Evidence-based, pharmacological treatment guideline for depression in Korea, revised edition

A Machine-Learning-Algorithm-Based Prediction Model for Psychotic Symptoms in Patients with Depressive Disorder

Psychotic symptoms are rarely concurrent with the clinical manifestations of depression. Additionally, whether psychotic major depression is a subtype of major depression or a clinical syndrome distinct from non-psychotic major depression remains controversial. Using data from the Research on Asian Psychotropic Prescription Patterns for Antidepressants, we developed a machine-learning-algorithm-based prediction model for concurrent psychotic symptoms in patients with depressive disorders. The advantages of machine learning algorithms include the easy identification of trends and patterns, handling of multi-dimensional and multi-faceted data, and wide application. Among 1171 patients with depressive disorders, those with psychotic symptoms were characterized by significantly higher rates of depressed mood, loss of interest and enjoyment, reduced energy and diminished activity, reduced self-esteem and self-confidence, ideas of guilt and unworthiness, psychomotor agitation or retardation, disturbed sleep, diminished appetite, and greater proportions of moderate and severe degrees of depression compared to patients without psychotic symptoms. The area under the curve was 0.823. The overall accuracy was 0.931 (95% confidence interval: 0.897–0.956). Severe depression (degree of depression) was the most important variable in the prediction model, followed by diminished appetite, subthreshold (degree of depression), ideas or acts of self-harm or suicide, outpatient status, age, psychomotor retardation or agitation, and others. In conclusion, the machine-learning-based model predicted concurrent psychotic symptoms in patients with major depression in connection with the “severity psychosis” hypothesis.

Global mapping of interventions to improve quality of life of patients with depression during 1990-2018

PURPOSE

The number of patients with depressive disordered globally increased and affects people of all ages and countries and has a significant and negative impact on the quality of life (QoL). Depression if left untreated may lead to severe consequences. However, there are several types of effective treatments, but often patients need support from health staff to find suitable treatments. This study aims to examine the global trend of the publications as well as the development of interventions for depressing treatment.

METHODS

We download and analyzed 15,976 scientific research from the Web of Science from 1990 to 2018. A text mining based on Latent Dirichlet and terms' co-occurrence in titles and abstracts to identify hidden research topics and research landscapes.

RESULTS

We found that the number of papers related to non-pharmacological treatment (such as cognitive-behavioral, mindfulness, or family and social support) to improve the QoL of patients with depression has increased. The number of papers on this serious health issue in low-middle income countries (LMICs) was not as high as in high-income countries (HICs).

CONCLUSION

It is necessary to increase support of the treatment of depression in LMICs as well as applied non-pharmacological interventions to patients with depression.

Symptom-based selection of antidepressants

Most evidence-based pharmacological guidelines recommend selective serotonin reuptake inhibitors, serotoninnorepinephrine reuptake inhibitors, norepinephrine-dopamine reuptake inhibitors or norepinephrine and specific serotonin antidepressants as the first-line treatment for major depression. Since the clinical factors associated with treating patients with depression are relatively complex, it can be challenging to apply the recommendations of evidence-based medicine verbatim. Furthermore, the diagnostic criteria of major depressive disorders, which are defined in a polythetic and operational manner, inevitably result in their heterogeneity. Studies have inferred that depressive syndrome may be connected with “family resemblance” rather than being shared with a neurobiological essence. Therefore, the symptom-based selection of antidepressants can be supported by a network analysis that provides a novel perspective on the symptom structure of major depression. The symptom-based treatment algorithm suggests treatment options that can be applied to the symptoms that are included in and excluded from the diagnosis criteria of major depressive disorder. The symptom-based selection of antidepressants and other psychotropic agents involves matching the deconstructed symptoms of depression to the specific neuroanatomical regions and neurotransmitters. This ensures timely and optimized treatment options for patients with depression.

Analysis of Time-Course, Dose-Effect, and Influencing Factors of Antidepressants in the Treatment of Acute Adult Patients With Major Depression

OBJECTIVE

Model-based meta-analysis was used to describe the time-course and dose-effect relationships of antidepressants and also simultaneously investigate the impact of various factors on drug efficacy.

