... 學會通訊

Erin, Chia-Hsuan Wu, M.D., M.A.,¹ Kun-Po Chen, M.D.,² Wen-Ho Chang, M.D. ¹,³ and Keh-Ming Lin, M.D., M.P.H.^4
1Department of Psychiatry, National Taiwan University Hospital
²Taipei City Psychiatric Center
³Department of Psychiatry, Buddhist Dalin Tzu Chi General Hospital
⁴National Health Research Institutes (NHRI)

Rooted in the Japanese Colonial Era (1895 – 1945), the development of Taiwanese psychiatry since the end of World War II has been largely influenced by the trends and developments in psychiatry and mental health movements in the North American continent, albeit with additional infusion of ideas and talents from China and other countries. Along with rapid economic development and the modernization of the society, Taiwanese psychiatry has witnessed remarkable progress in the past century, and has become in recent years increasingly active in the international arena. In the following, the authors briefly review these developments, with a special focus on the biological dimension of psychiatric research and practice. Based on these surveys, the future directions of biological psychiatry in Taiwan also will be discussed.

Japanese Colonial Era (1895-1945)

As is true in most societies, there is a long and rich tradition for the care of the disabled and disadvantaged, including the mentally ill, in Taiwan¹⁸. However, to the best of our knowledge, modern psychiatry as a branch of organized medicine did not reach this island country until 1910, 15 years into the Era of Japanese Colonial Administration, when a team of researchers led by Shusan Go (吳秀三), an esteemed professor from the Imperial Tokyo University, came to Taiwan to study cretinism. This paved the way for Nakamura（中村讓）and subsequently a number of other Japanese psychiatrists to come to work and teach in Taiwan. From 1916 to 1938, these pioneers established at least nine psychiatric hospitals and/or care facilities, totaling close to 400 beds. They conducted four waves of community surveys for the prevalence of major psychiatric conditions and reported on cases of neuropsychiatric disorders, especially those with general paresis of insane. Of particular note during this period is the publication of a series of case reports prepared by Nakamura for the purpose of forensic evaluation, with diagnoses ranging from delirium tremor²⁷ to pyromania²⁶.

Succeeding Nakamura, Syuzo Naka（中脩三）became the leader of psychiatry in Taiwan in 1934. In the following decade, as Professor and Chair of the Department of Psychiatry at the Imperial Taihoku (Taipei) University, he recruited and mentored a cadre of dedicated academicians who were active in psychiatric research. His followers included not only those who had been educated in Japan, but also several native born psychiatrists. Their main areas of investigation included the biochemistry in the brain²³,²⁴, electroconvulsive therapy²⁵ and psychopathology specific to the “tropic populations,” particularly “tropical neurasthenia,” a term that may have been coined by this group¹⁶,³⁵. Remarkably, but probably reflective of the German influences of modern Japanese medical research and practices, their approaches were basically descriptive and biological in nature. The productivity of the group is clearly reflected in the fact that by 1945, a total of 67 data-based articles appeared in the Journal of Formosa Medical Association (JFMA), probably the only medical journal in Taiwan during that period (founded in 1902).

Taiwanese Psychiatry:“the First Generation”(1946-1970)

Towards the end of World War II (WWII), as the majority (four of seven, including Noritaka Shinfuku (新福尚武)) of the psychiatric teaching faculty members of the Imperial Taihoku (Taipei) University were drafted into the Japanese Army, the academic activities of the group were practically completely interrupted. Naka returned to Kyushu soon after the end of WWII in 1945, leaving several Japanese psychiatrists behind, with Kurosawa (黑澤良介) in charge until the end of 1946, when the responsibility of the Department was transferred to Tsung-yi Lin (林宗義), a graduate of the Imperial Tokyo University with training in Japanese and German psychiatry²⁸.

The development of psychiatry in subsequent years, led by generations of psychiatrists from Taiwan, has been in our opinion truly remarkable. It may be roughly divided into three generations: the first quarter century maybe characterized by the building of the foundation and basic infrastructures, which was followed by two decades of rapid expansion in manpower and services, as well as a renaissance of what may be broadly described as descriptive psychiatry. Finally, the last fifteen years or so have witnessed a new wave of energy and a new level of confidence, with a new generation of psychiatric researchers increasingly making visible contributions in the world literature, increasingly participating at the forefront in our collective search for a better understanding of psychiatric problems as well as more effective therapies for our patients. It should be noted that the demarcation of these stages is approximate, and is offered here primarily for the convenience of our narratives.

