The Change of Suicidal Ideation Over a 12-Week Naturalistic Treatment of Depression: Comparison Between Young People and Older Adults

OBJECTIVE

We investigated the differences in suicidality between young people and older adults with depression over the course of 12-week naturalistic treatment with antidepressants.

METHODS

A total of 565 patients who had moderate to severe depression (Hamilton Depression Rating Scale [HAM-D] score ≥14) and significant suicidal ideation (Beck Scale for Suicide Ideation [SSI-B] score ≥6) were recruited from 18 hospitals. Participants were classified into two groups: the younger group (13-24 years of age, n=82) and the older group (≥25 years of age, n=483). Total scores over time on the SSI-B, HAM-D, and Hamilton Anxiety Rating Scale (HAM-A) were assessed and compared between the two groups.

RESULTS

At baseline, the younger group had lower HAM-D scores (21.0 vs. 22.2; p=0.028) but higher SSI-B scores (19.4 vs. 15.6; p<0.001) compared with the older group. The overall 12-week proportion of patients with resolved suicidality was 44.1% in the younger group and 69.2% in the older group. Although the improvement in the HAM-D and HAM-A scores did not differ between the groups, suicidal ideation in the younger group remained more severe than in the older group throughout the treatment. The ratio of the subjects who achieved HAM-D remission or response but did not achieve SSI-B remission was significantly higher in the younger group than in the older group.

CONCLUSION

These data suggest that in depressed youths, suicide risk is a serious concern throughout the course of depression even when favorable treatment outcomes are obtained.

ZNF804A Gene Variants Have a Cross-diagnostic Influence on Psychosis and Treatment Improvement in Mood Disorders

Objective

Genetic variations in the gene encoding zinc finger protein 804A gene (ZNF804A) have been associated with major depression and bipolar disorder. In this work we focused on the potential influence of ZNF804A variations on the risk of developing specific sub-phenotypes as well as the individual response to available treatments.

Methods

We used two samples of different ethnic origin: a Korean sample, composed by 242 patients diagnosed with major depression and 132 patients diagnosed with bipolar disorder and 326 healthy controls; an Italian sample composed 151 major depression subjects, 189 bipolar disorder subjects and 38 outpatients diagnosed for a primary anxiety disorder.

Results

Our analyses reported an association of rs1344706 with psychotic phenotype in the cross-diagnostic pooled sample (geno p = 4.15 × 10⁻⁴, allelic p = 1.06 × 10⁻⁴). In the cross-diagnosis Italian sample but not in the Korean one, rs7597593 was involved with depressive symptoms improvement after treatment (geno p = 0.025, allelic p = 0.007).

Conclusion

The present study evidenced the role of ZNF804A alterations in symptoms improvement after treatment. Both manic and depressive symptoms seem to be modulated by ZNF804A, though the latter was observed in the bipolar pooled sample only. The role of this factor is likely related to synaptic development and maintenance; however, further analyses will be needed to better understand the molecular mechanics involved with ZNF804A.

TAAR6variation effect on clinic presentation and outcome in a sample of schizophrenic in-patients: An open label study

We recently reported an association betweenTAAR6(trace amine associated receptor 6 gene) variations and schizophrenia (SZ). We now report an association of a set ofTAAR6variations and clinical presentation and outcome in a sample of 240 SZ Korean patients. Patients were selected by a Structured Clinical Interview, DSM-IV Axis I disorders – Clinical Version (SCID-CV). Other psychiatric or neurologic disorders, as well as medical diseases, were exclusion criteria. To assess symptom severity, patients were administered the CGI scale and the PANSS at baseline and at the moment of discharge, 1 month later on average.TAAR6variations rs6903874, rs7452939, rs8192625 and rs4305745 were investigated; rs6903874, rs7452939 and rs8192625 entered the statistical investigation after LD analysis. Rs8192625 G/G homozygosis was found to be significantly associated both with a worse clinical presentation at PANSS total and positive scores and with a shorter period of illness before hospitalization. No haplotype significant findings were found. The present study stands for a role of theTAAR6in the clinical presentation of SZ. Moreover, our results show that this genetic effect may be counteracted by a correct treatment. Haplotype analysis was not informative in our sample, probably also because of the incomplete SNPs' coverage of the gene we performed. Further studies in this direction are warranted.

Genes Involved in Neurodevelopment, Neuroplasticity and Major Depression: No Association for CACNA1C, CHRNA7 and MAPK1

Objective

Genetics factors are likely to play a role in the risk, clinical presentation and treatment outcome in major depressive disorder (MDD). In this study, we investigated the role of three candidate genes for MDD; calcium voltage-gated channel subunit alpha1 C (CACNA1C ), cholinergic receptor nicotinic alpha 7 subunit (CHRNA7 ), and mitogen-activated protein kinase 1 (MAPK1).

Methods

Two-hundred forty-two MDD patients and 326 healthy controls of Korean ancestry served as samples for the analyses. Thirty-nine single nucleotide polymorphisms (SNPs) within CACNA1C, CHRNA7, and MAPK1 genes were genotyped and subsequently tested for association with MDD (primary analysis) and other clinical features (symptoms’ severity, age of onset, history of suicide attempt, treatment outcome) (secondary analyses). Single SNPs, haplotypes and epistatic analyses were performed.

Results

Single SNPs were not associated with disease risk and clinical features. However, a combination of alleles (haplotype) within MAPK1 was found associated with MDD-status. Secondary analyses detected a possible involvement of CACNA1C haplotype in resistance to antidepressant treatment.

Conclusion

These data suggest a role for MAPK1 and CACNA1C in MDD risk and treatment resistance, respectively. However, since many limitations characterize the analysis, the results must be considered with great caution and verified.

Reduced CXCL1/GRO chemokine plasma levels are a possible biomarker of elderly depression

BACKGROUND

Depression is the single largest contributor to non-fatal health loss worldwide. A role of inflammation in major depressive disorder (MDD) was suggested, and we sought to determine if cytokine levels predict the severity of depressive symptomatology or distinguish MDD patients from healthy controls (HCs).

METHODS

The severity of depressive symptoms and cognitive impairment were assessed by the Korean version of the Geriatric Depression Scale (GDS-K) and Mini-Mental State Examination (MMSE-KC) in 152 elderly subjects (76 with MDD). Plasma levels of 28 cytokines were measured and analysed as continuous predictors or dichotomized using the median value. The association between individual cytokines, MDD risk and depressive symptoms severity was investigated using multiple logistic and linear regressions that included the relevant covariates. A Cytokine Weighted Score (CWS) was calculated by weighting cytokines according to previously reported effect sizes on MDD risk. Sensitivity analyses were performed excluding subjects with significant cognitive impairment.

RESULTS

CXCL10/IP-10 levels were higher in subjects with MDD vs. HCs while the opposite was observed for CXCL1/GRO. Only the second association survived after adjusting for possible confounders and excluding subjects with severe cognitive impairment. Using dichotomized cytokine levels, CXCL1/GRO and TNF-α were negatively associated with MDD. The CWS was also negatively associated with MDD. Cytokine levels did not predict the severity of depressive symptoms.

LIMITATIONS

Our cross-sectional approach was not able to longitudinally evaluate any temporal fluctuations in the considered cytokine levels.

