Country variations in depressive symptoms profile in Asian countries: Findings of the Research on Asia Psychotropic Prescription (REAP) studies.

INTRODUCTION: This study was to assess differences in the symptom profile of depressive illness across various countries/territories in Asia. The study was a part of the Research on Asia Psychotropic Prescription project. The participating countries/territories include China, Hong Kong, India, Indonesia, Japan, Korea, Malaysia, Singapore, Taiwan, and Thailand. METHODS: The pattern of depressive symptoms in 1,400 subjects with depressive disorder from 42 psychiatric centers in 10 Asian countries/territories was assessed. We collected information on socio-demographic and clinical characteristics with a standardized protocol and data collection procedure. RESULTS: The most common presentations of depressive symptoms were persistent sadness, loss of interest, and insomnia. Similar findings were found regardless of the region, country, or its income level. Patients with depressive disorder from high-income countries presented significantly more with vegetative symptom cluster (P < 0.05), while those from the upper middle-income countries had significantly more with both mood (P < 0.001) and cognitive symptom clusters (P < 0.01). In lower middle-income countries, patients with depressive symptoms had significantly less mood symptom cluster (P < 0.001) but significantly more cognitive symptom cluster (P < 0.05). DISCUSSION: This study demonstrates that in Asia, despite variations in the initial symptom reported by the patients, across different countries/territories, core depressive symptoms remain the same. Variations have been found in presentation of depressive symptoms with regards to the level of income of countries. Physical or vegetative symptoms were reported more by centers in higher income countries, while depressive cognition and suicidal thoughts/acts were more frequently reported from lower income countries.

Are reports of cognitive testing among older electroconvulsive therapy recipients clinically valid?

OBJECTIVES: Electroconvulsive therapy (ECT) administration rises in frequency with age, with older depressed adults often showing clinical features predictive of good response. Recent reviews suggest that older people experience few if any long-term cognitive adverse effects after contemporary ECT, despite their increased vulnerability to these. However, the broader clinical validity of research findings is not assured as most studies of ECT-related cognitive effects do not discuss cognitive test nonparticipants. This study examines whether cognitive test participants and nonparticipants are comparable. METHODS: We recently completed a study of cognition in depressed patients 65 years and older treated with ECT. Only 35% of eligible patients completed neuropsychological testing at 2 time points, the remainder either refusing or unable to consent. To examine whether exclusion of most eligible patients from cognitive testing might have affected the clinical applicability of findings, we compared demographic and clinical characteristics of patients who participated with those who did not based on a subset of patients from our original study. RESULTS: The 2 patient groups differed in several respects. Most notably, nonparticipants were significantly more likely to be involuntary patients; to refuse food and fluids; and to require treatment with a bitemporal or mixed electrode placement. CONCLUSIONS: Our findings suggest cognitive test nonparticipants to be more severely psychiatrically unwell than test participants. As their exclusion might bias results and confound understanding of this important ECT-related topic, special mention of participation rates and comparison of participants and nonparticipants is recommended to establish the clinical relevance of future study findings.

The change in electrical energy delivered to aged patients over a course of moderate dose unilateral electroconvulsive therapy.

BACKGROUND: To prove effective, the electrical energy delivered as part of unilateral electroconvulsive therapy (ECT) must exceed the seizure threshold. Although high dose treatment (six times the threshold) is most effective, it results in more cognitive deficits to which aged patients are especially vulnerable. As a compromise, Australian psychogeriatricians often prescribe moderate dose (three times the threshold) treatment. However, older patients' thresholds sometimes rise steeply as treatment progresses. If energy levels are kept low to make treatment safer, the result might be that patients' recovery is delayed. We report here on changes in prescribed energy over a course of six unilateral treatments. METHODS: A retrospective review of data collected routinely on 42 depressed patients aged ≥ 65 years given moderate dose unilateral ECT in five aged psychiatry services in Victoria, Australia. RESULTS: Prescribed energy rose with time, but only 31% of patients reached high dose levels by their sixth treatment. CONCLUSIONS: We cannot comment on the safety or effectiveness of moderate dose ECT. We focus instead just on changes in prescribed energy levels. These did not rise quickly in most cases, suggesting that moderate dose ECT cannot be dismissed as a treatment option simply because of the rate of change in electrical stimulation.

The safety and tolerability of clozapine in aged patients: a retrospective clinical file review.

OBJECTIVES: A clinical file review was conducted of clozapine use in three aged psychiatry services in Melbourne, Australia, to compare its safety and tolerability with findings reported in the literature. METHODS: The review period spanned the intervals from 2008 to the services' origins between 11 and 15 years earlier. The files of all patients treated with clozapine during this period were checked with respect to adverse effects and the reasons for ceasing treatment. RESULTS: Clozapine was prescribed to 75 patients (mean age 74.2 years, range 65-89) with doses ranging from 25-800 mg daily (mean 296 mg). Treatment was stopped within the review period in 37 (49%) cases. Reasons for discontinuation included death (n=14), non-fatal adverse events (n=12), patient choice (n=8) and other factors (n=3). While none of the 14 deaths could be linked directly to treatment, orthostatic hypotension might have contributed to a single fatal cerebrovascular accident. There were three cases of "red alert" leukopenia, none of which progressed to agranulocytosis. In general, side effects were more frequent than in a previous report concerning aged patients, most probably because clozapine doses were higher. CONCLUSIONS; Most of the adverse events leading to treatment cessation occurred within the first month, emphasising the need for slow titration. Strict monitoring procedures ensured that there were no fatal haematological adverse events.