Validity of the Korean Version of the Brief Irritability Test in Psychiatric Patients.

OBJECTIVE: This study aimed to investigate the validity and reliability of the Korean version of the Brief Irritability Test (BITe) and adapt it for Korean patients with psychiatric disorders. METHODS: A total of 296 patients at the Department of Psychiatry of Hanyang University Guri Hospital completed the BITe, Korean Beck Depression Inventory-II, Korean Beck Anxiety Inventory, the Korean version of the State-Trait Anger Expression Inventory, and Barratt Impulsiveness Scale-11. Construct validity was confirmed through exploratory factor analysis (EFA) and confirmatory factor analysis (CFA). Reliability testing included assessments of internal consistency (Cronbach's α) and item-total correlations. Convergent validity was examined through correlational analyses with variables such as anxiety, depression, anger, and impulsivity. RESULTS: First, the scale had good internal consistency with a Cronbach's α of 0.88. Second, EFA indicated a single dimensionality of the BITe, and CFA demonstrated a reasonable fit for the single-factor model (comparative fit index=0.97, Tucker-Lewis Index=0.95, normed fit index=0.97, goodness-of-fit index=0.96, root mean square error of approximation=0.12, standardized root mean residual=0.03). Finally, the convergent validity analysis revealed a significant positive correlation with depression, anxiety, and anger, except for anger control, which is a sub-variable of anger. CONCLUSION: The results showed that the Korean version of the BITe had good psychometric properties, and might serve as a valuable tool for assessing irritability in Korean patients with psychiatric disorders.

Temperament and Character of High Suicide Risk Group Among Psychiatric Patients.

OBJECTIVE: The purpose of this study was to classify patients with suicidal tendencies into suicide attempts (SA), suicidal ideation (SI), and non-suicidal self-injury (NSSI) and to identify differences in temperaments and characters of the groups. It also aimed to identify difference between the groups and non-suicidal tendencies. METHODS: Using psychiatric diagnostic data of 195 patients, temperaments and characters were measured with the Temperament and Character Inventory, and the level of depression was measured with the Beck Depression Inventory. The subjects were classified into SA, SI, NSSI, psychiatric patients without suicidal tendencies (PP), and non-patient (Normal) groups, and multivariate analysis of variance and multinomial logistic regression were conducted. RESULTS: The NSSI group had higher novelty seeking compared to the SI group, while having higher harm avoidance, lower persistence, and lower self-directedness compared to the SA group. Furthermore, low persistence was a better predictor for the SA group between SA and NSSI groups, and low novelty seeking was found to be a better predictor for the SI group between the SI and NSSI groups. CONCLUSION: As a result, the group differences in temperaments and characters were found, which would be useful to identify patients with suicidal tendencies and provide appropriate interventions tailored to the temperaments and characters of each group.

Network analysis of psychiatric symptoms in schizophrenia: Findings from the Research on Asian Psychotropic Prescription Patterns for Antipsychotics (REAP-AP).

AIMS: Schizophrenia is a major mental disorder with a wide range of psychiatric symptoms. This study explored the structure of psychiatric symptoms of schizophrenia using network analysis in a large representative Asian sample based on a survey of clinical features and treatment used in schizophrenia patients across 15 countries/territories in Asia. METHODS: Data on the demographic characteristics and psychiatric symptoms in schizophrenia patients were extracted from the dataset of the fourth Research on Asia Psychotropic Prescription for Antipsychotics (REAP-AP) project. The presence of the following psychiatric symptoms including delusions, hallucinations, disorganized speech, grossly disorganized or catatonic behavior, negative symptoms, social/occupational dysfunction, verbal aggression, physical aggression, and affective symptoms were analyzed. RESULTS: A total of 3681 patients were included. The network analysis revealed that verbal aggression, hallucinations, and social/occupational dysfunction were the most central symptoms, while the connections between social/occupational dysfunction and verbal aggression, and between hallucinations and disorganized speech were the two strongest edges. There were significant gender differences in the network structure based on the network structure invariance test (M=0.74, P = 0.03) and invariant edge strength test. The positive correlation between verbal aggression and hallucinations was significantly stronger in the female network than that in the male network (P = 0.03), while a negative correlation between affective symptoms and negative symptoms was found in the female, but not the male network (P < 0.01). CONCLUSION: Central symptoms including verbal aggression, hallucinations, and socio-occupational dysfunction should be addressed in developing targeted treatment strategy for schizophrenia patients.

Coprescription of mood stabilizers in schizophrenia, dosing, and clinical correlates: An international study.

