Preventive effect of aripiprazole once-monthly on relapse into mood episodes in bipolar disorder: A multicenter, one-year, retrospective, mirror image study

BACKGROUND

We conducted a one-year, retrospective, mirror-image study to investigate the clinical effectiveness and safety of aripiprazole once monthly (AOM) in patients with bipolar disorder (BD). We compared pre-treatment conditions with outcomes after 12 months of AOM treatment.

METHODS

Seventy-five bipolar patients were recruited from 12 hospitals in Korea. We included 75 patients with BD who had received at least three AOM treatments from September 2019 to September 2022 and had accessible electronic medical record (EMRs) for the year before and after the baseline visit.

RESULTS

The overall number of mood episodes significantly decreased from a mean of 1.5 ± 1.2 episodes pre-AOM to 0.5 ± 1.2 episodes post-AOM. Manic episodes significantly decreased from 0.8 ± 0.8 episodes pre-AOM to 0.2 ± 0.5 episodes post-AOM, and depressive episodes significantly decreased from 0.5 ± 0.8 episodes pre-AOM to 0.2 ± 0.6 episodes post-AOM (p = 0.017). Moreover, the number of psychiatric medications and pills and the proportion of patients treated with complex polypharmacy were significantly decreased post-AOM.

LIMITATIONS

The small sample size was insufficient to fully represent the entire population of individuals with BD, and potential selection bias was introduced due to only including subjects who received AOM three or more times.

CONCLUSION

The results of this study suggest that AOM can reduce mood episode relapse and may be clinically beneficial in the treatment of BD patients, potentially reducing issues associated with polypharmacy in some individuals.

Patient's Perspective on Psychiatric Drugs: A Multicenter Survey-Based Study

OBJECTIVE

We aimed to identify the expectations and preferences for medication and medical decision-making in patients with major psychiatric disorders.

METHODS

A survey was conducted among patients with major psychiatric disorders who visited psychiatric outpatient clinics at 15 hospitals between 2016 and 2018 in Korea. The survey consisted of 12 questions about demographic variables and opinions on their expectations for medication, important medical decision-makers, and preferred drug type. The most preferred value in each category in the total population was identified, and differences in the preference ratio of each item among the disease groups were compared.

RESULTS

A total of 707 participants were surveyed. In the total population, patients reported high efficacy (44.01%±21.44%) as the main wish for medication, themselves (37.39%±22.57%) and a doctor (35.27%±22.88%) as the main decision makers, and tablet/capsule (36.16%±30.69%) as the preferred type of drug. In the depressive disorders group, the preference ratio of high efficacy was significantly lower, and the preference ratio of a small amount was significantly higher than that of the psychotic disorder and bipolar disorder groups. The preference ratio of a doctor as an important decision maker in the bipolar disorder group was higher compared to the other groups.

CONCLUSION

This study revealed the preference for medications and showed differences among patients with psychiatric disorders. Providing personalized medicine that considers a patient's preference for the drug may contribute to the improvement of drug compliance and outcomes.

Prevalence and Comorbidities of Adult Attention-deficit/hyperactivity Disorder in a Community Sample from Korea

Objective

: Attention-deficit/hyperactivity disorder (ADHD) is prevalent in adults, and psychiatric comorbidities are common in adults with ADHD. We aimed to examine the prevalence of adult ADHD with several common psychiatric conditions in a community sample in Korea and the association between adult ADHD and risk of psychiatric comorbidities.

Methods

: This study used a cross-sectional survey design. We provided supplementary and optional self-report questionnaires, including the Korean version of the World Health Organization Adult ADHD Self-Report Scale (ASRS) short screening scale, Patient Health Questionnaire-9 for screening for depression, Alcohol Use Disorders Identification Test alcohol consumption questions, and the Korean version of the Mood Disorders Questionnaire, to Korean adults who visited one of six centers of a large private healthcare company for the National General Health Examination.

Results

: A total of 17,799 subjects included in this study, and 430 (2.4%) were positive on the ASRS screen. ADHD was significantly associated with the 19-30-year-old age group (odds ratio [OR] = 3.938), lower income (OR = 1.298), depression (OR = 11.563), and bipolar disorder (OR = 3.162).

Conclusion

: Adult ADHD was highly associated with depression and bipolar disorder, suggesting that clinicians should carefully evaluate and treat such psychiatric disorders in adults with ADHD symptoms.

Protaetia Brevitarsis-Derived Protein Hydrolysate Reduces Obesity-Related Colitis Induced by High-Fat Diet in Mice through Anti-Inflammatory Pathways

Ulcerative colitis is an inflammatory bowel disease characterized by inflammation in the mucosal and submucosal layers of the colon. Obesity is closely related to the occurrence and progression of colitis. The most plausible mechanism linking obesity and colitis is an excessive adipogenesis-related inflammatory response, which causes mucosal dysfunction. Obesity and colitis are linked by several etiologic mechanisms, including excessive adipogenesis, lipotoxicity, pro-inflammatory adipokines/cytokines, macrophage polarization, oxidative stress, endoplasmic reticulum (ER) stress, and gut microbiota. These low-grade enteric inflammations cause mucosal layer damage, especially goblet cell dysfunction through mucin 2 (MUC2) misfolding, ultimately leading to colitis. Inhibiting the inflammatory response can be the most effective approach for treating obesity-related colitis. We focused on the anti-inflammatory effects of polyphenols in Protaectia brevitas larvae. The P. brevitas was prepared as a low molecular protein hydrolysate (PHPB) to increase the concentration of anti-inflammatory molecules. In the current study, we investigated the anti-inflammatory effect of PHPB in an obesity-induced colitis mouse model. Compared with the high-fat diet (HFD) group, the group treated with PHPB exhibited reduced body/organ/fat weight, appetite/food intake inhibition, hypolipidemic effect on ectopic fat, and anti-adipogenic mechanism through the AMPK signaling pathway. Furthermore, we observed attenuated expression of PPARγ and C/EBPα, inhibition of pro-inflammatory molecules, stimulation of anti-inflammatory molecules, probiotic-like effect against obesogenic gut microbiota, inhibition of macrophage polarization into M1, suppression of oxidative/ER stress, and reduction of Muc2 protein misfolding in colon. These diverse anti-inflammatory responses caused histological and functional recovery of goblet cells, eventually improving colitis. Therefore, our findings suggest that the protein hydrolysate of Protaetia brevitarsis can improve obesity-related colitis through its anti-inflammatory activities.

COVID-19 vaccine acceptance and related behavioral and psychological characteristics in individuals with mental disorders in Korea

Objective

This study aimed to investigate COVID-19 vaccine acceptance and related factors in individuals with mental disorders in Korea.

Methods

We surveyed 572 individuals with mental disorders about their attitudes toward COVID-19 vaccination using a 7-item self-rating questionnaire on vaccine acceptance and hesitancy. We categorized the respondents into groups based on their level of vaccine acceptance using hierarchical clustering. In addition, we evaluated the respondents' vaccination status and trust in sources of information regarding COVID-19 vaccines, and assessed their psychological characteristics using the Patient Health Questionnaire-9, Gratitude Questionnaire-6, and Big Five Inventory-10.

Results

Clustering revealed three groups according to vaccine acceptance: 'totally accepting' (n= 246, 43.0%), 'somewhat accepting' (n= 184, 32.2%), and 'hesitant' (n= 142, 24.8%) groups. Three quarters of all participants, who belonged to the 'totally accepting' or 'somewhat accepting' groups, were willing to receive a COVID-19 vaccine despite concerns about its side effects. Individuals in the high vaccine acceptance group were older (F= 12.52, p< 0.001), more likely to receive the influenza vaccine regularly, and more likely to trust formal information sources. Additionally, they had higher levels of gratitude (F= 21.00, p< 0.001) and agreeableness (F= 4.50, p= 0.011), and lower levels of depression (χ²= 11.81, p= 0.003) and neuroticism (F= 3.71, p= 0.025).

Conclusion

The present study demonstrated that individuals with mental disorders were generally willing to receive COVID-19 vaccination. However, they weighed its need and effectiveness against potential side effects before coming to a decision. It is important to understand the behavioral and psychological characteristics associated with vaccine acceptance, to effectively communicate its importance to individuals with mental disorders.