METHODS

This study is a reanalysis of a published network meta-analysis. Only placebo-controlled trials were included in this study. The change rate in depression rating scale scores from baseline was used as an efficacy indicator because a continuous variable is more likely to reflect subtle differences in efficacy between drugs.

RESULTS

A total 230 studies containing 64 346 patients were included in the analysis. The results showed that the number of study sites (single or multi-center) and the type of setting (inpatient or noninpatient) are important factors affecting the efficacy of antidepressants. After deducting the placebo effect, the maximum pure drug efficacy value of inpatients was 18.4% higher than that of noninpatients, and maximum pure drug efficacy value of single-center trials was 10.2% higher than that of multi-central trials. Amitriptyline showed the highest drug efficacy. The remaining 18 antidepressants were comparable or had little difference. Within the approved dose range, no significant dose-response relationship was observed. However, the time-course relationship is obvious for all antidepressants. In terms of safety, with the exception of amitriptyline, the dropout rate due to adverse events of other drugs was not more than 10% higher than that of the placebo group.

CONCLUSION

The number of study sites and the type of setting are significant impact factors for the efficacy of antidepressants. Except for amitriptyline, the other 18 antidepressants have little difference in efficacy and safety.

The association between antidepressant use and deaths from road traffic accidents: a case-crossover study

PURPOSE

Antidepressants are some of the most commonly used psychiatric medications, but little information is available about the effects of antidepressant treatment on the risk of traffic accidents across classes of antidepressants or associated with each substance individually. To investigate the relationship between exposure to antidepressants and risk of fatality in road traffic accidents.

METHODS

We used a Korean national road traffic authority database linked with a national health insurance database between January 1, 2010 and December 31, 2014 and applied a case-crossover design. The study subjects were drivers in South Korea who died from traffic accidents and who had prescriptions for antidepressants within 1 year prior to the date of the accident. We compared the status of prescription for antidepressants with the hazard period and four matched control periods using conditional logistic regression, adjusting for other drug use. The trends of antidepressant utilization were described in terms of the number of prescriptions. A case-case-time-control design was applied to drugs with an increasing trend in use and a significant case-crossover odds ratio (OR).

RESULTS

A total of 1250 antidepressant-using drivers were included, and an increased risk was observed during the 30-day hazard period (adjusted OR 1.30; 95% CI 1.03-1.63). Selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) showed significant risks, but tricyclic antidepressants did not. However, the associations of all antidepressants, SSRIs, SNRIs, escitalopram, and duloxetine did not remain significant after adjusting for trends in utilization. Paroxetine and milnacipran were associated with increased risks, with no obvious increase in their utilization, but the possibility of confounding by indication could have affected the results for milnacipran.

CONCLUSION

Considering the trends of antidepressant prescription and utilization, the use of paroxetine increased the risk of fatal traffic accidents.

Paroxetine versus Venlafaxine and Escitalopram in Korean Patients with Major Depressive Disorder: A Randomized, Rater-blinded, Six-week Study

Objective

The purpose of this study was to compare the efficacy and safety of escitalopram, paroxetine and venlafaxine in Korean patients with major depressive disorder (MDD).

Methods

A total of 449 Korean MDD patients were recruited in a six-week, randomized, rater-blinded, active-controlled trial and were evenly randomized to paroxetine, venlafaxine, or escitalopram treatment.

Results

When comparing the mean difference for the Montgomery-Åsberg Depression Rating Scale (MADRS) and the Hamilton Depression Rating Scale (HDRS) total scores during six weeks, paroxetine (−6.4±0.4, and −5.4±0.4, respectively) was found to be significantly superior to escitalopram (−3.7±0.5 and −3.1±0.4, respectively). Venlafaxine had a significantly lower MADRS total score (−5.4±0.4) than escitalopram. When adjusting baseline variables, the response, according to the MADRS and HDRS scores, in the paroxetine group was greater than that for the escitalopram group (odds ratio [OR]=2.43, 95% confidence interval [CI]=1.42–4.16 for MADRS; and OR=2.32, 95% CI=1.35–3.97 for HDRS) and the venlafaxine group (OR=1.94, 95% CI=1.17–3.21 for MADRS; and OR=1.71, 95% CI=1.03–2.83 for HDRS). Despite that the overall tolerability was high and similar among the three groups, a total of 268 subjects (59.7%) prematurely discontinued treatment, representing the main limitation of the present study.

