Anxiety Hastened Depressive Recurrence in Bipolar Disorder :An Interim Analysis of Prospective Follow-Up Study

Objectives@#Despite growing attention to anxiety in bipolar disorder (BD), little research has assessed anxiety symptoms in the course of BD. The current prospective follow-up study examines the influence of subjectively and objectively measured anxiety symptoms on the course of BD. @*Methods@#A total of 49 patients with BD were followed-up prospectively for average of one year at an average of four months interval. The Korean version of the Beck Anxiety Inventory (K-BAI), the Hamilton Anxiety Rating Scale, heart rate variability (HRV) were used to measure anxiety subjectively, objectively and physiologically. Participants were divided into high and low anxiety groups based on their K-BAI scores. Kaplan-Meier survival analysis was performed to compare the recurrence of mood episode, suicide attempt, emergency room visit, and psychiatric hospitalization between two groups. Mediators were investigated with Cox proportional hazards models. @*Results@#Compared to the low anxiety group, the high anxiety group reported significantly higher impulsiveness (p = 0.016) and lower high frequency component on HRV (p = 0.007) after controlling for severity of BD. Regarding survival analysis, the high anxiety group showed hastened depressive episode recurrence (p = 0.048) and suicidal ideation was the mediator of the hazard ratio (HR) 1.089 (p = 0.029) in the Cox model. Moreover, the high anxiety group showed a tendency of accelerated suicide attempt (p = 0.12) and impulsivity was the risk factor of suicide attempt (HR = 1.089, p = 0.036). @*Conclusions@#This interim analysis of prospective study suggests that high anxiety level in BD may anticipate unfavorable course.Further studies are needed to understand the multifactorial mechanism of anxious bipolar patients.

A Recognition Survey by Psychiatry Residents Regarding the Quality of Psychotherapy Training and Psychotherapy Competencies in Korea / 신경정신의학

Objectives@#This study surveyed the quality of psychotherapy training and psychotherapy competencies during residency in Korea. @*Methods@#A questionnaire developed by The Committee of Residency Training of the Korean Neuropsychiatric Association was completed by fourth-year residents of Korean psychiatry (n=120). The questionnaire examined their demographic characteristics, their experience of clinical psychotherapy training, their degree of satisfaction in the quality of psychotherapy training, and self-rated competence regarding the six types of psychotherapies, including supportive psychotherapy, cognitive behavioral therapy, interpersonal psychotherapy, psychoanalytic psychotherapy, group psychotherapy, and family psychotherapy. @*Results@#The degree of satisfaction of the residents with the psychotherapy training was diverse among the types of psychotherapy and contents of training. Across all types of psychotherapies, the satisfaction levels of the quantity and quality of supervision education were low, except for psychoanalytic psychotherapy. Overall, more than 70% of residents were not satisfied with the theoretical education, clinical practice, and supervision education in three types of psychotherapies, including interpersonal psychotherapy, group psychotherapy, and family psychotherapy. A positive correlation was found between the degree of satisfaction with the quality of training experience and self-rated competence of psychotherapy. Specifically, the self-rated competence of psychotherapy was more highly correlated with the experience of clinical cases and supervision than theoretical education @*Conclusion@#This study showed the quantitative and qualitative status of psychotherapy training in Korean psychiatry residency programs, and the satisfaction level of psychotherapy education was low except for psychoanalytic psychotherapy. There is a strong need for the improvement of psychotherapy training programs in Korea.

Anxiety Hastened Depressive Recurrence in Bipolar Disorder :An Interim Analysis of Prospective Follow-Up Study

Objectives@#Despite growing attention to anxiety in bipolar disorder (BD), little research has assessed anxiety symptoms in the course of BD. The current prospective follow-up study examines the influence of subjectively and objectively measured anxiety symptoms on the course of BD. @*Methods@#A total of 49 patients with BD were followed-up prospectively for average of one year at an average of four months interval. The Korean version of the Beck Anxiety Inventory (K-BAI), the Hamilton Anxiety Rating Scale, heart rate variability (HRV) were used to measure anxiety subjectively, objectively and physiologically. Participants were divided into high and low anxiety groups based on their K-BAI scores. Kaplan-Meier survival analysis was performed to compare the recurrence of mood episode, suicide attempt, emergency room visit, and psychiatric hospitalization between two groups. Mediators were investigated with Cox proportional hazards models. @*Results@#Compared to the low anxiety group, the high anxiety group reported significantly higher impulsiveness (p = 0.016) and lower high frequency component on HRV (p = 0.007) after controlling for severity of BD. Regarding survival analysis, the high anxiety group showed hastened depressive episode recurrence (p = 0.048) and suicidal ideation was the mediator of the hazard ratio (HR) 1.089 (p = 0.029) in the Cox model. Moreover, the high anxiety group showed a tendency of accelerated suicide attempt (p = 0.12) and impulsivity was the risk factor of suicide attempt (HR = 1.089, p = 0.036). @*Conclusions@#This interim analysis of prospective study suggests that high anxiety level in BD may anticipate unfavorable course.Further studies are needed to understand the multifactorial mechanism of anxious bipolar patients.

