Prescription Patterns for Patients with Schizophrenia in Korea: A Focus on Antipsychotic Polypharmacy

OBJECTIVE: This study investigated the prescription patterns for Korean patients with schizophrenia with a particular focus on antipsychotic polypharmacy. All data were gathered from patients presenting at 41 tertiary university hospitals and 8 secondary hospitals. METHODS: Data from three multicenter studies conducted in Korea were retrospectively reviewed and integrated to identify patients with schizophrenia who had their antipsychotic medication switched to paliperidone extended-release between 2008 and 2009. The rates for antipsychotic polypharmacy, combined use of different antipsychotic classes with a special focus on atypical antipsychotics, and psychotropic polypharmacy using benzodiazepines, mood stabilizers, and other relevant drugs were identified. RESULTS: Of the 851 Korean patients analyzed in this study, 20.4% (n=173) had been prescribed antipsychotic polypharmacy. Of the 678 patients receiving antipsychotic monotherapy, 6.9% (n=47) were prescribed a typical antipsychotic and 93.1% (n=631) were prescribed an atypical antipsychotic. Of the 173 patients receiving a combination of antipsychotic drugs, only 6.4% (n=11) had been prescribed polypharmacy with typical antipsychotics, while 46.82% (n=81) were prescribed atypical+atypical antipsychotics or typical+atypical antipsychotics. The highest co-prescription rates for other psychotropic drugs in conjunction with antipsychotics included benzodiazepines (30.3%), anticholinergic drugs (28.8%), antidepressants (13.3%), beta-blockers (10.1%), and mood stabilizers (8.7%). CONCLUSION: The present findings demonstrate that the rate of antipsychotic polypharmacy is relatively low in Korea and that Korean clinicians prefer to prescribe atypical, rather than typical, antipsychotic drugs. This suggests that there is a distinct prescription pattern in Korea that is focused on antipsychotic polypharmacy.

The Influence of Previous Antipsychotic Polypharmacy Versus Monotherapy on the Effectiveness of Antipsychotic after Switching to Paliperidone Extended-release

OBJECTIVE: Although antipsychotic polypharmacy is widely used in the pharmacotherapy of schizophrenia, its effectiveness is controversial. In particular, clinicians tend to avoid switching to monotherapy in patients who have been prescribed polypharmacy. In the present study, the authors investigate whether there is difference in time to discontinuation of antipsychotics between patients on previous monotherapy or polypharmacy. METHODS: Pooled analysis was conducted on two 24-week, multicenter, open-label, non-comparative studies that were originally designed to investigate the effectiveness of switching to paliperidone extended-release (ER) in patients with schizophrenia. Patients were divided into two groups according to previously prescribed antipsychotics, that is, to a polypharmacy group or a monotherapy group. The primary outcome measure was time to discontinuation of paliperidone ER. In addition, the authors sought to identify clinical variables that influence time to discontinuation. RESULTS: Before switching to paliperidone ER, 535 of 673 (79.5%) patients were prescribed antipsychotic monotherapy, and the remaining 138 (20.5%) patients were prescribed antipsychotic polypharmacy. No significant differences in time to discontinuation of paliperidone ER were observed between the polypharmacy and monotherapy groups. Personal and social performance scale score was the only factor found to influence time to discontinuation of paliperidone ER. No differences in psychopathology or adverse effects were found between the monotherapy and polypharmacy groups. CONCLUSION: Our results suggest that number of antipsychotics prescribed before switching to monotherapy does not influence clinical prognosis in patients with schizophrenia.

