in prediction of treatment response. This lecture reviews several techniques, including morphometric approaches including cortical thickness analysis, shape analysis and volume analysis, study of white matter hyperintensities and diffusion tensor imaging that have been used to examine these brain abnormalities with a focus on the type of information obtained by each method as well as each method's limitations. The authors argue that the available methods provide complementary information and that, when combined judiciously, can increase the knowledge gained from neuroimaging findings and conceptually advance the field of geriatric psychiatry.

S 20-3

Image the serotonin transporter in major depressive disorder in Asian population

Yuan-Hwa Chou

Department of Psychiatry, Taipei Veterans General Hospital, Taiwan

The serotonin system provides a logical source for research that is linked to mood disorders, because this system is the target of selective serotonin reuptake inhibitors (SSRIs) that are effective in the treatment of depression and other psychiatric disorders. The serotonin

transporter (SERT) has received particular attention because it is involved in the reuptake of serotonin at brain synapses. A polymorphism in the promoter region of the SERT gene has two frequent alleles that are designated long (L) and short (S). The S-allele leads to decreased transcriptional efficiency of SERT. It has been reported that the L-allele may act as a protective factor for major depression, whereas the low-functioning S-allele is associated with increased disease susceptibility upon exposure to adverse life events. The functionality of the SERT in the human brain has not been consistently replicated. BDNF is recognized as a plethoric factor that regulates a wide repertoire of functions, including neuronal survival, migration, phenotypic differentiation, axonal and dendritic growth and synapse formation. In addition, BDNF has emerged as a key regulator of synaptic plasticity and behavior, which has been linked to the etiology of mood disorders. It has been reported that BDNF promotes the survival and morphological differentiation of SERT neurons in vitro and in vivo. A close link between serotonin and the neurotrophin has been suggested. In the presentation I will firstly demonstrate how properly to image the serotonin transporter in the human brain. Secondly, I will explore the interaction of SERT expression in terms of SERT gene and the role of BDNF between the interaction of phenotype and genotype of SERT in the human subject. Based on our image study, we hypothesize that a combination of BDNF and genetic marker could a biomarker for the development of antidepressant, particular for Asian population.

S 20-4

Current understanding in neurobiology of depressive disorders: Imaging genetic studies

Byung-Joo Ham

Department of Psychiatry, Korea University College of Medicine, Korea

Depressive disorders have strong genetic components. However, conventional linkage and association studies have not yielded definitive results. These might be due to the absence of objective diagnostic tests, the complex nature of human behavior or the incomplete penetrance of psychiatric traits. Imaging genetics explores the influences of genetic variation on the brain function or structure. This technique could provide a more sensitive assessment than traditional behavioral measures in psychiatric studies. Imaging genetics is relatively new field of psychiatric researches, and may improve our

understanding on neurobiology of psychiatric disorders. In this talk, current understanding in neurobiology of depressive disorders, especially imaging genetic studies will be discussed.

Symposium 21

DSM-V and ICD-11

S 21-1

Psychiatric diagnostic systems: Whither and wither?

Graham Mellsop

Department of Psychiatry, University of Auckland, New Zealand

The performances of present classifications will be briefly reviewed. The needs for the future touched on. Emerging signs of DSM-V and ICD-11 will be referred to. The conclusion will be opined that we may have three steps backwards for every step forwards.

S 21-2

Classification and diagnostic criteria of dementia in DSM-V and ICD-11

Seong Yoon Kim

Department of Psychiatry, Asan Medical Center, Korea

Although DSM-V and ICD-11 was to be published in 2012, that timeline does not seem to be realistic considering current situation. There have been numerous updates, meetings, forums, task force activities to refine each diagnostic system and also to harmonize the two systems, but we still have a long way to go ahead of us. WHO has postponed its publication of ICD-11 to 2014, and American Psychiatric Association also revised the timeline of DSM-V to 2013. The diagnostic system for dementia is somewhat more complicated. Compared to other mental disorders, the diagnosis of dementia syndrome relied less on descriptive phenomenology, but more on pathology, imaging, and other biomarkers. This may explain why, in addition to DSM-IV and ICD-10 diagnostic criteria, most of the published articles on Alzheimer's disease or vascular dementia mention NINCDS-ADRDA or NINDS-AIREN as their main diagnostic criteria. Furthermore, development of molecular imaging, genetic and biochemical methodology in dementia research call for new

diagnostic criteria for future research and medical practice. Such a demand is already reflected in recent new diagnostic criteria proposed by several US and European researchers. Even though these proposed criteria need vigorous reviews and revisions, it seems certain that the diagnostic criteria for cognitive disorders are unique compared to other mental disorders. In this symposium, the author would like to introduce the current state of DSM-V and ICD-11 publication, and the recent development of new diagnostic criteria on dementia focusing on Alzheimer's disease.

S 21-3

Issues in new proposals for DSM-V classification of patients with multiple somatic symptoms

Do-Hyung Kang

Department of Psychiatry, Seoul National University Hospital, Korea

Somatic symptoms that cannot be explained with a medical condition are a major challenge in psychiatry field. When we think about patients experiencing multiple somatic symptoms, we need to take into consideration many relevant factors other than simply the physical symptoms reported. Until now, however, we tended to view somatic symptoms as an epiphenomenon or secondary response, thinking that it was only important because it provided information about physical pathology. For patients with multiple medically unexplained somatic symptoms, the DSM classification of psychiatric disorders suggests the diagnosis of somatoform disorders. Since its introduction in DSM-III, the somatoform disorders category has been controversial. In fact, the DSM-IV somatoform diagnoses are used rarely in clinical settings; and the terms cause miscommunications among doctors and make stigma for patients. Recently, DSM-V work group suggested a complete revision of the category of somatoform disorder to overcome these problems of promoting dualism and assuming psychogenesis with DSM-IV diagnoses. Furthermore, because of low interrater reliability, the distinction between 'medically explained' and 'medically unexplained' was abolished. Instead it defines disorders on the basis of positive symptoms (distressing somatic symptoms + excessive thoughts, feelings, and behaviors in response to these symptoms). Our aim is to discuss issues in new proposals for DSM-V classification of people with multiple somatic complaints in psychobiological perspective of somatic symptoms.

S 21-4

Views from a WHO officer and by a clinician

Naotaka Shinfuku

Department of School of Human Sciences, Seinan Gakuin University, Japan

The author experienced several different positions dealing with psychiatric diagnoses in his career, first clinician, public health administrator, researcher and once again clinician. I observed both the usefulness and the limitation of psychiatric diagnoses in different settings. 1. In my first career as a young psychiatrist in 1970th, I used the traditional diagnoses and found no problems. 80% of patients were diagnoses as shizophr-nics. 2. In 1980th, operational diagnoses, DSM and ICD, were introduced into Japan and their uses were spread quickly as they had better inter-rater-reliability than traditional operational diagnoses. 3. WHO collects data on changing trend of morbidity and mortality of diseases from over all the world to plan strategies for prevention, intervention and treatment of diseases. Common language in the form of operational diagnoses is essential for international public health organization such as WHO. 4. While I was at WHO for the office of the Western Pacific, WHO was in the process to formulate ICD-10. As WHO officer, I have tried to involve many member states to reflect the views of Asian psychiatrists. ICD-10 was completed in 1992. 5. In Kobe, I experienced the Hanshin Awaji Earthquake. A victim showed the symptoms which could be diagnosed as panic disorder, insomnia, anxiety disorder, depression and alcohol dependence consequently. A psychiatric diagnose at one point will have a very limited value to understand the whole person. Back in clinical work, I am giving the psychiatric diagnosis to prescribe a certain psychotropic drug to suit for the guideline. 6. In conclusion, operational diagnoses are essential for statistics, research and education. However, its usefulness is limited in real clinical world. Patient changes symptoms over time. Present operational diagnostic systems are not sufficient to understand a patient as a whole who has own history. Also, diagnose in real world are influenced by insurance systems.

Symposium 22

Current Issues in Pharmacogenetics

S 22-1

Pharmacogenetics of antipsychotics

Seung-Gul Kang

Department of Psychiatry, Gachon University Gil Hospital, Korea

The antipsychotic drugs are mainstay of the treatment of these major psychiatric illnesses; however they have a long way to go due to the relatively low response rate and delayed response. In case where patients are treated with such antipsychotic drugs that may cause insufficient treatment responses or certain side effects, they are likely to suffer from serious problems later on, including, but not limited to deterioration of the illness and economic losses. In clinical practice, the physicians have to undergo trial-and-error processes in choosing the best antipsy-chotics for a specific patient. In this context, the phar-macogenetics may provide a promising tool in clinical management of schizophrenia patients. Up to recently, many researches have been performed in this field. The pharmacogenetic studies of antipsychotic response have shown that DRD2, DRD3, HTR2A, and COMT genes are significantly associated with treatment responses. The DRD2, DRD3, HTR2A, and CYP2D6 genes have shown the significant association with TD. For antipsychotic-induced weight gain, HTR2C gene is known to be consistently associated. Korean people are ethnically a homogeneous population; therefore, has an advantage in the genetic study. Our group has investigated the association of the promising candidate genes with the antipsychotic-induced TD, weight gain, and RLS. At present, we are analyzing the pharmacogenetic data of the amisulpride study. In conclusion, pharmaco-genetic research of antipsychotics is promising and significant in the field of psychiatric research. It is recommended that 1) genetic studies need to be designed not as a secondary area to clinical studies, but as a focus on pharmacogenetic studies, 2) phenotypes need to be more specific and consistent, 3) prospective studies rather than retrospective studies will be desirable. Foregoing efforts will, if made, certainly lead the pharmaco-genetic studies of antipsychotics to a higher level and expedite the advent of the tailored medicine era.

