BACKGROUND:Evidence regarding schizophrenia relapse following acute electroconvulsive therapy (ECT) is sparse compared with that for depression, and we have no clear consensus on relapse proportions. We aimed to provide longitudinal information on schizophrenia relapse following acute ECT. STUDY DESIGN:This systematic review and meta-analysis included randomised controlled trials (RCTs) and observational studies on post-acute ECT relapse and rehospitalization for schizophrenia and related disorders. For the primary outcome, we calculated the post-acute ECT pooled relapse estimates at each timepoint (3, 6, 12, and 24 months post-acute ECT) using a random effects model. For subgroup analyses, we investigated post-acute ECT relapse proportions by the type of maintenance therapy. STUDY RESULTS:Among a total of 6413 records, 29 studies (3876 patients) met our inclusion criteria. The risk of bias was consistently low for all included RCTs (4 studies), although it ranged from low to high for observational studies (25 studies). Pooled estimates of relapse proportions among patients with schizophrenia responding to acute ECT were 24% (95% CI: 15-35), 37% (27-47), 41% (34-49), and 55% (40-69) at 3, 6, 12, and 24 months, respectively. When continuation/maintenance ECT was added to antipsychotics post-acute ECT, the 6-month relapse proportion was 20% (11-32). CONCLUSION:Relapse occurred mostly within 6 months post-acute ECT for schizophrenia, particularly within the first 3 months. Relapse proportions plateaued after 6 months, although more than half of all patients could be expected to relapse within 2 years. Further high-quality research is needed to optimise post-acute ECT treatment strategies in patients with schizophrenia.

Functional connectivity (FC) is often used to identify personalized targets for transcranial magnetic stimulation (TMS). However, existing methods often overlook individual differences in whole-cortex network organization. Furthermore, in some personalized TMS protocols, lower stimulation intensity is used for targets closer to the scalp, which may improve patient tolerance. Here, we develop an algorithm to simultaneously optimize FC and scalp proximity for target localization. We first use the multi-session hierarchical Bayesian model (MS-HBM) to estimate high-quality individual-specific cortical networks. A tree-based algorithm is then used to select the optimal target. With essentially no parameter to tune, our framework may potentially improve generalizability across populations. We compare our approach with existing "cluster" and "cone" algorithms. In two test-retest datasets of healthy individuals from the United States and Singapore, tree-based MS-HBM reliably identifies personalized TMS targets for depression near the scalp. Tree-based MS-HBM targets compare favorably with cluster and cone targets in terms of reliability, scalp proximity, and FC to the subgenual anterior cingulate cortex (sACC) in new out-of-sample MRI sessions. To demonstrate versatility, the same algorithm identifies personalized anxiety targets without tuning any parameter. In patients with treatment-resistant depression, tree-based MS-HBM targets compare favorably with cluster and cone targets in terms of reliability, scalp proximity, and sACC FC, hypothetically reducing stimulation intensity by 15% and 5%, respectively. MS-HBM also exhibits the best (most negative) electric-field hotspot sACC FC and highest reliability in induced electric fields. Overall, tree-based MS-HBM provides a robust, generalizable framework to estimate near-scalp personalized targets across populations.

Background Trauma exposure and emotion dysregulation are transdiagnostic risk factors for post-traumatic stress disorder (PTSD) and severe mental disorders (e.g., depression, and schizophrenia spectrum disorders). The present study elucidated the latent profiles and interrelationships between emotion dysregulation and psychopathology (PTSD, dissociation, psychosis, and affective symptoms) in a trauma-exposed severe mental illness population. Methods We recruited a large sample of trauma-exposed outpatients with mood disorders and schizophrenia spectrum disorders in Singapore (N = 461; Mage = 35.47). PTSD and dissociation were assessed with the Clinician Administered PTSD Scale for DSM-5. Psychosis and affective symptoms were assessed with the Brief Psychiatric Rating Scale-Expanded. Emotion regulation ability deficits were assessed with the Difficulties with Emotion Regulation Scale. Maladaptive emotion regulation strategies were assessed with the Ruminative Response Scale (rumination), Penn State Worry Questionnaire (worry), and Emotion Regulation Questionnaire (expressive suppression). Results Latent profile analysis identified three distinct risk profiles: severe emotion dysregulation and psychopathology (Profile 3; 19.1 %), moderate emotion dysregulation and psychopathology (Profile 2; 37.5 %), and low emotion dysregulation and psychopathology (Profile 1; 43.4 %). Network analysis identified distinct emotion dysregulation and psychopathology networks for each latent profile. Profile 3 had the highest network density and the strongest bridge connections between emotion dysregulation (poor emotional clarity) and psychopathology (PTSD symptoms of negative alterations in cognitions and mood and positive psychotic symptoms). Conclusions We synergised both latent profile analysis and network analysis to identify subgroups of at-risk patients and elucidate interrelationships between emotion dysregulation and psychopathology within each subgroup to inform personalized assessments and interventions.