Korean Medication Algorithm Project for Bipolar Disorder 2022: Comparisons with Other Treatment Guidelines

The objective of this study was to compare recommendations of the Korean Medication Algorithm Project for Bipolar Disorder 2022 (KMAP-BP 2022) with other recently published guidelines for treating bipolar disorder. We reviewed a total of six recently published global treatment guidelines and compared treatment recommendation of the KMAP-BP 2022 with those of other guidelines. For initial treatment of mania, there were no significant differences across treatment guidelines. All guidelines recommended mood stabilizer (MS) or atypical antipsychotic (AAP) monotherapy or a combination of an MS with an AAP as a first-line treatment strategy in a same degree for mania. However, the KMAP-BP 2022 recommended MS + AAP combination therapy for psychotic mania, mixed mania and psychotic depression as treatment of choice. Aripiprazole, quetiapine and olanzapine were the first-line AAPs for nearly all phases of bipolar disorder across guidelines. Some guideline suggested olanzapine is a second-line options during maintenance treatment, related to concern about long-term tolerability. Most guidelines advocated newer AAPs (asenapine, cariprazine, long-acting injectable risperidone, and aripiprazole once monthly) as first-line treatment options for all phases while lamotrigine was recommended for depressive and maintenance phases. Lithium and valproic acid were commonly used as MSs in all phases of bipolar disorder. KMAP-BP 2022 guidelines were similar to other guidelines, reflecting current changes in prescription patterns for bipolar disorder based on accumulated research data. Strong preference for combination therapy was characteristic of KMAP-BP 2022, predominantly in the treatment of psychotic mania, mixed mania and psychotic depression.

Psychometric Properties of the Korean Version of Functioning Assessment Short Test in Bipolar Disorder

Objective

The Functioning Assessment Short Test (FAST) is a relatively specific test for bipolar disorders designed to assess the main functioning problems experienced by patients. This brief instrument includes 24 items assessing impairment or disability in 6 domains of functioning: autonomy, occupational functioning, cognitive functioning, financial issues, interpersonal relationships, and leisure time. It has already been translated into standardized versions in several languages. The aim of this study is to measure the validity and reliability of the Korean version of FAST (K-FAST).

Methods

A total of 209 bipolar disorder patients were recruited from 14 centers in Korea. K-FAST, Young Mania Rating Scale (YMRS), Bipolar Depression Rating Scale (BDRS), Global Assessment of Functioning (GAF) and the World Health Organization Quality of Life Assessment Instrument Brief Form (WHOQOL-BREF) were administered, and psychometric analysis of the K-FAST was conducted.

Results

The internal consistency (Cronbach's alpha) of the K-FAST was 0.95. Test-retest reliability analysis showed a strong correlation between the two measures assessed at a 1-week interval (ICC = 0.97; p < 0.001). The K-FAST exhibited significant correlations with GAF (r = -0.771), WHOQOL-BREF (r = -0.326), YMRS (r = 0.509) and BDRS (r = 0.598). A strong negative correlation with GAF pointed to a reasonable degree of concurrent validity. Although the exploratory factor analysis showed four factors, the confirmatory factor analysis of questionnaires had a good fit for a six factors model (CFI = 0.925; TLI = 0.912; RMSEA = 0.078).

Conclusion

The K-FAST has good psychometric properties, good internal consistency, and can be applicable and acceptable to the Korean context.

Korean Medication Algorithm Project for Bipolar Disorder 2022, Fifth Revision: An Executive Summary

OBJECTIVE

We revised the Korean Medication Algorithm Project for Bipolar Disorder (KMAP-BP), first published in 2002 and revised in 2006, 2010, 2014, and 2018, to reflect recent progress in the treatment of bipolar disorder.

METHODS

The questionnaires consisted of 56 items for adult patients and 7 items for child/adolescent patients, and were used to obtain the consensus of experts regarding pharmacological treatment strategies for various phases of bipolar disorder. The review committee included 87 Korean psychiatrists and 40 child and adolescent psychiatry experts.

RESULTS

For treatment of manic episodes, a combination of a mood stabilizer (MS) and atypical antipsychotics (AAP), or monotherapy with MS or AAP were recommended as first-line treatments. Combinations of MS and AAP, or AAP and lamotrigine (LMT) were recommended as first-line treatments for depressive episodes regardless of the severity. Monotherapy with MS, AAP, or LMT were also first-line treatments for mild to moderate depressive episodes. For mixed features, a combination of MS and AAP, or monotherapy with AAP or MS were recommended as first-line treatments, and a combination of AAP and LMT, or MS and LMT were the first-line treatments for depressive mixed state.

CONCLUSION

The recommendations of the KMAP-BP 2022 have changed from the previous version, to reflect the evolution of the social culture and healthcare system in Korea and recent evidence regarding pharmacotherapy of bipolar disorder. The KMAP-BP 2022 provides clinicians with a wealth of information regarding appropriate strategies to treat patients with bipolar disorder.

Amisulpride Augmentation in Schizophrenia Patients with Poor Response to Olanzapine: A 4-week, Randomized, Rater-Blind, Controlled, Pilot Study

Objective

The purpose of this study was to compare the efficacy and tolerability of continued olanzapine (OLA) versus amisulpride (AMI) augmentation in schizophrenic patients with poor response to OLA monotherapy.

Methods

The present 4-week, randomized, rater-blinded study included 25 patients with schizophrenia who were partially or completely unresponsive to treatment with OLA monotherapy. Eligible subjects were randomly assigned at a 11 ratio to continuation of OLA monotherapy (OLA group) or OLA with AMI augmentation (AMI group). Efficacy was primarily evaluated using the Positive and Negative Syndrome Scale (PANSS) at baseline and at 1, 2, and 4 weeks.

Results

The changes in PANSS total score and PANSS-positive subscale score were significantly different (p < 0.05) between the OLA and AMI groups. The differences between the two groups in PANSS-negative subscale, PANSS-general subscale, Brief Psychiatric Rating Scale, and Clinical Global Impression-Severity (CGI-S) scale scores were not statistically significant.

Conclusion

AMI augmentation could be an effective strategy for patients with schizophrenia who show inadequate early response to OLA monotherapy.

The Korean Medication Algorithm Project for Depressive Disorder 2021: Comparisons with Other Treatment Guidelines

The Korean Medication Algorithm Project for Depressive Disorder (KMAP-DD) first was published in 2002, and has been revised four times, in 2006, 2012, 2017, and 2021. In this review, we compared recommendations from the recently revised KMAP-DD 2021 to four global clinical practice guidelines (CPGs) for depression published after 2010. The recommendations from the KMAP-DD 2021 were similar to those from other CPGs, although there were some differences. The KMAP-DD 2021 reflected social culture and the healthcare system in Korea and recent evidence about pharmacotherapy for depression, as did other recently published evidence-based guidelines. Despite some intrinsic limitations as an expert consensus-based guideline, the KMAP-DD 2021 can be helpful for Korean psychiatrists making decisions in clinical settings by complementing previously published evidence-based guidelines, especially for some clinical situations lacking evidence from rigorously designed clinical trials.

Korean Medication Algorithm for Depressive Disorder 2021, Fourth Revision: An Executive Summary

Objective

In the 19 years since the Korean College of Neuropsychopharmacology and the Korean Society for Affective Disorders developed the Korean Medication Algorithm Project for Depressive Disorder (KMAP-DD) in 2002, four revisions have been conducted.

Methods

To increase survey efficiency in this revision, to cover the general clinical practice, and to compare the results with previous KMAP-DD series, the overall structure of the questionnaire was maintained. The six sections of the questionnaire were as follows: 1) pharmacological treatment strategies for major depressive disorder (MDD) with/without psychotic features; 2) pharmacological treatment strategies for persistent depressive disorder and other depressive disorder subtypes; 3) consensus for treatment-resistant depression; 4) the choice of an antidepressant in the context of safety, adverse effects, and comorbid physical illnesses; 5) treatment strategies for special populations (children/adolescents, elderly, and women); and 6) non-pharmacological biological therapies. Recommended first-, second-, and third-line strategies were derived statistically.

Results

There has been little change in the four years since KMAP-DD 2017 due to the lack of newly introduced drug or treatment strategies. However, shortened waiting time between the initial and subsequent treatments, increased preference for atypical antipsychotics (AAPs), especially aripiprazole, and combination strategies with AAPs yield an active and somewhat aggressive treatment trend in Korea.

Conclusion

We expect KMAP-DD to provide clinicians with useful information about the specific strategies and medications appropriate for treating patients with MDD by bridging the gap between clinical real practice and the evidence-based world.

IL-10 Deficiency Aggravates Renal Inflammation, Fibrosis and Functional Failure in High-Fat Dieted Obese Mice

BACKGROUND:

High-fat diet-induced obesity is one of the major cause of chronic renal failure. This obesity-related renal failure is mainly caused by inflammatory processes. However, the role of the major anti-inflammatory cytokine interleukin (IL)-10 has not been researched intensively.

METHODS:

To evaluate the effect of IL-10 deficiency on obesity-related renal failure, the in vivo study was carried with four animal groups; (1) Low-fat dieted C57BL/6 mice, (2) Low-fat dieted IL-10 knockout (KO) mice, (3) High‐fat dieted C57BL/6 mice and (4) High‐fat dieted IL-10 KO mice group. The analysis was carried with blood/urine chemistry, H&E, Oil-Red-O, periodic acid-Schiff and Masson’s trichrome staining immunohistochemistry and real-time PCR methods.