S 22-2

Pharmacogenetic and pharmacokinetic determinants of trajectory of the therapeutic response in patients with panic disorder

Kazutaka Shimoda

Department of Psychiatry, Dokkyo Medical University, Japan

Selective serotonin reuptake inhibitors (SSRIs) are thought to interact with the serotonergic nervous system and to be effective for the treatment of panic disorder (PD). The efficacy of SSRIs including paroxetine (PAX) in PD treatment has been established in several placebo-controlled trials, indicating SSRIs as first-line agents. Serotonin (5HT) transporter (5-HTT) removes serotonin from the synaptic cleft and the protein is the primary target of action for SSRIs. A meta-analysis of association studies found the 5-HTT gene-linked polymorphic region (5-HTTLPR) was not associated with PD. We evaluated genetic and pharmacokinetic factors to establish the pharmacotherapeutic effect of PAX in drug-naive patients with PD. All subjects were administered PAX (10 mg/ day) for 4 weeks, and the PD severity was assessed using the Panic and Agoraphobia Scale (PAS) at baseline and at 2 and 4 weeks after initiation of treatment. Plasma concentration of PAX was determined by high performance liquid chromatography. 5-HTTLPR variants and the -1019C/G promoter polymorphism of the serotonin 1A receptor (5-HT1A) gene were determined by poly-merase chain reaction. Multiple regression analysis revealed that the plasma concentrations of PAX, 5-HTTLPR genotype and -1019C/G 5-HT1A gene polymorphism were significant factors affecting clinical response to PAX (reduction ratio of PAS score) at 2 weeks after the initiation of pharmacotherapy. The -1019C/G 5-HT1A gene promoter polymorphism, PAS score at baseline and adverse effects were found to be the significant factors affecting clinical response to PAX at 4 weeks after initiation of pharmacotherapy. Our study revealed that plasma concentration of PAX, 5-HTTLPR genotype, -1019C/G 5-HT1A genotype, PAS score at baseline and adverse effect may influence the therapeutic response to PAX in PD.

S 22-3

Advances to clinical application: Is pharmacogenetics ready for clinical application?

Min-Soo Lee

Department of Psychiatry, Korea University College of Medicine, Korea

For establishment of predictor for individual treatment outcomes by psychotropic drugs, pharmacogenetics has been in the limelight over the past few decades. Although data accumulated from the approaches have provided us with the understandings of genetic backgrounds for individual differences in treatment response and have successfully offered cornerstones of recent advances in pharmacogenetics, the many of them are still controversial due to the lack of replication derived from ethnic

differences of therapeutic responses, allele frequencies or LD structure, differences of phenotype definitions and the use of various drugs. The recent efforts in pharmaco-genetics have been focused on to overcome these limitations by studying genome-wide association, gene-gene and gene-environment interaction. In other hand, we have tried to compare pharmacogenetic characteristics of MDD patients treated with different kinds of antidepres-sants. Although it was preliminary study and had several limitations, some genetic polymorphisms showed different patterns of association with specific drugs, indicating that this approach may be helpful to find appropriate genetic predictor used for determining the first line drug suitable for individuals. These efforts may be useful for understanding complex traits of individual differences in treatment outcomes and for establishing clinical application of pharmacogenetics.

Symposium 23

Helping Survivors from Disaster; Tsunami, Fire, and War

S 23-1

Disaster survivors in Korea: Screening and early psychological intervention

Joo Eon Park

Department of Psychiatry, Keyo Hospital, Korea

Trauma is often the central issue of mental health. Acute stress disorder and posttraumatic stress disorder are typical consequences of natural and human-made disasters. Other psychological sequelae after disasters are well known to include other anxiety disorders, depression, alcohol use disorders, personality changes, suicide and so on. To my knowledge, disaster triage systems including screening methods and some interventions immediately after traumatic incidents and during acute stress disorder are not well formulated. Even if they have been already proposed, there is still a lack of evidences to utilize on the ground of a large scale disaster. Furthermore, recent meta-analyses using psychological debriefing did not prove as a useful intervention for the prevention of posttraumatic stress syndromes, although the efficacy of debriefing has been at the center of controversy. Taken together, there does not seem to be an appropriate system to fit early screening and managing processes. Then this lecture will introduce the concept of their processes and will discuss the useful tools that match our situation in South Korea.

S 23-2

Anxiety symptoms among natural disaster rescuers

Hin-Yeung Tsang

Department of Psychiatry, Kaohsiung Municipal Kai-Syuan Psychiatric Hospital, Taiwan

Natural disasters in Asia Pacific region are common and unpredictable. Many studies focused on issues related to post-traumatic stress disorder. Little concern or study was on the training of rescue team members as well as their mental health after facing natural disaster. The research questions included: What have we learned from previous disasters? Do our rescuers and health professionals get

well prepared to help the victims of the disasters? Do the rescuers aware of the psychological impact aftermath? Professional rescuers should receive proper training in relevant skills. However, first-line rescuers also include policemen, fire-fighters, emergency medical personals, military officers or even volunteers. They receive training in skills of the physical resuscitation rather than mental reactions of survivors and of themselves. Awareness of possible psychological impact among first-line rescuers is a matter of concern. On the other hand, medical professionals usually serve as second-line rescuers. Theoretically, medical professionals are familiar with physical and mental health issues related to disasters. Studies showed very high prevalence of minor mental disorders among medical and hospital staffs during the severe acute respiratory syndrome (SARS) period in Taiwan in 2004. The content of this presentation includes (1) Prevalence of minor mental disorders amount health care professionals and relevant hospital staffs; (2) Rationale and structure of disaster rescue organization; (3) Training curriculum and exercises in the organization. Results of the present study may throw light to the policy makers to aware of this critical issue to minimize psychological impact of rescuers aftermath.

S 23-3

Mental health consequences after the Great East Japan Earthquake

Yuriko Suzuki

Department of Adult Mental Health, National Center of Neurology and Psychiatry, Japan

On 11th of March, 2011, a massive earthquake hit Northeast coast of Japan, and Japanese mental health community responded to the Great East Japan Earthquake based on experience to natural disaster amassed in the past. In early response to the calamity, mental health teams took major role to provide care for the affected people with organized manner. Principle of psychological first aid was applied not to over-pathologise 'common reaction to abnormal situation'. The work to reconstruct mental health system and long term support in the affected areas are ongoing, mainly with local resources and continuous external support. The expectation from the affected people in early phase is tested for mental health community if we can develop accessible and effective mental health service for the people affected.

S 23-4

Disaster survivors in Korea: Psychological results and their significance

Jeong-Ho Chae

Department of Psychiatry, Seoul St. Mary's Hospital, The Catholic University of Korea, Korea

Trauma is often the main issue for people with mental health problems. Historical disasters such as Holocaust and Chernobyl nuclear accident have proven it. High intensity and long duration of trauma, and man-made disaster have been noted to have more adverse results of posttraumatic stress reactions, although trauma-related disorders and some psychological reactions after disaster could have wide appearance. This lecture would be covered the issues of survivors of a disaster in Korea such as Taean Oil Spill case, Cheonan-Ham Attack Incident, and Bombardment of Yeonpyeong. The reactions in Korean people have also varied as different countries. In addition, the psychological aftereffect of Cambodian Genocide might remain distinct from that of other disasters in the rest of the world. However, there are few studies comparing sequelae after trauma between disasters until now. So this lecture will introduce the incidences of acute stress disorder, PTSD and depression, and the proportions of psychological symptoms in cases of South Korean and the comparison with Cambodian Genocidal survivors. It will also discuss how each disaster is likely to impact psychological results.

Symposium 24

Current Issues in Woman Psychiatry

S 24-1

Working moms and their children

Lee Jaffe

Department of Psychiatry, University of California-San Diego, U.S.A.

Nowadays, many women must balance the demands of a job or a career, with the demands of being a mother and raising children. More and more, both women psychiatrists and their female patients are working moms. While this reality can make for a full, satisfying life, it can be a source of unnecessary worry for mothers and potentially a real developmental interference in the life of a child. This presentation will explore the complexities and

challenges of this modern day reality from the psychoanalytic and developmental points of view of the child, the mother and the female psychiatrist. Special attention will be given to the child's emotional needs at different ages, to the mom's ability to distinguish between real and imagined problems, and to the female psychiatrists' potential reactions to her female patient's worries.

S 24-2

Psychosocial status of Korean women

Weonjeong Lim

Department of Psychiatry, Ewha Womans University Mokdong Hospital, Korea

Korea not only experienced modernization and industrialization in the 20th century but also experienced rapid social changes, which in turn resulted in extensive changes in the psychosocial status of Korean women. As the level of education of women and the desire for self-realization increased, the traditionally established discrimination between men and women reduced and gender equality spread; the social as well as legal status of women increased. Gradually, the traditional values regarding marriage collapsed, and the idea that marriage and childbirth are not mandatory choices became more common; the formation of families through marriage became delayed and the divorce rate increased, which socially resulted in low birth rate. At the same time, along with the population aging and change in understanding of the concept of family, female employment and economic activity are increasing. However, level of participation in economic activity of women is still lower than that by men. Although the understanding of professional identity is rapidly changing with women employees becoming more educated and advancing professionally, the organizational understanding is still based on men and changing at a slow pace. As the participation of women in economic activity increases, it is difficult to maintain the balance between work and family, where in the present situation it will be difficult to produce satisfactory results at work. Moreover the excessive expectations and values are still attributed to the family. The social attitude that views a woman as a dependent self and the auxiliary role in the family coming from Confucian and familistic Korean tradition still remains in Korean minds and has its tacit influence, which results in conflict and mental stress for the women.