Lin and his colleagues were the prime movers of the field during the first stage. Soon after his arrival in Taiwan, Lin attracted a whole cadre of medical graduates from the National Taiwan University (NTU; renamed from the Imperial Taihoku (Taipei) University), many of whom were just a few years to his junior. In the ensuing years, in addition to conducting waves of psychiatric epidemiological surveys that became “classics” and were widely quoted, they also laid the groundwork for community psychiatry, cultural psychiatry, child psychiatry, consultation-liaison psychiatry, dynamic psychiatry, neurology and biological psychiatry. Descriptive psychiatry and biologically-oriented research continued to be well represented during this stage²⁸. “New” intervention methods were introduced and attempts were made to evaluate their efficacy. These included not only electroconvulsive therapy (ECT), insulin shock therapy, but also psychosurgery (lobotomy; leucotomy). The practice of the latter in Taiwan was fortunately more circumscribed compared to Japan and the U.S., involving perhaps some seventy cases or so. Neuroleptics also were introduced during this time and gradually became the mainstay for the management of most hospitalized patients. In addition to therapeutics, attempts were made to understand the biological substrates of psychopathological conditions. Examples include the study of sympathetic and parasympathetic tones in psychiatric patients as proxies for the activities of the hypothalamus³⁶, the biochemistry of neuropsychiatric disorders³³ and the genetics study of Down’s syndrome³². Chinese versions of some psychological and psychopathological assessment tools also were developed during this time. Electroencephalography (EEG) became a commonly used tool in neuropsychiatry (the two fields were not officially separated until 1980), and there also were studies of EEG patterns in psychiatric patients. Initial attempts at establishing sleep EEG laboratories also were made towards the end of this period.

However, starting from the early 50’s, there was a drastic “paradigm shift” in the field towards dynamic psychiatry, which to a large extent eclipsed earlier emphasis on the biological substrates of psychiatric phenomena. This trend was largely a reflection of post-war American dominance in the region. Lin went to Boston for advanced training in 1952, and became increasingly active as a player in the international arena (Lin was Director of the Division of Mental Health at WHO, 1965 - 1975, and served as President of the World Federation on Mental Health, 1974 - 1979). In the following decade, with a few prominent exceptions, practically all Taiwanese psychiatric leaders pursued a similar path. At the same time, along with significant infusion of resources from the U.S., Taiwan also benefited from advisors from Western countries who visited often and helped to shape the direction of academicians’ interests¹⁷. Since at the time American psychiatry was dominated by psychoanalysts, dynamic orientation ascended likewise in Taiwan, and the assumed inseparable bonds between the mind and the brain were largely ignored if not denied. This was clearly reflected in the proportion of publications in Taiwan that might be broadly classified as “biological,” which had represented 50% in 1956, but declined to 27% by the year of 1970[1].

Taiwanese Psychiatry:“the Second Generation”(1970–1990)

Efforts made by the pioneering Taiwanese psychiatrists during the previous stage paved the way for the rapid expansion and blossoming of the field in the early 70’s. In the next two decades, budget for mental health services increased by 6000% (admitted starting from a very low baseline), and the number of psychiatrists increased from around 50 to more than 500. These developments led to increasing diversification of services and research programs, and culminated in the passing of the National Mental Health Act in 1990. Along with these new developments, psychiatric research also witnessed remarkable progress, with evident expansion in researchers and institutions conducting cutting edge research projects. The development of the Taipei City Psychiatric Center (TCPC, renamed as “Psychiatric Center, Taipei City Hospital”) perhaps provides a good example of this trend of expansion and diversification. Although its originally purpose was (and still is) for the care of mental health patients, under the leadership of Professor Eng-Kung Yeh (葉英堃), its founding Director, TCPC soon became one of the most important training centers for young mental health clinicians, and also developed important research programs ranging from psychiatric epidemiology to substance abuse research and biological psychiatry (also see below). In addition, other major academic centers including the Taipei Veterans Administration Medical Center and the Tri-Services Medical Center also started to develop significant psychiatric research programs. Thus, while NTU continued to play a leading role, Taiwanese psychiatry was increasingly enriched by the infusion of new resources and talents from other institutions.