RESULTS:

At week 12, high‐fat dieted IL-10 KO mice showed 1) severe lipid accumulation in kidneys, cholesterol elevation (in total, serum kidney) and low-density lipoprotein increasion through the SCAP-SREBP2-LDLr pathway; (2) serious histopathologic alterations showing glomerulosclerosis, tubulointerstitial fibrosis and immune cell infiltration; (3) increased pro‐inflammatory cytokines and chemokines expression; (4) enhanced renal fibrosis; and (5) serious functional failure with high serum creatinine and BUN and proteinuria excretion compared to other groups.

CONCLUSION:

IL-10 deficiency aggravates renal inflammation, fibrosis and functional failure in high-fat dieted obese mice, thus IL-10 therapy could be applied to obesity-related chronic renal failure.

The Korean Medication Algorithm Project for Bipolar Disorder (KMAP-BP): Changes in preferred treatment strategies and medications over 16 years and five editions

OBJECTIVES

The Korean Medication Algorithm Project for Bipolar Disorder (KMAP-BP) is based on expert consensus and has been revised five times since 2002. This study evaluated the changes in treatment strategies advocated by the KMAP-BP over time.

METHODS

The five editions of the KMAP-BP were reviewed, and the recommendations of the KMAP-BP were compared with those of other bipolar disorder (BP) treatment guidelines.

RESULTS

The most preferred option for the initial treatment of mania was a combination of a mood stabilizer (MS) and an atypical antipsychotic (AAP). Either MS or AAP monotherapy was also considered a first-line strategy for mania, but not for all types of episodes, including mixed/psychotic mania. In general, although lithium and valproic acid were commonly recommended, valproic acid has been increasingly preferred for all phases of BP. The most notable changes over time included the increasing preference for AAPs for all phases of BP, and lamotrigine for the depressive and maintenance phases. The use of antidepressants for BP has gradually decreased, but still represents a first-line option for severe and psychotic depression.

CONCLUSIONS

In general, the recommended strategies of the KMAP-BP were similar to those of other guidelines, but differed in terms of the emphasis on rapid effectiveness, which is often desirable in actual clinical situations. The major limitation of the KMAP-BP is that it is a consensus-based rather than an evidence-based tool. Nevertheless, it may confer advantages in actual clinical practice.

The Influence of Current Mood States on Screening Accuracy of the Mood Disorder Questionnaire

Objective

In this study we investigated whether current mood states of patients with bipolar disorder have an influence on the screening accuracy of the Mood Disorder Questionnaire (MDQ).

Methods

A total of 452 patients with mood disorder (including 192 with major depressive disorder and 260 with bipolar disorder completed the Korean version of the MDQ. Patients with bipolar disorder were subdivided into three groups (bipolar depressed only, bipolar euthymic only, bipolar manic/hypomanic only) according to current mood states. The screening accuracy of the MDQ including sensitivity, specificity and area under the curve (AUC) of receiver operating characteristic (ROC) curves were evaluated according to current mood states.

Results

The optimal cutoff of MDQ was 5 in this study sample. Sensitivity and specificity were not significantly different according to current mood states. Significant differences in AUCs of four independent ROC curves were not found (ROC 1st curve included all bipolar patients; ROC 2nd curve included only bipolar depressed patients; ROC 3rd curve included only bipolar manic/hypomanic patients; ROC 4th curve included only bipolar euthymic patients).

Conclusion

The study results showed that current mood states (either euthymic state, depressed or manic/hypomanic) did not significantly influence the screening accuracy of the MDQ suggesting that the MDQ could be a useful screening instrument for detecting bipolar disorder in clinical practice regardless of the current mood symptoms of subjects.

Clinical correlates associated with the long-term response of bipolar disorder patients to lithium, valproate or lamotrigine: A retrospective study

Background

Although mood stabilizers such as lithium (LIT), valproate (VAL), and lamotrigine (LMT) appear to be efficacious treatments for bipolar disorder (BD) in research settings, the long-term response to these mood stabilizers in clinical practice is highly variable among individuals. Thus, the present study examined the characteristics associated with good or insufficient responses to long-term treatment with LIT, VAL, or LMT for BD.

Methods

This study retrospectively analyzed the medical records of patients who visited an outpatient clinic with a diagnosis of BD I or II. Data from patients who were treated with one of three mood stabilizing medications (LIT, VAL, or LMT) for more than 6 months were selected, and the long-term treatment responses were evaluated using the Alda scale. For the purposes of this study, two response categories were formed: insufficient response (ISR), including non-response or poor response (Alda total score ≤ 6), and good response (GR; Alda total score ≥ 7).

Results

Of the 645 patients included in the present study, 172 were prescribed LIT, 320 were prescribed VAL, and 153 were prescribed LMT for at least 6 months. A binary logistic regression analysis revealed that a diagnosis of BD II (odds ratio [OR], 8.868; 95% confidence interval [CI], 1.123–70.046; p = 0.038), comorbid alcohol/substance use disorder (OR, 4.238; 95% CI, 1.154–15.566; p = 0.030), and a history of mixed episodes (OR, 4.363; 95% CI, 1.191–15.985; p = 0.026) were significant predictors of LIT-ISR. Additionally, a depressive-predominant polarity significantly predicted LMT-GR (OR, 8.586; 95% CI, 2.767–26.644; p < 0.001).

Conclusion

The present findings demonstrated that patients with a diagnosis of BD II, a comorbid alcohol/substance problem, or a history of mixed episodes were not likely to respond to LIT treatment. Additionally, LMT might be a better treatment choice for patients with a depressive-predominant polarity.

Efficacy and safety of blonanserin transdermal patch in patients with schizophrenia: A 6-week randomized, double-blind, placebo-controlled, multicenter study

BACKGROUND

Blonanserin is a second-generation antipsychotic used for the treatment of schizophrenia. This study determined the efficacy, safety and pharmacokinetics of a blonanserin transdermal patch in patients with acutely exacerbated schizophrenia.

METHODS

This double-blind, multicenter, phase 3 study consisted of a 1-week observation period during which patients were treated with two patches of placebo, followed by a 6-week double-blind period where patients were randomized (1:1:1) to receive once-daily blonanserin 40 mg, blonanserin 80 mg, or placebo patches. The primary endpoint was the change from baseline in the total Positive and Negative Symptom Scale (PANSS) score. Safety assessments included treatment-emergent adverse events (TEAEs).

RESULTS

Between December 2014 and October 2018, patients were recruited and randomly assigned to blonanserin 40 mg (n = 196), blonanserin 80 mg (n = 194), or placebo (n = 190); of these, 77.2% completed the study. Compared with placebo, blonanserin significantly improved PANSS total scores at 6 weeks (least square mean [LSM] difference vs placebo: -5.6 with blonanserin 40 mg; 95% confidence interval [CI] -9.6, -1.6; adjusted p = 0.007, and - 10.4 with blonanserin 80 mg; 95% CI -14.4, -6.4; adjusted p < 0.001). Blonanserin was well tolerated; the most common TEAEs reported were application-site erythema and pruritus, akathisia, tremor, and insomnia.

CONCLUSIONS

Blonanserin transdermal patch improved the symptoms of acute schizophrenia with acceptable tolerability.

The prevalence and diagnostic classification of mixed features in patients with major depressive episodes: A multicenter study based on the DSM-5

OBJECTIVES

The purpose of this study was to evaluate the prevalence of mixed features using the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) and to examine how patients with mixed states would be classified using the DSM-5.

METHODS

In total, 12 hospitals participated in this study, and data on the demographic characteristics and clinical diagnoses of patients treated between October 2013 and September 2016 were obtained. We reviewed the data for opposite-polarity symptoms according to the DSM-5 criteria and the research-based diagnostic criteria.

RESULTS

Of the 859 patients included in the final analysis, the prevalence of mixed features in patients with major depressive episodes based on the DSM-5 remained low. Patients with major depressive disorder were more likely to be classified as experiencing anxious distress and/or a cluster-B personality disorder in mixed state patients not diagnosed with DSM-5 mixed features, whereas more mixed state patients with bipolar disorder were diagnosed with mixed features using the DSM-5.

CONCLUSIONS

The prevalence of mixed features did not increase significantly when the DSM-5 was used, and patients with mixed states were more likely to be classified as having anxious distress and/or a cluster-B personality disorder in addition to mixed features.

Validation of the Korean Version of the Depression in Old Age Scale and Comparison with Other Depression Screening Questionnaires Used in Elderly Patients in Medical Settings

Objective

The Depression in Old Age Scale (DIA-S) is a new screening tool for assessing depression in the elderly. The primary aims of this study were to describe the validation of the Korean version of the DIA-S (K-DIA-S) and to compare its validity with that of other depression screening questionnaires used in elderly outpatients in medical settings.