A Recognition Survey by Psychiatry Residents Regarding the Quality of Psychotherapy Training and Psychotherapy Competencies in Korea / 신경정신의학

Objectives@#This study surveyed the quality of psychotherapy training and psychotherapy competencies during residency in Korea. @*Methods@#A questionnaire developed by The Committee of Residency Training of the Korean Neuropsychiatric Association was completed by fourth-year residents of Korean psychiatry (n=120). The questionnaire examined their demographic characteristics, their experience of clinical psychotherapy training, their degree of satisfaction in the quality of psychotherapy training, and self-rated competence regarding the six types of psychotherapies, including supportive psychotherapy, cognitive behavioral therapy, interpersonal psychotherapy, psychoanalytic psychotherapy, group psychotherapy, and family psychotherapy. @*Results@#The degree of satisfaction of the residents with the psychotherapy training was diverse among the types of psychotherapy and contents of training. Across all types of psychotherapies, the satisfaction levels of the quantity and quality of supervision education were low, except for psychoanalytic psychotherapy. Overall, more than 70% of residents were not satisfied with the theoretical education, clinical practice, and supervision education in three types of psychotherapies, including interpersonal psychotherapy, group psychotherapy, and family psychotherapy. A positive correlation was found between the degree of satisfaction with the quality of training experience and self-rated competence of psychotherapy. Specifically, the self-rated competence of psychotherapy was more highly correlated with the experience of clinical cases and supervision than theoretical education @*Conclusion@#This study showed the quantitative and qualitative status of psychotherapy training in Korean psychiatry residency programs, and the satisfaction level of psychotherapy education was low except for psychoanalytic psychotherapy. There is a strong need for the improvement of psychotherapy training programs in Korea.

Cortical Volumetric Correlates of Childhood Trauma, Anxiety, and Impulsivity in Bipolar Disorder

Objective@#More recently, attention has turned to the linkage between childhood trauma and emotional dysregulation, but the evidence in bipolar disorder (BD) is limited. To determine neurobiological relationships between childhood trauma, current anxiety, and impulsivity, we investigated cortical volumetric correlates of these clinical factors in BD. @*Methods@#We studied 36 patients with DSM-5 BD and 29 healthy controls. Childhood trauma, coexisting anxiety, and impulsivity were evaluated with the Korean version-Childhood Trauma Questionnaire (CTQ), the Korean version-Beck Anxiety Inventory (BAI), and the Korean version-Barratt Impulsiveness Scale (BIS). Voxel-based morphometry (VBM) was used to assess gray matter volume (GMV) alterations on the brain magnetic resonance imaging (MRI). Partial correlation analyses were conducted to examine associations between the GMV and each scale in the BD group. @*Results@#Childhood trauma, anxiety, and impulsivity were interrelated in BD. BD patients revealed significant inverse correlations between the GMV in the right precentral gyrus and CTQ scores (r=-0.609, p<0.0003); between the GMV in the left middle frontal gyrus and BAI scores (r=-0.363, p=0.044). Moreover, patients showed similar tendency of negative correlations between the GMV in the right precentral gyrus and BIS scores; between the GMV in the left middle frontal gyrus and CTQ scores. @*Conclusion@#The present study provides evidence for a neural basis between childhood trauma and affect regulations in BD. The GMV alterations in multiple frontal lobe areas may represent neurobiological markers for anticipating the course of BD.