As is true in other parts of the world, the proven efficacy and widespread use of psychotropics led to a renewed interest in psychopharmacology, in the refocusing of researchers’ attention back to the brain, and in the “rediscovery” of descriptive psychiatry in Taiwan. These led to the development of research programs in the pharmacokinetics and pharmacodynamics of psychotropics and other psychoactive substances (e.g., alcohol, amphetamine)³ , studies on the extent of and mechanisms responsible for ethnic variations in psychotropic responses, classification of psychiatric disorders, the reliability and validity of assessment tools for psychopathologies, as well as neurobiological correlates (“biological markers”) of major psychiatric conditions including depression and schizophrenia¹⁰.

Perhaps one of the most exciting developments of Taiwanese psychiatry during this period was the arrival of Wen-Ho Chang (張文和) 1in 1983, who served as Director of the Laboratory of Biological Psychiatry at TCPC until 1999. A graduate of the School of Medicine, Peking University, Chang’s pioneer works in China in the 60’s on the role of serotonin in schizophrenia was interrupted by the Great Cultural Revolution. He returned to his Alma Mater in 1979, became a Visiting Fellow in 1981 at the National Institute of Mental Health in the U.S., and decided to move on to Taiwan two years later. In the subsequent tow decades, Chang’s research career in biological psychiatry blossomed, and he motivated and trained a number of remarkably creative and productive younger researchers in the meantime. Together, they published more than 100 papers in high impact international journals, contributing significantly to our field’s understanding of the relationship among the clinical phenotype of schizophrenia, the role of neurotransmitters and the effects of antipsychotics. Their contributions included both animal and human studies, and their clinical projects were unique in that they typically included both short-term and long-term data. Further, their studies on “biological markers” benefited from the “pharmacological dissection” of the clinical phenomena (classifying patients according to their treatment response). At the same time, biological findings helped to formulate better intervention strategies (e.g., homovanillic acid concentrations and neuroleptic responses) and the subtyping of clinical syndromes. A series of publications on the pharmacokinetics of haloperidol, and later on the atypical neuroleptics, pushed Chang and his colleagues forward as the world expert on these issues³.

Taiwanese Psychiatry:“the Third Generation”(1990-current)

The development during the previous stage paved the way for the blossoming of research in biological psychiatry in recent years, which is characterized by the further diversification of researchers and research institutions. While leaders from the previous generation remained active (e.g., George Chiao-Chicy Chen 陳喬琪, Hai-Gwo Hwu 胡海國, Ru-Band Lu 陸汝斌), they also had mentored a large number of clinical investigators who then initiated new and innovative research programs, examining cutting-edge and eminently clinically relevant issues such as the natural course of bipolar disorders²⁹, and the therapeutic effects of glutamatergic agents for the treatment of schizophrenia ¹⁴. These developments also have benefited from the “return” of several Taiwanese-American psychiatrists who had been active in American academia for decades (e.g., Sidney Chang 張信義, Keh-Ming Lin 林克明, Winston Shen 沈武典, and Tom Tung-Ping Su 蘇東平). Together with others who have remained abroad (e.g., Ming-Tse Tsuang 莊明哲) but maintained close ties with researchers in Taiwan, they have further broadened the talent pool, and helped to maximize international collaborations and cross-fertilization.

As is true worldwide, the direction of psychiatric research in Taiwan has been profoundly influenced in recent years by the rapid developments in genomic medicine and brain imaging. Genotyping, microarray and fine mapping methods have become widely available, enabling a new generation of researchers to use these tools to examine factors that might be associated with the vulnerability for psychiatric and behavioral problems. Of note, in particular, are the contributions on the elucidation of the “protective” and vulnerabilities genes associated with alcoholism, and evidences pointing to interactive effects among these genes ^5,7,9. Although less dramatic, similar efforts on schizophrenia^11,12,15,mood disorders and neurological diseases^30,31are leading to fruitful results as well. A plethora of studies also contributed to the field’s understanding of predictors of response and adverse effects of psychotropics^1,6,13. Progresses in brain imaging methods⁸ and neuropsychology²² similarly exerted significant impacts on biological research in Taiwan. Combined with advances in neuropsychology and neurophysiology, such studies have started to yield fruitful results in schizophrenia research as well as in the understanding of other psychiatric conditions.

