Effects of Paliperidone Palmitate on Healthcare Utilization and Costs for Patients with Schizophrenia: A Claim-based Mirror-image Study in South Korea

Objective@#Long-acting injectable (LAI) antipsychotics, such as paliperidone palmitate (PP), are known to improve treatment adherence in patients with schizophrenia, which can lead to reductions in relapse and hospitalization rates. However, relatively few studies have demonstrated the economic impact of LAIs, especially in Asian populations. @*Methods@#We conducted a claim-based mirror-image study to explore changes in healthcare utilization and associated costs, among 1,272 South Korean patients with schizophrenia (ICD-10-CM code F20), between the 1-year periods before and after the initiation of PP treatment. @*Results@#Patients accessed outpatient services more frequently after versus before starting PP treatment, with the number of prescription days increasing by 133.45 (p ＜ 0.0001) and the associated costs increasing by USD 1,497.15 (p ＜ 0.0001). The number of admission days was reduced by 11.33 after starting PP treatment (p ＜ 0.0001) and the associated costs were reduced by USD 1,220.75 (p ＜ 0.0001). However, admission cost savings were different according to patients’ oral drug compliance. The daily dosages for benztropine, procyclidine, and propranolol decreased, showing that there were fewer side-effects after PP-treatment (p ＜ 0.0001). @*Conclusion@#Although the high acquisition cost of PP has been regarded as an obstacle to its clinical use, our results imply that the high prescription costs for PP may be counterbalanced by the reduced admission costs associated with its use. Economic outcomes for patients treated with LAIs should be investigated further to help healthcare decision-makers and providers to determine the value of LAIs relative to other treatment medications.

Increased Frontal Gamma and Posterior Delta Powers as Potential Neurophysiological Correlates Differentiating Posttraumatic Stress Disorder from Anxiety Disorders

OBJECTIVE: Posttraumatic stress disorder (PTSD) is distinct from anxiety disorders in its etiology and clinical symptomatology, and was reclassified into trauma- and stressor-related disorders in DSM-5. This study aimed to find neurophysiological correlates differentiating PTSD from anxiety disorders using resting-state quantitative electroencephalography (qEEG). METHODS: Thirty-six patients with either PTSD or acute stress disorder and 79 patients with anxiety disorder were included in the analysis. qEEG data of absolute and relative powers and patients’ medication status on the day of qEEG examination were obtained. Electrodes were grouped into frontal, central, and posterior regions to analyze for regional differences. General linear models were utilized to test for group differences in absolute and relative powers while controlling for medications. RESULTS: PTSD patients differed from those with anxiety disorders in overall absolute powers [F(5,327)=2.601, p=0.025]. Specifically, overall absolute delta powers [F(1,331)=4.363, p=0.037], and overall relative gamma powers [F(1,331)=3.965, p=0.047] were increased in PTSD group compared to anxiety disorder group. Post hoc analysis regarding brain regions showed that the increase in absolute delta powers were localized to the posterior region [F(1,107)=4.001, p=0.048]. Additionally, frontal absolute gamma powers [F(1,107)=4.138, p=0.044] were increased in PTSD group compared to anxiety disorder group. CONCLUSION: Our study suggests increased overall absolute delta powers and relative gamma powers as potential markers that could differentiate PTSD from anxiety disorders. Moreover, increased frontal absolute gamma and posterior delta powers might pose as novel markers of PTSD, which may reflect its distinct symptomatology.

Effects of an Online Imagery-Based Treatment Program in Patients with Workplace-Related Posttraumatic Stress Disorder: A Pilot Study

OBJECTIVE: We developed easily accessible imagery-based treatment program for patients with post-traumatic stress disorder (PTSD) related to workplace accidents and investigated the effects of the program on various PTSD related symptoms. METHODS: The program was based on an online platform and consisted of eight 15-min sessions that included script-guided imagery and supportive music. Thirty-five patients with workplace-related PTSD participated in this program 4 days per week for 4 weeks. Its effects were examined using self-report questionnaires before and after the take-home online treatment sessions. RESULTS: After completing the 4-week treatment program, patients showed significant improvements in depressed mood (t=3.642, p=0.001) based on the Patient Health Questionnaire-9 (PHQ-9), anxiety (t=3.198, p=0.003) based on the Generalized Anxiety Disorder seven-item (GAD-7) scale, and PTSD symptoms (t=5.363, p < 0.001) based on the Posttraumatic Stress Disorder Check List (PCL). In particular, patients with adverse childhood experiences exhibited a greater degree of relief related to anxiety and PTSD symptoms than those without adverse childhood experiences. CONCLUSION: The present results demonstrated that the relatively short online imagery-based treatment program developed for this study had beneficial effects for patients with workplace-related PTSD.

