Cost analysis of depression using the national insurance system in South Korea: a comparison of depression and treatment-resistant depression

Short- and long-term neuropsychiatric outcomes in long COVID in South Korea and Japan

We investigated whether SARS-CoV-2 infection is associated with short- and long-term neuropsychiatric sequelae. We used population-based cohorts from the Korean nationwide cohort (discovery; n = 10,027,506) and the Japanese claims-based cohort (validation; n = 12,218,680) to estimate the short-term (<30 days) and long-term (≥30 days) risks of neuropsychiatric outcomes after SARS-CoV-2 infection compared with general population groups or external comparators (people with another respiratory infection). Using exposure-driven propensity score matching, we found that both the short- and long-term risks of developing neuropsychiatric sequelae were elevated in the discovery cohort compared with the general population and those with another respiratory infection. A range of conditions including Guillain-Barré syndrome, cognitive deficit, insomnia, anxiety disorder, encephalitis, ischaemic stroke and mood disorder exhibited a pronounced increase in long-term risk. Factors such as mild severity of COVID-19, increased vaccination against COVID-19 and heterologous vaccination were associated with reduced long-term risk of adverse neuropsychiatric outcomes. The time attenuation effect was the strongest during the first six months after SARS-CoV-2 infection, and this risk remained statistically significant for up to one year in Korea but beyond one year in Japan. The associations observed were replicated in the validation cohort. Our findings contribute to the growing evidence base on long COVID by considering ethnic diversity.

Risk factors of reattempt among suicide attempters in South Korea: A nationwide retrospective cohort study

This study aimed to identify underlying demographic and clinical characteristics among individuals who had previously attempted suicide, utilizing the comprehensive Health Insurance Review and Assessment Service (HIRA) database. Data of patients aged 18 and above who had attempted suicide between January 1 and December 31, 2014, recorded in HIRA, were extracted. The index date was identified when a suicide attempt was made within the year 2014. The medical history of the three years before the index date and seven years of follow-up data after the index date were analyzed. Kaplan-Meier estimate was used to infer reattempt of the suicide attempters, and Cox-proportional hazard analysis was used to investigate risk factors associated with suicide reattempts. A total of 17,026 suicide attempters were identified, of which 1,853 (10.9%) reattempted suicide; 4,925 (28.9%) patients had been diagnosed with depressive disorder. Of the reattempters, 391 (21.1%) demonstrated a history of suicide attempts in the three years before the index date, and the mean number of prior attempts was higher compared to that of the non-reattempters (1.7 vs.1.3, p-value < 0.01). Prior psychiatric medication, polypharmacy, and an increase in the number of psychotropics were associated with suicide reattempt in overall suicide attempters. (Hazard ratio (HR) = 3.20, 95% confidence interval [CI] = 2.56-4.00; HR = 2.42, 95% CI = 1.87-3.14; HR = 19.66, 95% CI = 15.22-25.39 respectively). The risk of reattempt decreased in individuals receiving antidepressant prescriptions compared to those unmedicated, showing a reduction of 78% when prescribed by non-psychiatrists and 89% when prescribed by psychiatrists. Similar risk factors for suicide reattempts were observed in the depressive disorder subgroup, but the median time to reattempt was shorter (556.5 days) for this group compared to that for the overall attempters (578 days). Various risk factors including demographics, clinical characteristics, and medications should be considered to prevent suicide reattempts among suicide attempters, and patients with depressive disorder should be monitored more closely.

Projecting the 10-year costs of care and mortality burden of depression until 2032: a Markov modelling study developed from real-world data

Background

Based on real-world data, we developed a 10-year prediction model to estimate the burden among patients with depression from the public healthcare system payer's perspective to inform early resource planning in Hong Kong.

Methods

We developed a Markov cohort model with yearly cycles specifically capturing the pathway of treatment-resistant depression (TRD) and comorbidity development along the disease course. Projected from 2023 to 2032, primary outcomes included costs of all-cause and psychiatric care, and secondary outcomes were all-cause deaths, years of life lived, and quality-adjusted life-years. Using the territory-wide electronic medical records, we identified 25,190 patients aged ≥10 years with newly diagnosed depression from 2014 to 2016 with follow-up until 2020 to observe the real-world time-to-event pattern, based on which costs and time-varying transition inputs were derived using negative binomial modelling and parametric survival analysis. We applied the model as both closed cohort, which studied a fixed cohort of incident patients in 2023, and open cohort, which introduced incident patients by year from 2014 to 2032. Utilities and annual new patients were from published sources.