Methods

A total of 385 elderly outpatients completed the K-DIA-S and underwent the Mini International Neuropsychiatric Interview to diagnose depressive disorders. Other measures included the 15-item short form of the Geriatric Depression Scale (SGDS), the 9-item depression module of the Patient Health Questionnaire (PHQ-9), and the Montgomery–Asberg Depression Rating Scale (MADRS). Reliability and validity tests, an optimal cutoff point estimate, and receiver operating characteristic curve analysis were performed to investigate the diagnostic validity of the K-DIA-S. Areas under the curves (AUCs) for the K-DIA-S, SGDS, and PHQ-9 were compared statistically.

Results

The K-DIA-S showed good internal consistency and strong correlations with the SGDS (r = 0.853), PHQ-9 (r = 0.739), and MADRS (r = 0.772). The cut-off point of the K-DIA-S that can be recommended for screening depressive symptoms was a score of 4. For “any depressive disorder”, the AUC (standard error) for the K-DIA-S was 0.896 (0.015), which was significantly larger than that for the PHQ-9 (p = 0.033).

Conclusion

The present findings suggest that the K-DIA-S has good psychometric properties and is a valid and reliable tool for assessing depressive symptoms in elderly populations and medically ill patients.

Switching Antipsychotics to Blonanserin in Patients with Schizophrenia: An Open-label, Prospective, Multicenter Study

Objective

This study was performed to investigate the efficacy and tolerability of blonanserin in schizophrenic patients who were previously treated with other antipsychotics but, due to insufficient response, were switched to blonanserin.

Methods

A total of 52 patients with schizophrenia who were unresponsive to treatment with antipsychotic monotherapy or combination therapy were recruited into this 12-week, open-label, prospective, multicenter study. Patients were switched to blonanserin from their existing antipsychotics over a maximum 2-week tapering-off period. Efficacy was primarily evaluated using the 18-item Brief Psychiatric Rating Scale (BPRS). Assessments were performed at baseline, and at weeks 1, 2, 4, 8, and 12.

Results

Switching to blonanserin resulted in a significant decrease in the mean total score on the BPRS from baseline (56.8 ± 9.4) to week 12 (42.1 ± 13.8, p < 0.001). The most common adverse events were extrapyramidal symptoms (n = 12, 23.1%), insomnia (n = 10, 19.2%), and emotional arousal (n = 6, 11.5%). Overweight or obese patients (body mass index ≥ 23 kg/m², n = 33) who switched to blonanserin exhibited significant weight loss from 75.2 ± 9.3 kg at baseline to 73.5 ± 9.2 kg at week 12 (p = 0.006). The total cholesterol (baseline, 236.1 ± 47.6 mg/dl; endpoint [week 12], 209.9 ± 28.0 mg/dl; p = 0.005) and prolactin levels (baseline, 80.0 ± 85.2 ng/ml; endpoint [week 12], 63.2 ± 88.9 ng/ml; p = 0.003) were also significantly improved in patients with hypercholesterolemia or hyperprolactinemia.

Conclusion

The results of the present study suggest that switching to blonanserin may be an effective strategy for schizophrenic patients unresponsive to other antipsychotic treatments.

Lurasidone in the treatment of schizophrenia: Results of a double-blind, placebo-controlled trial in Asian patients

INTRODUCTION

To evaluate efficacy and safety of lurasidone for the treatment of Asian patients with schizophrenia.

METHODS

Patients with schizophrenia from Japan, South Korea, Malaysia, and Taiwan were randomly assigned to 6 weeks of double-blind treatment with 40 or 80 mg/d of lurasidone or placebo. The primary efficacy measure was change from baseline to week 6 on the Positive and Negative Syndrome Scale (PANSS) total score. Efficacy was evaluated using a mixed-model repeated-measures (MMRM) analysis in the modified intention-to-treat (mITT) population.

RESULTS

On the basis of the analysis for the mITT population, the estimated difference score for lurasidone 40 and 80 mg/d vs placebo was -4.8 (P = 0.050) and -4.2 (P = 0.080). For the full intention-to-treat (ITT) population, the difference score for lurasidone 40 and 80 mg/d vs placebo was -5.8 (P = 0.017) and -4.2 (P = 0.043). The most frequent adverse events in the lurasidone 40 and 80 mg/d and placebo groups, respectively, were akathisia (7.3%, 10.4%, 3.3%), somnolence (6.0%, 2.6%, 0.7%), and vomiting (6.0%, 5.8%, 2.0%). The proportion of patients experiencing clinically significant weight gain (≥7%) was 5.3% for lurasidone 40 mg/d, 1.3% for 80 mg/d, and 1.4% for placebo. End point changes in metabolic parameters and prolactin were comparable for both lurasidone groups and placebo.

CONCLUSIONS

In the ITT (but not the mITT) population, treatment with lurasidone was associated with significant improvement in the PANSS total score in patients with schizophrenia. Lurasidone was generally well tolerated with minimal impact on weight and metabolic parameters.

Korean Medication Algorithm for Bipolar Disorder 2018: Comparisons with Other Treatment Guidelines

The objective of this study was to compare recommendations of the Korean Medication Algorithm Project for Bipolar Disorder 2018 (KMAP-BP 2018) with other recently published guidelines for treating bipolar disorder. We reviewed a total of five recently published global treatment guidelines and compared treatment recommendation of the KMAP-BP 2018 with those of other guidelines. For initial treatment of mania, there were no significant differences across treatment guidelines. All guidelines recommended mood stabilizer (MS) or atypical antipsychotic (AAP) monotherapy or a combination of an MS with an AAP as a first-line treatment strategy for mania. However, the KMAP-BP 2018 did not prefer monotherapy with MS or AAP for psychotic mania. Quetiapine, olanzapine and aripiprazole were the first-line AAPs for nearly all phases of bipolar disorder across guidelines. Most guidelines advocated newer AAPs as first-line treatment options for all phases while lamotrigine was recommended for depressive and maintenance phases. Lithium and valproic acid were commonly used as MSs in all phases of bipolar disorder. As research evidence accumulated over time, recommendations of newer AAPs (such as asenapine, cariprazine, paliperidone, lurasidine, long-acting injectable risperidone and aripiprazole once monthly) became prominent. KMAP-BP 2018 guidelines were similar to other guidelines, reflecting current changes in prescription patterns for bipolar disorder based on accumulated research data. Strong preference for combination therapy was characteristic of KMAP-BP 2018, predominantly in the treatment of psychotic mania and severe depression. Further studies were needed to address several issues identified in our review.

Pharmacological Treatment of Major Depressive Episodes with Mixed Features: A Systematic Review

We reviewed clinical studies investigating the pharmacological treatment of major depressive episodes (MDEs) with mixed features diagnosed according to the dimensional criteria (more than two or three [hypo]manic symptoms+principle depressive symptoms). We systematically reviewed published randomized controlled trials on the pharmacological treatment of MDEs with mixed features associated with mood disorders, including major depressive disorder (MDD) and bipolar disorder (BD). We searched the PubMed, Cochrane Library, and ClinicalTrials.gov databases through December 2017 with the following key word combinations linked with the word OR: (a) mixed or mixed state, mixed features, DMX, mixed depression; (b) depressive, major depressive, MDE, MDD, bipolar, bipolar depression; and (c) antidepressant, antipsychotic, mood stabilizer, anticonvulsant, treatment, medication, algorithm, guideline, pharmacological. We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We found few randomized trials on pharmacological treatments for MDEs with mixed features. Of the 36 articles assessed for eligibility, 11 investigated MDEs with mixed features in mood disorders: six assessed the efficacy of antipsychotic drugs (lurasidone and ziprasidone) in the acute phase of MDD with mixed features, although four of these were post hoc analyses based on large randomized controlled trials. Four studies compared antipsychotic drugs (olanzapine, lurasidone, and ziprasidone) with placebo, and one study assessed the efficacy of combination therapy (olanzapine+fluoxetine) in the acute phase of BD with mixed features. Pharmacological treatments for MDEs with mixed features have focused on antipsychotics, although evidence of their efficacy is lacking. Additional well-designed clinical trials are needed.

Korean Medication Algorithm Project for Bipolar Disorder 2018 (KMAP-BP 2018): Fourth Revision

Objective

The Korean Medication Algorithm Project for Bipolar Disorder (KMAP-BP) was first published in 2002 through an expert consensus of opinion, and updated in 2006, 2010, and 2014. This study constitutes the fourth revision of the KMAP-BP.

Methods

A 50-item questionnaire was used to obtain the consensus of experts regarding pharmacological treatment strategies for various phases of adult bipolar disorder and six items for pediatric bipolar disorder. The review committee included 84 Korean psychiatrists and 43 child and adolescent psychiatry experts.