S 24-3

Positive correlates of successful ageing in Singapore women

Rathi Mahendran

Department of Psychiatry, National University of Singapore, Singapore

The focus and interest in successful ageing has grown in tandem with the rapidly ageing populations around the world. As women outlive men, there is particular need to understand how they can be supported in ageing well and remaining healthy. We present findings from the Singapore Longitudinal Ageing Study (SLAS), a community-based research of individuals living in the south-western part of the island. The study population is Chinese females aged 60 years and above. We adapted criteria for successful ageing from the work of Rowe and Kahn and determined the factors that enabled successful ageing in women 60 years and above. These included the Mini Mental State Examination, Quality of Life, Geriatric Depression Scale, Life Satisfaction, Activities of Daily Living and Instrumental Activities of Daily Living. We subsequently studied the correlates of successful ageing amongst different age groups focusing in particular amongst the oldest-old.

illnesses. Since there are many patients with comorbidity, existing programs were modified to meet their needs. This hospital has 80 beds including 15 beds for women. From April 2010 to March 2011, there were 703 new patients. The ratio of male to female was 523:180. There were 307 patients admitted for addiction. The ratio of male to female was 59:33 for drugs and 172:43 for alcohol. There were 29 female patients suffering from alcoholism and 25 female patients with drug addiction from Oct 2010 to September 2011. Among those with alcohol addiction, 14 had ED and 2 had a past history of ED. Among those with drug addiction, 6 patients had ED and 4 had a past history of ED. Strategies for addiction are effective on patients who have eating disorders and alcoholism. Typically they are put on behavioral therapy with psycho-education until they reach a certain weight. Then they are introduced to a self-help group. At the symposium, strategies to treat female addiction and its effect will be shared with a case presentation.

Symposium 25

Transnational Interactions for Promising Young Residents to be the Leaders of the 21C Psychiatry

S 24-4

Treating women at a specialized hospital for addiction in Kanagawa, Japan

Kumi Aoyama-Uehara

Department of Psychiatry, Kanagawa Psychiatric Center, Serigaya Hospital, Japan

At the symposium, Current Issues in Woman Psychiatry, topics related to women and addiction will be addressed. Although the prevalence of addiction is lower in females, the average age is younger and the cases tend to be more sever. Also, they are known to show various comorbidi-ties of psychiatric illnesses including eating disorders (ED). Due to a high percentage of comorbidity, females tend to require comprehensive support such as physical care for ED, administrative support for themselves and their children, and all female rehabilitation programs. In Japan, there is inadequate medical support to meet the needs of female patients with comorbidity. Serigaya Hospital specializes in addiction. It was founded in 1963 to treat patients with all types of substance addiction, including alcoholism, together with other comorbidity

S 25-1

Differences and commonalities among the Pacific rim countries from a cross-cultural perspective

Christopher Chung

Department of Psychiatry, UCLA, U.S.A.

To a large extent, the USA has looked across the Atlantic Ocean to Europe, over the last two hundred years. In fact, the cultural, ethnic, and historical heritages, politics, and economics, were closely tied between the two continents. Their ties have played an important role in leading the world. Likewise, medical and mental health polices, as well as the practice of psychiatry, have been based upon the philosophies driven by Western values. In recent decades, Pacific Rim countries have begun to receive greater attention because of a variety of reasons. Some of these reasons include increasing trade and economic development, booming population growth, and increasing needs for outsourcing. The Pacific Rim includes the countries that lie along the Pacific Ocean, composed of 30 countries, which include the USA, Canada, Japan, China, Korea, Taiwan and Australia. These Pacific Rim

countries are also defined as being industrialized in contrast to those countries that are less industrialized or developing. The differences in language, economic development, cultural values, and mental health resources, among these Pacific Rim countries, are tremendous. If the Atlantic Ocean was historically termed the bridge of similarity, then the Pacific Ocean may well be termed the bridges of difference. One of the tasks for mental health professionals in the Pacific Rim is to cooperate with each other to develop ways to meet the needs of cultural understanding. Another goal is specifically to help one another to learn the cultural impacts on mental health and illness. Furthermore, the sharing of knowledge in neuroscience will be an important role for leaders of mental health in this region. The author will also present the various cultural differences among the countries in the Pacific Rim, and their impact on mental health from the perspectives of collectivism vs. individualism, masculine vs. feminine cultures, and truth-seeking vs. virtue-seeking cultures.

S 25-2

Thirteen-years of experience of joint workshop for psychiatric residents of Japan and Korea

Michiko Fujimoto

Department of Psychiatry, Osaka University Graduate School of Medicine, Japan

The Joint Workshop for Psychiatric Residents of Korea and Japan (JWPRKJ) was established in 2000 by Prof. Byung-Kun Min and Prof. Masahisa Nishizono who are the leaders in the field of psychiatry in Korea and Japan, respectively. JWPRKJ has been held alternately in Fukuoka and Seoul every summer for 13 years. The participants are the psychiatric residents from both Korea and Japan. In addition, some of them join the workshop again as OB/ OG. The theme of the workshop covers the current topic in the various fields including disaster psychiatry in 2011. There are several lectures provided by the experts, followed by the workshops along the theme. In the workshop, the participants discuss the psychiatric problems in the topic based on the different background of culture. The feature of JWPRKJ is not only to learn the knowledge of psychiatry, but also to experience the different culture through the 4-day workshop with colleagues. The workshop also gives the opportunity to expand the human network beyond the country. This unique style and the great efforts to continue the workshop by the psychiatric leaders in both countries have facilitated the transnational interaction between young psychiatrists since 2000. The

13th JWPRKJ is held in Fukuoka in August, 2012. Although it will be the last workshop at the moment, the transnational interaction is needed continuously in the alternative way to restore the intellectual results from the 13-years experience of JWPRKJ to the psychiatric field and society. The cross-cultural experience would provide the better communication skills to take the international leadership as well as increase the knowledge of psychiatry in both clinical medicine and basic science.

S 25-3

A vistas of the joint workshop for psychiatric resident relative to the further development of the PRCP

Byung Kun Min

Department of Psychiatry, Ulsan University College of Medicine, Korea

The founding spirit of our PRCP was an extraordinary, respectable and a worthy to give applaud. i) Sharing 'intimate' friendship. ii) keep continue healthier exchanges with colleagues elsewhere like the friends in the Asian countries. iii) Share the academic data to keep all the members stand together on the top. The core persons of the founders were the members at the UCLA. Professors Pasnau, Yamamoto, Yeh, Chen were those I remember. Every one of them were well known leaders of American psychiatrists. Nishizono, Lee, Tasman, Singh, Noda are the eminent leaders among others who paid so much of their energy to keep rolling our PRCP. Presently our PRCP is, however, suffering from shortage of manpower and of the budget. Again, these factors are the most threats against our PRCP's revival for the future. Increase the manpower and that of the budget to suit the reality are the crucial 'musts' of our PRCP. Regarding the transcul-turally oriented psychiatric residents' training. one may say it is just a waste of energy and the budget. Another would say it is too idealistic like a dream. The speaker, however, strongly propose this program to add to the long range plans of the PRCP. We have a good example as such. JWPRKJ has an evident answer. With setting the ideas quite similar to the PRCP we originally planned to go ahead with candidates of10 each. But, the 1st JWPRKJ in Aug. 2000, we started with 34 (150%+), and the numbers of the candidate increased every year. The 13th, last Aug. the there were 56. We set the workshops' 1st aim is to make intimate friendship each other. And from the 2nd workshop the committee encouraged the OBs to conjoin. This report covers key words of; 1. PRCP, 2. multinational or transculturally oriented psychiatric resident's conjoint training.

S 25-4

Earlier exposure to the exchanged advanced research trainings and transcultural interactions will establish fundamental basis for the future development in psychiatry in Pacific Rim area

Tung-Ping Su

Department of Psychiatry, National Yang-Ming University, Veterans General Hospital, Taiwan

In Taiwan, most of the psychiatric institutes sent their young attending doctors to study in advanced countries. However, only the Department of Psychiatry at Taipei Veterans General Hospital actively sent residents to study abroad.

The philosophy of VGH Psychiatry is 'Research is the key promotion for clinical practice and development in psychiatry'. We thought earlier exposure to research may be beneficial for the subsequent development in their career. Thus, VGH Psychiatry sent senior residents to the advanced research training program in USA. Over the past 6 years, 7 fellows received one year training in the special areas such as substance abuse, schizophrenia, autism, sleep disorders, dementia and PET imaging in mood disorders and MRI in schizophrenia in the programs at the universities of Harvard, Yale, John-Hopkins, USC and NIMH. This program is equivalent to the fellowship training post-residency in the United States. The outcome has been rated well, since there have several advantages as follows; 1) To establish their subspecialty earlier in their career and to constitute team work for research; 2) To build solid foundation for the future development of the Department; 3) To learn the updated new technology in clinical psychiatric medicine; 4) To set up channels for collaboration with the experts in foreign countries.

Few Psychiatric institutes in Taiwan received international residents or fellows. The Department of Psychiatry at Chang Gung Medical Center is one of the exceptions. CGMH Psychiatry offers international fellowship programs for psychosomatic medicine, sleep medicine, women's mental health, men's mental health and child psychiatry. Over the past 5 years, it received 5 international clinical or research fellows from Vietnam, United States, Korea, Fiji and Hong Kong. Their stay ranged from 1 to 6 months. International fellows interacted with the Taiwanese colleagues very well and brought new ideas and transcultural stimulations to the organization.