In view of the remarkable progress, it is somewhat a surprise that no official organization focused on biological psychiatry until 2002, when the Taiwanese Society of Biological Psychiatry and Neuropsychopharmacology (TSBPN) was established with a membership of around 150. Since then, however, the Society has been active, sponsoring successful annual conferences and other academic activities, publishing a widely circulated bulletin and participating in national and international conferences and other activities organized by professional organizations, such as the World Federation for Societies of Biological Psychiatry (WFSBP), the World Psychiatric Association (WPA) and the Collegium Internationale Neuropsychopharmacologicum (CINP). Members of the TSBPN have long been active in these organizations, and have contributed visibly in the world psychiatric literature.

The establishment of the Division of Mental Health and Substance Abuse Research, at the National Health Research Institutes (NHRI) represents another milestone in the development of psychiatric and neuroscience research in Taiwan. Inaugurated in 2004, with the senior author as its founding Director, it has grown rapidly and is now at its beginning stage of establishing the infrastructures and research initiatives including research ward(s), the Taiwanese Psychiatric Research Network (TPRN), neuroscience and pharmacogenomic research laboratories, Neurobehavioral and neurophysiological laboratories, new CNS drug development programs, cell lines and DNA bank, brain tissue repository facilities, psychoimmunological research programs, clinical research fellowship and other research training programs for psychiatrists and nurses¹⁹. Complementing the resources and talents already in existence at the other major academic and clinical centers, these new developments at NHRI should further accelerate the development of neuropsychopharmocology and biological psychiatry in Taiwan.

Future Directions

Building upon the foundations as briefly described above, it is reasonable to expect a bright future for biological psychiatry in Taiwan. To further facilitate such developments, it is crucial that researchers strive at fostering the sharing of ideas, talents and resources. Similar to other branches of medicine, success in neuroscience research programs increasingly relies on teamwork as well as the availability and integration of highly specialized expertise in fields such as genomics, bioinformatics and brain imaging. Unless mechanisms are established for encouraging the sharing of these valuable resources and talents, both across institutions and among investigators, future progress in the field could be severely hampered or stalled. Examples of recent progress in teasing out complex issues and demonstrating the how genes and environmental factors interact point out the importance and feasibility of such collaborations and integrations.

Such collaborations and integration are equally important, if not even more so, in the arena of “translational research,” which might be regarded as a particular strength for psychiatric research in Taiwan. Even though the term per se has not yet been used widely in Taiwan, it is apparent from this review that the majority of the researchers in Taiwan have been clinicians who have mastered some aspects of laboratory skills, and have been able to integrate the two perspectives, such that there were flows between the two, with clinical observations generating research questions for the laboratories, and laboratory methods pursued for the purpose of clinical application. While this tradition will most likely continue to guide future direction of research in Taiwan, such integration might take increasingly more efforts in the future since advances in knowledge and technologies have made it virtually impossible for individual researchers to master divergent fields, particularly between clinical and basic domains. A major challenge for the continuation of this “translational” tradition of Taiwanese psychiatric research would thus be in the promotion of collaboration among researchers who possess different disciplinary backgrounds, such that they could work as a team to move research agenda forward.

For similar reasons, international collaborations will become increasingly important. While the importance of such collaborations as well as exchange of expertise and ideas have long been recognized and promoted, in reality they often occurred in a haphazard fashion and depended largely on ties and connections among individual researchers. Most of these ties also tended to be between “non-Western” and “Western” (primarily the U.S.) countries, in ways that might be regarded as “asymmetrical” (i.e., “non-Western” researchers serving as “junior” partners). As science grows and matures in Asian countries, it is crucial that such collaborations become less “Eurocentric” (in this case the term is used to include North America), more “bi-directional” or “multi-directional.” In such a context, collaborations among researchers and institutions across geopolitical demarcation lines in the Pacific Asian region will become increasingly important. To further promote such collaborations, it is important that we gain better and in-depth understanding of the history and current status of our profession in different countries in this region. We hope that this article serves as a beginning step for bridging this information gap, and helps to promote further interchanges and the formation of bonds that will stimulate collaborations, cross-fertilization and the blossoming of our joint quest in the understanding of the brain, the mind, and human behavior.

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