OBJECTIVE: Studies examining coprescription and dosages of mood stabilizers (MSs) with antipsychotics for psychotic disorders are infrequent. Based on sparse extant data and clinical experience, we hypothesized that adjunctive MS use would be associated with certain demographic (e.g., younger age), clinical factors (e.g., longer illness duration), and characteristics of antipsychotic treatment (e.g., multiple or high antipsychotic doses). METHODS: Within an Asian research consortium focusing on pharmaco-epidemiological factors in schizophrenia, we evaluated rates of MS coprescription, including high doses (>1000 mg/day lithium-equivalents) and clinical correlates. RESULTS: Among 3557 subjects diagnosed with schizophrenia in 14 Asian countries, MSs were coprescribed with antipsychotics in 13.6% (n = 485) of the sample, with 10.9% (n = 53) on a high dose. Adjunctive MS treatment was associated (all p < 0.005) with demographic (female sex and younger age), setting (country and hospitalization), illness (longer duration, more hospitalizations, non-remission of illness, behavioral disorganization, aggression, affective symptoms, and social-occupational dysfunction), and treatment-related factors (higher antipsychotic dose, multiple antipsychotics, higher body mass index, and greater sedation). Patients given high doses of MSs had a less favorable illness course, more behavioral disorganization, poorer functioning, and higher antipsychotic doses. CONCLUSIONS: Schizophrenia patients receiving adjunctive MS treatment in Asian psychiatric centers are more severely ill and less responsive to simpler treatment regimens.

Patterns of long acting injectable antipsychotic use and associated clinical factors in schizophrenia among 15 Asian countries and region.

INTRODUCTION: Patterns of clinical use of long-acting injectable (LAI) antipsychotic drugs in many countries, especially in Asia, for treatment of patients diagnosed with chronic psychotic disorders including schizophrenia are not well established. METHODS: Within an extensive research consortium, we evaluated prescription rates for first- (FGA) and second-generation antipsychotic (SGA) LAI drugs and their clinical correlates among 3557 subjects diagnosed with schizophrenia across 15 Asian countries and region. RESULTS: Overall, an average of 17.9% (638/3557; range: 0.0%-44.9%) of treated subjects were prescribed LAI antipsychotics. Those given LAI vs orally administered agents were significantly older, had multiple hospitalizations, received multiple antipsychotics more often, at 32.4% higher doses, were more likely to manifest disorganized behavior or aggression, had somewhat superior psychosocial functioning and less negative symptoms, but were more likely to be hospitalized, with higher BMI, and more tremor. Being prescribed an FGA vs SGA LAI agent was associated with male sex, aggression, disorganization, hospitalization, multiple antipsychotics, higher doses, with similar risks of adverse neurological or metabolic effects. Rates of use of LAI antipsychotic drugs to treat patients diagnosed with schizophrenia varied by more than 40-fold among Asian countries and given to an average of 17.9% of treated schizophrenia patients. We identified the differences in the clinical profiles and treatment characteristics of patients who were receiving FGA-LAI and SGA-LAI medications. DISCUSSION: These findings behoove clinicians to be mindful when evaluating patients' need to be on LAI antipsychotics amidst multifaceted considerations, especially downstream adverse events such as metabolic and extrapyramidal side effects.

Prescription of antipsychotic and concomitant medications for adult Asian schizophrenia patients: Findings of the 2016 Research on Asian Psychotropic Prescription Patterns (REAP) survey.

OBJECTIVE: Regular surveys are important to monitor the use of psychotropic medications in clinical practice. This study examined the psychotropic prescription patterns in adult Asian schizophrenia patients based on the data of the Research on Asian Psychotropic Prescription (REAP) 2016 survey. METHODS: This cross-sectional survey across 15 Asian countries/territories collected socio-demographic and clinical data with standardized procedures between March and May 2016. The socio-demographic and clinical characteristics of the patients were recorded with a standardized questionnaire. RESULTS: Altogether 3,537 adult patients with schizophrenia were consecutively screened and enrolled in the survey. The mean age was 38.66 ±â€¯11.55 years and 59.7% of the sample were male. The mean dose of antipsychotics in chlorpromazine equivalents (CPZeq) was 424 ±â€¯376 mg/day; 31.3% and 80.8% received first- and second- generation antipsychotics, respectively and 42.6% had antipsychotic polypharmacy, 11.7% had antidepressants, 13.7% had mood stabilizers, 27.8% had benzodiazepines, and 45.6% had anticholinergics. CONCLUSIONS: Psychotropic prescription patterns in Asian adult patients with schizophrenia varied across countries. Regular surveys on psychotropic medications for schizophrenia are important to monitor pharmacotherapy practice in Asia.