Findings

With 9217 new patients in 2023, our closed cohort model projected the 10-year cumulative costs of all-cause and psychiatric care to reach US$309.0 million and US$58.3 million, respectively, with 899 deaths (case fatality rate: 9.8%) by 2032. In our open cohort model, 55,849-57,896 active prevalent cases would cost more than US$322.3 million and US$60.7 million, respectively, with more than 943 deaths annually from 2023 to 2032. Fewer than 20% of cases would live with TRD or comorbidities but contribute 31-54% of the costs. The greatest collective burden would occur in women aged above 40, but men aged above 65 and below 25 with medical history would have the highest costs per patient-year. The key cost drivers were relevant to the early disease stages.

Interpretation

A limited proportion of patients would develop TRD and comorbidities but contribute to a high proportion of costs, which necessitates appropriate attention and resource allocation. Our projection also demonstrates the application of real-world data to model long-term costs and mortality, which aid policymakers anticipate foreseeable burden and undertake budget planning to prepare for the care need in alternative scenarios.

Funding

Research Impact Fund from the University Grants Committee, Research Grants Council with matching fund from the Hong Kong Association of Pharmaceutical Industry (R7007-22).

The prevalence and economic burden of treatment-resistant depression in Thailand

BACKGROUND

The objectives of this study were to investigate the proportion of treatment-resistant depression (TRD) among patients with diagnosed major depressive disorder (MDD) and undergoing antidepressant treatment, to estimate the economic cost of MDD, TRD, and non-treatment-resistant depression (non-TRD), and to examine the differences between TRD and non-TRD MDD in a Thai public tertiary hospital.

METHODS

This was a combined study between retrospective review of medical records and a cross-sectional survey. The sample size was 500 dyads of antidepressant-treated MDD patients and their unpaid caregivers. MDD patients' medical records, the concept of healthcare resource utilization, the Work Productivity and Activity Impairment Questionnaire: depression and mood & mental state versions (WPAI: D, MM), the Class Impairment Questionnaire (CIQ), and the Family Experiences Interview Schedule (FEIS) were applied as the tools of the study. Pearson Chi's square, Fisher's Exact test, and independent T-test were employed for statistical analysis.

RESULTS

The proportion of TRD was 19.6% among antidepressant-treated MDD patients in a Thai tertiary public hospital. The results of the study indicated that several factors showed a statistically significant association with TRD criteria. These factors included younger age of MDD patients, a younger age of onset of MDD, lower body mass index (BMI), a history of suicide attempts and self-harm, as well as frequent smoking behavior. The annualized economic cost of TRD was 276,059.97 baht per person ($7,668.33), which was significantly higher than that of cost of non-TRD (173,487.04 baht or $4,819.08). The aggregated economic costs of MDD were 96.8 million baht annually ($2.69 M) if calculated from 500 MDD patients and unpaid caregivers. This contributed to the economic cost of TRD 27.05 million baht (98 respondents) and the economic cost of non-TRD 69.74 million baht (402 respondents).

CONCLUSIONS

The economic burden associated with TRD was significantly higher compared to non-TRD among antidepressant-treated MDD patients. Specifically, both direct medical costs and indirect costs were notably elevated in the TRD group.

Exome-wide association study of treatment-resistant depression suggests novel treatment targets

