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Dating from the early 8th century and created in Anglo-Saxon Northumbria, Codex Amiatinus is the oldest intact single-volume Bible in any language. Within its extensive prefatory material is an image of Ezra, the scribe who according to legend rewrote the whole of the Old Testament, while behind him stands a large open book cupboard in which nine volumes of the scriptures are displayed. In this paper, I will argue that this image depicts a tension between two versions of the Old Testament that the compilers of the codex have had to resolve. In the image, this Bible represents itself as the product of the decisions that have gone into its making.

Background: Borderline personality disorder (BPD) is a heterogeneous and highly comorbid disorder. Suicidality, aggression and substance abuse are common presentations of BPD. Our case series is the first to highlight the role of brexpiprazole in improving these symptoms in patients with BPD. Case presentation: We describe three cases demonstrating the role of brexpiprazole in improving BPD’s prominent features and comorbidities. All cases improved when brexpiprazole was added to their treatment regime. Case 1: A 26-year-old woman who was diagnosed with BPD and cyclothymia, presented to the psychiatric emergency unit with impulsive suicidal behaviour. Case 2: A 43-year-old woman suffering from BPD sought help due to her violent behaviour and emotional dysregulation. Case 3: A 22-year-old woman with underlying attention deficit and hyperactivity disorder, polysubstance use disorder and BPD presented with dysregulated emotions. Conclusions: Our case series provides anecdotal evidence of the potential role of brexpiprazole in attenuating suicidality, aggression and substance abuse in patients with BPD. We postulate that brexpiprazole’s high affinity for the 5HT1A/5HT2A receptors, coupled with its low intrinsic effect on the D2/D3 receptor system, is fundamental in its actions to stabilise the aberrant dopaminergic and serotonergic signalling in BPD. Future research should focus on well-designed clinical trials investigating the efficacy of brexpiprazole in patients with BPD.

Medical students are vulnerable to depression and anxiety due to the nature of their academic life. This study aimed to determine the prevalence of depressive and anxiety symptoms among medical students and the association between religious coping, religiosity and socio-demographic factors with anxiety and depressive symptoms. A cross sectional design was used for this study. Scales used were the Malay version of the Duke Religious Index (DUREL-M), the Malay version of the Brief Religious Coping Scale (Brief RCOPE) and the Malay version Hospital and Anxiety Depression Scale (HADS-M). 622 students participated in this study. They scored moderately on the organized (mean: 3.51) and non-organized religious (mean: 3.85) subscales of the DUREL, but had high intrinsic religiosity (mean: 12.18). The prevalence of anxiety and depressive symptoms were 4.7% and 17.4% respectively, which is lower than local as well as international data. Islam, negative religious coping and the presence of depressive symptoms were significantly associated with anxiety symptoms. Only the presence of anxiety symptoms was significantly associated with depressive symptoms. Negative religious coping, rather than positive religious coping, has significant association with depressive and anxiety symptoms. Redirecting focus towards negative religious coping is imperative to boost mental health outcomes among medical students.

Background Blastocystis sp. is one of the most common colonisers of the intestinal tract that demonstrate strong interaction with accompanying gut bacteria. Previously, the protozoan isolated from individuals with irritable bowel syndrome (IBS) showed altered phenotypic features suggesting that it can be triggered to become pathogenic. Previous studies reported altered gut microbiota and high prevalence of Blastocystis sp. in schizophrenia patients. However, the phenotypic characteristics of Blastocystis sp. isolated from individuals with SZ have yet to be described. Methods In this study, faecal samples from 50 patients with severe schizophrenia (SZ) and 100 non-schizophrenic (NS) individuals were screened for Blastocystis sp. infection. Positive isolates were subjected to genotypic and phenotypic characterization. Results We found that 12 out of 50 (24%) SZ and 5 out of 100 (5%) NS individuals were detected Blastocystis sp. positive using both in vitro culture and PCR method with no significant association to age and gender. Out of the 15 sequenced isolates, ST3 was the most prevalent subtype (66.7%) followed by ST1 (20%) and ST6 (13.3%). The isolates from SZ individuals demonstrated significant slower growth rate (34.9 ± 15.6 h) and larger range of cell diameter (3.3–140 µm). We detected higher amoebic forms and metronidazole resistance among SZ isolates with variation in cell surface glycoprotein where 98% of cells from SZ showed consistent medium to high binding affinity (+ 2 to + 3) to Concavalin A staining compared to NS isolates that demonstrated only 76% high lectin (+ 3) binding affinity. Cysteine and serine protease levels were predominantly found among SZ isolates. We also demonstrate the presence of metalloprotease in Blastocystis sp. especially among NS isolates. Introduction of solubilised antigens from SZ isolates increased the cell proliferation of HCT116 cells by two fold when compared to NS isolates. Conclusion Our findings demonstrated Blastocystis sp. isolated from SZ individuals showed variation in phenotype specifically in morphology and drug resistance. The findings indicate that the gut environment (SZ and NS) and treatment of SZ could have influenced the phenotype of Blastocystis sp. Graphical Abstract