Attitudes Toward Suicide in Middle-School Students

OBJECTIVES: The aim of this study was to examine attitudes of middle-school students toward happiness, suicide, and factors associated with suicide. METHODS: A self-administered questionnaire was used in a cluster sample of 1,319 middle-school students (male 793, female 526). Data were obtained on a wide range of constructs regarding their attitude towards happiness, suicidal ideation and attempts, and factors associated with suicide. RESULTS: Middle-school students choose 'love within family' as most important factor for their happiness. Subjective mental health status was mostly associated with happiness. Subjects in lower socioeconomic status tended to respond their mental health status was not good and have more suicidal idea. 48.7% of subjects had permissive attitudes toward suicide, especially, girls. However, 65.0% responded that suicide was preventable problem. Compared to older people, middle-school students perceived that environmental factors were more important than innate and personal factors for suicide. CONCLUSION: Results of the study indicate that middle-school students have permissive attitudes toward suicide, but positive attitudes for the prevention of suicide. This suggest that education in these age group could be effective for the prevention of suicide. Also, approaches to suicide prevention programs should be developed based on the family intervention. Especially, we should care about girls and adolescents in lower socioeconomic status.

Influencing Factors and Predictors of Early Response in Schizophrenia Patients Receiving the Paliperidone Extended-Release Tablets (Paliperidone ER)

OBJECTIVE: Paliperidone extended-release tablet (paliperidone ER) is a new oral psychotropic agent developed for schizophrenia treatment. There have been some studies about paliperidone's good efficacy and tolerability. Clinicians appear to change the antipsychotic medication to paliperidone ER. However, it is not known what patients are favorable responsive to paliperidone ER. The aim of this study was to evaluate the characteristics of early responders and investigate predictors of acute response when the medications changed to paliperidone ER. METHODS: Data were analyzed from schizophrenic patients who participated in a multi-center, open-label, non-comparative clinical trial. Total 320 patients were examined in this study. Sociodemographic, psychopathology, social function and metabolic data were evaluated. Unpaired t-test for continuous and chi2 for categorical data, respectively, were used to compare early responder and non-responders. Logistic regression analysis was used to establish a prediction model. RESULTS: 38.7% of study subjects (124 of 320) responded to paliperidone ER treatment. Logistic regression analysis showed that a good paliperidone ER response was more likely when patients were social drinkers, when patients had started medication at inpatient, when negative symptoms were less severe, and when patients' social relationship and self-care were better. CONCLUSION: Early response to paliperidone ER treatment is associated with less negative symptoms and good social relationships and self-care. Strategies to reduce these symptoms may contribute to early response to paliperidone ER.

Factors Affecting Treatment Discontinuation and Treatment Outcome in Patients with Schizophrenia in Korea: 10-Year Follow-Up Study

OBJECTIVE: There have been few long-term studies that have assessed factors influencing treatment discontinuation and long-term outcome of schizophrenia in Korea. The present study aimed to evaluate factors affecting treatment discontinuation and treatment outcome, after 10 years, in patients with schizophrenia. METHODS: Among hospitalized patients between 1997 and 1999, 191 patients were given continuous follow-up service. We examined the clinical characteristics and outcome of patients who remained in treatment. Regression analyses were used to find any clinical factors affecting treatment discontinuation. RESULTS: One hundred thirty-three patients (71.12%) discontinued the treatment. The treatment retention group contained more female patients, paranoid-type patients, patients who had shown self-harming behavior, patients receiving clozapine, and patients with good medication compliance. The recovery rate was 25%. However, 42.3% did not have gainful employment. Further, most patients couldn't live independently. CONCLUSION: The results show the importance of gender, patient behavior, medication, and medication compliance in predicting treatment discontinuation in patients with schizophrenia.

A Study for the Progress after Psychiatric Intervention for Patients Who Visit the Emergency Room due to Suicidal Attempts / 신경정신의학