Results

The preferred first-step strategies for acute mania were the combination of a mood stabilizer (MS) and an atypical antipsychotic (AAP), MS monotherapy, and AAP monotherapy. A combination of a MS and an AAP, and AAP monotherapy were preferred for psychotic mania. The first-step strategies for mild to moderate bipolar depression were monotherapy with MS, AAP, or lamotrigine (LMT), and the combination of a MS and an AAP or LMT, or a combination of an AAP and LMT. The combination of two among a MS, AAP, and LMT were preferred for non-psychotic severe depression. A combination of a MS and an AAP or the combination of an AAP with an antidepressant or LMT were the first-line options for psychotic severe depression.

Conclusion

The recommendations of the KMAP-BP 2018 have changed from the previous version by reflecting recent developments in pharmacotherapy for bipolar disorder. KMAP-BP 2018 provides clinicians with a wealth of information regarding appropriate strategies for treating patients with bipolar disorder.

Screening with the Korean Version of the Mood Disorder Questionnaire for Bipolar Disorders in Adolescents: Korean Validity and Reliability Study

Objective

This study aimed to evaluate the validity and reliability of a Korean version of the Mood Disorder Questionnaire-Adolescent version (K-MDQ-A) as a screening instrument for bipolar disorders in adolescents.

Methods

One hundred two adolescents with bipolar disorders and their parents were recruited from November 2014 to November 2016 at 7 training hospitals. One hundred six controls were recruited from each middle school in two cities of South Korea. The parent version of the original MDQ-A was translated into Korean. The parents of all participants completed the K-MDQ-A. The diagnoses of bipolar disorders were determined based on the Korean version of K-SADS-PL. The test-retest reliability with a 10-month interval was investigated in 33 bipolar adolescents.

Results

K-MDQ-A yielded a sensitivity of 0.90 and a specificity of 0.92 when using a cut-off score of endorsement of 5 items, indicating that symptoms occurred in the same time period and caused moderate or serious problems. The internal consistency of the K-MDQ-A was good. The correlations between each item and the total score ranged from 0.40 to 0.76 and were all statistically significant. Factor analysis revealed 3 factors that explained 61.25% of the total variance. The mean total score was significantly higher in bipolar adolescents (7.29) than in controls (1.32). The Pearson correlation coefficient for the total test-retest score was 0.59 (p＜0.001).

Conclusion

The K-MDQ-A completed by parents showed the excellent validity and reliability and may be a useful screening tool for adolescents with bipolar disorders attending in- and outpatient psychiatric clinics.

Improving the Screening Instrument of Bipolar Spectrum Disorders: Weighted Korean Version of the Mood Disorder Questionnaire

Objective

It is not easy to diagnose bipolar disorders accurately in the clinical setting. Although Korean version of the Mood Disorder Questionnaire (K-MDQ) is easily administered, it still has weakness regarding case finding. In this study, we suggest a new weighted version of the K-MDQ to increase its screening power.

Methods

Ninety-five patients with bipolar disorders and 346 controls (patients with schizophrenia, patients with depressive disorders, patients with anxiety disorders, and subjects without any psychiatric disease) were enrolled in this study. The subjects received brief information on the K-MDQ, and then independently completed the questionnaire.

Results

Using odds ratios, we constructed a new weighted K-MDQ (W-K-MDQ). Item 1 (feel so good or hyper) was weighted 7 times and item 4 (less sleep) 3.5 times. Item 7 (easily distracted) and item 11 (more interested in sex) were excluded. Part 2 (simultaneity) and 3 (functional impairment) were also excluded as in the original K-MDQ. The sensitivity of the W-K-MDQ with a cutoff value of 10 was enhanced to 0.789. The area under the receiver operating characteristic curve was increased to 0.837.

Conclusion

We suggested a new formula for K-MDQ using 11 of its items. The W-K-MDQ can be easily applied with good sensitivity to screen for bipolar disorders in clinical settings in Korea. Further evaluations with larger samples are needed to establish the usefulness of the W-K-MDQ.

Psychometric Properties of the Hypomania Checklist-32 in Korean Patients with Mood Disorders

Objective

The aim of this study was to examine the validity of the Korean version of the Hypomania Checklist-32, second revision (HCL-32-R2) in mood disorder patients.

Methods

A total of 454 patients who diagnosed as mood disorder according to Structured Clinical Interview for DSM-IV Axis I Disorders, clinician version (SCID-CV) (bipolar disorder [BD] I, n=190; BD-II, n=72; and major depressive disorder [MDD], n=192) completed the Korean module of the HCL-32-R2 (KHCL-32-R2).

Results

The KHCL-32-R2 showed a three-factorial structure (eigenvalue >2) that accounted for 43.26% of the total variance. Factor 1 was labeled “active/elated” and included 16 items; factor 2, “irritable/distractible” and included 9 items; and factor 3 was labeled “risk-taking/indulging” and included 9 items. A score of 16 or more on the KHCL-32-R2 total scale score distinguished between BD and MDD, which yielded a sensitivity of 70% and a specificity of 70%. MDD and BD-II also could be differentiated at a cut-off of 15 with maximized sensitivity (0.67) and specificity (0.66). Cronbach’s alpha of KHCL-32-R2 and its subsets (factors 1, 2, and 3) were 0.91, 0.89, 0.81 and 0.79, respectively. Correlations between KHCL-32-R2 and Montgomery-Asberg Depression Rating Scale, Young Mania Rating Scale and Korean version of Mood Disorder Questionnaire were −0.66 (p=0.41), −0.14 (p=0.9), and 0.61 (p<0.001), respectively.

Conclusion

The KHCL-32-R2 may be a useful tool in distinguishing between bipolar and depressive patients in clinical settings.

Use of a smartphone application to screen for depression and suicide in South Korea

OBJECTIVE

This is a cross-sectional study using a free depression and suicide screening smartphone application, which contains the data from the Center for Epidemiological Studies-Depression (CES-D) and a Suicide Behaviors Questionnaire-Revised (SBQ-R).

METHOD

The free application was downloaded worldwide from Apple's App Store and Android Market, and the participants who downloaded the application were actively measured.

RESULTS

The subjects totaled 208,683 men and women. 72.6% of the subjects were females, and 81.4% of the subjects were aged between 10 and 29years. In total, 25.7% of the participants were recorded CES-D positive, and there were differences among the groups based on sex (χ2=1065.82, p<0.001), age (χ2=1420.75, p<0.001), and psychiatric history (χ2=1502.21, p<0.001). The highest score of CES-D, 40.69±15.79 and that of SBQ-R, 13.68±4.97 was reported by the participants with a history of schizophrenia. The characteristics associated with suicide were as follows: depression (OR 8.92, 95% CI: 8.71-9.13), female (OR 1.39, 95% CI: 1.36-1.43), 30-49 age group (OR 2.51, 95% CI: 2.29-2.72), 50 or older age group (OR 1.48, 95% CI: 1.35-1.61), and psychiatric history (OR 1.98, 95% CI: 1.89-2.06).

CONCLUSION

The smartphone application may be a useful tool for screening depression and suicide.

Use of a smartphone application to screen for bipolar spectrum disorder in a community sample

This study describes the use of a smartphone application based on the Korean version of the Mood Disorder Questionnaire in screening for bipolar spectrum disorders in a large general population. All data were collected between May 2011 and July 2011. A total of 27,159 individuals participated in the survey, using a smartphone application. The prevalence of positive screening results for bipolar spectrum disorders among 27,159 participants using the smartphone Korean Mood Disorder Questionnaire application was 8.2 percent. These results are similar to traditional paper-based results. The Korean Mood Disorder Questionnaire positive group exhibited more frequent occurrences of previous psychiatric treatment than the group with negative results. In a logistic regression analysis involving subjects with past psychiatric history, age group significantly predicted Korean Mood Disorder Questionnaire results. The smartphone application may be a useful screening tool for bipolar spectrum disorders. This study included only individuals who actively participated, and thus, the possibility of a selection bias should be considered.

Current prescription pattern of maintenance treatments for bipolar patients in Korea: A focus on the transition from acute treatments

AIMS

We examined prescription patterns in maintenance treatment for recovered bipolar patients and compared these with acute treatments.

METHODS

Using retrospective methods, the bipolar patients in clinical recovery (Clinical Global Impression Bipolar Version score ≤ 2 for 6 months) after acute episode were selected. We reviewed differences between prescription patterns at remission and after a maintenance period of at least 6 months.

