The prevalence and economic burden of treatment-resistant depression in Thailand.

BACKGROUND: The objectives of this study were to investigate the proportion of treatment-resistant depression (TRD) among patients with diagnosed major depressive disorder (MDD) and undergoing antidepressant treatment, to estimate the economic cost of MDD, TRD, and non-treatment-resistant depression (non-TRD), and to examine the differences between TRD and non-TRD MDD in a Thai public tertiary hospital. METHODS: This was a combined study between retrospective review of medical records and a cross-sectional survey. The sample size was 500 dyads of antidepressant-treated MDD patients and their unpaid caregivers. MDD patients' medical records, the concept of healthcare resource utilization, the Work Productivity and Activity Impairment Questionnaire: depression and mood & mental state versions (WPAI: D, MM), the Class Impairment Questionnaire (CIQ), and the Family Experiences Interview Schedule (FEIS) were applied as the tools of the study. Pearson Chi's square, Fisher's Exact test, and independent T-test were employed for statistical analysis. RESULTS: The proportion of TRD was 19.6% among antidepressant-treated MDD patients in a Thai tertiary public hospital. The results of the study indicated that several factors showed a statistically significant association with TRD criteria. These factors included younger age of MDD patients, a younger age of onset of MDD, lower body mass index (BMI), a history of suicide attempts and self-harm, as well as frequent smoking behavior. The annualized economic cost of TRD was 276,059.97 baht per person ($7,668.33), which was significantly higher than that of cost of non-TRD (173,487.04 baht or $4,819.08). The aggregated economic costs of MDD were 96.8 million baht annually ($2.69 M) if calculated from 500 MDD patients and unpaid caregivers. This contributed to the economic cost of TRD 27.05 million baht (98 respondents) and the economic cost of non-TRD 69.74 million baht (402 respondents). CONCLUSIONS: The economic burden associated with TRD was significantly higher compared to non-TRD among antidepressant-treated MDD patients. Specifically, both direct medical costs and indirect costs were notably elevated in the TRD group.

Effect of behavioral activation on time and frequency domain heart rate variability in older adults with subthreshold depression: a cluster randomized controlled trial in Thailand.

BACKGROUND: Increased prevalence of depression highlights the need for effective interventions. Behavioral activation (BA), which can easily be adapted for non-clinical populations, has been the recommended treatment for depression. It is based on a model of psychopathology explaining that losses or chronically low levels of positive reinforcement yield behavioral and emotional changes in depression and that encouraging individuals to increase their engagement in reinforcing activities can improve their mood and enhance their valuable life experiences. Heart rate variability (HRV) provides indices of autonomic function related to depression, but only a few studies have investigated the effect of BA on HRV, particularly among older adults with subthreshold depression. Accordingly, we aimed to investigate the effect of BA on HRV in older adults with subthreshold depression. METHODS: We conducted a 9-month cluster randomized controlled trial in two Health Promoting Hospitals (HPHs). Eighty-two participants were randomized into either intervention (BA with usual care) or control (usual care only) groups, with 41 participants per group. Daily step count was collected weekly during the 12-week BA intervention period, while HRV parameters, including the Standard Deviation of the Normal-to-Normal interval (SDNN), High Frequency (lnHF), Low Frequency (LF), and Low Frequency/High Frequency ratio (LF/HF), were examined at 0, 3, 6 and 9 months. Generalized Estimating Equations (GEEs) were used in the data analysis. RESULTS: Over nine months, the intervention and control groups differed significantly in the unadjusted mean change of HRV, SDNN [7.59 ms (95% CI: 1.67, 13.50)], lnHF [0.44 ms2 (95% CI: 0.04, 0.85)], and LF [0.53 ms2 (95% CI: 0.09, 0.98)], whereas the groups did not differ significantly in LF/HF ratio [0.01 ms2 (95% CI: -0.04, 0.06)]. CONCLUSION: Our results suggest that BA may have a therapeutic effect on depression symptoms of older adults with subthreshold depression via improved HRV. TRIAL REGISTRATION: TCTR20211019003 , thaiclinicaltrials.org, retrospectively registered on 19 October 2021.

Effectiveness of Behavioral Activation in Treating Thai Older Adults with Subthreshold Depression Residing in the Community.