Polypharmacy and psychotropic drug loading in patients with schizophrenia in Asian countries: Fourth survey of Research on Asian Prescription Patterns on antipsychotics.

AIM: The aim of the present study was to survey the prevalence of antipsychotic polypharmacy and combined medication use across 15 Asian countries and areas in 2016. METHODS: By using the results from the fourth survey of Research on Asian Prescription Patterns on antipsychotics, the rates of polypharmacy and combined medication use in each country were analyzed. Daily medications prescribed for the treatment of inpatients or outpatients with schizophrenia, including antipsychotics, mood stabilizers, anxiolytics, hypnotics, and antiparkinson agents, were collected. Fifteen countries from Asia participated in this study. RESULTS: A total of 3744 patients' prescription forms were examined. The prescription patterns differed across these Asian countries, with the highest rate of polypharmacy noted in Vietnam (59.1%) and the lowest in Myanmar (22.0%). Furthermore, the combined use of other medications, expressed as highest and lowest rate, respectively, was as follows: mood stabilizers, China (35.0%) and Bangladesh (1.0%); antidepressants, South Korea (36.6%) and Bangladesh (0%); anxiolytics, Pakistan (55.7%) and Myanmar (8.5%); hypnotics, Japan (61.1%) and, equally, Myanmar (0%) and Sri Lanka (0%); and antiparkinson agents, Bangladesh (87.9%) and Vietnam (10.9%). The average psychotropic drug loading of all patients was 2.01 ± 1.64, with the highest and lowest loadings noted in Japan (4.13 ± 3.13) and Indonesia (1.16 ± 0.68), respectively. CONCLUSION: Differences in psychiatrist training as well as the civil culture and health insurance system of each country may have contributed to the differences in these rates. The concept of drug loading can be applied to other medical fields.

Serum Levels of Growth Factors in Alcohol-dependent Patients according to Comorbid Depressive Symptoms.

OBJECTIVE: This study aims to reveal the relationship of depression with growth factors such as brain-derived neurotrophic factor (BDNF), nerve growth factor (NGF), and insulin-like growth factor-1 (IGF-1) in inpatients diagnosed with alcohol dependence, and to identify candidate growth factors as biological markers to indicate the comorbid of alcohol dependence and depression. METHODS: This study examined demographic factors in 45 alcohol-dependent patients. The ADS (Korean version of the Alcohol Dependence Scale) and BDI (Korean version of Beck's Depression Inventory) were used. BDNF, NGF, and IGF-1 were measured through ELISA. RESULTS: The average drinking quantity and the ADS score were significantly more severe in alcohol-dependent patients with depression than in those without depression. Linearly comparing BDNF, NGF, and IGF-1 with BDI values, IGF-1 was the growth factor significantly correlated with BDI scores. BDI scores were significantly correlated with ADS scores. IGF-1 was significantly higher in alcohol-dependent patients with depression. Alcohol-dependent patients with depression had greater alcohol use and more severe ADS scores. BDNF and NGF showed no significant difference between alcohol-dependent patients with and without depression, but IGF-1 was significantly higher in those with than in those without depression. CONCLUSION: IGF-1 was found to be associated with depression in alcohol-dependent patients, suggesting that IGF-1 in alcohol- dependent patients could be an important biomarker to indicate whether alcohol-dependence is accompanied by depression.

Supplementation of n-3 Polyunsaturated Fatty Acids for Major Depressive Disorder: A Randomized, Double-Blind, 12-Week, Placebo-Controlled Trial in Korea.

BACKGROUND: Controversy over the efficacy of n-3 polyunsaturated fatty acids (PUFAs) in depression continues to this day. The present study investigated the hypothesis that n-3 PUFA supplementation reduces depressive symptoms in Korean patients with major depressive disorder. METHODS: In a randomized, double-blind, placebo-controlled, 12-week, parallel-group trial, 35 patients with Center for Epidemiological Studies Depression Scale Korean version (CES-D-K) scores ≥25 and depression confirmed by a psychiatrist were assigned to take either 3 capsules of n-3 PUFAs (1,140 mg of EPA + 600 mg of DHA; n = 18) or placebo (olive oil + safflower oil; n = 17). RESULTS: Supplementation with n-3 PUFAs significantly reduced Clinical Global Impression Improvement (CGI-I) scores as compared with intake of placebo using intention-to-treat analysis with last-observation-carried-forward after adjusting for energy, fat, and fish intake. However, the CES-D-K, Hamilton Depression Rating Scale-17, and Clinical Global Impression Scale scores did not significantly differ between the n-3 PUFA and placebo groups. After supplementation with n-3 PUFAs, the erythrocyte levels of n-3 PUFAs were significantly increased, but n-6 PUFA levels were decreased. CONCLUSIONS: n-3 PUFAs demonstrated an advantage over placebo that did not reach clinical significance, although CGI-I score was significantly decreased in the n-3 PUFA group as compared with the placebo group.