RESULTS

A total of 340 bipolar disorder patients were selected. During the maintenance period, more than half of the patients (192, 56.5%) took a mood stabilizer (MS) + antipsychotic (AP) combination. Among the MS, valproate (149, 43.8%) was most prescribed, and lithium (98, 28.8%) was second, but as patients moved into maintenance treatment, lithium use decreased, and the use of lamotrigine (86, 25.3%) increased. Preferred AP were quetiapine (125, 36.8%), aripiprazole (67, 19.7%), risperidone (48, 14.1%), and olanzapine (39, 11.5%). The use of olanzapine in maintenance was greatly decreased compared with that during acute treatment (67, 19.7%). Most patients did not take an antidepressant (AD), but the proportion using one or more AD was increased during maintenance (17.9% to 30.3%), and bupropion (28, 8.2%) was the preferred AD. Doses were decreased in all drugs, but lamotrigine was maintained at a dose of 133.2 ± 68.5 mg/day.

CONCLUSIONS

The most common prescription combination for bipolar maintenance treatment was MS + AP. The use of AP was decreased, whereas the use of AD in combination with MS and/or AP was increased. The doses of MS and AP were generally decreased during the maintenance periods, with the exception of lamotrigine.

Bioequivalence of Generic and Brand Name Clozapine in Korean Schizophrenic Patients: A Randomized, Two-Period, Crossover Study

OBJECTIVE

Clozapine is the treatment of choice for refractory schizophrenia. The aim of this study was to compare the pharmacokinetics of the brand name (Clozaril) formulation and a generic formulation (Clzapine) of clozapine in Korean schizophrenic patients.

METHODS

A prospective, randomized, crossover study was conducted to evaluate the steady-state pharmacokinetic profiles of Clozaril and Clzapine. Schizophrenic patients were randomized to receive either the brand name or generic formulation (100 mg twice daily) for 10 days, followed by the other formulation for 10 days. Plasma samples were collected on the last day of each treatment period.

RESULTS

Twenty-two of 28 patients (78.6%) completed the study. The mean Cmax,ss values for Clzapine and Clozaril were 524.62 and 551.18 ng/mL, and the mean AUC0-12 values were 4479.90 hr·ng/mL and 4724.56 hr·ng/mL, respectively. The 90% CI values for the natural logarithmically transformed Cmax,ss and AUC0-12 ratios (Clzapine to Clozaril) after a single oral dose (100 mg) were 0.934 (0.849-1.028) and 0.936 (0.869-1.008), respectively. Five patients (20.8%) among 24 patients who took Clzapine reported 11 adverse events and six adverse events were reported by four patients (15.4%) among 26 who took Clozaril; there were no significant differences on physical examination or in vital signs, ECG, and laboratory tests between groups.

CONCLUSION

Generic clozapine (Clzapine) appears to be bioequivalent to brand name clozapine (Clozaril).

The Relationship between Cognitive Decline and Psychopathology in Patients with Schizophrenia and Bipolar Disorder

OBJECTIVE

The primary goals of the present study were to assess intellectual function in participants with schizophrenia or bipolar disorder (BD) and to investigate the relationships between cognitive decline and the severity of each type of psychopathology.

METHODS

The present study included 51 patients with schizophrenia and 42 with BD who were recruited from the psychiatry outpatient clinic of Jeju University Hospital between March 2011 and March 2014. The Korean Wechsler Adult Intelligence Scale (K-WAIS) was administered to each of the 93 participants, and they were categorized into two groups based on their current intelligence quotient (IQ) and their estimated premorbid IQ: severely impaired group (SIG) and mildly impaired group (MIG). The Minnesota Multiple Personality Inventory (MMPI) and the Brief Psychiatric Rating Scale (BPRS) were used to assess psychopathology.

RESULTS

The SIG schizophrenia participants exhibited significantly higher scores on the frequent (F) and schizophrenia (Sc) subscales of the MMPI, but significantly lower scores on the correction (K) and psychopathic deviate (Pd) subscales compared with the MIG schizophrenia participants. Furthermore, the BPRS scores were significantly higher in the SIG schizophrenia participants relative to the MIG schizophrenia participants. The SIG BD participants had significantly higher F, masculinity-femininity (Mf), paranoia (Pa), and Sc but significantly lower Pd scores compared with the MIG BD participants.

CONCLUSIONS

The present findings revealed a significant discrepancy between the estimated premorbid levels of cognitive function and current cognitive function in participants with schizophrenia or BD. Moreover, this discrepancy was correlated with severity of psychopathology in both groups.

Korean Medication Algorithm for Bipolar Disorder 2014: comparisons with other treatment guidelines

Our goal was to compare the recommendations of the Korean Medication Algorithm Project for Bipolar Disorder 2014 (KMAP-BP 2014) with other recently published guidelines for the treatment of bipolar disorder. We reviewed a total of four recently published global treatment guidelines and compared each treatment recommendation of the KMAP-BP 2014 with those in other guidelines. For the initial treatment of mania, there were no significant differences across treatment guidelines. All recommended mood stabilizer (MS) or atypical antipsychotic (AAP) monotherapy or the combination of an MS with an AAP as a first-line treatment strategy for mania. However, the KMAP-BP 2014 did not prefer monotherapy with MS or AAP for dysphoric/psychotic mania. Aripiprazole, olanzapine, quetiapine, and risperidone were the first-line AAPs in nearly all of the phases of bipolar disorder across the guidelines. Most guidelines advocated newer AAPs as first-line treatment options in all phases, and lamotrigine in depressive and maintenance phases. Lithium and valproic acid were commonly used as MSs in all phases of bipolar disorder. As research evidence accumulated over time, recommendations of newer AAPs - such as asenapine, paliperidone, lurasidone, and long-acting injectable risperidone - became prominent. This comparison identifies that the treatment recommendations of the KMAP-BP 2014 are similar to those of other treatment guidelines and reflect current changes in prescription patterns for bipolar disorder based on accumulated research data. Further studies are needed to address several issues identified in our review.

Prevalence of distorted body image in young Koreans and its association with age, sex, body weight status, and disordered eating behaviors

PURPOSE

To define the prevalence of distorted body image in 10-24-year-old Koreans and determine its relationship with sex, age, body weight status, and disordered eating behaviors.

METHODS

A total of 3,227 young Koreans were recruited from elementary, middle, and high schools, as well as from universities. The participants completed a self-reported questionnaire on body image, eating behaviors (Eating Attitude Test-26), and body weight status.

RESULTS

The prevalence of a distorted body image in males was 49.7% and that in females was 51.2%. Distorted body image was more frequent in adolescents (age, 10-17 years) than in young adults (age, 18-24 years). The highest prevalence (55.3%) was reported in female elementary school students (age, 10-12 years). Distorted body image was associated with disordered eating behaviors and abnormal body weight status.

CONCLUSION

These results suggest that distorted body image is a public health problem, given its high frequency in young Koreans, and that it is associated with abnormal body weight status and disordered eating behaviors.

Korean Medication Algorithm Project for Bipolar Disorder: third revision

OBJECTIVE

To constitute the third revision of the guidelines for the treatment of bipolar disorder issued by the Korean Medication Algorithm Project for Bipolar Disorder (KMAP-BP 2014).

METHODS

A 56-item questionnaire was used to obtain the consensus of experts regarding pharmacological treatment strategies for the various phases of bipolar disorder and for special populations. The review committee included 110 Korean psychiatrists and 38 experts for child and adolescent psychiatry. Of the committee members, 64 general psychiatrists and 23 child and adolescent psychiatrists responded to the survey.

RESULTS

The treatment of choice (TOC) for euphoric, mixed, and psychotic mania was the combination of a mood stabilizer (MS) and an atypical antipsychotic (AAP); the TOC for acute mild depression was monotherapy with MS or AAP; and the TOC for moderate or severe depression was MS plus AAP/antidepressant. The first-line maintenance treatment following mania or depression was MS monotherapy or MS plus AAP; the first-line treatment after mania was AAP monotherapy; and the first-line treatment after depression was lamotrigine (LTG) monotherapy, LTG plus MS/AAP, or MS plus AAP plus LTG. The first-line treatment strategy for mania in children and adolescents was MS plus AAP or AAP monotherapy. For geriatric bipolar patients, the TOC for mania was AAP/MS monotherapy, and the TOC for depression was AAP plus MS or AAP monotherapy.

CONCLUSION

The expert consensus in the KMAP-BP 2014 differed from that in previous publications; most notably, the preference for AAP was increased in the treatment of acute mania, depression, and maintenance treatment. There was increased expert preference for the use of AAP and LTG. The major limitation of the present study is that it was based on the consensus of Korean experts rather than on experimental evidence.

Is it useful to use the Korean version of the mood disorder questionnaire for assessing bipolar spectrum disorder among Korean college students?

INTRODUCTION

The purpose of this study was to assess the usefulness of the Korean version of the Mood Disorder Questionnaire (K-MDQ) as a screening tool for the identification of bipolar spectrum disorder (BSD) among Korean college students.