AIM:This study examines early ECT response and correlations between repeat ECT courses, focusing on patients whose treatment indications changed between courses. METHODS:Our retrospective observational study included patients from the Institute of Mental Health (Singapore) who underwent at least 2 ECT courses for different indications between March 2017 and May 2023. For each course, the MADRS and BPRS scores were assessed 1 to 2 days before the first ECT session and after the sixth. Pearson correlation and paired t tests were employed to analyze the relationship between responses to the first and second ECT courses, along with 6 additional clinical outcome assessments (GAF, VAS, CGI-S, US, Q-LES-Q-SF, and MoCA) spanning illness severity, quality-of-life, and cognition. RESULTS:Twenty-five patients were included. Psychosis was the most common indication for the first course and mania for the second. Overall, early response rates were 38.9% for the first course and 42.1% for the second, with no significant correlation between responses across courses ( P = 0.229). Notably, no patients with catatonia responded to acute treatment in the first course, even when indications changed in the second. Strong correlations were found for global illness severity (CGI-S, r = 0.519, P = 0.023) and quality-of-life (US, r = 0.935, P < 0.001) across the 2 courses. CONCLUSION:Changes in ECT indications between courses suggested a poorer prognosis, but those who showed improvement in global illness severity and quality-of-life tended to experience similar benefits in subsequent ECT courses. Given the lack of correlation between symptom-specific early response across courses, a poor early response in a previous ECT course should not preclude patients from future ECT when clinically indicated.

Background: While not all trauma-exposed individuals develop post-traumatic stress disorder (PTSD), many experience severe and enduring emotional effects. In Singapore, no study has investigated the prevalence and correlates of subthreshold PTSD and PTSD using gold-standard clinical interviews.Objectives: This study was the first to examine the prevalence and correlates of PTSD, subthreshold PTSD, and correlates associated while exploring a broad range of adverse experiences, including Criterion A (e.g. physical and sexual abuse) and non-Criterion A (e.g. emotional abuse) events.Method: We recruited 500 outpatients, aged 21-65, with mood or schizophrenia spectrum disorders from Singapore's only tertiary psychiatric hospital. Self-report measures assessed emotion dysregulation, suppression, and total trauma events. Clinical interviews, like the Clinician-Administered PTSD Scale (CAPS-5), measured dissociation and PTSD, while the Brief Psychiatric Rating Scale measured negative affect. Among trauma-exposed individuals (n = 461), multinomial regression examined differences between subthreshold PTSD, PTSD and the no-PTSD reference group, with analyses conducted separately for Criterion A and non-Criterion A events.Results: In the overall sample, PTSD prevalence was 15.0% and subthreshold PTSD was 18.4% among individuals with an index event classified as Criterion A. PTSD following an index event classified as Criterion A was associated with a broader range of correlates than index events classified as non-Criterion A. Conversely, among individuals exposed to events classified as non-Criterion A, PTSD was primarily associated with emotional correlates when subthreshold PTSD was defined as 'two of four criteria.' PTSD is also associated with a broader set of correlates than subthreshold PTSD across exposure types and subthreshold PTSD definitions. Correlates of subthreshold PTSD vary depending on exposure type. Negative affect was most frequently associated with multiple definitions of subthreshold PTSD and PTSD across trauma types.Conclusion: Findings suggest distinct symptom profiles by trauma type and emphasise the clinical relevance of non-Criterion A events and subthreshold PTSD.

Personalized connectivity-guided accelerated intermittent theta burst stimulation (iTBS), like the Stanford Accelerated Intelligent Neuromodulation Therapy (SNT), shows high efficacy for treatment-resistant depression (TRD) in Western cohorts. However, generalizability to other demographics with substantial comorbidity remains unclear. Here, we evaluate connectivity-guided iTBS in a naturalistic Asian TRD population with high comorbidity burden. Twenty TRD participants received 50 sessions of TAO-TMS (Tree-based Algorithm for Optimized Transcranial Magnetic Stimulation) over 5 days. Participants averaged 1.6 psychiatric comorbidities, including personality disorders, autism and obsessive-compulsive disorder. TAO-TMS personalizes targets within attentional networks and maximize anti-correlation with the subgenual anterior cingulate cortex. Its near-scalp targets reduce stimulation intensity under the SNT protocol, improving patient comfort. Clinical response was defined as ≥50% reduction in the Montgomery-Åsberg Depression Rating Scale within four weeks of treatment. TAO-TMS yielded 70% response rate. Among patients who met typical randomized-trial eligibility criteria (N = 11), response rate was 83%. For context, non-accelerated BeamF3 TMS at the same hospital historically achieved response rate of 21%, indicating a patient population profile less responsive to TMS than those recruited in typical clinical trials. Post-hoc electric-field modeling showed that TAO-TMS improved network focality by 21% over BeamF3 targets. Functional connectivity changes were significant within every participant, but highly heterogeneous across participants. TAO-TMS was more cost-effective than electroconvulsive therapy (ECT), saving US$37,838 with higher quality-adjusted life years (QALYs 0.69 vs 0.65). These findings provide early evidence for the generalizability of connectivity-guided personalized TMS in a naturalistic Asian TRD population with substantial psychiatric comorbidities. TAO-TMS offers a cost-effective alternative to ECT, positioning it as a viable precision psychiatry intervention.