Evidence-based, pharmacological treatment guideline for depression in Korea, revised edition.

This paper aims to introduce, summarize, and emphasize the importance of the 'Evidence-Based, Pharmacological Treatment Guideline for Depression in Korea, Revised Edition'. The guideline broadly covers most aspects of the pharmacological treatment of patients in Korea diagnosed with moderate to severe major depression according to the DSM-IV TR. The guideline establishment process involved determining and answering a number of key questions, searching and selecting publications, evaluating recommendations, preparing guideline drafts, undergoing external expert reviews, and obtaining approval. A guideline adaptation process was conducted for the revised edition. The guideline strongly recommends pharmacological treatment considered appropriate to the current clinical situation in Korea, and should be considered helpful when selecting the appropriate pharmacological treatment of patients diagnosed with major depressive disorder. Therefore, the wide distribution of this guideline is recommended.

[Development of the scale of strategies for enhancing self-esteem among medical school students].

PURPOSE: From the point of view that medical students are under the pressure of academic achievement and vulnerable to subjective distress, there is need for evaluate their strategies for enhancing self-esteem when they failed academically. This study was to develop the scale for enhancing self-esteem and to confirm the convergent, discriminant and criteria validity. METHODS: Data were collected from 279 students at a medical school in Seoul. The scale of strategies for enhancing self-esteem (SSES) comprised comparison with inferior, doubting academic failure, accepting failure, and attribution to incidental factors. Also, to confirm the validities, participants responded to items measuring self-esteem, narcissism, 5 personality factors, depression and adjustment. RESULTS: By explanatory factor analysis of SSES, composed of three factors-comparison, doubting, and acceptance-and in the confirmatory factor analysis, 3 dimensions were best fit. Notably, comparison and doubting strategies were positively associated with depression and negatively associated with adjustment. In contrast, acceptance strategies were negatively associated with depression and positively associated with adjustment. Additionally, comparison and doubting strategies were positively associated with narcissism. CONCLUSION: The SSES of medical school students after academic failure yields 3 dimensions reliably and consistently. Also, it shows satisfactory convergent and concurrent validities.

[Predictors and longitudinal changes of depression and anxiety among medical college students].

PURPOSE: This longitudinal study was designed to examine the change in depression and anxiety and their predictors over 1 year among premedical and medical students. We compared depression and anxiety from 2 waves and determined the predictive power of personality, narcissism, social comparison, and social reward value on them. METHODS: Two hundred twenty-six students at a medical school in Seoul were divided into 4 groups according to academic year and completed a questionnaire at the end of 2010 and 2011. The questionnaire included the Zung Depression Scale; Zung Anxiety Scale; scales for social comparison, narcissism, and social reward value; and Neuroticism-Extraversion-Openness Personality Inventory. RESULTS: Among first- and second-year medical students, depression and anxiety increased significantly over the previous year. However, irrespective of academic year, depression increased significantly after 1 year. Also, social reward value had a moderating effect. Specifically, among students with low social reward value who entered their first year of medical school, the negative impact of the tendency toward depression and anxiety was amplified compared with older students. CONCLUSION: Because the predictors of mental health differ between groups, each group must receive specific, appropriate education. Also, because social reward value is important moderating factor of mental health, education and intervention programs that focus on social reward value are needed.

Nature of Persecutors and Their Behaviors in the Delusions of Schizophrenia: Changes between the 1990s and the 2000s.

OBJECTIVE: Research suggests that the contents of delusions in schizophrenia are influenced by culture and social environment. However, few studies have investigated the chronological change of such delusions within a society. To investigate specifically the changes in the persecutory delusions of schizophrenia that have occurred over time, we compared the nature of the persecutors and their persecutory behaviors among inpatients with schizophrenia. METHODS: All admissions to the psychiatric unit of Hanyang University Guri Hospital with discharge diagnoses of schizophrenia during two different five-year time frames (1996-2000 and 2006-2010) were reviewed. From their inpatient medical records, we investigated the descriptions of persecutors and their persecutory behaviors in the delusions of 124 patients (54 in the1990s and 72 in the 2000s). RESULTS: Overall, persecutory behaviors and nature of persecutors in the delusions of schizophrenia did not differ between the two time frames. However, subgroup analysis revealed that in women but not in men, rejection as a persecutory behavior was significantly higher in the 1990s (p<0.05). CONCLUSION: The ten-year time interval may be too short to find significant changes in delusional content in general. However, our additional finding in women may be a result of the tremendous change in status of Korean women during the last decade.