BACKGROUND: In recent years, behavioral activation (BA) has attracted increased interest as an effective depression treatment. However, empirical evidence supporting its effectiveness in non-Western countries is currently limited. OBJECTIVE: To examine the effectiveness of BA in reducing depressive symptoms, stress, and anxiety among Thai older adults with subthreshold depression. METHODS AND SUBJECTS: A clustered randomized controlled trial was conducted in two health promoting hospitals (HPHs) in the Samut Songkhram province of Thailand. One hospital was used for the intervention (BA+usual care group) and the other for the control (usual care-only group). Each HPH randomly selected 41 eligible older adults residing in their jurisdictions to take part in the study. Mental health outcomes were assessed using the Thai Geriatric Depression Scale (TGDS) and Depression Anxiety Stress Scales (DASS). The BA effectiveness was evaluated using generalized estimating equations (GEE) at a group level and the reliable change index (RCI) at the individual level. RESULTS: Over 9 months, the adjusted mean change in depression (TGDS) scores [-2.47 (95% CI: -3.84, -1.00)], mental health status (DASS), specifically depression and stress score [-1.47 and -1.87 (95% CI: -2.43, -0.50 and -2.94, -0.79, respectively)], improved significantly in the BA+usual care group compared to the usual care-only group, whereas anxiety score improved significantly only at 6 months [-0.87 (95% CI: -1.52, -0.23)]. Additional RCI analysis showed that BA was directly associated with 14.63 to 24.39% points increase in the reliable improvement of depressive outcome compared to the usual care-only group. CONCLUSION: This study showed that the BA effectively improved depression, stress, and anxiety in older adults with subthreshold depression in a Thai community setting. Future research should evaluate the longer-term effectiveness of BA in diverse population groups.

Randomized Controlled Trial of Group Cognitive Behavioural Therapy for Post-Traumatic Stress Disorder in Children and Adolescents Exposed to Tsunami in Thailand.

BACKGROUND: Post-traumatic stress disorder (PTSD) is a common and debilitating consequence of natural disaster in children and adolescents. Accumulating data show that cognitive behavioural therapy (CBT) is an effective treatment for PTSD. However, application of CBT in a large-scale disaster in a setting with limited resources, such as when the tsunami hit several Asian countries in 2004, poses a major problem. AIMS: This randomized controlled trial aimed to test for the efficacy of the modified version of CBT for children and adolescents with PSTD. METHOD: Thirty-six children (aged 10-15 years) who had been diagnosed with PSTD 4 years after the tsunami were randomly allocated to either CBT or wait list. CBT was delivered in 3-day, 2-hour-daily, group format followed by 1-month posttreatment self-monitoring and daily homework. RESULTS: Compared to the wait list, participants who received CBT demonstrated significantly greater improvement in symptoms of PTSD at 1-month follow-up, although no significant improvement was observed when the measures were done immediately posttreatment. CONCLUSIONS: Brief, group CBT is an effective treatment for PTSD in children and adolescents when delivered in conjunction with posttreatment self-monitoring and daily homework.

Association of adolescent substance use: behavioral problems and family background among school students in Tsunami affected area in southern Thailand.

OBJECTIVE: To study the prevalence of substance use and associated factors in school students in Tsunami affected areas in southern Thailand. MATERIAL AND METHOD: The study was a school-based, cross-sectional, anonymous survey that used a translated questionnaire, ESPAD-03, in 5 schools. Chi-square tests and odds ratios were used to evaluate factors associated with substance use. RESULTS: Two thousand seven hundred and sixteen students (87.8%) were enrolled in the study. Lifetime, last 12 months, and last 30 days prevalence rates of any substance use were 50.3, 33.9, and 24.8%, respectively. Lifetime, last 12 months, and last 30 days prevalence rates of alcohol use were 43.2, 30.1, and 17.5%, respectively. Lifetime and last 30 days prevalence rates of smoking were 21.7 and 12.0%. Fighting, stealing, truancy, running away, unsafe sex, and thought of self-harming were associated with alcohol and substance use. Siblings and friends with alcohol and substance use were risk factors. Close support from parents and friends were protective factors. CONCLUSION: There was a high prevalence of smoking, alcohol, and substance use among school students in Tsunami affected areas. Behavioral problems and psychosocial risk factors were associated with history of smoking, alcohol and substance use. School-based intervention in students with behavioral problems seems to be a worthwhile investment. However, longitudinal studies should be done to confirm the correlation of PTSD and substance use.