Electroconvulsive therapy (ECT) is widely used to treat various psychiatric disorders, with patients often undergoing multiple courses of ECT. However, it remains unclear whether responses to one ECT course can be replicated in subsequent treatment courses. A retrospective cohort study at the Institute of Mental Health, Singapore, studied 226 patients who underwent at least two courses of ECT between March 2017 and May 2023. The study compared the correlation of response rates, illness severity, quality of life (QoL), and cognition between 2 courses of ECT using Pearson's chi-square test and Pearson correlation coefficients. The results showed no significant correlation in response rates or cognition between the two courses of ECT. However, small correlations were observed at the group level between the Clinical Global Impression - Improvement (CGI-I) scale, which measures illness severity, and the Quality of Life Enjoyment and Satisfaction Questionnaire - Short Form (Q-LES-Q-SF) scores. Pearson correlation coefficients were r = 0.16 (p = 0.04) for CGI-I and r = 0.28 (p = 0.009) for Q-LES-Q-SF. In subgroup analysis, patients with schizophrenia showed a small correlation between CGI-I (r = 0.21, p = 0.029) and Q-LES-Q SF scores (r = 0.26, p = 0.048), while those with depression showed a moderate correlation in Q-LES-Q SF scores (r = 0.52, p = 0.013), with no correlation in CGI-I. No correlation was observed in the mania or catatonia subgroups. These results suggest that while previous responses to ECT may not reliably predict future outcomes, improvements in illness severity and QoL tend to follow a similar trajectory, highlighting the value of collaborative decision-making in treatment planning.

Background Chronic insomnia disorder, a condition associated with frequent and persistent difficulty in initiating or maintaining sleep, is one of the most common reasons for patients consulting general practitioners and psychiatrists in Singapore. Objectives The landscape for managing chronic insomnia disorder is constantly changing but a clear, updated guidance for its management is lacking. Methods This guidance document provides guidance and recommendation for the diagnosis, assessment, and management of chronic insomnia disorder in Singapore based on a review of the current clinical practice guidelines and recent evidence including findings specific to Singapore. Results and Conclusion This document further summarises the properties and safety profiles of various pharmacological agents and provides guidance for their use across patient profiles. Lastly, this document provides recommendations from a panel of 5 clinicians with expertise in treating patients with sleep disorders.

Schizophrenia is the leading indication for electroconvulsive therapy (ECT) in Asia; however, optimal ECT parameters for this condition remain under-researched. This study examines the impact of stimulus dosage in bifrontal ECT on symptomatic improvement in 122 patients treated at the Institute of Mental Health, Singapore.In this retrospective analysis, patients were categorized into two groups based on a 1.5 × seizure threshold (DRST) cutoff: a standard dosage group (≤1.5 × DRST) and a high dosage group (>1.5 × DRST). Paired t-tests were used to assess changes in clinical scores—positive psychotic symptoms, quality of life, and cognition—after six ECT sessions. Generalized linear models evaluated associations between dosage groups and symptomatic changes.Both groups showed significant improvements in positive psychotic symptoms, as measured by the Brief Psychiatric Rating Scale (BPRS) positive psychotic symptom subscale (p < 0.001), and in quality of life (Q-LES-Q-SF and EQ-5D utility scores; p < 0.03 for the high-dose group, p = 0.006 for the standard-dose group). Only the standard dosage group demonstrated significant cognitive improvement (MoCA, p = 0.04), while the high-dose group did not. Notably, the high-dose group experienced greater reductions in positive psychotic symptom scores (p = 0.004) and greater improvements in quality of life (p = 0.002) compared to the standard-dose group. However, linear regression analysis found no significant between-group differences in post-treatment MoCA scores.These findings suggest that higher suprathreshold dosages of bifrontal ECT may accelerate improvement in positive psychotic symptoms in schizophrenia, highlighting the need for further research to optimize ECT protocols and treatment outcomes.