CONCLUSIONS

This study found significantly lower CXCL1/GRO chemokine plasma levels in elderly subjects with MDD compared to HCs.

Neuroplasticity, Neurotransmission and Brain-Related Genes in Major Depression and Bipolar Disorder: Focus on Treatment Outcomes in an Asiatic Sample

Introduction

Mood disorders are common and disabling disorders. Despite the availability of over 100 psychotropic compounds, only one-third of patients benefit from first-line treatments. Over the past 20 years, many studies have focused on the biological factors modulating disease risk and response to treatments, but with still inconclusive data. In order to improve our current knowledge, in this study, we investigated the role of a set of genes involved in different pathways (neurotransmission, neuroplasticity, circadian rhythms, transcription factors, signal transduction and cellular metabolism) in the treatment outcome of major depressive disorder (MDD) and bipolar disorder (BD) after naturalistic pharmacological treatment.

Methods

Totals of 242 MDD, 132 BD patients and 326 healthy controls of Asian ethnicity (Koreans) were genotyped for polymorphisms within 19 genes. Response and remission after 6–8 weeks of treatment with antidepressants and mood stabilizers were evaluated. In secondary analyses, genetic associations with disease risk and some disease-associated features (age of onset, suicide attempt and psychotic BD) were also tested.

Results

None of the variants within the investigated genes was significantly associated with treatment outcomes. Some marginal association (uncorrected p < 0.01) was observed for HTR2A, BDNF, CHL1, RORA and HOMER1 SNPs. In secondary analyses, HTR2A (rs643627, p = 0.002) and CHL1 (rs4003413, p = 0.002) were found associated with risk for BD, HOMER1 (rs6872497, p = 0.002) with lifetime history of suicide attempt in patients, and RORA with early onset and presence of psychotic features in BD. Marginal results were also observed for ST8SIA2 and COMT.

Discussion

Despite limitations linked to multiple testing on small samples, methodological shortcomings and small significance of the findings, this study may support the involvement of some candidate genes in the outcomes of treatments for mood disorders, as well as in BD risk and other disease features.

Electronic supplementary material

The online version of this article (10.1007/s12325-018-0781-2) contains supplementary material, which is available to authorized users.

Genes Involved in Neurodevelopment, Neuroplasticity, and Bipolar Disorder: CACNA1C, CHRNA1, and MAPK1

BACKGROUND

Bipolar disorder (BPD) is a common and severe mental disorder. The involvement of genetic factors in the pathophysiology of BPD is well known. In the present study, we tested the association of several single-nucleotide polymorphisms (SNPs) within 3 strong candidate genes (CACNA1C, CHRNA7, and MAPK1) with BPD. These genes are involved in monoamine-related pathways, as well as in dendrite development, neuronal survival, synaptic plasticity, and memory/learning.

METHODS

One hundred and thirty-two subjects diagnosed with BPD and 326 healthy controls of Korean ancestry were genotyped for 40 SNPs within CACNA1C, CHRNA17, and MAPK1. Distribution of alleles and block of haplotypes within each gene were compared in cases and controls. Interactions between variants in different loci were also tested.

RESULTS

Significant differences in the distribution of alleles between the cases and controls were detected for rs1016388 within CACNA1C, rs1514250, rs2337980, rs6494223, rs3826029 and rs4779565 within CHRNA7, and rs8136867 within MAPK1. Haplotype analyses also confirmed an involvement of variations within these genes in BPD. Finally, exploratory epistatic analyses demonstrated potential interactive effects, especially regarding variations in CACNA1C and CHRNA7.

LIMITATIONS

Limited sample size and risk of false-positive findings.

DISCUSSION

Our data suggest a possible role of these 3 genes in BPD. Alterations of 1 or more common brain pathways (e.g., neurodevelopment and neuroplasticity, calcium signaling) may explain the obtained results.

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.

Efficacy of antidepressants: bias in randomized clinical trials and related issues

INTRODUCTION

Countless antidepressant randomized trials were conducted and showed statistically significant benefits of selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) over placebo. Meanwhile, critics are increasing regarding the efficacy of antidepressants in the treatment of MDD because at least a proportion of clinical trials could be hampered by various biases. In contrast, number of failed trials is increasing in the recent years which have made developing psychiatric medications progressively more time-consuming and expensive. Areas covered: Biases and related issues in clinical trials for antidepressants can be identified as an important common contributing factor to the two paradoxical phenomenon. This review identifies possible biases that can occur before, during, and after clinical trials of antidepressant. Expert commentary: Recent studies not only may over-estimate efficacy of antidepressants, but also may exaggerate placebo response because of various biases. Sponsorship and publication biases have been one of the targets of the criticism and ethical debate. Thus, initiating new trend of research by re-organizing academic-industry partnership will be the most important task in the next five years.

Clinical Validation of the Psychotic Depression Assessment Scale, Hamilton Depression Rating Scale-6, and Brief Psychiatric Rating Scale-5: Results from the Clinical Research Center for Depression Study

OBJECTIVE

The aim of this study was to validate the psychotic depression assessment scale (PDAS), which includes the six-item melancholia subscale from the Hamilton depression rating scale (HAMD-6) and the five-item psychosis subscale from the brief psychiatric rating scale (BPRS-5). Data from the Clinical Research Center for Depression (CRESCEND) study, which is a 52-week naturalistic trial, were analyzed.

METHODS

Fifty-two patients with psychotic depression from the CRESCEND study met our inclusion criteria. The patients underwent the following psychometric assessments: the PDAS, including HAMD-6 and BPRS-5, the clinical global impression scales, the HAMD, the positive symptom subscale, and the negative symptom subscale. Assessments were performed at the baseline and then at weeks 1, 2, 4, 8, 12, 24, and 52. Spearman correlation analyses were used to assess the clinical validity and responsiveness of the PDAS.

RESULTS

The clinical validity and responsiveness of the PDAS, including HAMD-6 and BPRS-5, were acceptable, with the exception of the clinical responsiveness of the PDAS for positive symptoms and the clinical responsiveness of BPRS-5 for negative symptoms.

CONCLUSION

The clinical relevance of the PDAS has been confirmed and this clinical validation will enhance its clinical utility and availability.

Genetic Variants Within Key Nodes of the Cascade of Antipsychotic Mechanisms: Effects on Antipsychotic Response and Schizophrenia Psychopathology in a Naturalistic Treatment Setting in Two Independent Korean and Italian Samples

INTRODUCTION

Schizophrenia (SCZ) is one of the most disabling psychiatric disorders. Genetic factors play an important role in both SCZ liability and its treatment outcome. In the present paper, we investigated the effects of several single nucleotide polymorphisms (SNPs) within ten strong candidate genes involved with antipsychotics (APs) mechanisms of action.

METHODS

Two independent samples were investigated in the present study. Totals of 176 SCZ subjects and 326 controls of Korean ancestry, and 83 SCZ subjects and 194 controls of Italian ancestry were recruited and genotyped. SCZ risk and other parameters were also investigated.