Cinemeducation: A pilot student project using movies to help students learn medical professionalism.

BACKGROUND: Using movies has been accepted worldwide as a tool to help students learn medical professionalism. In the second year, a group of medical students conducted the "Cinemeducation" project to promote professionalism in the "Medical Ethics and Critical Thinking" course. METHOD: Five movies with professionalism issues were screened with 20-30 students attending each session. After the show, participants then were asked to reflect on what they had learned in terms of professionalism. Two students led group discussion emphasizing questioning and argumentation for 60 min. Additional learning issues emerging from each session were also explored in more depth and arranged into a report. RESULTS: In the Cinemeducation Project, medical students have learned five main ethical issues in each film, which were the doctor-patient relationship, informed consent and clinical trials in patients, management of genetic disorders, patient management, and brain death and organ transplantation. In addition to issues of professionalism, they also developed critical thinking and moral reasoning skills. CONCLUSION: Using a case-based scenario in movies has proven to be an effective and entertaining method of facilitating students with learning on professionalism.

Assessment of psychopathological consequences in children at 3 years after tsunami disaster.

BACKGROUND: At 1 year after the Tsunami disaster, 30% of students in two high risk schools at Takuapa district of Phang Nga Province still suffered from post traumatic stress disorder (PTSD). The number ofpatients was sharply declined after 18 months. The psychological consequences in children who diagnosed PTSD after the event were reinvestigated again at 3 years, as there were reports of significant comorbidity and continuing of subsyndromal post traumatic stress symptoms in children suffered from other disasters. OBJECTIVE: To assess psychological outcomes and factors contributed at 3-year follow up time in children diagnosed PTSD at 1-year after the Tsunami disaster MATERIAL AND METHOD: There were 45 students who were diagnosed PTSD at 1-year after the disaster At 3-year follow up time, clinical interview for psychiatric diagnosis was done by psychiatrists. RESULTS: 11.1% of students who had been diagnosed as PTSD at 1-year after Tsunami still had chronic PTSD and 15% had either depressive disorder or anxiety disorder 25% of students completely recovered from mental disorders. Nearly 50% ofstudents were categorized in partial remission or subsyndromal PTSD group. Factors which influenced long-term outcomes were prior history of trauma and severe physical injury from the disaster. CONCLUSION: Although the point prevalence of PTSD in children affected by Tsunami was declined overtime, a significant number of students still suffer from post traumatic stress symptoms, depressive disorder or anxiety disorder which need psychological intervention.

Cognitive-behavioral intervention for young tsunami victims.

OBJECTIVE: To evaluate the efficacy of the cognitive-behavioral intervention provided to children by volunteer professionals in a tsunami-hit area in Thailand. The intervention was aimed to prevent the severe development of post traumatic stress symptoms, and to help the children who might recover spontaneously to do so more quickly. MATERIAL AND METHOD: One hundred and sixty children in Ranong province voluntarily participated in 2-days group activities on the 57h day after the tsunami. The manualized intervention had been designed based on cognitive-behavioral model. Three domains of post traumatic stress reactions were targeted, intrusion, arousal, and avoidance. The Children's Impact of Events Scale (13) (CRIES-13) was completed by the participants before and 2 weeks after the intervention. RESULTS: The program was generally well understood by the children. No difference in CRIES scores was observed before and after the children entered the intervention program. However when the sample was categorized into two groups, the group that was more likely to develop PTSD showed a significant reduction in the scores, whereas a significant increase in the scores was evident in the other group. CONCLUSION: The findings supported the efficacy of cognitive-behavioral intervention in the children who were prone to develop PTSD. The program needed to be adapted to suit the religious, socio-economic, and cultural background of the sample. The unchanged Avoidance scores in the present study were possibly explained by the general feeling that a tsunami might happen again and the parental involvement. The increase of post-intervention scores in otherwise normal sample, though not exceeding the cut-off raised some concern, and possibly the need for screening before the intervention.

Advances in alternative pharmacotherapy of ADHD.

Several alternatives to psychostimulants have been developed and expanded the variability of the treatment of ADHD. Clonidine is a good option for managing core behavioral symptoms, especially hyperactivity and impulsivity. Bupropion and venlafaxine seem potentially promising. Significant new options include norepinephrine reuptake inhibitors, such as atomoxetine, and possibly selective dopamine agonists. Central anticholinesterases, such as donepezil, may improve core ADHD symptoms.