In-Depth Relationships between Emotional Intelligence and Personality Traits in Meditation Practitioners

OBJECTIVE: Meditation can elicit trait-like changes in psychological and social styles, as well as enhancement of emotional regulatory capacity. We investigated the relation between personality traits and emotional intelligence in meditation practitioners. METHODS: Seventy-two long-term practitioners of mind-body training (MBT) and 62 healthy comparative individuals participated in the study. The participants completed emotional intelligence questionnaires and the Myers-Briggs Type Indicator (MBTI). RESULTS: The MBT group revealed higher scores on all five emotional intelligence factors than did those in the control group, such as emotional awareness and expression, empathy, emotional thinking, emotional application, and emotional regulation (all p≤0.001). MBT practitioners also had higher scores on the intuition of perceiving function (t=−2.635, p=0.010) and on the feeling of the judging function (t=−3.340, p=0.001) of the MBTI compared with those in the control group. Only the MBT group showed a robust relationship with every factor of emotional intelligence and MBTI-defined intuitive styles, indicating that higher scores of emotional intelligence were related to higher scores for intuition. CONCLUSION: Emotional intelligence of meditation practitioners showed notable relationships with some features of personality trait. In-depth associations between emotional intelligence and personality traits would help to foster psychological functions in meditation practitioners.

The Effects of Continuation-Maintenance Electroconvulsive Therapy on Reducing Hospital Re-Admissions in Patients with Treatment-Resistant Schizophrenia

OBJECTIVE: Continuation-maintenance electroconvulsive therapy (C/M-ECT) is used to prevent relapse or recurrence in patients with severe mental illnesses. We aimed to investigate the effect of C/M-ECT on reducing hospital re-admissions in patients with treatment-resistant schizophrenia. METHODS: We applied a mirror-image design by retrospectively examining re-hospitalization rates of 18 patients with schizophrenia spectrum disorders. We compared the numbers of psychiatric admissions during the actual period over which C/M-ECT was administered with the same period prior to the beginning of C/M-ECT. RESULTS: The number of psychiatric admissions was reduced significantly during C/M-ECT (0.33±0.77) compared with that of the same period prior to C/M-ECT (2.67±1.33) (Wilcoxon signed rank Z=−3.663; p < 0.001). CONCLUSION: This finding shows that C/M-ECT augmentation could successfully reduce the re-hospitalization rates in patients with treatment-resistant schizophrenia.

Effects of Cognitive-Behavioral Therapy on Empathy in Patients with Chronic Pain

OBJECTIVE: Cognitive-behavioral therapy (CBT) is effective in patients with chronic pain. However, the efficacy of CBT for impaired empathy has not been studied in this population. We investigated the effect of CBT on empathy in patients with chronic pain. METHODS: Patients with severe chronic pain were recruited. Empathy was assessed before and after CBT using the Interpersonal Reactivity Index (IRI). The patients underwent eight sessions over the course of 1 month conducted. Additional symptoms were assessed using the Short-Form McGill Pain Questionnaire (SF-MPQ), Beck Depression Inventory, Beck Anxiety Inventory, World Health Organization Quality of Life Scale Abbreviated Version, and the Scale for Suicide Ideation. RESULTS: A total of 26 participants were included. Pre-CBT pain severity assessed using the SF-MPQ was significantly correlated with the IRI-empathic concern subscale score (p=0.021), and the relationship remained significant after adjusting for sex, age, education level, and marital status. After CBT, the IRI-perspective-taking subscale scores (p=0.004) increased significantly and the IRI-personal distress subscale scores (p=0.013) decreased significantly in all participants. The SF-MPQ scores increased significantly (p=0.021). CONCLUSION: CBT improved empathy in patients with chronic pain independent of its effect on pain, suggesting that CBT is useful for improving interpersonal relationships in patients with chronic pain.

Do Patients Want to Listen to a Diagnosis of Dementia in Korea? Preferences on Disclosing a Diagnosis of Dementia and Discussing Advance Care Planning in Elderly Patients with Memory Concerns and Their Families

OBJECTIVE: In this study, we aimed to investigate preferences regarding the disclosure of a dementia diagnosis and advance care planning (ACP) in patients with memory complaints and their families. METHODS: A total of 98 patients who visited the department of psychiatry at a tertiary hospital with memory complaints and 62 family members completed a structured questionnaire. The questionnaire included preferences on disclosure of dementia and cancer diagnosis, awareness and preferences on ACP. RESULTS: In total, 96.9% of patients were willing to know their dementia diagnosis. There were no significant differences in preferences between the diagnosis of cancer and dementia. Only 24.7% of patients and 45.8% of family members have heard of ACP. However, 82.8% of patients agreed on the necessity of ACP under the current condition. Multivariate analysis revealed that younger patients were more likely to agree with necessity for ACP under the current condition. CONCLUSION: In Korea, patients with memory complaints and their family members strongly favored a disclosure of dementia diagnosis. The majority of participants also agreed on the necessity of ACP. More active involvement of patients is needed in treatment decisions and care planning in cases of dementia as well as other life-threatening illnesses.