Treatment-resistant depression (TRD) is a severe form of major depressive disorder (MDD) with substantial public health impact and poor treatment outcome. Treatment outcome in MDD is significantly heritable, but genome-wide association studies have failed to identify replicable common marker alleles, suggesting a potential role for uncommon variants. Here we investigated the hypothesis that uncommon, putatively functional genetic variants are associated with TRD. Whole-exome sequencing data was obtained from 182 TRD cases and 2021 psychiatrically healthy controls. After quality control, the remaining 149 TRD cases and 1976 controls were analyzed with tests designed to detect excess burdens of uncommon variants. At the gene level, 5 genes, ZNF248, PRKRA, PYHIN1, SLC7A8, and STK19 each carried exome-wide significant excess burdens of variants in TRD cases (q < 0.05). Analysis of 41 pre-selected gene sets suggested an excess of uncommon, functional variants among genes involved in lithium response. Among the genes identified in previous TRD studies, ZDHHC3 was also significant in this sample after multiple test correction. ZNF248 and STK19 are involved in transcriptional regulation, PHYIN1 and PRKRA are involved in immune response, SLC7A8 is associated with thyroid hormone transporter activity, and ZDHHC3 regulates synaptic clustering of GABA and glutamate receptors. These results implicate uncommon, functional alleles in TRD and suggest promising novel targets for future research.

Quantification of the Effect of Vitamin E Intake on Depressive Symptoms in United States Adults Using Restricted Cubic Splines

Background

Depression is a rapidly increasing public health concern, affecting >4% of the global population. Identification of new nutritional recommendations is needed to help combat this increasing public health concern.

Objectives

The study aimed to examine the association between vitamin E intake and depressive symptoms.

Methods

A retrospective study was conducted by using a nationally representative, modern cohort (NHANES 2017-2020). Depressive symptoms were assessed through the validated 9-item Patient Health Questionnaire (PHQ-9). All adult patients ([≥18 y old], 8091 total adults) who answered the PHQ-9 and daily nutritional values questionnaires were selected for this study. Per literature, patients with PHQ-9 scores ≥10 were considered to have depressive symptoms. Univariable and multivariable logistic regressions were used to investigate the effect of vitamin E on depressive symptoms as ascertained by PHQ-9. The acquisition and analysis of the data within this study was approved by the NCHS ethics review board.

Results

After controlling for potential confounders (age, race, sex, and income), we observed that increased vitamin E (up until 15 mg/d) was associated with decreased rates of depressive symptoms, with each 5 mg increase in vitamin E associated with 13% decreased odds of symptoms of depression (OR: 0.87; 95% CI: 0.77, 0.97; P < 0.01). Additional intake above 15 mg/d, the daily recommended amount by the Food and Nutrition Board, did not change the odds of depression (OR: 1.05; 95% CI: 0.92, 1.16; P = 0.44).

Conclusions

Increased vitamin E intake (up to 15 mg/d) is associated with decreased depressive symptoms. Further prospective studies are required to ascertain whether increased vitamin E can protect against depressive symptoms and the specific therapeutic dose-response relationship.

The significant association between quick return and depressive symptoms and sleep disturbances in paid workers: A nationwide survey

Objectives

Although many studies have examined the association between shift work and depression or insomnia, few studies have examined the relationship between quick return (QR) to work and depressive symptoms, regardless of shift work. Thus, in this study, we aimed to assess the association between depressive symptoms (DS)/sleep disturbances (SDs) and QR.

Methods

Data from the 6^th Korean Working Conditions Survey (2020) were used for this study. Paid workers aged between 20 and 65 years were included. DS were defined using the World Health Organization Well-Being Index (WHO-5) with a cut-off 50, and SD was defined as the occurrence of the following symptoms several times per month: difficulty in falling asleep, waking up in the middle of the night, or feeling tired even after waking up. QR was defined as "at least one case where the working interval between leaving work and the next day's work was < 11 h in the past month." Multivariable logistic regression was performed to estimate the adjusted odd ratios (aORs) and 95% confidence intervals (CIs). Mediation analysis was conducted to examine whether SD was a significant mediator in the association between QR and DS.

Results

Among the 27,554 participants, DS occurred in 8,277 patients, while SD occurred in 6,264 patients. The aORs (95% CIs) of DS and SD by QR were 2.01 (1.78-2.27) and 3.24 (2.87-3.66), respectively, after adjusting for age, gender, income, education, working hours, job status, working duration, region, shift work, and occupation. SD was a significant mediator in the association between QR and DS.

Conclusion

QR is significantly associated with DS or SD regardless of demographic factors and the working environment. The significant relationship between QR and DS may be mediated by SD.