International interaction is important for professional growth of an individual, and also, of an institute. We are looking forward to seeing the well-developed exchanged residency training program between countries.

Symposium 26

New Models of Bipolar Treatment

S 26-1

Different white matter abnormalities between the major depression and bipolar depression

Lingjiang Li

Department of The Mental Health Institute, The Second Xiangya Hospital, China

Background: This study compared the different brain white matter abnormalities between DSM-IV major depression disorder and bipolar depression disorder. Method: Thirty two patients with major depression disorders, 29 with bipolar depression disorders, and 30 healthy controls were assessed on diffusion tensor imaging.

Results: As compared to healthy controls, significantly higher white matter density in left lingulate gyrus, and significantly higher white matter volume in right middle temporal gyrus, and significantly lower white matter volume in left medial frontal gyrus, left middle temporal gyrus, left brainstem in patients with bipolar depression disorder were exhibited. However, as compared to healthy controls, significantly lower white matter density in right middle temporal and left parahip-pocampal gyrus and significantly higher white matter density in right lingual gyrus, and significantly lower white matter volume in right inferior temporal gyrus, right limbic lobe, left hippocampus, and left frontal lobe in major depression disorder subjects were shown. Furthermore, patients with bipolar depression disorder showed reduced white matter density in left prefrontal gyrus and reduced white matter volume in right medial frontal gyrus relative to major depression disorder subjects.

Conclusions: We tentatively speculate that although bipolar and unipolar depression disorders have same clinical depression symptoms while assessment under MRI, but the neuroimaging characteristics of brain white matter have difference. It suggests that there is distinguishing nerve pathology between major depression disorder and bipolar depression disorder.

Key word: major depression disorder, bipolar disorder, magnetic resonance imaging, brain white matter

S 26-2

Heterogeneity of bipolar disorder and its implication into pharmacological treatments

Yeon Ho Joo

Department of Psychiatry, University of Ulsan, Asan Medical Center, Korea

As known, bipolar disorder is heterogeneous especially in terms of course, outcome and treatment response. We are trying to subdivide patients with bipolar disorder into more homogeneous groups according to longitudinal clinical manifestations including predominant polarity and interepisodic recovery. We will compare those groups regarding pharmacological modalities and response.

S 26-3

Today's new treatment of bipolar disorder - from a standpoint of clinical practice

Shinji Shimodera

Department of Neuropsychiatry, Kochi Medical School, Kochi University, Japan

Bipolar disorder is still often misdiagnosed as major depression in clinical practice. If patients had no previous history of manic or hypomanic episodes, physicians could become aware of misdiagnosis only after starting medication. It is necessary to check the family history and to ask someone other than the patient himself/herself in greater detail about any hypomanic episodes in the past. With regard to aids in the diagnosis, near-infrared spectroscopy (NIRS) has drawn attention, although evidence is still accumulating. Also, it is often more difficult to inform patients about the diagnosis of bipolar disorder as compared to that of major depression. Mainly mood stabilizers, including lamotrigine, are used in drug therapy, and atypical antipsychotics have also come to be actively used. It is often more difficult to rehabilitate patients with bipolar disorder than to rehabilitate those with depression, although rehabilitation is important as psychosocial treatment to enable the patient to return to work. In addition, psychoeducation is important to prevent recurrence and to support the mental health of

the patients' families. In this lecture, I shall describe new findings useful in clinical practice.

S 26-4

Contemporary psychotherapy in the treatment of bipolar disorder

Jun-Seok Lee

Department of Psychiatry, KARF Hospital, Korea

Bipolar disorder (BD) is a chronic illness characterized by traumatic episodes of mania and by periods of depression. What is today, officially termed 'BD' has been recognized throughout much of this century as 'manic-depressive insanity.' The manic-depressive insanity was the condition that Kraeplin differentiated from the schizophreniform disorders in his classic work of the early twentieth century. The psychopathologic phenomena of 'manic-depressive insanity' are not well understood psychoanalytically for two reasons. First, ego psychology and conflict theory seem particularly forced when applied to this insanity. However, the analytic contributions have not led to the development of theories accepted widely even within the analytic community. Despite many enthusiastic attempts, it became obvious that although classical analysis might shed much light on the nature of manic-depressive insanity patients' unconscious conflicts, it could not bring about a type of cure. Second, analytic experience with patients is very limited. Analysts have rarely used their most powerful research tool, the psychoanalytic setup, to explore the patients. Recently, contemporary psychoanalysts' extensive work with BD patients has developed over the years and shifted in emphasis from patients' conflicts, to pathogenic deficits in psychic structure and functions seen in BD psy-chopathology. I have worked analytically with two BD patients. The two are in psychoanalytic psychotherapy at present, one for 3 years, and the other for 1 year. Both patients were on pharmacotherapy, which I managed. The patients were seen two times a week, face to face, using self psychological analytic techniques. In this symposium I will present some major themes in the psychoanalytic psychotherapy of the BD patients, indicate some commonalities among the patients, and offer a hypothesis about the psychology of the illness.

Symposium 27

Historical Perspectives on Suicide in Pacific Rim

S 27-1

Suicide prevention in Asia

Helen Chiu

Department of Psychiatry, The Chinese University of Hong Kong, Hong Kong

In 2008, over 780,000 people committed suicide in the world. Suicide is a major health challenge in Asia, as Asia accounts for over 60% of the suicides in the world. Suicide prevention is thus an important health agenda in this part of the world. Some of the features of suicide in Asia and barriers to suicide prevention include the following. Many low and middle-income countries in Asia have lack of surveillance systems to monitor the situation and changes in suicide rates and this hampers the monitoring of effectiveness of suicide prevention interventions. In some countries, there is a high suicide rate due to ingestion of pesticides in rural communities. In China, the suicide rate in young women is very high in rural areas. Further, elderly suicide rates are high in many countries in Asia despite the respect for elderly. This presentation will describe some of the programs of suicide prevention in Asia, in particular suicide prevention in elderly. Suicide prevention by means restriction, the elderly suicide prevention program in Hong Kong and some other suicide prevention programs will be highlighted.

KASP made networks for suicide prevention and some practical programs for general population and high risk groups of suicide. In 2011, Korean government made a law for suicide prevention. According to the law, the central suicide prevention center was made in Seoul. The central suicide prevention center is working for practical issues for suicide prevention in Korea. The other many facilities and associations are working for suicide prevention in Korea. However, the rate is not decreasing now. In this presentation, the activities and programs for suicide prevention in Korea will be introduced and new plans for suicide prevention in the future will be suggested.

S 27-3

Elderly suicide in Chinese populations

Emily Ho Chui Ling

Department of Psychiatry, National University Hospital, Singapore

Studies on suicide rate in the elderly have shown vast differences in different regions. This session summarizes the literature on the elderly suicide trend in Chinese populations, namely China, Hong Kong, Taiwan and Singapore, comparing these data to those in the USA and the UK. By looking at the suicide prevention programs and their relationship with the suicide trend, we hope to bring across a strong message that suicide in preventable, and to encourage more research in this field, especially in preventive medicine, targeting at-risk individual in the community.

S 27-2

Newer issues related to suicide prevention in Korea

Kang Seob Oh

Department of Psychiatry, Gangbuk Samsung Medical Center, Korea

Recently, suicide rate in Korea is very high. The rate is more than 31/100,000 in general population. The suicide rate is also rapidly increasing during the past decade. Korea was introduced as one of the rapidly developing countries. However, suicide problem is a very serious issue in Korea. In Korea, government and NGO including Korean Association for Suicide Prevention (KASP) tried to decrease the suicide rate. KASP was founded in 2003.

S 27-4

Suicide and suicide prevention in Japan

Tadashi Takeshima

Department of Center for Suicide Prevention, National Institute of Mental Health, National Center of Neurology and Psychiatry, Japan

Japan has suffered from high suicide rates since 1998. Thus there is strong pressure for suicide prevention measures that could be effective and implemented widely. The development of Japan's suicide prevention can be broken down into three phases. Firstly, the Ministry of Health, Labour and Welfare started and tried to lead suicide prevention activities (1998-2005). Secondly, the central government organized a liaison committee of related ministries and agencies for comprehensive suicide

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prevention measures (2005-2006). Thirdly, the Cabinet Office led comprehensive suicide prevention measures under the Basic Act for Suicide Prevention (2006) and the General Principles of Suicide Prevention Policy (GPSP) in 2007 (2006-present). The GPSP will be reviewed and re-evaluated in accordance with changes in social and economic situations, suicide situations as well as policy and target progress in 2012. Following the establishment of the GPSP, substantial progress has been achieved in terms of awareness and it can be considered as modalities of universal prevention. Another positive outcome observed as a result of the GPSP is the establishment of a powerful infrastructure for suicide prevention at regional and local, in most Prefectures (WHO Visit to Japan on Suicide Prevention Final Report, 2012). The advancements and the effort for universal prevention created the ground for putting in place more specific interventions; selective prevention and indicated prevention. In this symposium, I'll present actual condition of suicide, the development of suicide prevention and its future expected.

prescription from FGA to SGA in all countries. 3) The usage of a particular anti-psychotic in a county is influenced more by national drug policy, licensing system, cost, insurance coverage, tradition and side effects than EBM (Evidence based Medicine). 4) The changes from FGA to SGA has resulted in several changes in the pattern of sides effects. Metabolic side effects have been increasingly noticed. REAP group will make presentations on specific aspects of the results of REAP studies. For example, 1) Poly-pharmacy, 2) Use of clozapine. 3) Underrecognition of a specific side effect, 4) Concomitant use of mood stabilizer, etc, 5) Prescription for the old age schizophrenics and 6) Prescription pattern and its analysis in a particular country. In 2008, India, Malaysia and Thailand joined REAP survey and their results could also be presented. Also, REAP undertook the survey on the use of anti-depressants in 2004. REAP plans to follow up its survey on the use of anti-depressants in Asia REAP study has several shortcomings and limitations. These points will be covered. We would like to have young Asian psychiatrists to join the group.