Conclusion

Although a low study completion rate limits generalizability, our findings suggest that paroxetine might be superior to escitalopram in Korean MDD patients. Further studies should be conducted to draw a definite conclusion.

Gender differences in depressive symptom profiles and patterns of psychotropic drug usage in Asian patients with depression: Findings from the Research on Asian Psychotropic Prescription Patterns for Antidepressants study

OBJECTIVES

The purpose of this study was to investigate whether there were gender-specific depressive symptom profiles or gender-specific patterns of psychotropic agent usage in Asian patients with depression.

METHOD

Clinical data from the Research on Asian Psychotropic Prescription Patterns for Antidepressant study (1171 depressed patients) were used to determine gender differences by analysis of covariates for continuous variables and by logistic regression analysis for discrete variables. In addition, a binary logistic regression model was fitted to identify independent clinical correlates of the gender-specific pattern on psychotropic drug usage.

RESULTS

Men were more likely than women to have loss of interest (adjusted odds ratio = 1.379, p = 0.009), fatigue (adjusted odds ratio = 1.298, p = 0.033) and concurrent substance abuse (adjusted odds ratio = 3.793, p = 0.008), but gender differences in other symptom profiles and clinical features were not significant. Men were also more likely than women to be prescribed adjunctive therapy with a second-generation antipsychotic (adjusted odds ratio = 1.320, p = 0.044). However, men were less likely than women to have suicidal thoughts/acts (adjusted odds ratio = 0.724, p = 0.028). Binary logistic regression models revealed that lower age (odds ratio = 0.986, p = 0.027) and current hospitalization (odds ratio = 3.348, p < 0.0001) were independent clinical correlates of use of second-generation antipsychotics as adjunctive therapy for treating depressed Asian men.

CONCLUSION

Unique gender-specific symptom profiles and gender-specific patterns of psychotropic drug usage can be identified in Asian patients with depression. Hence, ethnic and cultural influences on the gender preponderance of depression should be considered in the clinical psychiatry of Asian patients.

[Evidence-based choice and antidepressants treatment in psychiatry]

Depression is a severe and usually recurrent mental disorder which leads to a prominent impairment of physical and social functioning, a reduced quality of life of the patients, implies as well an increased morbidity and mortality. Reducing the social-economic depression burden is possible in the optimization of decision-making process of antidepressant choice (including SSRIs and SNRIs) based on the evidence-based risk/benefit ratio and resource saving potential treatment involving target psychosocial interventions and monitoring of long-term treatment adherence.

Hazardous drinking-related characteristics of depressive disorders in Korea: the CRESCEND study

This study aimed to identify clinical correlates of hazardous drinking in a large cohort of Korean patients with depression. We recruited a total of 402 depressed patients aged > 18 yr from the Clinical Research Center for Depression (CRESCEND) study in Korea. Patients' drinking habits were assessed using the Korean Alcohol Use Disorder Identification Test (AUDIT-K). Psychometric scales, including the HAMD, HAMA, BPRS, CGI-S, SSI-Beck, SOFAS, and WHOQOL-BREF, were used to assess depression, anxiety, overall psychiatric symptoms, global severity, suicidal ideation, social functioning, and quality of life, respectively. We compared demographic and clinical features and psychometric scores between patients with and without hazardous drinking behavior after adjusting for the effects of age and sex. We then performed binary logistic regression analysis to identify independent correlates of hazardous drinking in the study population. Our results revealed that hazardous drinking was associated with current smoking status, history of attempted suicide, greater psychomotor retardation, suicidal ideation, weight loss, and lower hypochondriasis than non-hazardous drinking. The regression model also demonstrated that more frequent smoking, higher levels of suicidal ideation, and lower levels of hypochondriasis were independently correlates for hazardous drinking in depressed patients. In conclusion, depressed patients who are hazardous drinkers experience severer symptoms and a greater burden of illness than non-hazardous drinkers. In Korea, screening depressed patients for signs of hazardous drinking could help identify subjects who may benefit from comprehensive therapeutic approaches.