RESULTS

Concerning APs response, only a nominal association with HOMER1 rs3822568 in the Korean sample was found. In the haplotype analysis, rs9801117 C-rs12668837 C-rs4621754 A haplotype within ESYT2 and NCAPG2 genes was associated with APs response in the same sample. As for secondary outcomes, rs7439 within PKDCC and rs12668837 within NCAPG2 were associated with SCZ risk in the Italian sample. In the haplotype analysis, rs2788478 G-rs2657375 T-rs1039621 A within the region between WDR60 and ESYT genes and rs2013 C (ESYT2)-rs6459896 A (NCAPG2) haplotypes were associated with SCZ in the same sample. No association was found in the Korean sample. Finally, our exploratory data suggest a possible modulation of HOMER1, ARC, BDNF, TXNRD2, WDR60, and ESYT2 genes in the APs response to specific symptom clusters.

CONCLUSION

Our results did not support a primary role for the genes investigated in the APs response. On the other hand, our secondary results suggest a possible involvement of NACPG2 and PKDCC in SCZ liability. Finally, our exploratory findings may deserve further investigations in specific studies.

Investigational dopamine antagonists for the treatment of schizophrenia

INTRODUCTION

Schizophrenia is a debilitating illness with a chronic impact on social function and daily living. Although various antipsychotics are available, there are still many challenges and unmet needs. Thus, many compounds with diverse mechanisms have been investigated, but all approved antipsychotics still require interactions with dopamine D₂ receptors. Areas covered: We searched for investigational drugs using the key words 'dopamine' and 'schizophrenia' in American and European clinical trial registers (clinicaltrials.gov; clinicaltrialsregister.eu). Published articles were searched in PubMed, Embase, Medline, PsycINFO, Cumulative Index to Nursing and Allied Health Literature (CINAHL), the Web of Science and the Cochrane Central Register of Controlled Trials Library. Expert opinion: The prospect of developing a dopamine antagonist is hopeful. Brexpiprazole and cariprazine, which were agents listed as 'investigational dopamine antagonists,' just received FDA approval. Novel agents such as BL 1020, ITI-007, and JNJ-37822681 have solid published data available, and agents such as L-THP, Lu AF35700, S33138, and SB-773812 are under vigorous investigation. However, the expected benefits of the newly developed antagonists may not be great because they offer little enhanced efficacy for negative symptoms, cognition and functional outcomes.

How many different symptom combinations fulfil the diagnostic criteria for major depressive disorder? Results from the CRESCEND study

BACKGROUND

The polythetic nature of major depressive disorder (MDD) in DSM- IV and DSM-5 inevitably leads to diagnostic heterogeneity.

AIMS

This study aimed to identify the number of depressive symptom combinations actually fulfilling the DSM-IV diagnostic criteria that can be found in Korean MDD patients and the relative frequencies of each combination.

METHODS

Using the data from the Clinical Research Center for Depression (CRESCEND) study in South Korea, we enrolled 853 MDD patients diagnosed using DSM-IV and scored as 8 or more on the Hamilton Depression Rating Scale (HAMD). Descriptive statistical analyses were performed to reveal the degree of diagnostic heterogeneity of the MDD.

RESULTS

This study identified 119 different depressive symptom combinations. The most common combination consisted of all nine depressive symptom profiles, and nine different combinations were each present in more than 3% of the patients.

CONCLUSION

The findings support the criticism that the diagnosis of MDD is not based on a single mental process, but on a set of 'family resemblances'.

Modafinil for the treatment of attention-deficit/hyperactivity disorder: A meta-analysis

Attention-deficit/hyperactivity disorder (ADHD) is one of the most common and a debilitating neuro-behavior disorder in the pediatric population. Although numerous effective psychostimulants are available, more than 30% of patients still do not show adequate treatment response rendering diverse pharmacological options. We aimed at assessing the efficacy and safety of modafinil in the treatment of children and adolescents with ADHD by conducting a meta-analysis. An extensive search of databases and clinical trial registries resulted in five published short-term randomized, double-blind, placebo-controlled trials. Primary efficacy measures were mean change in ADHD Rating Scale-IV Home (ADHD-RS-IV Home) and School Version (ADHD-RS-IV School) from baseline to study end point. The results showed that modafinil more significantly improved ADHD-RS-IV Home (SMD, -0.77 [95%CI, -1.11 to -0.44]) and School (SMD, -0.71 [95%CI, -0.96 to -0.47]) than placebo. Dropout rate due to adverse event did not significantly differ between two groups. In terms of commonly observed side effects, modafinil showed significantly higher incidence of decreased appetite (RR = 5.02, 95% CIs, 2.55 to 9.89, P < 0.00001) and insomnia (RR = 6.16, 95% CIs, 3.40 to 11.17, P < 0.00001). Modafinil did not cause a clinically significant increase of heart rate, systolic blood pressure, and diastolic blood pressure. Although we found that modafinil may be another treatment option in children and adolescents with ADHD, the results should be interpreted and translated into clinical practice with caution, as the meta-analysis was based on a limited number of clinical trials.

Association of treatment response with obesity and other metabolic risk factors in adults with depressive disorders: Results from a National Depression Cohort study in Korea (the CRESCEND study)

BACKGROUND

Available studies indicate that obesity may exert a moderational effect on antidepressant treatment response. The aim of this study was to investigate the relationship between treatment response and metabolic abnormalities amongst patients with depressive disorders in a large naturalistic clinical setting.

METHODS

A nationwide prospective study was conducted in 18 hospitals in South Korea; 541 depressive patients meeting DSM-IV criteria were recruited. After baseline evaluation, subjects received naturalistic clinician-determined antidepressant interventions. Assessment was performed at baseline and weeks 1, 2, 4, 8, 12, 24 and 52. Treatment response was defined as a ≥50% reduction from baseline on at least one evaluation point.

RESULTS

In univariate comparison, the patients who showed insufficient response to antidepressant therapy were more likely to be male, unmarried, unemployed, and obese. After adjusting for baseline variables, male sex (OR=1.82) and obesity (OR=1.55) remained as were significant variables. Stratification of the subjects into one of three groups, i.e. male, pre-menopausal female and post-menopausal female, revealed that males with concurrent metabolic problems, (i.e. the presence of one or more of hypertension, hyperglycemia, or hypercholesterolemia) had significantly higher risk for insufficient response (OR=2.32) and, after adjusting for baseline variables, obesity predicted insufficient response in post-menopausal female (OR=2.41).

CONCLUSIONS

The presence of metabolic abnormalities in patients with depressive disorders was associated with decreased treatment response to antidepressants. These results underscore the neurobiological relationship between obesity and the central nervous system, and provide empiric evidence supporting stratification of treatment response in depression.

Second Generation Antipsychotics in the Treatment of Major Depressive Disorder: An Update

Less than one third of patients who suffer from major depressive disorder (MDD) report remission following antidepressant treatments requiring more diverse treatment approaches. Augmentation of second generation antipsychotics (SGAs) has been increasingly recognized as an important treatment option. The authors have previously provided a comprehensive review of SGAs for the treatment of MDD in 2013. Since then, numerous additional clinical trials have been conducted to investigate diverse issues regarding the utility of SGAs in MDD. Moreover, a new SGA, brexpiprazole, was recently approved by the Food and Drug Administration in July 2015 for the treatment of MDD as an augmentation agent to antidepressants. Thus, the aim of this study was to provide a concise update of all the available SGAs for the treatment of MDD, in particular on the additional clinical trials which have been published since 2013.