METHODS

The sample of 1,020 college students was stratified to reflect geographical differences among the students. The K-MDQ and an epidemiological survey were administered between November 2006 and February 2007. To validate the K-MDQ as a screening tool for BSD, the Korean version of the Bipolar Spectrum Diagnostic Scale (K-BSDS) and the Structured Clinical Interview for DSM-IV (SCID) were also administered.

RESULTS

The rates satisfying MDQ criterion 1, and all three MDQ criteria, were 55.5% and 2.3%, respectively. According to the K-BSDS, 59.9% of the sample met the criteria for BSD using a threshold of 10, while no statistical differences were observed among subgroups. When we examined the diagnostic agreement between K-MDQ and K-BSDS, 79.5% of students who met MDQ criterion 1 were also positive on the BSDS. Sixteen (21.6%) of the 74 students who participated in the SCID interview were diagnosed with BSD.

DISCUSSION

Although the K-MDQ is a useful tool to assess BSD among inpatients and outpatients, it does not appear useful as a screening tool to detect BSD among college students.

Characteristics of bipolar symptoms in psychiatric patients: pattern of responses to the Korean version of the Mood Disorder Questionnaire

INTRODUCTION

Bipolar disorders are relatively frequent but easily misdiagnosed. The Korean version of the Mood Disorder Questionnaire (K-MDQ) is a screening instrument for bipolar disorders. The aim of this study was to establish the pattern of responses to the K-MDQ for several psychiatric disorders.

METHODS

The subjects for this study were 345 patients with bipolar disorders, schizophrenia, depressive disorders or anxiety disorders, as determined using the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, and 96 controls from five hospitals. The subjects completed the questionnaire by themselves.

RESULTS

The total K-MDQ score was higher in the bipolar disorder group than the other groups. Although the mean K-MDQ score differed significantly between the bipolar disorder group and the other groups, the distributions of total scores for the groups overlapped, and in particular with the schizophrenia group. The area under the receiver operating characteristics curve was relatively high for the bipolar disorder group and the other subjects, but it was less than 0.8 between the bipolar disorder group, and the schizophrenia and control groups.

DISCUSSION

There are some distinguishing features of the K-MDQ pattern for each disorder, but their similarities were significant. This made it difficult to differentially diagnose the disorder using only the total K-MDQ score. The diagnostic power of the K-MDQ can only be improved in the clinical setting by utilizing reinforcing criteria to diagnose bipolar disorders. Clinicians should be cautious in their interpretation of the K-MDQ, and the use of additional data is essential.

One-year rehospitalization rates of patients with first-episode bipolar mania receiving lithium or valproate and adjunctive atypical antipsychotics

AIM

We compared the 1-year rehospitalization rates of first-episode bipolar manic patients who were discharged while being treated with lithium or valproate in combination with an atypical antipsychotic.

METHODS

We investigated the rehospitalization status of first-episode bipolar manic patients who were discharged between 1 January 2003 and 31 December 2010 while they were taking lithium or valproate in combination with aripiprazole, olanzapine, quetiapine, or risperidone. Rehospitalization rates during a 1-year period after discharge were compared between the group receiving lithium plus an atypical antipsychotic and the group receiving valproate plus an atypical antipsychotic using the Kaplan-Meier method. A Cox regression model was used to analyze covariates hypothesized to affect time to rehospitalization.

RESULTS

The rehospitalization rate was 17.3% during the 1-year follow-up period. We found significant differences in the rehospitalization rates of patients in the lithium (23.1%) and the valproate (13.3%) groups using the Kaplan-Meier formula. According to Cox proportional hazards regression analysis, higher Clinical Global Impression-Bipolar Version-Severity score at discharge (P = 0.005) and lithium treatment (P = 0.055) contributed to the risk of rehospitalization.

CONCLUSION

Treatment with valproate and an atypical antipsychotic can be more effective than treatment with lithium and an atypical antipsychotic in preventing rehospitalization during the 1 year after hospitalization due to a first manic episode in patients with bipolar I disorder. Higher Clinical Global Impression-Bipolar Version-Severity scores at discharge also negatively affected rehospitalization rates.

The prevalence of bipolar spectrum disorder in elderly patients with recurrent depression

PURPOSE

Despite a growing body of knowledge on bipolar spectrum disorder (BSD), relatively little is known about the clinical characteristics of BSD in elderly people. We investigated the prevalence of BSD in elderly patients with recurrent depression.

PATIENTS AND METHODS

A total of 65 elderly outpatients (≥60 years of age) who met the Diagnostic and Statistical Manual of Mental Disorders IV criteria for recurrent major depressive disorder participated in the study. BSD was diagnosed according to the criteria developed by Ghaemi et al and the Mood Disorder Questionnaire (MDQ) was used to assess bipolarity.

RESULTS

Of 65 subjects, eleven (16.9%) and 54 (83.1%) were diagnosed with BSD and unipolar depression, respectively. A total of 32.3% (n=22) had a positive screen for bipolar disorder, and we found a significant association between the BSD criteria and the criteria for a positive MDQ (P<0.001). Patients with BSD had a longer duration of illness (P=0.040) and more prior depressive episodes (P<0.001) than did those with unipolar depression. The BSD criteria of first-degree relative with bipolar disorder (P=0.030), antidepressant-induced hypomania (P=0.034), hyperthymic personality (P=0.001), and atypical depression (P=0.030) were highly associated with MDQ-positive patients.

CONCLUSION

Our results indicate that many depressed elderly patients have bipolar-related illness; moreover, some features of the depression are associated with bipolarity.

Factors associated with antenatal depression in pregnant Korean females: the effect of bipolarity on depressive symptoms

BACKGROUND

This cross-sectional study sought to identify factors associated with antenatal depression in pregnant Korean females, including sociodemographic parameters, social support, social conflict, and bipolarity.

METHODS

Eighty-four pregnant women were recruited to complete questionnaires on sociodemographic factors, obstetric history, depressive symptoms, and bipolarity. Depressive symptoms were assessed using the Korean version of the Edinburgh Postnatal Depression Scale. Bipolarity was assessed using the Korean version of the Mood Disorder Questionnaire.

RESULTS

Nineteen participants (22.6%) had positive Mood Disorder Questionnaire scores, suggesting the presence of bipolarity, and were significantly more likely to score high on the Edinburgh Postnatal Depression Scale. Antenatal depression was associated with bad marital communication and marital dissatisfaction.

CONCLUSION

These results suggest that spousal interactions play a significant role in antenatal depression, and pregnant women with bipolarity may be more depressed than those without bipolarity.

Factors associated with body image distortion in Korean adolescents

PURPOSE

Body image incorporates cognitive and affective components as well as behaviors related to own body perception. This study evaluated the occurrence of body image distortion and its correlates in Korean adolescents.

METHODS

In a school-based cross-sectional survey, a total of 2,117 adolescents were recruited. They filled out self-completing questionnaires on body image distortion, eating attitudes, and behaviors (Eating Attitude Test-26) and related factors.

RESULTS

Body image distortions were found in 51.8 percent of adolescents. Univariate analyses showed that boys and older adolescents had higher rates of body image distortion. In the multivariate analyses, body image distortion was associated with high risk for eating disorders (odds ratio [OR] =1.69; 95% confidence interval [CI] 1.11-2.58; P=0.015) and being over weight (OR =33.27; 95% CI 15.51-71.35; P<0.001) or obese (OR =9.37; 95% CI 5.06-17.34; P<0.001).

CONCLUSION

These results suggest that body image distortion is relatively common in Korean adolescents, which has implications for adolescents at risk of developing eating disorders.

Korean medication algorithm for bipolar disorder: second revision

INTRODUCTION

The Feasibility Study of the Korean Medication Algorithm Project for Bipolar Disorder 2002 (KMAP-BP 2002) revealed its clinical usefulness in 2005. Since much more data had become available since 2002, it was revised in 2006 as KMAP-BP 2006. For the same reason, revision of KMAP-BP 2006 is now necessary.

METHODS

The questionnaire, amended on the basis of KMAP-BP 2006 and new data, was sent to 94 experts, 65 of whom replied.

RESULTS

In an acute manic episode, a combination of a mood stabilizer (MS) with an atypical antipsychotic (AAP) is recommended as first-line strategy. Monotherapy with MS is first-line in a hypomanic episode. Triple combination of a MS, an AAP, and an antidepressant (AD), is the first-line strategy in non-psychotic severe depression. Also MS+AAP and MS+AD are recommended as first-line. In psychotic bipolar depression, MS+AAP+AD, MS+AAP and AAP+AD are first-line strategies. In bipolar depression, lithium, lamotrigine and valproic acid are selected as first-line MS and quetiapine, olanzapine and aripiprazole are preferred antipsychotics. In maintenance treatment, a combination of MS with AAP and monotherapy of MS are recommended as first-line.

