Background: According to the latest report, over 15 million people in Pakistan are suffering from some form of mental illness. But for a population of 220 million, only 400 trained psychiatrists exist with few state-run psychiatric hospitals and a small number of psychiatric units in teaching and general hospitals. In a traditionalist society, there is frequently a social disgrace together with discussing dysfunctional or abnormal behaviors as mental health problems and is generally described as a “shortcoming of character.” Methods: We carried out comprehensive literature review to collect data on the current mental health picture in Pakistan, and we also compared and formulated the recommendations from the literature of the related countries in the region and developed countries whenever possible. Results: Mental healthcare is still not a priority in the health system in Pakistan. A dire need still exists for a recognition from both public and private sectors for improving mental health planning and services in the country. Government must actualize social strategies that should be simple, equitable, and practical, as well as being able to address the issues of the regular needs. Asset allotment for emotional wellness is horrifyingly low and wasted away by defilement and fumble. A requirement exists for expanded spending on mental healthcare and psychological and emotional well-being just as appropriate usage of accessible assets. Conclusion: In this review, we suggest that a progressive change is required in the current state of psychiatry in Pakistan and that a need exists for a continuing review about existing strategies with a focus on setting sustainable priorities in the field of mental health, especially in policymaking, capacity building, awareness among public, and the use of media to minimize stigma.

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Background: Sri Lanka is a multi-ethnic country with a rich cultural heritage and biodiversity. Sri Lanka has a population of 21 million with an annual population growth rate of 0.76%. Methods: The authors explored the evolution of mental health care, life-cycle approach to psychiatric disorders, addressing resource limitations in a developing country, and the dilemma of reducing the treatment gap while maintaining standards and quality of care. This review was based on the analysis of related literature, as well as through work experience. Results: As a result of continuous effort, Sri Lanka has more than 110 psychiatrists, practicing in all districts of the country. Academic psychiatry has flourished over the years. Measures to improve mental health literacy, training of allied disciplines, and targeted approaches to improve services for vulnerable groups are taking place at a reasonable rate. The psychiatrists employed throughout Sri Lanka, the Sri Lanka College of Psychiatrists, the Board of Study in Psychiatry, and Postgraduate Institute of Medicine, have taken initiative to improve quality of care, by joining hands with the Ministry of Health and other stakeholders. Conclusion: Sri Lanka has achieved quality mental health-care outcomes despite having considerable limitations in resource allocation. Mental health services need to be consistently revamped, giving priority to face ongoing challenges to provide quality as well as equitable and efficient service to all the citizens in this beautiful country.

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Objectives: Singapore is a city-state of about 5.7 million in population, having multi-ethnicities–Chinese (74.3%), Malays (13.4%), Indians (9.1%), and others (3.2%). In this review, the authors intended to familiarize the readers with the present state of mental health care in Singapore and to discuss the present and future challenges in service provision in handling psychiatric care and promoting mental health for all Singaporeans. Methods: Through published papers and personal experiences, the authors collected descriptive data on mental health-care service research, psychotherapy, training, stigma, and preventive psychiatry from the published papers and books. Information on recent and future developments was from interviews with clinicians and administrators. Results: There is a steady expansion of mental health-care service, training, and research in Singapore. Community and preventive psychiatry is currently emphasized. There are about 115 practicing psychiatrists in Singapore, giving a psychiatrist-to-population ratio of about 2.6/100,000, which is low compared with other developed countries such as the USA (13.7/100,000), the UK (11/100,000), and Australia (14/100,000). Conclusion: The authors suggest that the focus of mental health care should be on the community and on the Agency for Integrated Care to coordinate the plethora of services by hospitals, clinics, day centers, and nongovernmental organizations. We further stress the need of anchoring the service to a mental or general hospital community care or day hospital beside inpatient care in general hospital or institutions. We also recommend gathering community support, proper use of technology in early detection, referral management, and exploiting the benefits of artificial intelligence for mental health promotion in the future.