OBJECTIVES: This study aimed to examine the clinical characteristics of patients who attempted suicide and the effects of their admission to a psychiatric ward after suicide attempts. METHODS: We enrolled 147 patients who had visited the emergency room of Inha University Hospital between January 2007 and December 2008. We reviewed their medical records and investigated demographic factors, clinical characteristics, and acute stressors. We compared the progress of patients who had been admitted to a psychiatric ward and the progress of patients who had not been admitted to a psychiatric ward, to investigate the effects of psychiatric admission. RESULTS: In total, 73% of patients who attempted suicide were women with a mean age of 40.5 years. On the other hand, the mean age of the men who had attempted suicide was 60. In 40% of suicide attempts, patients visited the emergency room after drinking alcohol. The most common method of suicide was drug intoxication (82%). A quarter the of patients had a history of previous suicide attempts. The most common cause of suicide attempts was interpersonal conflict, including couple relationship problems, family problems, and peer group problems. But in men, economic problems and chronic illnesses are more important stressors. Many patients who visited the emergency room due to suicide attempts refused admission to a psychiatric ward because of poor insight, aversion to psychiatric wards, and economic problems. The follow-up rate of patients who were admitted to a psychiatric ward was 78%, and their average follow-up period was 286 days. On the other hand, the follow-up rate of patients who were not admitted to a psychiatric ward was 11% and their average follow-up period was 21 days. CONCLUSION: This study implies that interpersonal conflict is a significant cause of suicide attempts for both genders. Though many patients and their families refuse admission to a psychiatric ward, admission to a psychiatric ward is very important because it can serve psychiatric treatments for patients.

Antipsychotics Prescribing Patterns of Patients with Schizophrenia Admitted to Korean General Hospital Psychiatric Unit: 2001 to 2008

OBJECTIVE: Although the standard of treatment for schizophrenia is antipsychotic monotherapy, overall psychotropic polypharmacy including antipsychotic polypharmacy is increasingly practiced by clinicians. However, there are very few studies that assess the prescription patterns of psychotropic drugs for patients with schizophrenia in Korea. The objective of this study is to describe changes in prescription patterns with respect to antipsychotic polypharmacy and overall psychotropic polypharmacy. METHODS: In this retrospective study, we reviewed all psychotropic drugs prescribed at the time of discharge for patients diagnosed as having schizophrenia (DSM-IV criteria) who entered a psychiatric unit of a Korean general hospital from 2001 to 2008. These included a total of 467 patients. RESULTS: Of the 467 patients in this study, 205 (43.9%) were discharged with antipsychotic monotherapy and the rest, 262 (56.1%), were discharged with a polypharmacy regimen. A total of 9% of the studied patients received more than two antipsychotic drugs. The most frequent combination of antipsychotics was clozapine and aripiprazole, followed by clozapine and amisulpride, and risperidone and olanzapine. The ratio of patients discharged with a polypharmacy regimen including antipsychotic polypharmacy increased from 2001 to 2008. In relation to the mean dose of all antipsychotic drugs at the time of discharge, mean length of hospital stay and mean initial global assessment of functioning scores on admission statistically significant differences were not detected between both monotherapy and polypharmacy groups. CONCLUSION: The main finding of this study is that polypharmacy with antipsychotics and other psychotropic medicines increased in our psychiatric unit from 2001 to 2008. The rates of antipsychotic polypharmacy in our study were less than those described in our literature review.

Clinical Characteristics of Neurocognitive Function in Patients with Traumatic Brain Injury Referred for Mental Disability Evaluation / 신경정신의학

OBJECTIVES: The purpose of this study is to investigate the clinical characteristics of neurocognitive functions in patients with traumatic brain injury referred for mental disability evaluation. METHODS: The neurocognitive functions of 293 patients, who were referred for mental disability evaluation, were assessed using a computerized neurocognitive test. The patients were divided into three groups according to head trauma history and brain imaging studies. We also measured their intelligence and memory, using the K-WAIS and the Rey-Kim Memory Test. RESULTS: The group with organic mental disorder showed more impaired concentration, language, memory, intelligence, executive function and visuospatial function than those with nonorganic mental disorder without traumatic brain injury. The group with organic mental disorder also showed greater impairments in selective attention, some part of language, long-term memory, and hypothesis formation than those with postconcussional disorder. The group with organic mental disorder obtained lower intelligence and memory test scores than those with postconcussional disorder and nonorganic mental disorder without traumatic brain injury. There was no difference in intelligence or memory between postconcussional disorder and nonorganic mental disorder without traumatic brain injury. CONCLUSION: Patients with postconcussional disorder share the characteristics of neurocognitive function with organic mental disorder and nonorganic mental disorder without traumatic brain injury. We suggest the computerized neurocognitive test that evaluated details of neurocognitive functions for patients with traumatic brain injury referred for mental disability evaluation.