Concordance of the treatment patterns for major depressive disorders between the Canadian Network for Mood and Anxiety Treatments (CANMAT) algorithm and real-world practice in China

Background: Antidepressant (AD) algorithm is an important tool to support treatment decision-making and improve management of major depressive disorder (MDD). However, little is known about its concordance with real-world practice. This study aimed to assess the concordance between the longitudinal treatment patterns and AD algorithm recommended by a clinical practice guideline in China. Methods: Data were obtained from the electronic medical records of Shanghai Mental Health Center (SMHC), one of the largest mental health institutions in China. We examined the concordance between clinical practice and the Canadian Network for Mood and Anxiety Treatments (CANMAT) algorithm among a cohort composed of 19,955 MDD patients. The longitudinal characteristics of treatment regimen and duration were described to identify the specific inconsistencies. Demographics and health utilizations of the algorithm-concordant and -discordant subgroups with optimized treatment were measured separately. Results: The overall proportion of algorithm-concordant treatment significantly increased from 84.45% to 86.03% during the year of 2015-2017. Among the patients who received recommended first-line drugs with subsequent optimized treatment (n = 2977), the concordance proportion was 27.24%. Mirtazapine and trazodone were the most used drugs for adjunctive strategy. Inadequate or extended duration before optimized treatment are common inconsistency. The median length of follow-up for algorithm-concordant (n = 811) and algorithm-discordant patients (n = 2166) were 153 days (Q1-Q3 = 79-328) and 368 days (Q1-Q3 = 181-577) respectively, and the average number of clinical visits per person-year was 13.07 and 13.08 respectively. Conclusion: Gap existed between clinical practice and AD algorithm. Improved access to evidence-based treatment is required, especially for optimized strategies during outpatient follow-up.

Courses of treatment and risk factors for treatment-resistant depression in Finnish primary and special healthcare: A nationwide cohort study

OBJECTIVE

Investigate incidence, risk factors and courses of treatment for treatment-resistant depression (TRD) in primary and special healthcare.

METHODS

All patients identified from nationwide registers, aged 16-65 years, diagnosed with depression in Finland during 2004-2016 were included. New antidepressant users were identified with six-month washout period and followed-up for two years to observe for presence of TRD, which was defined as initiation of a third trial after having failed two pharmacological treatment trials with adequate duration.

RESULTS

During follow-up, 177,144 persons had their first registered antidepressant treated depression (mean age: 39.5, 62.5% women). Of them, 10.9% (N = 19,322) met TRD criteria. Among the TRD patients, most common first and second antidepressants trials were: SSRIs (44.6%), mirtazapine (19.0%) and SNRIs (16.5%). As the third treatment line, antidepressant monotherapy (44.2% of TRD patients) was most common, followed by a combination of ≥2 antidepressants (32.1%), antipsychotic or mood stabilizer augmentation and an antidepressant (15.8%), both combination of antidepressants and an augmentation with a mood stabilizer or antipsychotic (4.9%), antipsychotic or mood stabilizer monotherapy (2.7%) and ECT (0.3%). Of TRD patients, 16.5% (N = 3188) progressed to the fifth treatment line, in which the most common treatments were antidepressant monotherapy (33.4%), antidepressant combinations (27.5%) and augmentation (24.2%). Factors associated with higher risk of TRD included male gender, younger age, higher initial disease severity and hospitalization at initial onset of depression.

CONCLUSIONS

Antidepressant monotherapies were still the most common fifth line of depression treatment. Severe depression, hospitalization due to depression, young age and male gender may predispose to TRD.

Muscle Strength Moderates the Relationship between Nutritional Health Risk and Depression in Korean Older Adults

Background: Little is known about the relationships between muscle strength and nutritional health risk with late-in-life depression. This study aimed to investigate the moderating effect of lower-extremity muscle strength on the relationship between nutritional health risk and depression in Korean older adults. Methods: Data obtained from 5949 women and 3971 men aged ≥ 65 years in the 2020 Korea Longitudinal Study on Aging were used in this study. Exposures included lower-extremity muscle strength and nutritional health risk. Lower-extremity muscle strength was measured with a modified sit-to-stand test. The nutritional health risk was assessed using a screening tool. Depression was defined as a score ≥ 8 points on the Geriatric Depression Scale (GDS). Results: Logistic regression analyses showed that depression was positively associated with nutritional health risk (p < 0.001) and inversely associated with lower-extremity muscle strength (p < 0.001). A moderation analysis with Andrew Hayes’ PROCESS macro showed a significant moderating effect of lower-extremity muscle strength (β = −0.119; 95% confidence interval, −0.172 to −0.066; p < 0.001) on the relationship between nutritional health risk and depression; the weaker was the muscle strength, the steeper was the slope of the GDS score for nutritional health risk. Conclusions: The current findings suggest the need for an intervention targeting both high nutritional risk and weak muscle strength as a therapeutic strategy against depression in Korean older adults.