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Background: Japan has continuously received influences from foreign countries to improve care for patients suffering from mental diseases throughout its history. But an article documenting on the foreign influences on Japanese mental health (MH) care is not readily available. Methods: The author reviewed the published books, papers, and government documents on the MH care in Japan. For comparisons, the publications on MH and psychiatric care, especially those in the United States of America, the United Kingdom, as well as countries of the Organization for Economic Co-operation and Development, were also reviewed. The author also recounted his personal observations on the MH care over his own life. Results: Before the Meiji Restoration, Buddhism and temples played a major rôle in taking care of persons with mental illness. Kampo (Chinese medicine and medicinal herbs) was prescribed during the Edo era (1603–1867). After the Meiji Restoration in 1867, the Meiji government adopted Western medicine. German medicine was introduced as an exemplified model. Before World War II (WWII), Japanese psychiatry was under the heavy German influence. After WWII, American psychiatry was introduced. At the same time, the Japan Private Hospital Association (Nisseikyo) was formed, and it contributed to build MH care system. From 1955 to 1993, Japan continuously increased the number of private hospital beds, financed through public funds. The scandals at several private hospitals helped enact the Mental Health Law in 1987, making clear to change hospital-centered services to community-based MH services and improve the human rights of inpatients in Japan. Since then, efforts have been carried out to promote community-based MH care. But Japan nowadays is still characterized by hospital-centered MH care. Conclusion: At present, Japan has more than 1,000 psychiatric hospitals with 300,000 psychiatric beds. Japan has the largest number of psychiatric bedsthat is on the top among all countries in the world. In this review, the author expresses his own personal viewpoints on MH care for the mentally ill in Japan with focus on its international influences.

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Background: Tobacco products have been used by human for a long history. The prevalence of tobacco use varies in different countries. Tobacco use is different from tobacco use disorder. Tobacco use disorder is a problematic pattern of tobacco use leading to significant distress or impairment. Cigarette smoking is a chronic relapsing substance use disorder caused by addiction to nicotine. Tobacco smoke contains over 7,000 different chemical compounds, of which 93 of them are harmful substances. Methods: In this review, the authors intended to address the issues of harmful effects of cigarette smoking and how to cease smoking. Results: Abundant studies showed that tobacco use is the main risk factor of morbidity and mortality in the world. People who use tobacco products should be advised to quit smoking and offered appropriate treatment. It is better for health-care providers to make the smoking cessation treatment as a standard component of medical care. Data from evidence-based literature showed that smoking cessation therapy can significantly raise smoking cessation rates and should be routinely in persons who are willing to quit tobacco smoking. Smoking cessation treatment includes psychosocial interventions and pharmacological treatment, which may be used in combination. Nonpharmacological management may be individual or group sessions, and it may include motivational interviewing, cognitive behavioral therapy, and others. Delivery formats of stop-smoking interventions are varied. Pharmacological therapy includes nicotine replacement treatment and smoking aids such as bupropion and varenicline. Morbidity and mortality rates are decreased with tobacco cessation at any point in time, although cessation before the age of 40 years has the most significant effect. Conclusion: The Tobacco Hazards Prevention Act took effect since 1997 in Taiwan. Rates of Taiwanese tobacco use have been steadily declining. Brilliant achievements in the field of tobacco control in Taiwan draw international attention.

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Background: Attention-deficit hyperactivity disorder (ADHD) is the most commonly diagnosed neurodevelopmental disorder known to cause impairment across the lifespan. ADHD was ranked as approximately the 50th leading cause of global years lived with disability for children, coming in ahead of diabetes, meningitis, and intellectual disability. About 20%–40% of patients with ADHD would not achieve the treatment response and symptomatic remission, increasing future risks of substance abuse, suicidal behavior, and premature mortality. However, there is no standard consensus for defining treatment resistance in ADHD. Method: In this systematic review, we intend to focus on treatment-resistant ADHD in the aspects of disease definition, psychopathology, pathophysiology, and treatment. Results: We suggest that the more ideal strategy of defining treatment resistance should consider the improvement of ADHD symptoms and the global functioning simultaneously. Psychiatric comorbidities (i.e. destructive behavior disorders and mood disorders), physical comorbidities (i.e. epilepsy), and psychosocial adversities (i.e. parental psychopathology and poor family functioning) should be the first to be assessed in the evaluation of treatment response or resistance. The optimal medication adjustment or the combination of medications and psychotherapy may be the potential therapeutic strategy for treatment-resistant ADHD. Conclusion: Further studies would be necessary to elucidate the underlying mechanisms of treatment-resistant ADHD and to research the novel treatment strategies for ADHD.