Potential Relationship between Season of Birth and Clinical Characteristics in Major Depressive Disorder in Koreans: Results from the CRESCEND Study

We aimed to examine the potential relationship between season of birth (SOB) and clinical characteristics in Korean patients with unipolar non-psychotic major depressive disorder (MDD). Using data from the Clinical Research Center for Depression (CRESCEND) study in South Korea, 891 MDD patients were divided into two groups, those born in spring/summer (n=457) and those born in autumn/winter (n=434). Measurement tools comprising the Hamilton Depression Rating Scale, Hamilton Anxiety Rating Scale, Brief Psychiatric Rating Scale, Scale for Suicidal Ideation, Clinical Global Impression of severity, Social and Occupation Functional Assessment Scale, WHO Quality of Life assessment instrument-abbreviated version, Alcohol Use Disorder Identification Test, and Temperament and Character Inventory were used to evaluate depression, anxiety, overall symptoms, suicidal ideation, global severity, social function, quality of life, drinking, and temperament and character, respectively. Using independent t-tests for continuous variables and χ² tests for discrete variables, the clinical characteristics of the two groups were compared. MDD patients born in spring/summer were on average younger at onset of first depressive episode (t=2.084, p=0.038), had greater loss of concentration (χ²=4.589, p=0.032), and were more self-directed (t=2.256, p=0.025) than those born in autumn/winter. Clinically, there was a trend for the MDD patients born in spring/summer to display the contradictory characteristics of more severe clinical course and less illness burden; this may have been partly due to a paradoxical effect of the 5-HT system.

Clinical Significance of the Number of Depressive Symptoms in Major Depressive Disorder: Results from the CRESCEND Study

Our study aimed to establish the relationship between the number of depressive symptoms and the clinical characteristics of major depressive disorder (MDD). This would enable us to predict the clinical significance of the number of depressive symptoms in MDD patients. Using data from the Clinical Research Center for Depression (CRESCEND) study in Korea, 853 patients with DSM-IV MDD were recruited. The baseline and clinical characteristics of groups with different numbers of depressive symptoms were compared using the χ(2) test for discrete variables and covariance (ANCOVA) for continuous variables. In addition, the scores of these groups on the measurement tools were compared by ANCOVA after adjusting the potential effects of confounding variables. After adjusting the effects of monthly income and history of depression, a larger number of depressive symptoms indicated higher overall severity of depression (F [4, 756] = 21.458, P < 0.001) and higher levels of depressive symptoms (F [4, 767] = 19.145, P < 0.001), anxiety symptoms (F [4, 765] = 12.890, P < 0.001) and suicidal ideation (F [4, 653] = 6.970, P < 0.001). It also indicated lower levels of social function (F [4, 760] = 13.343, P < 0.001), and quality of life (F [4, 656] = 11.975, P < 0.001). However, there were no significant differences in alcohol consumption (F [4, 656] = 11.975, P < 0.001). The number of depressive symptoms can be used as an index of greater illness burden in clinical psychiatry.

Factors related to suicidal behavior in patients with bipolar disorder: the effect of mixed features on suicidality

OBJECTIVES

The aim of the present study was to investigate various risk factors of suicidal behaviors, including the mixed features specifier, in patients with bipolar disorder.

METHODS

We retrospectively reviewed medical charts from 2005 to 2014. A total of 334 patients diagnosed with bipolar disorder using the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision were enrolled. Subjects were categorized into two groups according to their history of suicidal behavior and the demographic and clinical characteristics of the groups were compared, including the mixed features specifier. We reevaluated the index episode using Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) criteria and classified subjects into an index episode with mixed features group and an index episode without mixed features group. Logistic regression was performed to evaluate significant risk factors associated with suicidal behavior.

RESULTS

Suicidal behavior had an independent relationship to mixed features at the index episode using DSM-5 criteria [odds ratio (OR)=3.39; 95% confidence interval (CI): 1.57-7.34] and number of previous depressive episodes (OR=1.62; 95% CI: 1.34-1.95) in bipolar patients. The mixed feature specifier was the strongest risk factor for suicidal behavior in the present study.

CONCLUSIONS

This study may help clinicians understand potential risk factors and manage bipolar disorders with suicidal behaviors. Clinicians should carefully monitor patients with bipolar disorder who exhibit numerous depressive episodes or mixed features for suicidal behavior.

Gender Differences in the Clinical Characteristics of Psychotic Depression: Results from the CRESCEND Study

OBJECTIVE

To test whether there are gender differences in the clinical characteristics of patients with psychotic depression (PD).

METHODS

Using data from the Clinical Research Center for Depression (CRESCEND) study in South Korea, we tested for potential gender differences in clinical characteristics among 53 patients with PD. The Psychotic Depression Assessment Scale (PDAS) and other psychometric scales were used to evaluate various clinical features of the study subjects. Independent t-tests were performed for normally distributed variables, Mann-Whitney U-tests for non-normally distributed variables, and χ(2)tests for discrete variables. In addition, to exclude the effects of confounding variables, we carried out an analysis of covariance (ANCOVA) for the normally distributed variables and binary logistic regression analyses for discrete variables, after adjusting the effects of marital status.

RESULTS

We identified more prevalent suicidal ideation (adjusted odds ratio [aOR]=10.316, p=0.036) and hallucinatory behavior (aOR=8.332, p=0.016), as well as more severe anxiety symptoms (degrees of freedom [df]=1, F=6.123, p=0.017), and poorer social and occupational functioning (df=1, F=6.265, p=0.016) in the male patients compared to the female patients.

CONCLUSION

Our findings suggest that in South Korean patients with PD, suicidal ideation, hallucinatory behavior, and anxiety is more pronounced among males than females. This should be taken into consideration in clinical practice.

Prevalence of Depressive Disorder of Outpatients Visiting Two Primary Care Settings

OBJECTIVES

Although the prevalence of depressive disorders in South Korea's general population is known, no reports on the prevalence of depression among patients who visit primary care facilities have been published. This preliminary study was conducted to identify the prevalence of depressive disorder in patients that visit two primary care facilities.

METHODS

Among 231 consecutive eligible patients who visited two primary care settings, 184 patients consented to a diagnostic interview for depression by psychiatrists following the Diagnostic and Statistical Manual of Mental Disorders-IV criteria. There were no significant differences in sociodemographic characteristics such as gender, age, or level of education between the groups that consented and declined the diagnostic examination. The prevalence of depressive disorder and the proportion of newly diagnosed patients among depressive disorder patients were calculated.

RESULTS

The prevalence of depressive disorder of patients in the two primary care facilities was 14.1% (95% confidence interval [CI], 9.1 to 19.2), with major depressive disorder 5.4% (95% CI, 2.1 to 8.7), dysthymia 1.1% (95% CI, 0.0 to 2.6), and depressive disorder, not otherwise specified 7.6% (95% CI, 3.7 to 11.5). Among the 26 patients with depressive disorder, 19 patients were newly diagnosed.

CONCLUSIONS

As compared to the general population, a higher prevalence of depressive disorders was observed among patients at two primary care facilities. Further study is needed with larger samples to inform the development of a primary care setting-based depression screening, management, and referral system to increase the efficiency of limited health care resources.