Developing and Clinical Application of a Smartphone Mobile Mood Chart Application in Korean for Patients with Bipolar Disorder / 신경정신의학

OBJECTIVES: The aim of this study was to develop a Korean version of a mood chart application on an Android platform. METHODS: This application is based on the traditional mood chart. Eighteen adults with DSM-5 bipolar disorder were enrolled from November 2016 to March 2017. They were asked to rate their daily mood scores and severity of irritability and impulsivity for six months. Their clinicians rated their symptom severity monthly using the Clinical Global Impression-7 (CGI-7) scale. After six months, the participants completed an anonymous questionnaire regarding their satisfaction with the application. RESULTS: Of the 18 patients, one withdrew their consent from this study and six were males (35.3%) ; their mean age was 31.71±8.56 years. The mean follow-up duration was 159.12±49.45 days and the period of application use was 143.65±52.11 days. The mean total response rate was 59.45% and the mean response rate on the same day was 43.06%. The adherence to using the application decreased significantly declined over the duration since enrollment [odds ratio (OR)=1.008, p=0.008] but tended to increase according to age (OR=0.958, p=0.002). The application mood scores were correlated significantly with the manic (β=0.307, p=0.004) and depressive (β=−0.701, p < 0.001) subscale, and the total (β=1.026, p=0.002) of the CGI-7 (linear mixed models). The majority of subjects agreed that the application helped them manage their symptoms (92.86%), stating that the application was easy to use (78.57%). CONCLUSION: This application could be a valid and useful tool to monitor the mood symptoms of patients with bipolar disorder in Korea.

Prescription Pattern of Antidepressants for Children and Adolescents in Korea Based on Nationwide Data

Antidepressant prescription for youths has recently been on the increase. There is a growing concern over the increasing off-label usage of antidepressants. Current data on off-label antidepressant usage vary across countries and healthcare systems. Therefore, we examined the extent and pattern of antidepressant prescription for Korean children and adolescents using population-based data. Our data was retrieved from the Korean National Health Insurance Service National Sample Cohort of the year 2013. Among 0.2 million children and adolescents aged 6–18 years from the cohort, subjects who had received any antidepressant medication in the year 2013 were investigated for the prescribed medication, concomitant psychotropic medication, and the associated diagnosis. A total of 2,190 children and adolescents (boys, 55.4%) received antidepressant medication. The most common diagnosis was depressive disorders (n = 469, 21.4%), followed by attention-deficit/hyperactivity disorder (n = 442, 20.2%). Among the prescriptions (n = 3,370), escitalopram (n = 650, 24.1%) and fluoxetine (n = 553, 20.5%) were the two most frequently prescribed drugs. A majority of prescriptions (n = 2,039, 60.5%) included concomitant psychotropic agents, consisting of antipsychotics (n = 901, 26.7%), sedatives (n = 263, 26.3%), medication for attention-deficit/hyperactivity disorder (n = 822, 24.4%), and some others. Our study shows the prescription pattern of antidepressants for children and adolescents in Korea, of which a large proportion is off-label. The results call for close monitoring by clinicians treating this population.

A Case of Catatonia Later Diagnosed with NMDA Receptor Encephalitis / 대한정신분열병학회지

We report a case of a young female patient with catatonic features who later turned out to be suffering from an anti-NMDA (N-methyl-D-aspartate)-receptor-antibody encephalitis. A previously healthy 21-year-old woman was admitted to psychiatric inpatient care presenting with acute psychotic behavior with catatonic features. Laboratory tests of serum and CSF (Cerebrospinal fluid), EEG (Electroencephalogram), brain MRI (Magnetic Resonance Imaging) were unremarkable except vague slow wave on EEG. However, subtle cognitive impairment at the bedside examination suggested further imaging studies to rule out possible organic etiology like autoimmune encephalitis. Brain PET (Positron Emission Tomography) and SPECT (Single Photon Emission Computed Tomography) suggested probable inflammation in the brain. In case of autoimmune encephalitis, given the severity of symptoms and worsening course, steroid pulse therapy was initiated promptly even though the diagnosis was not confirmed but presumed at that time. She recovered completely with steroid therapy. Later her disease turned out to be anti-NMDA-receptor-antibody encephalitis by the antibody test which was not available at the time of admission. Psychiatrists need to be aware of autoimmune encephalitis like anti-NMDA-receptor-antibody encephalitis in the differential diagnosis of acute psychosis with catatonic features. Subtle cognitive impairment which tends to be overlooked due to catatonic features might be a clue to suspect the organic etiology.