Symposium 28

Prescribing Patterns of Psychiatric Drugs in Asia

S 28-1

Prescription pattern of psychotropic drugs in Asia-outline

Naotaka Shinfuku

Department of Psychiatry, Seinan-Gakuin University, Japan

Research on East Asia Prescription Pattern of Psychotro-pic Drugs (REAP) is surely the largest and long lasting collaborative research project in the field of psychiatry in Asia. Since its first survey in 2001, REAP collected and analyzed more than 6,000 prescription of psychotro-pic drugs for schizophrenic inpatients in China, Korea, Japan, Hong Kong, Taiwan and Singapore. REAP survey took place in 2001, 2004 and 2008 each time gathering more than 2,000 prescription based on the unified research protocol and using the same questionnaire. REAP has yielded many interesting characteristics of prescription pattern in Asia. The results were published in more than 20 international and domestic journals by Asian psychiatrists. Some of the findings are: 1) Symptoms of schizophrenic inpatients are very similar across countries/areas. 2) There has been a major shift of

S 28-2

Prescribing for elderly depression: Excessive or inadequate?

Mian-Yoon Chong

Department of Psychiatry, Kaohsiung Chang Gung Memorial Hospital, Taiwan

Background: Depression in the elderly is frequently undetected or inadequately treated. This study aims to investigate pharmacotherapy of elderly depression by comparing prescribing pattern for inpatients of old age depression between psychiatrists and non-psychiatrists. Methods: A random sampling of 5% of inpatients in Taiwan from 2001 to 2003 was selected for the study. Elderly subjects aged 65 and older and with a diagnosis of any depressive disorders were included as the study sample. The prescribing pattern of the drugs and their dosages used were analyzed and compared. Results: An increased rate of depressive neurosis in female elderly inpatients was observed throughout the years. Eight-eight percent of elderly depressed inpatients had two or more comorbid physical illnesses. In the observations that followed, the most commonly prescribed psychotropic drugs were: antidepressants (71.4%), anxiolytics (62.6%) and hypnotics (51.4%). Results indicate that psychiatrists utilized a higher rate of antidepressants and other psychotropic drugs except for anxiolytics than non-psychiatrists. Although selective

serotonin reuptake inhibitors (SSRIs) were commonly prescribed, non-psychiatrists nevertheless preferred the use of moclobemide and the tricyclic antidepressants (TCAs). Trazodone was the most preferred antidepres-sant but was frequently used concomitantly with other antidepressant in lower dosages. While it was observed that there was a high-dose prescription in newer antide-pressants, there was lower dosage prescription in older drugs like TCAs.

Conclusion: Although there were differences in the prescribing pattern of antidepressants between psychiatrists and non-psychiatrists for the treatment of elderly depression, the antidepressants were however, generally underutilized and with inadequate dosages.

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Current prescription pattern of Korea: An analysis of national insurance data

Jong-Woo Paik

Department of Psychiatry, Kyung-hee University School of Medicine, Korea

Background: most of the information on drug utilization has been derived from a small study, it is necessary to investigate patterns of psychotropic medication using large population-based database. Methods: We conducted a cross-sectional study by collecting prescription data from National Health Insurance Database. Ambulatory patients aged 18 to 85 were selected if they were diagnosed with depression. Patients with schizophrenia and bipolar disorder were excluded. Results: The study population consisted of 648,237 outpatients. The mean age of patients was 51.6 years and 446,605 (68.9%) patients were female. Of these patients, 73.1% per claim were prescribed antidepressants and no significantly difference between male and female. Among patients with depressive disorder, the most common prescribed medication was tricyclic antidepressants (TCAs, 52.2%) followed by selective serotonin reuptake inhibitors (SSRIs, 38.6%), serotonin noradrenalin reuptake inhibitor (SNRIs, 5.5%). The elderly depressed patients more prescribed TCA than younger patients, while young patients were more likely to receive SSRIs. The concomitant psychotropic medications were prescribed 82.9% per claim.

Conclusion: This study showed that the prescription rate is 73.1% for antidepressants, 82.9% for concomitant psychotropic medications. TCAs were the most widely prescribed antidepressants until now. The elderly depressed patients prescribed more TCAs than younger

patients, but less likely to prescribe SSRIs. Although some limitations on interpretation, this study included nearly all drug utilization of depression patients of Korea.

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Pattern of prescribed psychotropic drugs

Andi Jayalangkara Tanra

Department of Psychiatry, Hasanuddin University, Indonesia

Introduction: Recently, Bipolar Disorder had been one of the most important topics in Psychiatric research worldwide. Little had been known about pattern prescribed psychotropic among Indonesian Bipolar Disorder Patients. This study was aimed to examine the frequency of prescribed psychotropic pattern among Indonesian Bipolar Disorder patients and to compare with result from other studies in developed countries. Method: A consecutive sample was collected from outpatient psychiatric clinics from several hospitals in Makassar, Indonesia. The cross sectional data of demography and clinical diagnostic based on ICD X and DSM-IV-TR and prescribed drug pattern were recorded using a standard protocol and data collection procedure. Result: All result and conclusion will be described and discuss in symposium later.

Symposium 29

Autism Spectrum Disorder across Life Span

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Clinical manifestations and eye tracking patterns of adults with autism spectrum disorders (ASD)

Nobumasa Kato

Department of Psychiatry, Showa University Karasuyama Hospital, Japan

Asperger syndrome is characterized by impaired development in social interaction and a restricted and stereotyped repertoire of activities and interests, but no history of language delay. Asperger syndrome and autism are thought to merge into the same spectrum, called autism spectrum disorders (ASD), since 1) after matured, high-functioning autism and Asperger syndrome exhibit the identical clinical manifestations, and 2) recent clinical

° _ statistics unanimously show the steep increase of ASD ctvi with high intelligence, reporting the prevalence as high 7 d as 1/100-150. We have opened a new outpatient clinic ( i— and day-service facility with social skills training in 2008 ac at Karasuyama Hospital in Tokyo, which focuses on c adults with neurodevelopmental disorders. After 4 years, 5 more than 2,000 patients newly visited our clinic and the visitors are required to fulfill Autism Spectrum Quotient (AQ), WAIS-III and PDD-Autism Rating Scale (PARS). When diagnosed as possible ASD, they are asked to take eye-tracking task as well as both volumetric and functional MRI studies. Our accumulating data are going to clarify the nature of impairments in non-verbal communication in adult ASD, which may cast new vistas in the future of autism research. Here some of our findings will be presented, as previously published in the list below in part.

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Genomic structural variations in patients with autism spectrum disorders from Taiwan

Chia-Hsiang Chen

Department of Mental Health and Addiction Medicine, National Health Research Institutes, Taiwan

Autism spectrum disorder (ASD) is a neurodevelopmen-tal disorder with a high genetic basis in its etiology. Understanding the genetic underpinnings of ASD is the foundation for the advancement of the treatment of patients with ASD. The genetic basis of ASD is a complex and heterogeneous that may involve many genes, inter-genic interactions, and gene-environment interactions. In this study, we conducted karyotype analysis and microar-ray based-comparative genomic hybridization (aCGH) analysis to understand the relationship between the genomic structural variations and ASD in our population. So far, we have detected two male patients with XXY, one male patient with XYY, one male with chromosomal translocation between chromosomes 4 and 14, one male patient with 4q deletion using conventional karyotyping analysis. In our aCGH study, we detected 17 submicro-scopic genomic copy number variations (CNV) in a sample of 383 patients, with the frequency of approximately 4.4%. Among these 17 patients, 10 patients had de novo CNVs, while 7 patients had CNVs inherited from their parents. Notably, we found a patient who inherited a microduplication at 4q12-q13.1 from his mother, and a microdeletion at 5q32 from his father, indicating a compound double hits of genomic mutations

might be associated with autism. Taken together, our study indicates that genomic structural variations contribute a significant role to the genetic underpinnings of ASD, and may shed a new insight into the pathogenesis of ASD.

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Issues in adolescents with ASD: Focused on social skills training

Hee Jeong Yoo

Department of Psychiatry, Seoul National University Bundang Hospital, Korea

Adolescent is an important transition in developmental trajectory. This lecture will discuss about the characteristics of symptoms, behavior and special needs for adolescents with autism spectrum disorders (ASD) in bio-psycho-social aspects. The second part of the lecture will focus on the Program for Evaluation and Enrichment of Relational Skills (PEERS, Laugeson et al., 2010). PEERS is parent-supported social skills training, developed for teaching skills needed starting and maintaining friendship in ecologically valid manner, acknowledging specific cognitive-behavioral patterns of teens of ASD. The basic principles and structures, contents of treatment sessions will be presented. Research data regarding treatment evidence will be presented, including data from US and randomized controlled trial data from Korea. Its clinical implication and further direction will be discussed in the context of cultural compatibility of PEERS program.