This open label study aims to test the effectiveness of accelerated transcranial magnetic stimulation (aTMS) (4 treatments a day for five days) for treatment-resistant depression and whether changing TMS frequency and coil target location (from 5 Hz left dorsal lateral prefrontal cortex (DLPFC) to 1 Hz right DLPFC) improves treatment response. A total of thirty-eight patients were enrolled and overall treatment response rates increased from 7 % immediately after treatment to 10 % two weeks later. Response rates were observed to be15.8 % immediately after an additional course of treatment for those initial non-remittent and subsequently increased to 18.8 % two weeks later, without any significant difference between the switching and non-switching groups (immediately: 11.1 % vs 20 %, p = 0.596; 2 weeks later: 12.5 % vs 25 %, p = 0.522). In conclusion, there was a possible sign of a delayed onset of treatment response of aTMS on depressive symptoms. Switching the TMS treatment protocol did not yield any outcome improvements.

Aim: To test the effectiveness of an accelerated acupuncture treatment as an augmentation therapy for patients with primary diagnosis of major depressive symptoms. Methods: Recruited patients were 1:1 randomly assigned to receive either treatment-as-usual (wait-list controlled group) or with additional acupuncture intervention (treatment group). The acupuncture treatment includes daily scalp acupuncture with manual stimulation for a total of 10 sessions conducted within 2–3 weeks. Blinded raters assessed patients’ depressive symptoms and quality of life at baseline (pre-treatment), immediately after treatment, 2 weeks, and 3 months post-treatment. Results: A total of 84 patients with 59 (70.2 %) Chinese, 17 (20.2 %) Malay and 4 (4.8 %) Indians participated in this trial. There is an overall improvement of depressive symptoms score assessed by Montgomery–Åsberg Depression Rating Scale (MADRS) and Quick Inventory of Depressive Symptomatology- Self report 16 items (QIDS-SR16), and an improvement of subjective Quality of life assessed by EQ5D Visual Analogue Score (VAS) and Utility Score (US) from pre-treatment to 3 months post-treatment for patients in both treatment groups and control group. In addition, compared to patients in control group, acupuncture induced an overall significantly better QIDS-SR16 (effect size η2 = 0.15, p = 0.025) and better EQ-5D Visual Analogue Scale score (η2 = 0.20, p = 0.005). Conclusion: Acupuncture induced an accumulated and delayed antidepressant treatment effect for patients with depression. Our study informed the potential of an accelerated acupuncture treatment as an augmentation antidepressant therapy within a multiethnic South-east Asian population.

ABSTRACT:Electroconvulsive therapy (ECT) is a recognized treatment option for patients with schizophrenia, especially when patients do not respond adequately to antipsychotic medication or when rapid response is needed in severe cases. The 3 common electrode placements, namely, bitemporal, bifrontal and right unilateral (RUL) modalities, have all been described by various studies to be efficacious in symptom reduction. However, the optimal electrode placement with the greatest success rate in the treatment of schizophrenia has yet to be ascertained. Furthermore, the benefit of switching ECT modalities after poor response to the initial electrode placement has not been well studied. Hence, to illustrate the twin issues of the optimal ECT modality as well as the effect of switching ECT modalities after initial nonresponse in patients with schizophrenia, we describe 2 distinct patients who underwent multiple courses of bifrontal and RUL ECT, but only responded well to bifrontal ECT. This is possibly due to the patients' anatomical differences as well as varying brain stimulation patterns produced by the different electrode placements. Thus, we believe that the prescription of ECT in patients with schizophrenia should be individualized, and a switch to a different ECT modality should be strongly considered if there is a lack of response to a particular modality.

BACKGROUND:Electroconvulsive therapy (ECT) has been a key treatment for various psychiatric disorders. Prior research has indicated racial disparities in ECT utilization, particularly in Western populations. This study examines racial differences in ECT use and outcomes in Singapore, a multiracial Asian context, focusing on Chinese, Malay, and Indian patients. METHODS:A retrospective analysis of medical records from the Singapore Institute of Mental Health (IMH) was conducted for patients who underwent ECT between 2017 and 2023. Data on sociodemographic profiles, clinical characteristics, pre-ECT clinical data, and post-ECT outcomes were collected. RESULTS:The final sample consisted of 1091 participants: 79.6% Chinese, 10.3% Malay, and 5.8% Indian. Chinese participants were older and more likely to be female. There were no differences between races in terms of primary psychiatric diagnosis, number of failed medications, or previous ECT use. There were no significant racial differences in ECT response rates, which were 48.3% for Chinese, 40.4% for Indian, and 42.7% for Malay participants. Cognitive outcomes also did not differ significantly by race. However, results showed that being Chinese was a significant predictor of better post-ECT utility scores. CONCLUSIONS:These findings align with literature suggesting that ECT's efficacy is generally unaffected by race. Chinese participants were found to have higher post-ECT quality of life measure scores, which may reflect potential differences in the subjective experiences and perceived utility of ECT between races. The results provide valuable insights into ECT practices in a non-Western context and suggest that ECT is equally effective and safe across different racial groups in Singapore.