Validation of a Video Based Scale for Measuring Social Cognition in Schizophrenia / 신경정신의학

OBJECTIVES: Social cognition plays an important role in psychiatric symptoms and prognosis in patients with schizophrenia. Diagnostic scales are predominantly text-based or intended for the evaluation of theoretical concepts, with limited usefulness in clinical settings. We therefore developed a video based social cognition scale. METHODS: Our scale consists of 20 video clips portraying frequently experienced social interactions in real life. Patients were asked which interactions were socially unnatural and the reasons for lies told by actors. Our scale was validated and social cognition and its relationship with symptoms was evaluated using item response theory. RESULTS: A total of 209 participants (schizophrenia, 101 ; bipolar disorder, 49 ; healthy controls 59) were enrolled. Our scale showed high reliability and concurrent validity compared with the order subtest of the short form of the Weschler Adult Intelligence scale. Internal validity also was high (Cronbach's alpha=0.904). Most items were easy to answer and highly discriminative. The test information curve showed our scale to be more informative in patients with low social cognition ability. CONCLUSION: Our scale may aid in the study of pathology and social cognition deficits in patients with schizophrenia.

Effectiveness and Safety of Electroconvulsive Therapy in Clinical Practice / 신경정신의학

OBJECTIVES: There is little research on the practice and effectiveness of electroconvulsive therapy (ECT) in Korea. This study investigated the practice pattern, effectiveness, and safety of ECT. METHODS: This chart review study included electronic medical records of 180 patients treated with ECT between January 2007 and December 2013 at the Asan Medical Center. Symptomatic improvement was assessed using Clinical Global Impression (CGI) scale. Treatment response was defined as CGI improvement scale score of 2 or less. Re-hospitalization was used as an indicator of recurrence. Safety was assessed by spontaneous reports from patients. RESULTS: One hundred and eighty patients underwent 1539 sessions of modified ECT. Their most frequent diagnosis was major depressive disorder (n=74, 41.1%). The most common indication for ECT was poor response to medication (n=177, 75.3%). Treatment response rate was 66.9% in acute phase group and 63.8% in the patients with poor response to medication. The recurrence rate at six months after the end of the course was 29.6%. Memory impairment or amnesia was the most common adverse effect. CONCLUSION: There was a remarkable improvement following ECT in patients who responded poorly to medications, and most adverse effects were tolerable and temporary. The present study suggests that ECT could be a useful treatment option.

Gender Difference in the Prodromal Symptoms of First-episode Schizophrenia

To investigate the gender difference of early symptoms appearing before the onset of the psychotic symptoms in patients with first-episode schizophrenia, we reviewed the medical records of 63 patients (38 males, 25 females), who were hospitalized for first-episode schizophrenia. The frequency and duration of prodromal and psychotic symptoms, Clinical Global Impression scale scores, Global Assessment of Functioning (GAF) scale scores at admission, and other clinical characteristics were recorded for all patients. Overall, the most common prodromal symptoms were attenuated positive symptoms (89%), followed by mood symptoms (86%). Negative symptoms were the most common in male patients (97.4%), whereas attenuated positive symptoms were the most common in female patients (84%). Male patients demonstrated more frequent negative, cognitive, and obsessive-compulsive symptoms than female patients did and also showed a tendency of having negative symptoms for the longer period. Correlational analysis showed a significant negative correlation between the duration of negative symptoms and GAF scores at admission in male patients. Our findings suggest that different patterns of prodromal symptoms between male and female begin before the onset of the psychosis. Further prospective studies should be needed.

Thalamic Volume in Schizophrenia Patients, Subjects at Ultra-High Risk for Psychosis and Controls / 신경정신의학

OBJECTIVES: To investigate the changes in thalamic volumes in subjects at ultra-high risk (UHR) for psychosis. Subjects manifest changes which are similar to but different from those found in subjects with schizophrenia, and thalamic structural changes were often reported in schizophrenic subjects. METHODS: Thalamic volumes of 29 UHR subjects, 31 subjects with schizophrenia and 29 healthy controls, were measured from their T1-weighted coronal magnetic resonance (MR) images using manual tracing. RESULTS: UHR subjects showed greater right (6.243+/-0.848 cm3) and total (12.254+/-1.532 cm3) thalamic volumes compared to healthy control subjects (right thalamic volume=5.527+/-0.715 cm3, total thalamic volume=11.058+/-1.490 cm3) or patients with schizophrenia (right thalamic volume=5.855+/-0.938 cm3, total thalamic volume=11.513+/-1.784 cm3). The difference was significant for right (F=5.837, p=0.004) and total (F=4.217, p=0.018) thalamic volumes after intracranial volume had been accounted for as a covariate in ANCOVA. However, thalamic volume of subjects with schizophrenia showed no significant difference from controls. This difference was not affected by the presence of major depressive disorder or the magnitude of psychotic symptoms. Those among the UHR subjects taking antipsychotic agents did not show enlarged thalamic volume compared to controls. CONCLUSION: Our findings suggest that the possibility of a volumetric alteration of the thalamus characteristic of the UHR state.