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Objectives: In this general review, we provide a timeline of how psychiatry in the United States of America has evolved and developed since the nation's inception in the 18th century. Methods: Besides our life time experiences in receiving training, teaching, and practicing psychiatry, we collected information from the literature pertinent to the history of development of American psychiatry in this review. Results: In this review, we have highlighted some of the more cardinal events in American history – the shift from asylums to deinstitutionalization of patients in chronic state hospitals; the birth and evolution of the Diagnostic and Statistical of Mental Disorders by the American Psychiatric Association inspired by a dire need to unite a field; the revolutionary discovery of psychotropic medications and the galvanization of pharmaceutical research, development, and use of psychotropic medications in America; and the growing passion for psychiatry over the last several years among senior medical students. Conclusion: In tandem with their colleagues in other countries, American psychiatrists have overcome many trials and tribulations in their endeavor to ease the suffering of the mentally ill in the United States. We are optimistic for the future of American psychiatry as exemplified by a growing passion for psychiatry among American senior medical students, the expansion of US psychiatry residencies, the continued commitment by the National Institute of Mental Health to fund psychiatric research, and the exciting and thoughtful research of our colleagues domestically and abroad.

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Background: Reforming psychiatric services in Sweden in the 1960s and 1970s caused a shift from inpatient to outpatient units. Methods: Besides my lifetime experiences in receiving training, teaching, and practicing psychiatry, I collected information from the literature pertinent to the mental health care in Sweden. Results: In this review, I have highlighted some of the more important mental health events in Sweden. The number of psychiatric beds in Sweden has reduced from 37,000 to 4,500. The national health insurance and the ethos of the welfare state have created an equitable and generous environment for patients who are mentally ill. The suicide rate has gone down over the last three decades. There has been a substantial increase in a Swedish diagnosis called exhaustion disorder (burnout), especially in medical staff, office workers, and in the schools. Also, against all predictions, children and adolescents increasingly report having aches, insomnia, and depressive symptoms. Diagnosis and treatment for attention deficit hyperactivity disorder has increased substantially in the last 15 years. Moving from the International Classification of Diseases, version 9 (ICD-9) in the 1980s to ICD-11 and the DSM nosologies was accompanied by evidence-based guidelines, resulting in revised curricula for undergraduate and graduate training. Current researchers are showing a growing interest in autoimmune conditions that are comorbid with traditional psychiatric disorders. Neurovirology and psychiatry have an interface with the COVID-19 pandemic that will require an immediate action plan and collaborative efforts. Conclusion: Demographic changes due to increasing proportions of elderly and multiethnic populations, as well as the COVID-19 epidemic, will profoundly affect the future provision of services.

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Background: The Philippines is an autonomous Southeast Asian country which has long been encumbered with the burden of mental health-related concerns. Aside from the commonly occurring psychiatric illnesses, it also has to contend with the dearth of epidemiological data on such disorders as well as the scarcity of mental health practitioners. On top of these, one enduring challenge is the absence of mental health legislation. Thus, the passage of Republic Act (R.A.) 11036 or the Philippine Mental Health Act has been considered one of the greater achievements in Philippine psychiatry in the recent years. Methods: In this review, the author examines the origins, highlights, and updates on the legislature of R.A. 11036. Results: This legislature (or the Philippine Mental Health Act) elaborates on its highlights which equitably covers the rights of patients and their families as well as that of the mental health professionals; the standards of psychiatric, psychosocial, and neurologic services that need to be upheld in both government and private hospitals; the promotion of mental health in educational institutions and in the workplace; the need for mental health providers to undergo capacity building and proper training in research and development; the duties and responsibilities of the government agencies involved; the creation of a council to serve as a policymaking, planning, coordinating, and advisory body to oversee the implementation of the law; and the penalty clauses involved with violations of the law. It also provides updates on the enactment of the law's implementing rules and regulations, namely, the upgrading of existing mental health facilities, the standardization of a community-based mental health program, the development of a national suicide prevention strategy, the integration of mental health into the educational system and the workplace, the first-ever Philippine national survey on mental health and well-being, as well as the augmentation of the practice of telepsychiatry to extend the reach of services to the geographically isolated Filipinos. Conclusion: The Philippines made a history through the passage of the first-ever Mental Health Act on June 21, 2018, now known as R.A. 11036. The Philippine Psychiatric Association and other related organizations spearheaded a multisectoral lobby in the drafting of the bill. It took 16 years, and 31 drafts before R.A. 11036 became a reality. We still need to monitor the implementation of the law closely. Future revisions are expected to better improve the mental health law for citizens to receive better rights of mental health treatment and human rights protection.