Optimizing the Use of Aripiprazole Augmentation in the Treatment of Major Depressive Disorder: From Clinical Trials to Clinical Practice

Major depressive disorder (MDD) is a recurrent, chronic, and devastating disorder leading to serious impairment in functional capacity as well as increasing public health care costs. In the previous decade, switching therapy and dose adjustment of ongoing antidepressants was the most frequently chosen subsequent treatment option for MDD. However, such recommendations were not based on firmly proven efficacy data from well-designed, placebo-controlled, randomized clinical trials (RCTs) but on practical grounds and clinical reasoning. Aripiprazole augmentation has been dramatically increasing in clinical practice owing to its unique action mechanisms as well as proven efficacy and safety from adequately powered and well-controlled RCTs. Despite the increased use of aripiprazole in depression, limited clinical information and knowledge interfere with proper and efficient use of aripiprazole augmentation for MDD. The objective of the present review was to enhance clinicians' current understanding of aripiprazole augmentation and how to optimize the use of this therapy in the treatment of MDD.

Predictors of premature discontinuation of outpatient treatment after discharge of patients with posttraumatic stress disorder

OBJECTIVE

This study aimed to examine the sociodemographic and disease-related variables associated with the premature discontinuation of psychiatric outpatient treatment after discharge among patients with noncombat-related posttraumatic stress disorder.

METHODS

We retrospectively reviewed the medical records of patients who were discharged with a diagnosis of posttraumatic stress disorder.

RESULTS

Fifty-five percent of subjects (57/104) prematurely discontinued outpatient treatment within 6 months of discharge. Comparing sociodemographic variables between the 6-month non-follow-up group and 6-month follow-up group, there were no variables that differed between the two groups. However, comparing disease-related variables, the 6-month follow-up group showed a longer hospitalization duration and higher Global Assessment of Function score at discharge. The logistic regression analysis showed that a shorter duration of hospitalization predicted premature discontinuation of outpatient treatment within 6 months of discharge.

CONCLUSION

The duration of psychiatric hospitalization for posttraumatic stress disorder appeared to influence the premature discontinuation of outpatient treatment after discharge.

A diagnosis of bipolar spectrum disorder predicts diagnostic conversion from unipolar depression to bipolar disorder: a 5-year retrospective study

BACKGROUND

The major aims of this study were to identify factors that may predict the diagnostic conversion from major depressive disorder (MDD) to bipolar disorder (BP) and to evaluate the predictive performance of the bipolar spectrum disorder (BPSD) diagnostic criteria.

METHODS

The medical records of 250 patients with a diagnosis of MDD for at least 5 years were retrospectively reviewed for this study.

RESULTS

The diagnostic conversion from MDD to BP was observed in 18.4% of 250 MDD patients, and the diagnostic criteria for BPSD predicted this conversion with high sensitivity (0.870) and specificity (0.917). A family history of BP, antidepressant-induced mania/hypomania, brief major depressive episodes, early age of onset, antidepressant wear-off, and antidepressant resistance were also independent predictors of this conversion.

LIMITATIONS

This study was conducted using a retrospective design and did not include structured diagnostic interviews.

CONCLUSIONS

The diagnostic criteria for BPSD were highly predictive of the conversion from MDD to BP, and conversion was associated with several clinical features of BPSD. Thus, the BPSD diagnostic criteria may be useful for the prediction of bipolar diathesis in MDD patients.

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.

Age-related differences in suicidality between young people and older adults with depression: data from a nationwide depression cohort study in Korea (the CRESCEND study)

This study compared young people and older adults with depression to identify differences in suicidality between these groups. A total of 1003 patients with moderate to severe depression (Hamilton Depression Rating Scale [HDRS] score ≥14) were recruited from a national sample of 18 hospitals. Of the patients included in this study, 103 (10.3%) were placed in the younger group (age <25years) and 900 (89.7%) were placed in the older group (age ≥25years). Suicide-related variables and predictive factors associated with significant suicidal ideation were compared between the two groups. Regardless of the severity of depression, subjects in the younger group were more likely than were those in the older group to report significant suicidal ideation (scores ≥6 on the Beck Scale for Suicide Ideation [SSI-B], 79.6 vs. 53.7%, respectively; p<0.001), have had a suicide attempt at the current episode (4.9 vs. 1.6%, respectively; p=0.037), and have a history of suicide attempts (43.7 vs. 19.4%, respectively; p<0.001). Logistic regression models revealed that, in contrast to the predictive factors in the older group, subjects in the younger group were more affected by their history of suicide attempts (OR [95% CI]: 12.4, [1.5-99.1]; p=0.018) and depressive episodes (OR [95% CI]: 13.0, [1.6-104.0]; p=0.016). Also in contrast to the older group, an increase in HDRS score was not identified as a possible precipitating factor of significant suicidal ideation in younger subjects. The present findings demonstrate that suicidality in depressed young people was more severe than in older adults, but that suicidality was not correlated with the severity of depression. These data suggest that close attention should be paid to young people even in mild or moderate depression.

Delays in depression treatment among Korean population

INTRODUCTION

Delays in mental health service utilization for patients with depression have been observed globally. To elucidate some aspects of delays, age-related associations with a series of variables representing different stages of mental health service use were studied concurrently.

METHODS

A total of 1,433 patients with depression participated in a nationwide Korean Depressive Patient Survey through the collaboration of 70 psychiatric clinics and hospitals. Using logistic and Poisson regression, we investigated whether there is variation in the associations by age.

RESULTS

Patients with depression in South Korea spent 3.4 years on average before starting a first depression treatment after the onset of depression, and 58% of them entered depression treatment in the first year of onset. Early onset appeared to lower the chance of "early depression treatment": e.g., adjusted odds ratio (OR)s for onset age of 40-54, 25-39 and <25 versus ≥55 were 0.65 (95% CI = 0.44, 0.94), 0.36 (95% CI = 0.16, 0.81) and 0.18 (95% CI = 0.06, 0.48), respectively. In contrast, favorable associations of early onset with "self-recognition as depression" and "number of nonpsychiatric clinics attended" before visiting psychiatrist were found. Younger cohorts were associated with more positive attitudes toward all mental health utilization measures.

DISCUSSION

Delays in depression treatment are lengthy in South Korea. Those with early onset are more likely to have delayed depression treatment but are more willing to seek help from a psychiatrist once they sought for the treatment.

Does age at onset of first major depressive episode indicate the subtype of major depressive disorder?: the clinical research center for depression study

PURPOSE

The purpose of this study was to evaluate the effects of age at onset of the first major depressive episode on the clinical features of individuals with major depressive disorder (MDD) in a large cohort of Korean depressed patients.

MATERIALS AND METHODS

We recruited 419 MDD patients of age over 18 years from the Clinical Research Center for Depression study in South Korea. At the start of the study, the onset age of the first major depressive episode was self-reported by the subjects. The subjects were divided into four age-at-onset subgroups: childhood and adolescent onset (ages <18), early adult onset (ages 18-44), middle adult onset (ages 45-59), and late onset (ages 60+). Using analysis of covariance (ANCOVA) and ordinal logistic regression analysis with adjusting the effect of age, the relationships between clinical features and age at onset of MDD were evaluated.