Serum Low-Density Lipoprotein Cholesterol Levels and Depressive Mood in Korean Adults: A Nationwide Population-Based Study

Background

The association between serum cholesterol levels and depression has been studied extensively; however, results are inconsistent. This study aimed to investigate the association between low-density lipoprotein cholesterol (LDL-C) levels and depressive symptoms among Korean adults.

Methods

This cross-sectional study used data obtained from the 2007–2015 Korea National Health and Nutrition Examination Survey. In total, 40,904 adults were included in the final analysis. Participants were categorized into five groups according to their LDL-C levels, using the Korean guidelines for dyslipidemia. Symptoms of depression were evaluated using a self-reported questionnaire. Weighted logistic regression was used to examine the relationship between LDL-C levels and self-reported depressive symptoms.

Results

Compared with the intermediate category, the lowest (<70 mg/dL) and highest (≥160 mg/dL) LDL-C categories were associated with depressive symptoms, after adjusting for potential confounding factors (odds ratio [OR], 1.191; 95% confidence interval [CI], 1.008–1.409; OR, 1.241; 95% CI, 1.073–1.435, respectively). The highest LDL-C category was positively associated with depressive symptoms in those who were middle-aged, female, had a low body mass index, and taking or not taking dyslipidemia medications.

Conclusion

A U-shaped association was identified between LDL-C categories and self-reported depressive symptoms. Our findings suggest that LDL-C levels that are too low or too high are associated with self-reported depressive symptoms. Further prospective studies are needed to determine the causal relationship of this association.

The relationship between lifestyle risk factors and depression in Korean older adults: a moderating effect of gender

Background

Little is known regarding the role of gender as a possible modulator in determining the associations between lifestyle risk factors and depression in older adults.

Objectives

This study examined whether gender modulates the relationship between depression and lifestyle risk factors in Korean adults aged 65 years and older (n = 3700).

Methods

Data were obtained from the 2016 and 2018 Korea National Health and Examination Survey. The primary outcome was depression, assessed with the patient health questionnaire-9. As exposures, smoking habits, at-risk alcohol consumption, and physical inactivity were assessed with a standardized questionnaire. In addition, mean adequacy ratio (MAR) as an indicator of overall nutritional inadequacy was assessed with dietary intakes of macro- and micronutrients.

Results

In men only, either two or three and more risk factors were significantly associated with higher depression risk (OR (95% confidence interval, CI) = 2.886 (1.003–8.299) and OR (95% CI) = 3.109 (1.064–9.097), respectively). In women only, either two or three and more risk factors were also significantly associated with higher depression risk (OR (95% CI) = 1.505 (1.067–2.124) and OR (95% CI) = 2.828 (1.527–5.239), respectively). In particular, the presence of smoking habits and MAR were the major determinants of depression (OR (95% CI) = 1.835 (1.09–3.10) and OR (95% CI) = 1.585 (1.125–2.233), respectively) in women only. Finally, a moderation analysis with the Hayes PROCESS Macro showed a significant moderating effect of gender (β (95% CI) = 0.633 (0.206 ~ 1.060)) on the relationship between risk factors and depression. In addition, the slope of the relationship was much steeper in women than in men.

Conclusion

Current findings suggest that lifestyle risk factors are more closely associated with depression risk in women than in men.