The LGBT+ community in Malaysia is vulnerable to mental disorders due to the pressures of being in a conservative heteronormative culture. This study aimed to study the association between coping strategies as well as the sociodemographic factors of LGBT+ individuals with mental disorders and quantify the occurrence of mental disorders among them. This study used a cross-sectional design. The self-rated Brief Coping Orientation to Problem Experienced Inventory (Brief COPE) and the Mini International Neuropsychiatric Interview (MINI) were used to this end. A total of 152 participants were recruited. Among the participants, 67.8% used mainly problem-focused coping strategies, 29.6% employed emotion-based coping, and 6.6% used avoidance coping. The prevalence of mental disorders in general and major depressive disorder was much higher than in the general Malaysian population (80.3% and 40.1%, respectively). The only sociodemographic factor that was significantly associated with mental disorders was bisexuality. Problem-focused coping is associated with fewer mental disorders, and emotion-based coping is associated with a higher prevalence of mental disorders. More studies need to be conducted to better understand and better manage the mental disorders of the Malaysian LGBT+ community.

Background and Objectives: Depression is a leading cause of disability globally, with treatment challenges including limited access, stigma, and poor adherence. Gamification, which applies game elements such as points, levels, and storytelling into non-game contexts, offers a promising strategy to enhance engagement and augment traditional treatments. Our research is the first study designed to explore the implementation of gamification within the Malaysian context. The objective was to explore the feasibility of implementation of gamification as an adjunctive treatment for adults with depression. Materials and Methods: Focus group discussions were held with five mental health professionals and ten patients diagnosed with moderate depression. The qualitative component assessed perceptions of gamified interventions, while quantitative measures evaluated participants’ depressive and anxiety symptomatology. Results: Three key themes were identified: (1) understanding of gamification as a treatment option, (2) factors influencing its acceptance, and (3) characteristics of a practical and feasible intervention. Clinicians saw potential in gamification to boost motivation, support psychoeducation, and encourage self-paced learning, but they expressed concerns about possible addiction, stigma, and the complexity of gameplay for some patients. Patients spoke of gaming as a source of comfort, escapism, and social connection. Acceptance was shaped by engaging storylines, intuitive design, balanced difficulty, therapist guidance, and clear safety measures. Both groups agreed that gamification should be used in conjunction with standard treatments, be culturally sensitive, and be presented as a meaningful therapeutic approach rather than merely as entertainment. Conclusions: Gamification emerges as an acceptable and feasible supplementary approach for managing depression in Malaysia. Its success depends on culturally sensitive design, robust clinical oversight, and seamless integration with existing care pathways. Future studies should investigate long-term outcomes and establish guidelines for the safe and effective implementation of this approach. We recommend targeted investment into culturally adapted gamified tools, including training, policy development, and collaboration with key stakeholders to realistically implement gamification as a mental health intervention in Malaysia.

The aetiology of schizophrenia is multifactorial, and the identification of its risk factors are scarce and highly variable. A cross-sectional study was conducted to investigate the risk factors associated with schizophrenia among Malaysian sub-population. A total of 120 individuals diagnosed with schizophrenia (SZ) and 180 non-schizophrenic (NS) individuals participated in a questionnaire-based survey. Data of complete questionnaire responses obtained from 91 SZ and 120 NS participants were used in statistical analyses. Stool samples were obtained from the participants and screened for gut parasites and fungi using conventional polymerase chain reaction (PCR). The median age were 46 years (interquartile range (IQR) 37 to 60 years) and 35 years (IQR 24 to 47.75 years) for SZ and NS respectively. Multivariable binary logistic regression showed that the factors associated with increased risk of SZ were age, sex, unemployment, presence of other chronic ailment, smoking, and high dairy consumption per week. These factors, except sex, were positively associated with the severity of SZ. Breastfed at infancy as well as vitamin and supplement consumption showed a protective effect against SZ. After data clean-up, fungal or parasitic infections were found in 98% (39/42). of SZ participants and 6.1% (3/49) of NS participants. Our findings identified non-modifiable risk factors (age and sex) and modifiable lifestyle-related risk factors (unemployment, presence of other chronic ailment, smoking, and high dairy consumption per week) associated with SZ and implicate the need for medical attention in preventing fungal and parasitic infections in SZ.