RESULTS

There was an apparent, but inconsistent correlation between clinical features and age at onset. Earlier onset MDD was significantly associated with higher proportion of female gender [adjusted odds ratio (AOR)=0.570, p=0.022], more previous suicide attempts (AOR=0.635, p=0.038), greater number of previous depressive episodes (F=3.475, p=0.016) and higher scores on the brief psychiatric rating scale (F=3.254, p=0.022), its negative symptom subscale (F=6.082, p<0.0001), and the alcohol use disorder identification test (F=7.061, p<0.0001).

CONCLUSION

Early age at onset may increase the likelihood of distinguishable MDD subtype, and age at onset of the first major depressive episode is a promising clinical indicator for the clinical presentation, course, and outcome of MDD.

Relationship of temperament and character in remitted depressed patients with suicidal ideation and suicide attempts--results from the CRESCEND study

The aim of this study was to evaluate the Temperament and Character Inventory (TCI) scores of a sample of Korean patients with remitted depression who had attempted suicide and reported suicidal ideation and to compare their scores with those of remitted depressed patients without suicidal ideation. Adult depression patients who had completed 12 weeks of follow-up (N = 138) were divided into three groups: patients with a history of suicide attempts (N = 23); patients with current suicidal ideation (N = 59); and patients without current suicidal ideation (N = 56). After controlling for covariates, no significant differences were found among the three groups on any measure of temperament or character except self-directedness and self-transcendence. The self-transcendence scores of the lifetime suicide-attempt group were significantly higher compared with those of the suicidal-ideation group; post hoc analysis revealed that self-directedness was significantly lower in the suicide-attempt group compared with the non-suicidal group. The results from the present study suggest that remitted depression patients with a history of suicide attempts do not differ from non-attempters in temperament, but do differ in certain character traits.

Distinctive Clinical Correlates of Psychotic Major Depression: The CRESCEND Study

OBJECTIVE

The purpose of this investigation was to identify distinctive clinical correlates of psychotic major depression (PMD) as compared with non-psychotic major depression (NPMD) in a large cohort of Korean patients with major depressive disorder (MDD).

METHODS

We recruited 966 MDD patients of age over 18 years from the Clinical Research Center for Depression of South Korea (CRESCEND) study. Diagnoses of PMD (n=24) and NPMD (n=942) were made with the DSM-IV definitions and confirmed with SCID. Psychometric scales were used to assess overall psychiatric symptoms (BPRS), depression (HAMD), anxiety (HAMA), global severity (CGI-S), suicidal ideation (SSI-Beck), functioning (SOFAS), and quality of life (WHOQOL-BREF). Using independent t-tests and χ(2) tests, we compared clinical characteristics of patients with PMD and NPMD. A binary logistic regression model was constructed to identify factors independently associated with increased likelihood of PMD.

RESULTS

PMD subjects were characterized by a higher rate of inpatient enrollment, and higher scores on many items on BPRS (somatic concern, anxiety, emotional withdrawal, guilt feelings, tension, depression, suspiciousness, hallucination, motor retardation, blunted affect and excitement) global severity (CGI-s), and suicidal ideation (SSI-Beck). The explanatory factor model revealed that high levels of tension, excitement, and suicidal ideation were associated with increased likelihood of PMD.

CONCLUSION

Our findings partly support the view that PMD has its own distinctive clinical manifestation and course, and may be considered a diagnostic entity separate from NPMD.

Personality traits associated with suicidal behaviors in patients with depression: the CRESCEND study

The aim of the current study was to identify personality traits associated with suicidal behavior in patients with depression. Of the 1183 patients screened for an observational cohort study of depression, 334 (28.2%) who completed the Temperament and Character Inventory (TCI) were included in these analyses. To minimize the effect of current mood state, the TCI was performed 12 weeks after initiation of treatment, and we adjusted for the severity of depression. Of the 344 participants, 59 had a lifetime history of at least one suicide attempt, 37 had a lifetime history of multiple suicide attempts, and 5 attempted suicide during the 12-week study period. At baseline, patients with a lifetime history of at least one suicide attempt, a lifetime history of multiple suicide attempts, and a suicide attempt during the study period expressed more serious current suicidal ideation than did those without such a history, despite the absence of differences among the groups in the severity of depressive and anxiety symptoms. Of the seven personality scales of the TCI, lower scores on the self-directedness scale of the character dimension were associated with a history of at least one suicide attempt (OR [95% CI], 0.91 [0.87-0.96]; p<0.001), a history of multiple suicide attempts (0.91 [0.86-0.97]; p=0.003), and suicide attempts during study period (0.80 [0.69-0.94]; p=0.006). These findings suggest that depressed patients with a history of suicidal behavior differ from non-attempters with regard to personality traits, especially the character dimension of self-directedness. It is noteworthy that this result emerged after controlling for the effect of current mood state.

How does antiepileptic drug induce suicidality? A case associated with levitracetam use

New antiepileptic drugs have been known to increase the risk of suicide. Among them, levitracetam is a widely used antiepileptic drug approved as a monotherapy treatment for partial seizures or as an adjunctive therapy for partial, myoclonic and generalized tonic-clonic seizures. It has been reported that the incidence of suicidal ideation during treatment with levitracetam was about 0.5-0.7%, but an explanation regarding a mechanism by which it causes suicidality is lacking. We made a multifaceted approach using the Hamilton Depression Rating Score (HDRS), the Hamilton Anxiety Rating Score (HARS), the Beck Hopelessness Scale (BHS), the Barratt Impulsiveness Scale (BIS), the Beck Scale for Suicidal Ideation (BSS) ideation daily and the Sheehan Suicidality Tracking Scale (SSTS) weekly in a patient taking levitracetam who acutely developed suicidal ideation after starting the medication. Suicidal ideation disappeared within 5 days of levitracetam discontinuation. We found that decreasing HDRS and BHS scores were correlated with BSS and SSTS scores. On the other hand, HARS and BIS did not change from their baselines. Our findings suggest that suicidality induced by an antiepileptic drug may be related to depression rather than anxiety and impulsiveness.

A reevaluation of the possibility and characteristics in bipolar mania with mixed features: a retrospective chart review

The aim of the present study was to reevaluate the feasibility of diagnosing a mixed features behind bipolar mania and to elucidate the clinical characteristics, treatment response, and course of the illness throughout a 12-month follow-up. The subjects (n=171) were inpatients diagnosed with bipolar I disorder, manic, between 2003 and 2010 and were classified into three groups: "mania" (n=67), "mania with probable mixed features" (n=79), and "mania with definite mixed features" (n=25). Diagnoses were in accordance with the Cincinnati criteria, which include the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision characteristics for a major depressive episode, except for agitation and insomnia. The charts of subjects were retrospectively reviewed for demographic and clinical characteristics prior to the index episode, clinical data regarding the index episode, and treatment courses over a 12-month follow-up period. Subjects in the mania with definite mixed features were more likely to be young at admission, to be female, to have a familial affective loading, and to have a history of suicidality relative to the mania. The results of the present study suggest the need for regular assessment of symptoms associated with both polarities during an episode in routine practice.

Persistence and resolution of suicidal ideation during treatment of depression in patients with significant suicidality at the beginning of treatment: the CRESCEND study

BACKGROUND

The appropriate length of time for patients who visit clinics with significant suicidal ideation to be closely monitored is a critical issue for clinicians. We evaluated the course of suicidal ideation and associated factors for persistent suicidality in patients who entered treatment for depression with significant suicidal ideation.