Fluoxetine Up-Regulates Bcl-xL Expression in Rat C6 Glioma Cells.

OBJECTIVE: To analyze both differentially expressed genes and the Bcl-xL protein expression after acute and chronic treatment with fluoxetine in rat C6 glioma cells. METHODS: C6 glioma cells were cultured for 24 h or 72 h after treatment with 10 µM fluoxetine, and gene expression patterns were observed using microarray and qRT-PCR. Then, cells were cultured for 6 h, 24 h, 72 h or 96 h after treatment with 10 µM fluoxetine, and the expression of Bcl-xL protein was measured using western blot. RESULTS: As determined by microarray, treatment with fluoxetine for 24 h up-regulated 33 genes (including Bcl-xL and NCAM140) and down-regulated 7 genes (including cyclin G-associated kinase). Treatment with fluoxetine for 72 h up-regulated 53 genes (including Gsα and Bcl-xL) and down-regulated 77 genes (including Gαi2 and annexin V). Based on the qRT-PCR results, there was an increase in Gsα mRNA and a decrease in Gαi2 mRNA at 72 h in fluoxetine-treated cells as compared to control, a result that was consistent with microarray. We also observed an increase in Bcl-xL mRNA (both at 24 h and at 72 h) in fluoxetine-treated cells as compared to control, demonstrating a tendency to increase gradually. Bcl-xL protein expression increased as the duration of fluoxetine treatment increased. CONCLUSION: These results suggest that chronic treatment with fluoxetine not only initiates the cAMP pathway through inducing Gsα expression but also induces Bcl-xL expression, thus inhibiting apoptosis.

Mental health of medical school students and the effects of their strategy for enhancing self-esteem.

PURPOSE: This study investigated the mental health status, self-esteem, social comparison, and narcissism among medical school students. In addition, the mediational effect of social comparison between self-esteem and narcissism was also tested with regard to whether the students compared themselves with others to enhance their own self-esteem. METHODS: Data were collected from 427 medical school students at a medical school in Seoul. The questionnaire included the Minnesota Multiphasic Personality Inventory (MMPI) 383 scale, the self-esteem scale, the Iowa-Netherlands Comparison Orientation Measure, and the narcissism scale. Using the MMPI findings, a clinical psychologist screened for possible clinical cases. Then, the frequencies of those with distress were compared between three groups, based on affiliation; premedical, medical, and graduate medical students. Also, the level of self-esteem, social comparison, and narcissism was tested by analysis of (ANCOVA), and the mediational role of social comparison was explored. RESULTS: Irrespective of affiliation, almost 10% of medical school students showed mental illness or distress. Of the clinical scales on the MMPI, the T scores of the Pa (Paranoia), Sc (Schizophrenia), and Ma (Hypomania) scales were higher in premedical and medical school students than in graduate medical school students. In addition, the mediational role of social comparison was confirmed only in medical school students. CONCLUSION: We demonstrated that subjective distress in certain medical school students needs to be addressed. Also, self-esteem was an important factor that correlated with mental health and distress indices. However, comparing oneself with others to enhance self-esteem by derogating or focusing could result in increased narcissism.

Factor structure of the Korean version of illness intrusiveness rating scale: cross-cultural implications.

The Illness Intrusiveness Rating Scale (IIRS) measures illness-induced disruptions to 13 domains of lifestyles, activities, and interests. A stable three-factor structure has been well documented; however, the cross-cultural validity of this scale needs to be tested. This study investigated the factor structure of the Korean version of IIRS in 712 outpatients at a university medical center. A predominant diagnosis of the patients was rheumatoid arthritis (47%). The Center for Epidemiological Studies-Depression Scale (CES-D), and Health Assessment Questionnaire (HAQ) were also administered. Exploratory Principal Component Analysis identified a two-factor structure, "Relationships and Personal Development (RPD)" and "Instrumental", accounting for 57% of the variance. Confirmatory analyses extracted an identical factor structure. However, a goodness-of-the fit test failed to support two-factor solution (chi(2)=138.2, df=43, p<.001). Two factors had high internal consistency (RPD, alpha=.89; Instrumental, alpha=.75) and significantly correlated with scores of HAQ (RPD, r=.53, p<.001; Instrumental, .r=44, p<.001) and CES-D (RPD, .r=55, p<.001; Instrumental, .r=43, p<.001). These findings supported construct validity of the Korean version of IIRS, but did not support cross-cultural equivalence of the factor structure.