Pericarditis with Pericardial Effusion and Bilateral Pleural Effusion Associated with Clozapine Treatment in an Adolescent Boy / 대한정신약물학회지

The clozapine has been associated with serious side-effects, such as agranulocytosis and seizure. Less attention has been given to clozapine's adverse cardiac complications, including myocarditis, pericarditis and cardiomyopathy despite a high mortality rate. Here we describe a case of an adolescent male patient who developed pericarditis with pericardial effusion and bilateral pleural effusion 17 days after being started on clozapine therapy, whose symptoms improved after discontinuation of clozapine. We also reviewed literatures of clozapine-related cardiac complications. We hope clinicians to be vigilant for clozapine-related cardiac complications against the many benefits of clozapine for patients with schizophrenia.

Pericarditis with Pericardial Effusion and Bilateral Pleural Effusion Associated with Clozapine Treatment in an Adolescent Boy / 대한정신약물학회지

The clozapine has been associated with serious side-effects, such as agranulocytosis and seizure. Less attention has been given to clozapine's adverse cardiac complications, including myocarditis, pericarditis and cardiomyopathy despite a high mortality rate. Here we describe a case of an adolescent male patient who developed pericarditis with pericardial effusion and bilateral pleural effusion 17 days after being started on clozapine therapy, whose symptoms improved after discontinuation of clozapine. We also reviewed literatures of clozapine-related cardiac complications. We hope clinicians to be vigilant for clozapine-related cardiac complications against the many benefits of clozapine for patients with schizophrenia.

Comparative Analysis of Involuntary Admission and Voluntary Admission in Schizophrenia: A 3-Year Follow Up / 신경정신의학

OBJECTIVES : The purpose of this study was to investigate differences between involuntarily and voluntarily hospitalized patients with schizophrenia. METHODS : Patients who were hospitalized between 2001 and 2005 with a diagnosis of DSM-IV schizophrenia were included. The subjects were grouped by whether their admission was voluntary or involuntary. The data were collected through inpatient medical records. The two groups were compared regarding demographic variables and clinical features, and we examined the number of rehospitalizations, duration of follow-up, follow-up retention rate and second admission pattern for a period of 3 years after discharge. RESULTS : 181 subjects were classified as according to their admission into the involuntary group, and 69 subjects as the voluntary group. There were more female patients, more past admissions and longer duration of illness in the involuntary group. The patients in the involuntary group had more problematic behaviors with their chief complaint being delusions. The follow-up retention rate was lower (44.8% vs. 59.4%) and the rate of the second involuntary admission was higher in the involuntary group. CONCLUSION : Involuntary hospitalization may be an important predictor for treatment maintenance in patients with schizophrenia.

Comparative Analysis of Involuntary Admission and Voluntary Admission in Schizophrenia: A 3-Year Follow Up / 신경정신의학

OBJECTIVES : The purpose of this study was to investigate differences between involuntarily and voluntarily hospitalized patients with schizophrenia. METHODS : Patients who were hospitalized between 2001 and 2005 with a diagnosis of DSM-IV schizophrenia were included. The subjects were grouped by whether their admission was voluntary or involuntary. The data were collected through inpatient medical records. The two groups were compared regarding demographic variables and clinical features, and we examined the number of rehospitalizations, duration of follow-up, follow-up retention rate and second admission pattern for a period of 3 years after discharge. RESULTS : 181 subjects were classified as according to their admission into the involuntary group, and 69 subjects as the voluntary group. There were more female patients, more past admissions and longer duration of illness in the involuntary group. The patients in the involuntary group had more problematic behaviors with their chief complaint being delusions. The follow-up retention rate was lower (44.8% vs. 59.4%) and the rate of the second involuntary admission was higher in the involuntary group. CONCLUSION : Involuntary hospitalization may be an important predictor for treatment maintenance in patients with schizophrenia.