METHODS

A total of 565 patients who had both moderate to severe depression (Hamilton Depression Rating Scale (HAMD) score ≥14) and significant suicidal ideation (Beck Scale for Suicide Ideation (SSI-B) score ≥6) were recruited from 18 hospitals in South Korea. Participants were assessed using the SSI-B, HAMD, Hamilton Anxiety Rating Scale, and Clinical Global Impression Scale-severity during a 12-week naturalistic treatment with antidepressant intervention. Participants were classified into resolved suicidality or persistent suicidality groups according to whether their suicidal ideation improved to SSI-B scores <6 and were sustained for 12 weeks.

RESULTS

During the 12-week treatment, 206 (36.4%) patients were classified in the resolved suicidality group. Persistent suicidality was associated with intervention with SSRIs, higher SSI-B baseline score, and no HAMD or HAMA remission. The proportions of participants who had persistent suicidal ideation even with HAMD remission or response were 0.25 and 0.34, respectively.

LIMITATIONS

This study was observational, and the treatment modality was naturalistic.

CONCLUSIONS

A considerable number of patients had persistent suicidal ideation despite 12 weeks of antidepressant treatment. Close monitoring for suicidal ideation may be needed beyond the initial weeks of treatment and even after a response to antidepressants is observed.

Does comorbid subthreshold anxiety predict treatment response in depression? Results from a naturalistic cohort study (the CRESCEND study)

OBJECTIVE

To investigate whether the anxious depression defined as depression with clinically significant anxiety but not comorbid anxiety disorder predicts poor outcomes of depression treatment in naturalistic clinical setting.

METHOD

From nationwide sample of 18 hospitals, 674 patients with moderate to severe depression who completed the DSM-IV-based Structured Clinical Interview (SCID) were recruited. Anxious depression was defined as not having comorbid anxiety disorder by SCID and having a Hamilton Rating Scale for Anxiety (HAM-A) total score ≥ 20. Participants were classified into three groups: anxious depression (N=259), non-anxious depression (N=351), or comorbid anxiety disorder (N=64). Rates of and time to remission and response and changes in scale scores were compared between these groups during 12 weeks treatment with antidepressant interventions freely determined by clinicians.

RESULTS

No significant differences were observed in the Hamilton Rating Scale for Depression (HAM-D) remission rate and the time to achieve HAM-D remission between anxious and non-anxious depression after adjustment for variables is not equally distributed at baseline. There were also no significant differences in HAM-D and HAM-A response rate and time to responses between two groups. Patients with comorbid anxiety disorder showed less improvement on HAM-D and HAM-A score than did those with anxious depression despite similar baseline symptom severity.

LIMITATION

This study was observational, and the treatment modality was naturalistic.

CONCLUSIONS

Anxious depression did not predict worse outcome to antidepressants treatment. This finding might result from exclusion of comorbid anxiety disorder from anxious depression population and allowance of broad treatment modality.

Prevalence and Clinical Correlates of Insomnia in Depressive Disorders: The CRESCEND Study

OBJECTIVE

To investigate the prevalence, clinical manifestations, and clinical correlates of insomnia in a large cohort of Korean patients with depressive disorders.

METHODS

We recruited 944 patients with depressive disorders from the Clinical Research Center for Depression of South Korea (CRESCEND) study. Psychometric scales were used to assess depression (HAMD), anxiety (HAMA), psychotic symptoms (BPRS), global severity (CGI-S), and functioning (SOFAS). Insomnia levels were determined by adding the scores for all items on the HAMD insomnia subscale. The clinical characteristics of the patients with 'low insomnia' (summed score ≤3 on the HAMD subscale) and 'high insomnia' (score ≥4) were compared using statistical analyses. A logistic regression model was constructed to identify factors associated with 'high insomnia' status.

RESULTS

Symptoms of insomnia were present in 93% of patients, while simultaneous early, middle, and late insomnia affected 64.1%. The high insomnia patients were characterized by significantly greater age, higher symptom levels (including core, gastrointestinal somatic and anxiety symptoms, and suicidal ideation), higher global severity and incidence of physical disorders, and greater insight. Explanatory factors of 'high insomnia' status were older age, higher gastrointestinal somatic and anxiety symptom levels, higher global severity, and greater insight.

CONCLUSION

In clinical psychiatry, insomnia has been significantly underdiagnosed and undertreated. It affects most patients with depressive disorders, and is indicative of the global severity of depression. Active efforts to diagnose and treat insomnia in patients with depressive disorders should be strongly encouraged. Further research is needed to improve the diagnosis and treatment of insomnia in depressive patients.

Impact of childhood adversity on the course and suicidality of depressive disorders: the CRESCEND study

OBJECTIVE

The impact of childhood adversity persists across the life course. This study aimed to investigate the associations of childhood adversity with the course, suicidality, and treatment outcomes of depressive disorders.

METHOD

A total of 919 people with depressive disorders were recruited. Childhood adversities (≤12 years old) were ascertained using a checklist, in sexual abuse, physical abuse by parents, and separation of parents. Various assessment scales were administered at baseline and over 12 weeks of antidepressants treatment.

RESULTS

All three forms of childhood adversity were associated with an increased likelihood of experiencing more current stressful events. Scores on the Beck Depression Inventory and Hamilton Anxiety Rating Scale were significantly higher in participants with a history of sexual abuse. Scores on the Beck Depression Inventory, Hamilton Depression Rating Scale, and Perceived Stress Scale were significantly higher, and scores on the WHO Quality of life instrument were significantly lower in participants with a history of physical abuse by parents. They were more likely to receive augmentation and combination treatment after the initial antidepressant treatment, whereas overall response rates to treatment did not differ. Scores on the Beck Scale for suicide ideation were significantly higher after treatment and/or at baseline in patients with sexual or physical abuse. Physical illness was more prevalent in individuals with physical abuse by parents or separation of parents.

CONCLUSIONS

Depressive patients with a history of childhood adversities had more severe and chronic forms of depression with high suicidality. More intensive treatment with particular clinical attention is indicated for this special population.

Association between FAT Gene and Schizophrenia in the Korean Population

OBJECTIVE

The aim of this study was to investigate the genetic association of the FAT gene with schizophrenia in the Korean population, as well as analyzing the association of FAT gene with clinical variables.

METHODS

Four variants within the FAT gene were investigated in 189 patients with schizophrenia and 119 healthy controls (rs2306987 A/C, rs2306990 T/C, rs2637777 G/T, and rs2304865 G/C).

RESULTS

Significant association at the rs273777 with schizophrenia was observed; however, rs2306987, rs2306990, and rs2304865 were not associated with schizophrenia. Haplotype analyses revealed that the haplotype A/T/T/G was associated with a significantly protective effect. Sliding window analysis (rs2637777 G/T and rs2304865 G/C) revealed the more common T/G haplotype, included in the A/T/T/G protective combination, showed a small protective effect, in particular the effect was due to the rs273777 T variant (minor allele).

CONCLUSION

The present finding suggests that FAT polymorphism may play a putative role in the susceptibility to schizophrenia in the Korean population. Further studies using a larger number of subjects should be performed to determine whether the FAT gene polymorphism may be truly involved in the development of schizophrenia.