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The relationship between ASD and ADHD in children

Soyoung Lee

Department of Psychiatry, Soonchunhyang University College of Medicine, Korea

Autism spectrum disorders (ASDs) and attention-deficit/ hyperactivity disorder (ADHD) overlap in the core impairments of the disorders (social interaction, communication, and restricted interests). However, the current edition of the DSM precludes making ADHD diagnosis in children with ADSs. Although previous studies indicate high levels of comor-bidities between ASDs and ADHD, very little is known

about what causes the association between these two disorders.

Thus, in this presentation, we will first review the phe-notypic overlap of ADHD and ASDs. Then, we will discuss the issue about the DSM precluding a comorbid diagnosis of ADSs and ADHD. As next, neuropsychological, genetic and neuroanatomical findings of ADSs and ADHD in regard to the comorbidity will be summarized.

Symposium 30

Psychotherapy Updated

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Both gods and doctors are needed: Strategies in psychotherapy for psychiatric patients with Chinese popular religion

Jung-Kwang Wen

Department of Psychiatry, Tsyr-Huey Mental Hospital, Taiwan

Chinese popular religion (or folk religion) is defined here as the blend of Daoism, Confucianism, Buddhism, and the primal religion: shamanism. Around 44% (most popular) of the general population in Taiwan belongs to this category. Belief in possession by spirits, evil or benevolent is most often associated with mental disorders. Shamanistic meditation, trance, and possession, either by self-practice in the family or group practice at temples or shrines are even more popular in these two decades. Both somatization and dissociation, instead of psychologization and repression, are two major coping mechanisms in Chinese societies where mental illness is heavily stigmatized. Hence, psychotherapy for psychiatric patients with Chinese folk beliefs should be practiced in a culturally sensitive manner that takes traditional religiosity and spirituality into account. The following strategies might be good for the conduct of psychotherapy in this regard: 1) Therapist's conceptual re-orientation and establishment of cultural competence in health care, and the adoption of the 'Bio-Psycho-Social-and Spiritual' theoretical model would be essential and useful. 2) Relationship-oriented and family-centered approach from the outset, which pay prior attention to the patient's 'relational self' and his family and their dynamic interactions in help-seeking and illness behaviors is vital. The therapist's open-minded, respectful, and comfortable attitude addressing their experiences would be helpful for

the making of good therapeutic relationship. 3) It needs to be more directive, supportive, and less analytic and insight-oriented. Patients tend to externalize the illness problems and be relationship (guanxi) oriented in their world views. 4) 'Both the visible (body) and the invisible (mind/soul) need to be treated.' Integration of psychotherapy and psycho-pharmacotherapy should be well provided. 5) 'Both gods and doctors are needed'. Collaboration of folk psycho-therapy and psychiatric treatment should be addressed and worked on in a positive way. Case illustration and discussion will be presented.

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The trends of recent psychotherapies

Yong Chon Park

Department of Psychiatry, Hanyang University Guri Hospital, Korea

There are more than 500 kinds of psychotherapies in the world. For the convenience, the author classified psychotherapies into three major areas. One is the behavior therapy. It deals with the behavior and tried to change the behavior itself. The second one is cognitive therapy. It deals with the thinking. Many techniques were developed to change the thinking. The cognitive therapists believe that changing the thinking can influence behavior and emotion. The third one is the dynamic therapy. It deals with the emotion and the dynamic therapists believe that the changing the emotion is the fundamental transformation which can influence the thinking and the behavior. In the aspect of time consuming and strength of influence, the author believe that dynamic therapy is the most fundamental among the psychotherapies because the dynamic therapy can influence the thinking and the thinking can influence the behavior. Therefore, the dynamic psychotherapy is the prerequisite of learning the psychotherapy. The understanding of dynamics of the patient is the start of treating the patient. Mastering of dynamic psychotherapy can be the shortcut of understanding cognitive therapy as well as behavior therapy. Nowadays it is well acknowledged that the curative factor of psychotherapy is the therapeutic alliance. Practitioner of the three kinds of therapies mentioned above may agree with that comment. Along with these lines Tao psychotherapy may be the best fit model. Dong Shick Rhee, the founder of Tao Psychotherapy emphasizes the importance of 'nuclear feeling'. Recently the cognitive therapy and the behavior therapy also show the importance of the emotion. Another way to promote the relationship with the patient is approaching the patient with supportive mode. The representative method is the Short

C/) CD

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term Psychodynamic Supportive Psychotherapy invented by the Netherland group. Approaching the patient with supportive rather than analytic way was proven to be successful.

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Brief Integrative Psychological Therapy (BIPT)

Ee Heok Kua

Department of Psychological Medicine, National University of Singapore, Singapore

There is a paucity of information on how psychological therapy is practiced in Asia. This presentation will discuss Brief Integrative Psychological Therapy or BIPT (Feng et al., 2011). Psychotherapeutic integration is motivated by a need to view beyond the restricted single-school approach to benefit the patient. Integration means intent to increase therapeutic effectiveness by looking beyond a monistic approach. Undoubtedly, commonalities in the different schools of psychotherapy to predict good outcome are a positive therapy relationship, empathetic therapist and hopeful client. BIPT evolves and transcends established schools of psychotherapy and is an attempt to ascertain what therapy is appropriate for particular patient or client. Besides the 3 main therapies - psycho-dynamic, cognitive-behavioural and supportive, other methods used include meditation, narrative therapy, and relaxation therapy. It is important to know what type of therapy fits what type of clients - what works best for them (Fonagy, 2010). In essence, psychological therapy has to be personalized and BIPT is a clinical approach to individualize therapy for the person. The emphasis should be on the centrality of personhood. Psychological therapy improves therapeutic relationship like in schizophrenia or depression and encourages medication compliance or adherence. Providing brief supportive psychological therapy combining with other non-pharmacological techniques like cognitive-behavioural therapy or mindfulness meditation can help. Understanding the cultural mores is crucial in psychological therapy and cultural issues are explored with affirmation of cultural values. Compared with psychodynamic psychotherapy, BIPT is more structured and directive but not dogmatic. Treatment is not just symptom relief but also to develop coping strategies for the future - building resilience or an undefeated mind. The keywords in this process are learn, growth and resilience. BIPT can equip a person to cope with life stressful personal situations and interpersonal relationships. What BIPT hopes to

achieve is a model of psychological balance. It is undeniable that brief therapy and integration are the psycho-therapeutic zeitgeist of the 21st century in Asia (Kua, et al., 2011).


Feng, L., Cao, Y., Zhang, Y. Wee, S.T., Kua, E.H. (2011) Psychological therapy with Chinese patients. Asia-Pacific Psychiatry, 3: 167-172. Fonagy, P. (2010) Psychotherapy research: do we know what works for whom? British Journal of Psychiatry, 197: 83-85.

Kua, E.H., Goh, L.G., Cheong, P.Y., Wee, S.T. (2011) Brief integrative psychological therapy. Proceedings of the Asia-Pacific Conference on Ageing, Singapore 24-26 March, 2011.

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An introduction to taopsychotherapy - Focusing on craving for love

Tae-Jin Choi

Department of Psychiatry, Insung Hospital, Korea

Dr. Rhee Dongshick, the founder of Taopsychotherapy had said that; The essence of Taopsychotherapy is to bring spring to the patient who is shivering in a frozen land. With his personality the therapist brings spring to the patient.

Spring is compassion, Jen (Confucianism), God's grace, and complete empathy. To achieve this, a therapist must purify his mind by removing his 'Nuclear Feeling.' The root of Nuclear Feeling is Craving for Love. To renunciate Craving for Love completely one must overcome life and death mind.

The process of confronting and overcoming existential anxiety and achieving vivid compassion is like the process of death and resurrection in the eyes of the author.

Symposium 31

Depression in Asia

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Managing major depression in Malaysia: Challenges and current issues

Hussain Habil

Department of Psychiatry, Director UMCAS, Malaysia

Major depression disorder is common psychiatric condition which has been noted to increase in its prevalence. In fact it is predicted that if not effectively tacked it will be the main cause to the burden of health among Malaysian communities. Unfortunately patients who suffer from such condition still are not accessible to services which aim to treat the condition. This is despite many attempts that has been implemented to make sure the sufferers are given opportunities to early interventions. It includes training primary care doctors, media conferencing and introduction of depressive awareness day. Among major concern was due to stigma toward the illness and lack of understanding about the condition which influence patients and their relative to seek treatment from health workers especially psychiatrist. The influence of traditional treatment in Malaysia was still strong. Hence there is tendency for many depressed patients to seek treatment from traditional healers which sometime delay medical therapeutic interventions. Many complications were reported due to such this type of treatment and among them include exorbitant fees and loss of income. For the past 15 years there has been new approach in managing depression with second generation antidepres-sant. It does show much more efficacious and fewer side effects compared with the 1st generation anti-depressant. Therefore it is user friendly especially if it's meant to be used by primary care doctors. In this regards more effort has been conducted to persuade more of them to identify and treat patients who suffer from the condition. In order to guide them ministry of health of Malaysia has also come out with clinical practice guidelines in management of major depressive disorder. It help doctors especially primary care practitioners how to treat patients with depression either using latest antidepressant or by psychosocial intervention.