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Background: The prevalence of major depressive disorder (MDD) by DSM criteria among cancer patients is about 14%–15% in oncological, hematological, and palliative services and the number is risen up to 20%–25% when other depressive disorders are also included. Like MDD patients in general, patients with cancer are thought to be underdiagnosed and undertreated. Untreated depression in cancer patients may lead to having distressed symptoms and signs, decreased quality of life, higher suicide risk, greater psychological burden on the family, longer hospital stays, poorer anticancer treatment compliance, as well as even increased risk for mortality. Methods: In this review, the authors reviewed published articles on the use of antidepressant use for patients with cancer, to familiarize the readers with the use of antidepressants. Results: Antidepressants have been found to be more effective than placebo in relieving depressive symptoms in patients with cancer, and the efficacy is positively associated with length of treatment. Although the rate of antidepressant prescription is increasing, still about 75% of cancer patients with depression have not yet received antidepressant treatment. Besides the use in treating mood and anxiety symptoms, antidepressants have also been found to have versatile rôles as palliative treatment for cancer-related symptoms – pain, hot flushes, nausea, anorexia/cachexia, and fatigue. Furthermore, antidepressants have been studied for their anticancer potentials. They can inhibit tumor growth through either indirectly regulating immunity by enhancing cytotoxic activity and modulating cytokine production, or directly initiating cancer cell death and arresting cancer cell proliferation. We also found important drug-drug interaction between antidepressants and tamoxifen. Conclusion: Besides treating depressive and anxiety disorders, antidepressants are effective in treating cancer-related symptoms (pain, hot flushes, nausea, anorexia/cachexia, and fatigue). Cancer patients are eager to receive more effective treatment against their cancer as well as comorbid depression, and physicians should be more aggressive in providing every beneficial regimen – including an antidepressant.

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Objective: In this study, we intended to evaluate the association between reinforcement sensitivity and male adults with attention-deficit/hyperactivity disorder (ADHD), as well as the association between reinforcement sensitivity and Internet addiction. Methods: We recruited 52 male adults with ADHD and 52 healthy male controls. All participants received a diagnostic interview for ADHD and completed ratings with the Behavior Inhibition Scale (BIS), Behavior Activation Scale (BAS), Adult ADHD Self-report Scale, and Chen Internet Addiction Scale to assess their reinforcement sensitivity, ADHD severity, and Internet addiction severity. Results: The study data showed that males with ADHD had significantly higher scores in BIS (22.06 ± 3.02 vs. 19.52 ± 2.49, p < 0.001), fun seeking (13.33 ± 2.03 vs. 11.10 ± 2.01, p < 0.001), BAS (44.42 ± 5.10 vs. 41.17 ± 4.79, p < 0.001), and Internet addiction (71.52 ± 14.60 vs. 51.98 ± 13.62, p < 0.001). Findings from the data showed that fun seeking was the most associated factor, followed by BIS. Furthermore, interpersonal and health problems were the most associated dimensions of Internet addiction associated with adult ADHD. The findings using the Pearson's correlation among adults with ADHD revealed that reward sensitivity, drive, and BAS were associated with the severity of hyperactivity. Additionally, BIS was associated with the severity of Internet addiction. Conclusion: Adult ADHD is associated with fun seeking, BAS, and BIS. We suggest that clinicians need to pay attention to reinforcement sensitivity when treating adults with ADHD. Furthermore, male adults with ADHD had higher severity of Internet addiction. Their BIS was positively associated with the severity of Internet addiction; thus, Internet addiction should be well assessed and treated among adults with ADHD, particularly among those with higher BIS.

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Objectives: Most studies of long-acting injectable antipsychotic (LAI) drugs have been focused on the efficacy of second-generation antipsychotic (SGA) LAIs through observation of the various outcomes of shifting from first-generation antipsychotic (FGA) LAIs to SGA LAIs. Rare studies have assessed the effectiveness of shifting from SGA LAIs to FGA LAIs. In this study, we intended to investigate the effectiveness of shifting from risperidone LAI to FGA LAIs in patients with schizophrenia. Methods: We included patients with schizophrenia and with the ownership of catastrophic illness card in the study. All the study patients had received risperidone LAI at least two months with a minimal dose of 50 mg per month. The case group included the patients who had been shifting from risperidone LAI to FGA LAIs (fluphenazine, haloperidol, or flupentixol). The control group included the patients who were continuously maintaining on risperidone LAI. The primary outcome was the time to hospitalization. The secondary outcomes were the side effects requiring to receive the use of concomitant anticholinergics, propranolol, and benzodiazepines. Results: We had 15 patients in the case group and 98 patients in the control group. The primary outcomes showed no significant between-group difference in the time to hospitalization (hazard ratio = 3.676, 95% confidence interval = 0.833 - 16.222). The secondary outcomes also showed no significant differences between the case and control groups. Conclusion: This study showed no significant differences in the treatment effectiveness and side effects between FGA LAIs and risperidone LAI. The results are compatible with those from a previous LAI study from the National Institute of Mental Health of the United States. But the relatively small effect with inadequate statistical power is the major study limitation, which may produce no significant differences in side effects. We suggest that further large-sample study is needed to confirm the results of this study.