Comparative Analysis of Cognitive Function in Schizophrenia with and without Obsessive Compulsive Disorder

OBJECTIVE: We investigated the neurocognitive deficits in schizophrenic patients with and without obsessive-compulsive disorder (OCD). METHODS: We grouped 27 patients as either obsessive-compulsive or non-obsessive-compulsive based on the presence of OCD. The two groups completed the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS), Positive and Negative Symptom Scale (PANSS), and Hamilton Depression Scale. The intelligence quotient (IQ) was tested using the Korean Wechsler Adult Intelligence Scale. The memory quotient (MQ) was tested using the Korean-Auditory Verbal Learning and Korean-Complex Figure Test. The executive intelligence quotient (EIQ) was determined using the Kims executive intelligence test (EXIT). RESULTS: Ten of the 27 patients had OCD. The compulsion score of Y-BOCS was positively correlated with positive symptoms, negative symptoms, and the total scores of PANSS. The OCD-schizophrenia patients had higher IQs. No difference was found in MQ. Although the EIQ did not differ between the two groups, the OCD-schizophrenia patients performed better at the Stroop-interference and verbal fluency tests, which was highly dependent on executive function. CONCLUSION: Our findings suggest that OCD may have a protective effect on some cognitive function, at least in relatively early stage of illness. Moreover, based on clinical, neurocognitive features, schizophrenia with OCD could be considered as a distinct subtype of schizophrenia.

Comparative Analysis of Cognitive Function in Schizophrenia with and without Obsessive Compulsive Disorder

OBJECTIVE: We investigated the neurocognitive deficits in schizophrenic patients with and without obsessive-compulsive disorder (OCD). METHODS: We grouped 27 patients as either obsessive-compulsive or non-obsessive-compulsive based on the presence of OCD. The two groups completed the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS), Positive and Negative Symptom Scale (PANSS), and Hamilton Depression Scale. The intelligence quotient (IQ) was tested using the Korean Wechsler Adult Intelligence Scale. The memory quotient (MQ) was tested using the Korean-Auditory Verbal Learning and Korean-Complex Figure Test. The executive intelligence quotient (EIQ) was determined using the Kims executive intelligence test (EXIT). RESULTS: Ten of the 27 patients had OCD. The compulsion score of Y-BOCS was positively correlated with positive symptoms, negative symptoms, and the total scores of PANSS. The OCD-schizophrenia patients had higher IQs. No difference was found in MQ. Although the EIQ did not differ between the two groups, the OCD-schizophrenia patients performed better at the Stroop-interference and verbal fluency tests, which was highly dependent on executive function. CONCLUSION: Our findings suggest that OCD may have a protective effect on some cognitive function, at least in relatively early stage of illness. Moreover, based on clinical, neurocognitive features, schizophrenia with OCD could be considered as a distinct subtype of schizophrenia.

Major Depressive Disorder Preceding the Onset of Progressive Supranuclear Palsy

Progressive supranuclear palsy (PSP) is a neurodegenerative disease characterized by vertical supranuclear palsy and parkinsonian symptoms. The neuropsychiatric symptoms of PSP include anhedonia, depressed mood and cognitive impairment. Patients with PSP have an increased risk for developing depressive disorders within the next year. However, it is rare to find that major depressive disorder was the antecedent diagnosis of a patient who was later diagnosed with PSP. We present here a patient who suffered from PSP with repetitive falls, a masked face and dysarthria after developing a major depressive disorder.