DISCUSSION

In treating bipolar disorder, even the first step of treatment, the expert consensus has changed from our studies in 2002 and 2006.

Chronic chorioamnionitis is the most common placental lesion in late preterm birth

OBJECTIVES

The pathogenesis of late preterm birth remains elusive for the mechanisms of disease responsible. Placental examination can often provide important clues for the pathogenesis of pregnancy complications. This study was conducted to determine placental pathologic findings according to the gestational age and the clinical circumstances of preterm birth.

STUDY DESIGN

Placental pathologic findings and obstetrical and neonatal outcomes were reviewed in a consecutive preterm birth cohort from a single tertiary center (N = 1206). Placentas of term births (N = 300) were used as normal controls.

RESULTS

Acute chorioamnionitis (22.7% vs. 16.7%), maternal vascular underperfusion (6.4% vs. 0.5%), and chronic chorioamnionitis (20.8% vs. 10.5%) were significantly more frequent in preterm births than in term births (P < 0.05, for each). Among preterm births, chronic chorioamnionitis was the most common pathology of late preterm birth (gestational age <37 and ≥34 weeks), while acute chorioamnionitis was the most common lesion of extremely preterm birth (gestational age <28 weeks). While the frequency of acute chorioamnionitis decreased with advancing gestation, that of chronic chorioamnionitis increased (P < 0.001, for each). The upward trend of the frequency of chronic chorioamnionitis was related to advancing gestation in both spontaneous and indicated preterm births (P < 0.001, for each).

CONCLUSIONS

Chronic chorioamnionitis is a common pathology of late preterm birth. It is suggested that chronic chorioamnionitis, a feature of maternal anti-fetal rejection, is an important etiology of preterm birth, especially of late preterm birth.

Efficacy of quetiapine in patients with bipolar I and II depression: a multicenter, prospective, open-label, observational study

PURPOSE

To evaluate and compare the therapeutic efficacy of quetiapine in bipolar I and II depression patients in the clinical setting.

PATIENTS AND METHODS

This was an 8-week, multicenter, open-label, observational study for bipolar depression. The dosage of quetiapine was flexible, and concomitant medications were permitted on clinician's judgments. A total of 1097 patients were enrolled, and 764 bipolar depression patients who exhibited good therapeutic compliance (>75% compliance rate) were analyzed.

RESULTS

Clinical Global Impression - Bipolar scale and Montgomery-Asberg Depression Rating Scale scores were significantly improved at weeks four and eight compared with the baseline scores. At the end of the 8-week study, the response rate was 58.9%, and the remission rate was 42.1%. However, there were no significant differences in the response and remission rates between bipolar I and II disorder (BD-I and BD-II) patients (response rate 60.1% versus 56.3%; remission rate 44.5% versus 37.0%). Montgomery-Asberg Depression Rating Scale score at baseline (β = 0.612, P < 0.001), duration of current episode (β = -0.152, P = 0.001), and presence of remission on previous episode (β = 0.111, P = 0.012) were significantly associated with improvements in depressive symptoms. Fatigue (16.0%), somnolence (14.9%), and manic/hypomanic switching (0.6% at week four, 0.3% at week eight) were observed throughout the study period.

CONCLUSION

The results of this study suggest that quetiapine improves depressive symptoms in BD-I and BD-II patients with a minimal incidence of manic switching. The therapeutic efficacy of quetiapine increased with time. Quetiapine could be an effective and safe modality for the treatment of BD-I and BD-II.

Prevalence of bipolar spectrum disorder in Korean college students according to the K-MDQ

BACKGROUND

The purpose of this study was to assess the prevalence of bipolar spectrum disorder (BSD) in the general Korean population.

METHODS

A sample of college students (n = 1026) was stratified to reflect geographical differences accurately in Korean college students. The Korean version of the Mood Disorder Questionnaire (K-MDQ) was administered and an epidemiological survey carried out between November 2006 and February 2007. BSD was defined as a score of at least seven K-MDQ symptoms that co-occurred and resulted in minimal or more functional impairment.

RESULTS

The prevalence of BSD was 18.6% (95% confidence interval [CI] 16.2-21.0) in total, being 19.8% (95% CI 16.3-23.2) in men and 17.5% (95% CI 14.2-20.8) in women. The prevalence of BSD was more common in rural dwellers than in urban dwellers (P = 0.008, chi-square test). Univariate and multivariate regression models showed that rural residence was a significant factor associated with BSD. There were significant relationships between BSD and gender, age, and socioeconomic status.

CONCLUSION

The prevalence of BSD found in the present study is higher than that reported by other epidemiological studies in Korea and in international studies.

The effect of paliperidone extended release on subjective well-being and responses in patients with schizophrenia

OBJECTIVE

This study aimed to evaluate the subjective well-being and attitudes toward antipsychotic medication of patients with schizophrenia who had switched to paliperidone extended release (ER).

METHODS

A total of 291 patients with schizophrenia treated with antipsychotics participated in this open-label, 24-week switching study. The primary outcome measures were the Subjective Well-Being under Neuroleptic Treatment Scale-short version (SWN-K) and the Drug Attitude Inventory (DAI). The Krawiecka scale, Clinical Global Impression-Schizophrenia (CGI-SCH), Personal and Social Performance scale (PSP) were used to evaluate psychopathology and psychosocial functioning, respectively.

RESULTS

Data from a total of 243 subjects who received the study medication and had at least one follow-up assessment without a major protocol violation were analyzed. Scores on the DAI and SWN-K showed significant improvement between baseline and end-point measurements beginning during the second week. Scores on the Krawiecka scale, all five subscales of the CGI-SCH scale, and the PSP scale were also significantly improved at the end point compared with the baseline. Significant predictors of improvements in the SWN-K and DAI after a switch to paliperidone ER were baseline scores, reductions in scores on the Krawiecka scale, and previous risperidone use. A clinically relevant increase in body weight (≥7% weight gain) occurred in one-fourth of the participants who completed the 24-week study.

CONCLUSION

Switching to paliperidone ER improved the subjective well-being and attitudes towards antipsychotic medication in patients with schizophrenia. Exploratory analyses revealed that these improvements were particularly pronounced in patients who had been treated with risperidone before treatment with paliperidone ER.

Prevalence of dementia and its correlates among participants in the National Early Dementia Detection Program during 2006-2009

OBJECTIVE

To investigate the prevalence of dementia and its correlates among people with poor socioeconomic status, poor social support systems, and poor performance on the Korean version of the Mini-Mental Status Exam (MMSE-KC).

METHODS

We used 2006-2009 data of the National Early Dementia Detection Program (NEDDP) conducted on Jeju Island. This program included all residents >65 years old who were receiving financial assistance. We examined those who performed poorly (standard deviation from the norm of <-1.5) on the MMSE-KC administered as part of the NEDDP, using age-, gender-, and education-adjusted norms for Korean elders. A total of 1708 people were included in this category.

RESULTS

The prevalence of dementia in this group was 20.5%. Multivariate logistic regression analysis revealed that the following factors were statistically significantly associated with dementia: age of 80 or older, no education, nursing home residence, and depression.

CONCLUSION

The prevalence of dementia is very high among those with lower MMSE-KC scores, and significant correlates include older age, no education, living in a nursing home, and depression. Enhancing lifetime education to improve individuals' cognitive reserves by providing intellectually challenging activities, encouraging living at home rather than in a nursing home, and preventing and treating depression in its early phase could reduce the prevalence of dementia in this population.

Aripiprazole plus divalproex for recently manic or mixed patients with bipolar I disorder: a 6-month, randomized, placebo-controlled, double-blind maintenance trial

OBJECTIVES

The goal of this study was to investigate the safety and efficacy in preventing relapse of a mood episode in recently manic or mixed episode patients with bipolar I disorder stabilized with aripiprazole and divalproex combination.

METHODS

This randomized, 24-week, double-blind, placebo-controlled multicenter study enrolled patients from 23 centers in Korea. Patients with bipolar I disorder who had manic or mixed episode entered a 6-week open-label stabilization phase. After meeting stabilization criteria, 83 patients were randomly assigned to placebo + divalproex or aripiprazole + divalproex treatment group for the 24-week, double-blind maintenance phase.

RESULTS

During the 6-month double-blind treatment, the time to relapse of any mood episode in the aripiprazole group was longer than the placebo group, but the difference did not reach statistical significance (p = 0.098). After controlling for mean divalproex level, the time to depressive episode relapse in the aripiprazole group was longer than those in the placebo group (p = 0.029). Weight gain (≥ 7% increase) occurred in 22.5% aripiprazole group and 18.6% placebo group (p = 0.787).

CONCLUSIONS

In this study, relapse of mood episode occurred fewer and later for aripiprazole with divalproex treatment than divalproex monotherapy, but the differences were not statistically significant.