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Background: South Korea or the Republic of Korea has an area of 100,412.6 km², and population of 52 million (51,781,000). Methods: Besides our lifetime experiences in receiving training, teaching, and practicing psychiatry, the authors collected information from the literature pertinent to the mental health care in South Korea. This review is intended to familiarize the readers of the Taiwanese Journal of Psychiatry with the information of mental health-care service as well as research and development (R and D) in South Korea. Results: Despite consistent improvement in the overall health status in Korea, the mental health status of the population is low compared with other countries in the Organization for Economic Co-operation and Development (OECD). For example, Korea has the highest suicide-related mortality and more years of life lost due to mental/behavioral diseases, compared to those of the average and a longer-than-average duration of hospital stay, respectively, of the OECD. Conversely, the government has made efforts to overhaul the mental health system. Several remarkable changes have been made in the areas of community-based service, involuntary admission, and unequal treatment. Conclusion: The mental health status is closely associated with the mental health service system, prevalence of mental disorders, health insurance system, admission system, and R and D budget for mental health. To change attitudes related to mental health, strong leadership among mental health professionals is urgently needed.

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Objectives: In this study, the authors intended to evaluate the efficacy and safety of paliperidone palmitate 1-month injection (PP1M) in patients with recent-onset schizophrenia (SCH). Methods: A subgroup analysis was done for patients enrolled in Taiwan in an Asia-Pacific, Phase 3b study (ClinicalTrials.gov identifier NCT01051531). Patients were switched from oral antipsychotics to intramuscular PP1M. Results: We included 61 patients (age: 31.2 ± 8.8 years). The Positive and Negative Syndrome Scale scores were significantly decreased, with the largest effect size observed in positive, disorganized, and depressive factors (Cohen's d = 0.52, 0.52, and 0.79, respectively). Most symptoms stabilized within six months, whereas stabilization of functional improvement required 1–1.5 years of PP1M treatment, especially for employment/academic status. PP1M treatment was well-tolerated, with over 70% of treatment satisfaction rate, and significantly reduced the average days of hospitalization (43.3–7.1/person-years). Conclusion: Switching to PP1M improved treatment outcome and satisfaction as well as reduced healthcare service use in patients with recent-onset SCH.

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Objective: The Ministry of Health and Welfare of Taiwan launched a project in June 2015 and provided community mental health outreach services and outpatient psychiatric treatment for child and adolescent patients with mental disabilities and psychiatric disorders from schools and institutions and in the community. The main purpose of this study project was intended to promote medical service quality for child and adolescent patients with mental disabilities and psychiatric disorders. Methods: Service team members from seven hospitals in Taiwan, including psychiatrists, clinical psychologists, and case managers, provided both outreach community services and outpatient psychiatric treatment. We collected the basic data and assessment scale scores of all outpatients from June 2015 to December 2018 (n = 163). Results: The findings revealed significant improvement in the scores of the Clinical Global Impression (CGI) – CGI-Severity Scale, Global Assessment of Functioning Scale, and Children's Global Assessment Scale (p < 0.001) and significant mild-to-moderate improvement of the CGI – Improvement Scale and internalizing problems (p < 0.05) and total problems (p < 0.01) of the Achenbach System of Empirically Based Assessment. Most outpatients presented fewer mood symptoms or behavioral disturbance, more improved adaptation, and higher academic performance at schools and institutions. Conclusion: This service model thus may provide effective medical services to the child and adolescent patients with mental disabilities and psychiatric disorders through both outreach community services and outpatient psychiatric treatment.