Platelet count alterations associated with escitalopram, venlafaxine and bupropion in depressive patients

The objective of the present study was to evaluate changes in platelet counts on three different kinds of antidepressant. All subjects (n = 131) in their drug-naïve state had been diagnosed with depression. Escitalopram (n = 42), venlafaxine (n = 50) and bupropion (n = 39) were prescribed, and platelet count was measured before and after 1 month of treatment and compared. Decrease in platelet count on escitalopram was significant, while the others were not. These findings suggest that escitalopram may be associated with decreased platelet count, and bupropion is less likely to exert an influence on platelet count.

Do we need more than one antidepressant for patients with major depressive disorder?

According to currently existing treatment guidelines, when a single antidepressant medication is not working, the common next step treatment is to switch to another class of antidepressants or to add another one to the first therapeutic agent. With regard to this issue, combination therapy has been suggested to provide unexpected synergy for patients, resulting in more remission compared with switching strategies, although some debates are still ongoing. Recently, Rush and colleagues have investigated whether two antidepressant combination treatments should produce a higher remission rate in first-step acute-phase (12 weeks) and long-term (7 months) treatment compared with monotherpay. They failed to find any superiority of combination treatment over monotherapy in terms of efficacy and safety. The remission and response rates and most secondary outcomes were not different among treatment groups at 12 weeks and 7 months, while the mean number of worsening adverse events was higher for combination treatment (5.7) than for monotherapy (4.7) at 12 weeks. This article will discuss the clinical and further research implications in the context of the potential limitations and significance of this recent study.

The acute and long-term effectiveness of amisulpride in patients with schizophrenia: results of a 12-month open-label prospective follow-up study

OBJECTIVE

To compare the effectiveness of amisulpride in acute (up to 8 weeks) and maintenance (week 8 to 12 months) phases of a 12-month course of treatment in a heterogeneous group of patients with schizophrenia.

METHODS

We conducted a 12-month, open-label clinical trial with flexible doses of amisulpride among 129 Korean patients with schizophrenia. The Positive and Negative Symptom Scale (PANSS) and several other scales measuring efficacy and tolerability were analyzed during the acute and maintenance phases.

RESULTS

The completion rates were 78.3% by week 8 and 55.8% by month 12. Total PANSS scores and scores on the negative-symptom and general-symptom subscales improved significantly during both acute and maintenance periods, but scores on the positive-symptom subscale improved only during the acute phase. Improvement during both treatment phases was significant in all other scales except for the Drug Attitude Inventory. The negative-symptom and mixed-symptom groups showed significant improvement in the PANSS negative subscale, the Clinical Global Impression scale, and the Global Assessment of Functioning during the maintenance period. Hyperprolactinemia and related events were commonly reported.

CONCLUSIONS

This study demonstrated the significant effectiveness and a good safety profile of amisulpride for treating acute and 12-month phases of schizophrenia under natural conditions.

The Symptom Frequency Characteristics of the Hamilton Depression Rating Scale and Possible Symptom Clusters of Depressive Disorders in Korea: The CRESCEND Study

OBJECTIVE

This study analyzed the symptom frequencies of 17-item Hamilton Depression Rating Scale (HDRS-17) to understand the characteristics of each item and to propose the possible symptoms clusters.

METHODS

From psychiatric clinics of 18 Hospitals in Korea, 1,183 patients, diagnosed with major depressive disorder (psychotic or non-psychotic), dysthymia or depressive disorder not otherwise specified. according to DSM-IV criteria, participated in this study from January 2006 to August 2008. The frequencies of each item of HDRS-17 were analyzed according to sex and severity. In addition, we compared this study with a previous study performed in England by Hamilton and with two studies performed in Korea by Kim et al.

RESULTS

The frequencies of HDRS-17 items varied widely in this study, ranging from 95.8% in work and activities to 37.4% in loss of weight. But, depressed mood, psychic anxiety and work and activities items exhibited constant and higher frequency or rank regardless of study, the severity of depression or sex. Insomnia early, somatic gastrointestinal, genital symptoms and insight showed relatively constant but lower frequency or rank in disregard of studies or the clinical variables. Other symptoms had variable frequencies or ranks according to the variable clinical situations (culture, time, sex, severity of depression).

CONCLUSION

WE PROPOSE THREE CLUSTERS OF SYMPTOMS IN DEPRESSIVE DISORDERS: core symptoms cluster, an associated symptoms, and a situation-specific symptoms. We can use these possible symptom clusters of depression in simplifying diagnosis of depression, increasing diagnostic specificity in special situation and indexing disease severity.

The Association between Economic Status and Depressive Symptoms: An Individual and Community Level Approach

OBJECTIVE

The study was conducted to investigate the association between economic status and depressive symptoms by comparing the prevalence rates of depressive symptoms at community level and analyzing the possibility of depressive symptoms at individual level.

METHODS

A survey was conducted from November, 2006 to November, 2007 on 966 and 992 representative subjects recruited by stratified clustered sampling in two regions located in Seoul. We used a standardized questionnaire including the Center for Epidemiologic Studies-Depression and questions on the socioeconomic characteristics. The adjusted prevalence rates of depressive symptoms were compared at community level, and multiple logistic regression analysis was performed to determine the association between depressive symptoms and economic statuses at individual level among each region.

RESULTS

The adjusted prevalence of depressive symptoms was higher in the region with a high socioeconomic status (23.1%) than in the region with a lower economic status (16.6%)(p<0.001). However, logistic regression analysis of individual level revealed that a higher economic status was significantly associated with a lower possibility of depressive symptoms among the females in the low economic status region. This tendency was not observed among the males in both of the regions.

CONCLUSION

The association between economic status and depressive symptoms was found to be different when it was approached at community level or individual level. In addition, the association of two variables was different by gender at individual level. Further studies that consider the third mediators are needed to determine the association between the two variables.

Antidepressant prescribing patterns in Korea: results from the clinical research center for depression study

OBJECTIVE

This study aimed to investigate antidepressant prescribing patterns, including initial choice, switching and combining, and concomitant use of non-antidepressant agents, for depressive disorders in naturalistic clinical care settings in Korea.

METHODS

Patients with depressive disorder were recruited from both outpatient and inpatient settings in 18 hospitals from all over Korea. Treatment was performed in naturalistic patterns based on each clinician's decision. Data were collected on the prescription of antidepressants and concomitant agents from baseline to 12-week follow-up.

RESULTS

Selective serotonin reuptake inhibitors (SSRIs) were the most commonly prescribed initial antidepressant (48.9%), followed by newer dual-action antidepressants (45.8%). When an SSRI was the initial antidepressant, 46.2% of patients whose medication was changed were moved to newer dual-action antidepressants, and 67.4% of combination cases were combined with newer dual-action ones. When a newer dual-action antidepressant was the initial antidepressant, 70.6% of patients whose medication was changed were moved to SSRIs, and other antidepressants including tricyclic antidepressants were most commonly added for combination treatment (50% of combination cases). During the treatment period, 20.6% of antidepressants prescribed were augmented by non-antidepressant agents, and 75.1% were used concomitantly with anxiolytics or hypnotics. The most commonly used concomitant non-antidepressant agent was quetiapine.

CONCLUSION

The selection of antidepressants and the concomitant use of non-antidepressant agents are becoming increasingly diversified, and the results of this study reflect changes in the prescribing pattern in actual Korean practices.