Mental health disorders (MHDs) among refugees has been recognized as a major public health issue. However, to date, there is limited evidence on the prevalence of MHDs among Rohingya refugees in Malaysia. This study aimed to examine the prevalence and associated factors of major depressive disorder (MDD), generalized anxiety disorder (GAD), and post-traumatic stress disorder (PTSD) among Rohingya refugees in Malaysia. A total of 220 refugees were randomly selected to participate in this cross-sectional study, conducted from June 2019 to November 2019. Perceived social support, religious orientation, food security, and sociodemographic characteristics were assessed as independent variables. The dependent variables assessed were MDD, GAD, and PTSD. The prevalence of GAD, PTSD, and MDD was reported at 92 (41.8%), 84 (38.2%), and 71 (32.3%). Several factors were significantly associated with MDD following multivariate analysis such as perceived low to moderate social support (AOR = 2.17; 95% CI 1.13, 4.19) and food insecurity (AOR = 2.77; 95% CI 1.19, 6.47). Exposure to violence (AOR = 38.46; 95% CI 16.27, 90.91) and food insecurity (AOR = 3.74; 95% CI 1.41, 9.91) were significantly associated with PTSD. Addressing these risk factors could be key in improving mental health outcomes among this vulnerable population.

The psychological distress reported among frontline healthcare workers (HCWs) is concerning. Little is known about the mental health of non-frontline, psychiatric HCWs, who play a central role in handling the mental health crisis during the COVID-19 pandemic. This study aimed to examine the prevalence of anxiety and depression among psychiatric HCWs and evaluate its association with socio-demographic, socio-economic, work-related factors and coping strategies. The authors proposed a cross-sectional study design using the Hospital Anxiety and Depressive Scale (HADS) and Brief-COPE scale. This study found that the prevalence of anxiety and depression were 22.0% and 16.8%, respectively. A multivariate analysis revealed that married psychiatric HCWs had a lower level of anxiety with OR = 0.31 (95% CI: 0.11–0.83). Psychiatric HCWs who were experiencing financial hardships, were unvaccinated and those who had a shorter duration of service in the psychiatric department had a higher level of depressive symptoms with OR = 0.31 (CI: 1.19–11.27), 3.21 (CI: 0.97–10.52), and 1.01 (CI: 1.00–1.02), respectively. For every increase of one unit of avoidant coping score among respondents, the odds of having anxiety and depression increased by 1.25 times (CI: 1.15–1.37) and 1.20 times (CI: 1.09–1.32), respectively, whereas for every increase of one unit of religious coping score among respondents, the odds of having anxiety reduced by 1.42 times (CI: 1.10–1.84). The authors highlight that psychosocial measures addressing the relatively high levels of anxiety and depression among psychiatric HCWs should be a key priority to ensure the sustainment of mental health services in the face of this prolonged pandemic.

The purpose of this article is to discuss the importance of addressing the psychological impact of coronavirus disease 2019 (COVID-19) on healthcare workers (HCWs) who are frontliners directly involved in mitigating the spread of the disease. This paper focuses on the utilization of a clinical practice protocol for identifying HCWs who are COVID-19-positive or under investigation and surveillance for suspected infection, in a tertiary, university teaching hospital of Malaysia. The protocol for Psychological First Aid (PFA), which is applied remotely via a mobile application and phone calls, outlines the work process in stages, with expected immediate, intermediate, and long-term goals within a “Specific, Measurable, Attainable, Relevant, and Realistic Timeframe” (SMART). This protocol is developed to provide a guideline for psychological crisis interventions that promote safety, calm, and hope in HCWs, allowing them to return to psychological functioning without being stigmatized. The unprecedented remote PFA protocol may serve as a platform for further research on the application of a goal-directed approach in a healthcare organization.