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Objectives: Drunk driving is related to accidents and poorer health, as well as causes a considerable economic cost. In this study, we intended to determine which sociodemographic factors can reduce health-related quality of life (QoL). Methods: We recruited 552 drunken driver recidivists and measured their alcohol use history and sociodemographic factors. We used the Alcohol Use Disorders Identification Test (AUDIT) and the Fifth Edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) criteria to evaluate severity of alcohol disorder. Psychological distress was measured using Beck Depression Inventory-II (BDI-II) and the status of well-being using the Short Form 12-Health Survey Questionnaire. We classified into several categories and analyzed with one-way analysis of variance or the Welch's test. Significant factors were further divided into subcategories for comparisons. Results: Alcohol use disorder according to DSM-5 criteria was found to be 34.2% mild, 16.7% moderate, and 44.7% severe in severity. The Depression Index according to BDI-II showed 70.5% in minimal, 13.2% mild, 10.5% moderate, and 5.8% severe depressed participants. In comparing subcategories according to the physical component summary (PCS), men who were older (p < 0.05), had fewer than 6 years of education (p < 0.001), unemployed (p < 0.05), homeless (p < 0.05), had monthly incomes below 15 thousand New Taiwan dollars (p < 0.05), and AUDIT scores ≥ 20 for severe depression (p < 0.001) had significantly lower QoL in PCS. In comparing subcategories according to the mental component summary (MCS), men who were unemployed (p < 0.05), homeless (p < 0.01), and AUDIT ≥ 20 for severe depression (p < 0.001) also had significantly lower QoL on MCS. Conclusion: Unemployment, homelessness, AUDIT scores ≥ 20, and higher BDI-II scores showed a reduction not only in PCS scores but also in MCS scores. Those findings could be used to determine the drunk drivers' behaviors and the well-being among those recidivists. Instead of incarceration or fining for drunk drivers, we need identification and referring them to treatment in those population, especially individuals with poor socioeconomic status, depression, and severe alcohol use disorder.

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Objectives: Patients with eating disorder (ED) have been associated with some risk factors for cancer, including nutritional deficiency, chaotic life styles, alcohol or tobacco use, dysfunctional immune system, and impaired organ functions. In this study, we intended to study the risk of cancer in ED patients. Methods: During the period of January 1998 to December 2013, 13,755 ED patients were identified from Taiwan's National Health Insurance Research Database. We enrolled 13,276 patients as study cohort, and 53,104 patients that had never been diagnosed with ED as age- and sex-matched comparisons. Participants were monitored for diagnoses of cancer during the follow-up period. We used the Cox proportional hazards model to investigate the risk of cancer between patients with ED and those without ED. Results: Compared with the non-ED controls, the study cohort had significantly higher prevalence of comorbidities, alcohol abuse, tobacco use disorder, and chronic obstructive pulmonary disease. After adjusting demographic data and comorbidities, there was no significant risk for later occurrence of cancer in ED patients, irrespective of anorexia nervosa (AN) type (hazard ratio [HR] = 1.10, 95% confidence interval [CI], = 0.83 – 1.47, nonsignificant difference) or non-AN type (HR = 0.98, 95% CI = 0.79 – 1.23, nonsignificant difference). Conclusion: There is no established evidence to support the relationship between cancer incidence and ED.

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Objective: We intended to investigate the risk of developing migraine among patients with posttraumatic stress disorder (PTSD). Methods: With the Taiwan's National Health Insurance Research Database, we examined 5,644 patients with PTSD and 22,576 age- and sex-matched controls between 2002 and 2009 and followed them to the end of 2011. Individuals who developed migraine during the follow-up period were identified. Results: Patients with PTSD had a significantly higher incidence of developing migraine (5.74 vs. 1.22 per 1,000 person-years, p < 0.001) during the follow-up period than the controls. We did Cox regression analysis with adjustments of demographic data and medical comorbidities and found that patients with PTSD were more likely to develop migraine (hazard ratio [HR] = 3.83, 95% confidence interval [CI] = 2.82–5.20) than the control group. Sensitivity analyses after excluding the 1st year (HR = 2.89; 95% CI = 2.04–4.08) or the first 3 years (HR = 2.07; 95% CI = 1.32–3.24) of observation showed consistent findings. Moreover, a high frequency of psychiatric clinics visiting for PTSD was associated with an increased risk of developing migraine. Conclusion: Patients with PTSD had a higher risk of migraine than the controls. The symptom severity of PTSD may be associated with an increased risk of migraine. Further studies are required to investigate the underlying pathophysiology between PTSD and migraine.

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