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Characteristics of depression in young Japan

Shigenobu Kanba

Department of Psychiatry, Kyushu University, Japan

Until the 1970s, the push for capitalist economics was an obvious value shared by Japanese, who sought material and economic wealth and convenience when recovering from the war. Based on this set of values, the Japanese system coupled lifetime employment and trade within affiliated groups by industry protected by government policies. The secular ethics of Shuchaku-kisitu (Typus Melancholicus) personalities had an affinity for this type of environment, and they took center stage in the ethics of many people. However, in the early 1990s, the collapse of the 'bubble' economy and the rapid fall in stock and land prices led to the abolishment of the 'convoy system,' In the second half of the 1990s, the Japanese system (lifetime employment, seniority system, family enterprises) broke down. In 1997 a major securities company and bank failed. In 1998, the number of suicides rose from 23,000 to 32,000 (particularly in 50-64-year-old males in large cities). Utilitarian business management by stockholders and 'survival of the fittest' pressure were loaded on both companies and workers. It is difficult for Shuchaku-kisitu (Typus Melancholicus) to find a place of their own when the trend in society overall is not toward an orientation of regularity and order, but toward free pursuit of self gain without constraint by the existing order (modern capitalist society). On the contrary, characteristics of depression in recent years were formulated by Tarumi (2004). We are beginning to see the appearance of not only a group that corresponds to Shuchaku-kisitu, but also many people who do not belong to that group. They are people who were not seen in the past 'work-oriented' age. Rather than being sticklers for norms, they dislike being bound by norms who present with depression complaining of constant fatigue and loss of interest. This tends to be seen more in younger people.

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Inadequate treatment of major depressive disorder or anxiety disorder in Taiwan: Problems and recommendations

Winston Shen

Department of Psychiatry, TMU-Wan Fang Medical Center, Taiwan

Treating depressive disorder or anxiety disorders adequately is a common problem in Taiwan, and it has not been well-addressed. This symposium lecture is intended to explore the magnitude of problems, and to recommend possible improvements for this situation. The medical care for all the patients in Taiwan has been under the coverage of National Health Insurance, a single payer for the whole country. The studies of the insurance claim data can serve as an easy tool in monitoring the problem of adequate treatments for those conditions. Outpatient prescription rates for antidepressants from psychiatric clinics in Taiwan in 2000 were 18.1% (Su et al. 2002), comparing to 63.3% in the USA (Pincus et al. 1998). The patients in Taiwan with the diagnosis of major depressive disorder received antidepressant at the rate of 90.9%, phobia 84.6%, obsessive-compulsive disorder 80%, various anxiety disorders 27.7%-30.4% (Chien et al. 2010). The top sale of venlafaxine in 2005 was ranked beyond the top sales of the 50 drugs in all prescriptions in Taiwan (comparing to three antidepressants were within top 10 drug sales in the US). The problems are summarized as the following factors: (A) over-presentation of the complaints or symptom of insomnia in the clinical picture by the patients in Taiwan, (B) insensitivity of diagnosing depressive disorder and anxiety disorder by the psychiatrists, (C) over-use of 'hypnotics' in dealing depressive and anxiety disorders by the patients and clinicians, and (D) inability to prescribe inadequate dose of an antidepressant in a daily defined dose. Those problems in patients in Taiwan may also exist clinically in patients in Eastern Asian countries. The presenter will address those issues in this presentation.

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Korea. In this study, we examined the baseline characteristics of the depressive participants as the hospital-based cohort.

Objectives: We performed this study to investigate the clinical risk factors, courses, and outcomes of depression in the Korean society. Also we evaluated the changes in the quality of life and the risk of suicide according to the clinical course of depression, as well as the actual social and economic burden of depression. The data gathered from the study will provide the clinical evidence for the development of Korean-specific diagnostic tools and clinical practice guidelines.

Methods: Participants were assessed using various instruments including the Clinical Global Impression scale, 17-item Hamilton Depression Rating Scale (HDRS-17), Hamilton Anxiety Rating Scale, Brief Psychiatric Rating Scale, Social and Occupational Functioning Assessment Scale, Beck Depression Inventory-Second Edition, Scale for Suicide Ideation, and World Health Organization Quality of Life assessment instruments-abbreviated version. Also, personal histories of medical and psychiatric illnesses and the range of socio-epidemiologic and clinical data were collected from each participant.

Results: One thousand one hundred eighty three participants were recruited from 18 hospitals. The mean age of the participants was 47.9 ± 15.9 year-old, 74.4% were female, 82.9% had been diagnosed of major depressive disorder, 40.9% were experiencing their first depressive episode, and 21.4% had a past history of suicide attempts. The majority (85.3%) of the participants were moderately to severely ill. The average HDRS-17 was 19.8 ± 6.1. Significant gender differences at baseline were shown in age, education, marriage, employment, religion, and first depressive episode. Conclusion: The baseline findings in the CRE-SCEND study showed some different characteristics of depression in Korea, suggesting a possibility of ethnic and cultural factors in depression. Key words: Depression, Hospital-based, Longitudinal, Observational, Prospective.

Cohort study of depressed patients in Korea; Focused on CRESCEND study

Tae-Youn Jun

Department of Psychiatry, The Catholic University of Korea, Korea

Introduction: The Clinical Research Center for Depression (CRESCEND) study is a 9-year observational collaborative prospective cohort study for the clinical outcomes in participants with depressive disorders in

Symposium 32

Return-to-Work Program; Current Situation of Supporting System for Returning to Work at Workplace for Employees with Mood Disorders, Examples of Implementation in Japanese Leading Companies

recovery through the Daily Activity Record Sheet,

(2) arranging a gradual RTW plan for 6 months, and

(3) monthly interviews with an occupational physician. We retrospectively evaluated 142 implementations of the old RTW program and 54 implementations of the new RTW program. The relapse-free job retention proportion within 1 year was 54.2% in the old program and increased to 91.6% in the new program.

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Occupational mental health in Japan and best practices for the return-to-work program at the workplace

Katsuyuki Namba

Department of Human Resources Management, Roche Group Chugai Pharmaceutical Co., Ltd., Japan

In Japan, mental disorders in workers have become a major national problem. According to the Occupational Safety and Health Law and other guidelines from the Ministry of Health, Labour and Welfare, employers have a legal duty to take care of workers' mental health problems and return-to-work (RTW). An employer with more than 50 employees must appoint an occupational physician, and an employer with 1,000 employees or more must appoint a full-time occupational physician. Many companies also hire occupational health nurses. Recently, workers' mental health is delegated to occupational psychologists and external EAP providers.

Overtime-work is another serious problem. Overtime-work causes death from ischemic heart disease or cere-brovascular disease, and suicide from mental health disorders. The number of certified workers' compensations due to mental health disorders has been increasing.

To alleviate this problem, Japanese companies are working on mental healthcare for workers from the perspective of compliance, risk management, prevention of health problems, cost and productivity, and corporate social responsibility.

Many companies have been working according to the government's guidelines regarding the RTW program. However, there have been many problems in implementing the RTW program, such as difficulty in evaluating recovery and forming an appropriate rehabilitation plan. Relapse after RTW is also a crucial issue. In this symposium, we introduce the improved RTW program in a Japanese company. We made the following improvements in the RTW program: (1) evaluation of

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How can occupational health staffs make early detection of mood disorder in work place and how can they support for returning to work?

Hisashi Eguchi

Department of Shiga Gamou Plant Environment and Safety Department, Kyocera Cooperation, Japan

In Japan, depression incidence rate is 1% in male, and 3% in female. According to a labor statistics in 2007, 7.6% of the workplaces have experienced that some employees are absent from work over a month by mental health disorders. 33.6% of the workplaces implement the mental health activities to reduce the number. In order to reduce the number of the employees with mood disorders, comprehensive preventions are very important, which include primary, secondary and tertiary implementations. The primary means to prevent from diseases completely, the secondary is early detection of mood disorder, and the tertiary is to prevent relapse through the return-to-work (RTW) program. In order to detect mood disorders as early as possible, we have two ways. One thing is the implementation of mental health check-up for all employees. The other is the communication with supervisors in workplaces. In my workplaces, every year, the brief job stress questionnaire is implemented for all employees and the worst 5% of the employees are interviewed by occupational physicians and nurses to evaluate their mental health condition. Meanwhile, supervisors are regularly educated and trained about occupational mental health. Through these implementations, supervisors get familiar with the occupational health staffs. And then, they become easier to consult with the healthcare staffs if mental health problems happen in their workplaces. During sick leave, the absent employees are interviewed by the occupational health staffs monthly to observe their daily activities and to determine whether they are ready to return to work or not. At that time, the occupational health staffs cooperate with the clinical psychiatrists in charge to facilitate the RTW in medical

facilities. In my presentation, I will explain specifically how occupational health staffs can make early detection of mood disorder in work place and how they can support for returning to work.

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Difference between the rework program at work-site and the rework assist program provided by employee assistance program, and its cooperation with each other

Rework program at Tokyo electric power company, incorporated

Yujiro Hara

Department of Tama branch, The Tokyo Electric Power Company, Incorporated, Japan

Mental health problems are getting bigger issues at Tokyo Electric Power Company (TEPCO). On the lines of the national guidelines in Japan concerning occupational mental health, TEPCO has implemented its own return-to-work program, which is named 'Rework Supported Service'. The purpose of 'Rework Supported Service' is to improve employees' engagement with work and feel comfortable in their jobs. TEPCO is such a big organization that actual management of the program differs from branch to branch by the arrangement of the occupational health staffs, the number of employees, the location, etc. The Tama branch, which is located in the western part of Tokyo and I have been concerned with as an occupational health psychiatrist, has about 1300 employees and nine business places. Each place has its own occupational health physician. Furthermore, there is a psychiatrist who has expertise in mental health problems. Those occupational health doctors usually work part-time and attend work a few times a month. Accordingly, if mental health problems happen, 2 nurses who work full-time deal with the cases firstly and then they are introduced to the psychiatrist. 'Rework Supported Service' is ordinarily adapted in the periods of 'leave of absence'. Once 'Rework Supported Service' is adapted for employees, the administrative staffs and the occupational health staffs coordinate on designing their own rework program which include operating PC, reading text books and writing document files, etc. Through the program, employees are supported and trained appropriately for three months at the maximum. Thus, 'Rework Supported Service' is characterized by the precise cooperation and the generous supports by each staff. Our programs are hospitable for the employees who suffered from mental disorders. The future subject of us is how we should reduce the number of the employees who often repeat 'leave of absence'.