Individual and Synergistic Relationships of Low Muscle Mass and Low Muscle Function with Depressive Symptoms in Korean Older Adults

This study examined the relationship of low appendicular skeletal muscle mass and low muscle function with depressive symptoms in Korean older adults. Community-dwelling Korean older adults aged 65 years and older (n = 521) participated in this study. Appendicular muscle mass (ASM) and muscle function (MF) scores were assessed using dual-energy X-ray absorptiometry (DXA) scanning and sit-to-stand mean power based on a 30 s chair stand test, respectively. Depressive symptoms were evaluated using the Korean form of the Center for Epidemiologic Studies Depression Scale. Logistic regression was used to estimate the odds ratios (ORs) and 95% confidence intervals (CIs) of depressive symptoms according to ASM- and MF-based subgroups; normal ASM/normal MF, low ASM/normal MF, normal ASM/low MF, and low ASM/low MF. The prevalence of depressive symptoms was 21.3% in all patients: 20.7% in women and 21.5% in men. Compared to the normal ASM/normal MF participants (OR = 1), the risk of depressive symptoms rose incrementally in subjects with low ASM/normal MF (OR = 2.963, p = 0.019), normal AMS/low MF (OR = 3.843, p = 0.002), and low ASM/low MF (OR = 7.907, p < 0.001), respectively. The current findings suggest that the coexistence of low ASM and low MF is significantly and independently associated with an increased risk for depressive symptoms, with dynapenia having a stronger relationship.

Epidemiology and costs of depressive disorder in Spain: the EPICO study

Depressive Disorders are the most common psychiatric diagnoses in the general population. To estimate the frequency, costs associated with Depressive Disorders in usual clinical practice, and in the whole Spanish population, a longitudinal, retrospective, observational study was carried out using data from the BIG-PAC database®. Study population: all patients aged ≥ 18 years with a diagnosis of a Depressive Disorder in 2015-2017. Prevalence was computed as the proportion of Depressive Disorder cases in the adult general population, and the incidence rate, as the number of new Depressive Disorder cases diagnosed per 1,000 person-years in the population using health services, during 2015-2017. We collected demographic variables, comorbidity, direct health costs, and indirect costs (temporary and permanent disability). Health costs related to Depressive Disorders were estimated according to the annual resource use rate (resource/patient/year). Indirect costs were calculated according to the human capital method. Using the study data and information from the Spanish National Institute of Statistics, we estimated the cost of Depressive Disorders corresponding to the Spanish adult population, including premature mortality. 69,217 Depressive Disorder patients aged ≥ 18 years who met the inclusion/exclusion criteria were studied (mean age: 56.8 years; female: 71.4%). Prevalence of Depressive Disorders in the general population was 4.73% (95% CI: 4.70-4.76%). Annual incidence rates (2015-2017) were 7.12, 7.35 and 8.02 per 1,000 person-years, respectively. Total costs observed in our Depressive Disorder patients were € 223.9 million (corresponding to a mean of € 3,235.3; mean/patient/year), of which, 18.4% were direct health care costs and 81.6%, non-health indirect costs (18% temporary occupational disability, 63.6% permanent disability). Considering also the cost of premature death, the mean cost per patient/year was € 3,402 and the estimated societal costs of Depressive Disorders in Spain were € 6,145 million. The prevalence and incidence of Depressive Disorders are consistent with other series reviewed. Resource use and total costs (especially non-health costs) were high.

The Relationship of Lifestyle Risk Factors and Depression in Korean Adults: A Moderating Effect of Overall Nutritional Adequacy

Background: Little is known regarding the role of nutrition in determining the associations between lifestyle risk factors and depression. Objectives: This study examined whether or not nutritional adequacy modulates the relationship between depression and lifestyle risk factors in Korean adults aged 18-65 years (n = 7446). Methods: Data were obtained from the 2016 and 2018 Korea National Health and Examination Survey. Depression, smoking, at-risk alcohol consumption, physical inactivity, sleep deprivation, and mean adequacy ratio (MAR) were assessed. Results: Individuals with two (OR = 1.960, p < 0.001), three (OR = 4.237, p < 0.001), or four (OR = 5.312, p < 0.001) risk factors had a significantly higher risk of depression compared to individuals with one or zero risk factor. In contrast, individuals with moderate MAR (OR = 0.607, p < 0.001) and high (OR = 0.698, p < 0.001) MAR had a lower depression risk compared to individuals with low MAR. Moderation analysis showed a moderating effect of MAR (coefficient = −0.220, p = 0.007) on the relationship between risk factors and depression. Conclusions: The current findings suggest that overall nutritional adequacy plays a modulating role in determining the relationship between depression and lifestyle risk factors in Korean adults.