Symptoms related to low systolic blood pressure

BACKGROUND: Recently in Europe, some epidemiologic studies reported that various physical symptoms and social, psychological wellbeing are related to low blood pressure. But in Korea, none has been studied on symptoms related to low blood pressure yet. In this study, we would like to see if the somatic symptoms and social, psychological wellbeing shown t,o be related to low SBP is truly associated with it. METHODS: Questionnaire interview was done to the people who have visited Department of family practice in two university hospitals and two health promotion center from April, 1996 to August, 1996. Seven somatic symptoms and Psychosocial Wellbeing Index(PWI) for the evaluation of social, psychological health status were included in the questionnaire. SAS statistics packages was used in statistical precess. We used logistic regression to see the frequency of somatic symptoms related to the systolic blood pressure(SBP) group and the confirmation of confounding variables was done by ANOVA. RESULTS: Total of 304 completed the questionnaire. Average age was 44 years old and average SBP was 115.4+/-16.4. 84 of them (27.6%) felt that they had a low BP & 69 were women compared to 21 men, being meaningfully more common. 107(35.2%) people answered that they had heard that their blood pressure was low and 66% were from doctors. Only 32(38.1%) of the group who felt of having hypotensive symptoms and 38 of the group who heard of having hypotension actually had SBP of below 100 mmHg. Vocation, income, smoking & alcohol history, present illness, marital status were not significant as a confounding variable. SBP of 100 or below group had a less presentation of fatigue & significantly higher PWI than the group of above 100mmHg (p<0.05). The group who felt that they had a low BP had more complaints of fatigue, dizziness, palpitation, cold hands and feet and had significnatly higher PWI than the group who didnt. CONCLUSIONS: SBP of 100mmHg or below group has more frequent manifestion of fatigue and low level of sociopsycholgiacl health index than the above 100mmHg group. But most of the people who complained of hypotensive symptoms didnt have low blood pressure and a lot of them misunderstand of having low blood pressure and after checking blood pressure by doctors, so great deal of caution is called for when seeing patients.

A case of zosteriform cutaneous metastatic adenocarcinoma of cholangiocarcinoma / 대한피부과학회지

We report a case of zosteriform cutaneous metastasis from choangiocarcinomasin a 56-year-old male patient who has asymptomatic and painless erythematous papules and scaly patches over the anterior side of his right upper abdomen along the back, Tendernatome level. Histopathologic examina.tions of the cutaneous lesion reveaed a tumor cell showing glandular structure and multifocal tumor emboli within dilated lymphalics. and a few signetring cells in the dermis. We found that the retrograde studies revealed cholangiocarcinom. after confirmation of zosteriform cutaneous metastasis. He died eight months after the appearance of zosteriform cutaneous metastasis.

Focal Dermal Hypoplasia Associated with Ichthyosis

We report a case of focal dermal hypoplasia associated with ichthyosis in an 18-year-old Korean female. The patient showed a yellowish atrophic patch on the left side of her abdomen, abnormal skin pigmentation, nail dystrophy and ichthyosis since birth.We could also find skeletal and dental deformities. The biopsy specimen obtained from the yellowish atrophic patch showed marked attenuation of collagen fibers and ectopic fatty tissue nearly reaching up to the upper dermis.

Focal Dermal Hypoplasia Associated with Ichthyosis

We report a case of focal dermal hypoplasia associated with ichthyosis in an 18-year-old Korean female. The patient showed a yellowish atrophic patch on the left side of her abdomen, abnormal skin pigmentation, nail dystrophy and ichthyosis since birth.We could also find skeletal and dental deformities. The biopsy specimen obtained from the yellowish atrophic patch showed marked attenuation of collagen fibers and ectopic fatty tissue nearly reaching up to the upper dermis.

A case of malignant histiocytosis with various skin manifestations / 대한피부과학회지

Malignant histiocytosis(MH) is a rapidly progressive and usally fatal disorder characterized clinically fever, generalized weakness, lymphadeno athy, hepatosplenomegaly accompanied by jaundice, and purpura. The frequency of skin manifestations has been repoterd about 15% of MH patients. Papules, plaques and niidules are commonly met. Histopathologically MH shows infiltrations of atypical histiocyte; with uarious maturity in many organs including skin. We present a case of a 32-year-old female with MH involving not only lymph node, liver, spleen and bone marrow but also skin with vaorious features ; erythematous papules, annular purpuric patches, subcutaneous nodules and hemomagic nodules. Immunohist,ochemically the majority of patients atypical histiocytes in lesional skin shows a-1 antitrysin positive, but lysozyme negative. It may suggest that these are poorly differentiated atypical histiocytes rather than well differentiated ones.