Rino Umanodan

Department of Occupational Mental Health, Kyoto office, Health Wave Co., Ltd., Japan

Employee Assistance Programs (EAPs) is a workplace program designed to assist (1) work organizations in addressing productivity issues, and (2) employees and family members in addressing personal difficulties (EAPA, 2011). In Japan, the EAP was first received as a counseling and consultation resource for a risk-management tool and an outsourcing of mental health services (Shima et al., 2002). In recent years, there have been four types of EAP systems: internal EAP - the system is provided solely by the employees of the company; external EAP - the system is provided by outsourcing mental health services; combination EAP -the system is provided as a combination of internal and external EAP and; consortium EAP, which means several companies are cooperating to outsource external EAP. In this symposium, we introduce return-to-work (RTW) service as an external EAP provider. In the area of return-to-work (RTW) program, Japanese Ministry of Health, Labor and Welfare implemented the national guidelines for workers who take sick leave because of mental problems. HEALTH WAVE Co., Ltd. often takes 'external EAP' and 'combination EAP' systems as an external EAP provider. However, small- and medium-sized firms tend to take the former system, while the big establishments opt for the latter because of the cost-effectiveness of EAP service. We would like to introduce our activity based on the size of the firm. The program will involve the a) cooperation of the organization staff; b) consultation to clients' supervisors; c) rehabilitation aid and/or counseling service for individuals who quit from their jobs and; d) prevention of a recurring psychological/ psychiatric issue.

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Current achievement and future challenges of EAP in Japan; Comparing with good examples in Sweden

Kazutoshi Maeda

Department of Psychiatry, LOV Corporation, Japan

A return to work of the worker who has been long-time absence because of a metal decease such as Depression is one of the big issues in an Occupational health care system in a Japanese company. Especially, so called, 'New type of Depression' is becomes big problem for the Occupational health staffs, as it has following unique characteristics. (1) 'New type of Depression' is often shown on the young aged workers who feel depressive during only the time of work. Without the work, they look like good condition and can be enjoy their private life. (2) Antidepressants, such as SSRI, are not so effective for them. (3) Many cases are seemed that their depression is caused by their low business skill, inexperienced in

business, or low communication skill. It is considered that 'New type of Depression' might be closed to the adjustment disorder. Occupational education and training are important for them to work continuously. EAP (Employee Assistance Program) is expected the big role for 'New type of Depression' workers. EAP has the both functions to assist the workers by Psychological treatment, and to support the Occupational education and training. Those functions might be quite effective for those workers. The good examples in Sweden give many suggestions for us. Sweden is known as their superior services from their occupational health care system. Additionally, they have leading public pension plan which can support a person who has severe mental decease. And their high level of public education support program for the adult-age generations, such as the free tuition and the scholarship, is valuable for brushing up or getting new business skills. It means that the pension plan is the safety net service and good education support program is the preventive service in the Occupational health care system.

O o 2 en 3 i t CD Q.

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Case Conference 1

A Case of Dr. Rhee's Taopsychotherapy: 31 Years Old Woman with Schizophrenia

Introduction and summary of the case

Sungchul Chung

Department of Psychiatry, Dr. Chung's NP Clinic, Korea

This consultation interview by professor Rhee took place on November 25, 2005 at the request of a counselor named K. This patient was 31 years old single woman with schizophrenia and had been medicated anti-psychotics for more than 15 years. Counselor K had started her therapy with the patient on April 1, 2005. The patient became acquainted with counselor K who was featured in her parish church newsletter. She decided to see counselor K because she felt that her previous therapist was not empathic to her feelings for a man whom she considered like a brother. The patient had been seeing her previous therapist for 3 years, mainly in cognitive-behavioral orientation, followed by 12 inconsistent therapy sessions with counselor K. The patient was the only child and both of her parents were deceased. Her father died from a stroke in 1985 at age 61 when she was 11-years-old. Her mother also died from a stroke in 1994 at the same age of 61 when the patient was 20-years-old. The first episode of the patient's several psychotic breakdowns occurred in 1990 when she was a sophomore in high school. The episode was preceded by a dream in which her mother died. The patient was hospitalized for 4 months. After her discharge, she was taken in by a nun under her care at a parish church. She was hospitalized in 1998 for the second time for 2 months. She had been medicated since first breakdown and also been receiving psychotherapy since 2002. The patient's symptoms included severe anxiety, paranoid ideation and delusion as well as feeling of anger and guilt. She suffered from delusions of everyone around her disliking and hating her. She thought people blamed her and regarded her as strange. She reported the feeling of inhibition by the recurrent image of Jesus severely bleeding in pain and thought she was guilty for Jesus' death. The reason for counselor K's consultation to Professor Rhee was (1) Would it be right to have further interviews with this patient in spite of the fact that the sessions were abrupt and requested only when the patient felt urgent from being overwhelmed by enormous anger and resentment. (2) How to deal with the patient's feeling of intense anger

and resentment, and simultaneous feelings of shame and guilt. Counselor K was in extreme difficulties in dealing with them. After this consultation interview with Dr. Rhee, the patient reported that she came to understand her hostility toward her mother clearly. She also verbalized that she was in favor of counselor K addressing her emotions. She became more emotionally expressive during the interview with counselor K. However, she continued to get overwhelmed by shame and anger. She said during those times she felt naked and had difficulties in expressing her feelings. The patient still called counselor K from time to time when she gets emotionally unstable.

Case Conference 2

The Cultural Universality of the Dream Analysis

The cultural universality of dream analysis

Mingeol Kim

Department of Psychiatry, Min Mind to Mind Clinic, Korea

Freud said that the universal nocturnal phenomenon of dreaming provided compelling evidence for mental life below the surface of consciousness. The latent content calls forth opposing forces whose aim is to disguise, repress, or otherwise censor the disturbing wish. This mental conflict leads to the dream work. The operations of the dream work involve modes of primary-process thinking such as displacement, condensation, substitution, and symbolic representation, as well as secondary elaboration. The final result is the dream's manifest content - the remembered dream (Brandell 2004). Dream is ubiquitous, however, many of western psychoanalysts have been doubted that the efficacy of psychoanalysis for non-western people. Some authors reported that the conflicts between the 'future time' and 'individualistic' values of psychoanalysis, and the veneration for the 'past' and 'loyalty' to the extended family incorporated into Chinese (Fong 1968) and Japanese (Doi 1964) ethnic values. The value placed by Japanese and other Asians on formality and fine-tuning of facial and body messages in contrast to the informality and unawareness with which Americans engage in nonverbal communication (Johnson, Marsella, and Johnson 1974). Underutilization of psychotherapy services by Asian-Americans has been noted by others (Sue and McKinney 1975). It is usually

attributed to a combination of staff attitudes ('They have no problems'), and Asian values opposed to self-assertion, open expression of feelings, or seeking help outside of the boundaries of the group (Ho 1976). In this

psychoanalytic case seminar, we will present a Korean analyst-analysand case that shows how to successfully analyze transference and dreams during the mid phase of the psychoanalytic process.

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Workshop 1

Research Method in Pharmacoepidemiology W 1-1

Research methods in pharmacoepidemiological study

Mian-Yoon Chong

Department of Psychiatry, Kaohsiung Chang Gung Memorial Hospital, Taiwan

Studies have confirmed that large differences exist between the conditions of pre-marketing clinical trials and those of the actual practice several years into the market life of a pharmaceutical product. Employing methods of epidemiology into the content area of clinical psychopharmacology could allow us to assess the utilization and impact (benefit and risk in 'real life' conditions) of drugs at the level of the population actually treated. The aims of this workshop are to introduce the basic concepts and epidemiological methods used in studying psychopharmacological drugs. The workshop consists of 3 parts: an introduction, statistical analysis, and an exercise. It begins with an introductory of the 3 main areas of pharmacoepidemiological study: drug utilization, prescribing behavior and pharmacoeconomics. The second part will provide introductions on the basic concepts for commonly used statistical techniques as well as the regression modeling of explanatory variables in literatures, with illustration on the applicable situations for different regressions, and the interpretation of parameter

estimates. It will specifically focus on modeling explanatory variables for diagnosing confounding effect, interaction effect and medical related mechanism. Through the step-by-step engagement, you will be benefited from this workshop with a clear understanding of the various kinds of method used, especially the modeling techniques and the interpretation of the results of any pharmacoepide-miological study.

Statistical analysis in pharmacoepidemiological study

Yi-Hsin Yang

Department of Pharmacy, Kaohsiung Medical University, Taiwan

Pharmacoepidemiology studies are to investigate the effects of drugs in population; particularly, benefits and ADR. This lecture intends to provide basic concepts for commonly used statistical techniques as well as the regression modeling of explanatory variables in literatures. Introductions will be first given on the applicable situations for different regressions, and the interpretation of parameter estimates. Special focuses will be on modeling explanatory variables for diagnosing confounding effect, interaction effect and medical related mechanism. Learning the modeling techniques from this workshop, researchers would find a wider interpretation of their study results.