Correlation between Quantitative Electroencephalogram Findings and Neurocognitive Functions in Patients with Obsessive-Compulsive Disorder and Schizophrenia

OBJECTIVES: Obsessive-compulsive disorder (OCD) and schizophrenia have many common clinical and neurocognitive features. However, not all of them share the same underlying mechanism. The aim of this study was to discover evidences that indicate a pathophysiological mechanism specific to OCD by comparing correlations of quantitative electroencephalography (QEEG) patterns and neurocognitive function in patients with OCD and schizophrenia. METHODS: Resting-state QEEG data of total 265 patients were acquired retrospectively and parameters such as absolute power, relative power and peak frequency were analyzed from the data. Stroop test and Trail Making Test results as well as demographic features were reviewed for this study. The correlation of neurocognitive functions and brain electrical activities in each group were assessed and compared by correlation analysis. RESULTS: Compared with the OCD group, the schizophrenia group performed poorly in neurocognitive tests. Mean values of QEEG parameters in patients with OCD and schizophrenia did not show significant differences. Both absolute and relative power of alpha rhythm in central and frontal regions showed significant positive correlation with Stroop test results in OCD patients. CONCLUSIONS: Findings in this study shows distinctive correlations between frontal executive dysfunction and frontal alpha rhythm in the OCD patients, both of which might be a candidate for endophenotype underlying obsessive rumination.

Impaired Empathic Abilities among Patients with Complex Regional Pain Syndrome (Type I)

OBJECTIVE: The aims of this study were to evaluate differences in empathic abilities between patients with complex regional pain syndrome (CRPS) Type I and healthy control subjects (HCs) and to assess correlations between empathic abilities and multidimensional aspects of pain. METHODS: Empathic ability was measured in 32 patients with CRPS Type I and in 36 HCs using the Interpersonal Reactivity Index (IRI). A comprehensive assessment of pain was conducted in the patient group using the West Haven-Yale Multidimensional Pain Inventory (WHYMPI). Psychiatric symptoms were assessed using the Beck Depression and Anxiety Inventories (BDI and BAI), and quality of life was evaluated using the WHO Quality of Life (WHOQOL-BREF) questionnaire. RESULTS: Patients with CRPS showed impaired cognitive and emotional empathic abilities compared with HCs. Significantly lower levels of perspective taking and empathic concern and higher levels of personal distress on the IRI were exhibited by the patient group. Perspective taking and personal distress were associated with affective distress and poor quality of life in social contexts (BDI, BAI, and WHOQOL). However, empathic concern was positively correlated with pain severity and social support from others (WHYMPI). CONCLUSION: A tendency toward self-oriented distress in social cognition was exhibited among patients with CRPS Type I. Impaired empathic ability was shown to have potentially negative effects on subjective emotional outcomes and social performance in the lives of patients. Interventions to improve emotional awareness and theory of mind would be beneficial for enhancing social functioning in patients with CRPS Type I.

Clinical Features of Right-Sided Infective Endocarditis Occurring in Non-Drug Users

Right-sided infective endocarditis (RIE) occurs predominantly in intravenous drug users in western countries, and it has a relatively good prognosis. Clinical features and prognosis of RIE occurring in non-drug users are not well known. We investigated the clinical findings of RIE in non-drug users. We retrospectively reviewed 345 cases diagnosed with IE. Cases with RIE or left-sided infective endocarditis (LIE) defined by the vegetation site were included and cases having no vegetation or both-side vegetation were excluded. Clinical findings and in-hospital outcome of RIE were compared to those of LIE. Among the 245 cases, 39 (16%) cases had RIE and 206 (84%) cases had LIE. RIE patients were younger (40+/-19 yr vs 50+/-18 yr, P=0.004), and had a higher incidence of congenital heart disease (CHD) (36% vs 13%, P<0.001) and central venous catheter (CVC) (21% vs 4%, P=0.001) compared to LIE patients. A large vegetation was more common in RIE (33% vs 9%, P<0.001). Staphylococcus aureus was the most common cause of RIE, while Streptococcus viridans were the most common cause of LIE. In-hospital mortality and cardiac surgery were not different between the two groups. CHD and use of CVC were common in non-drug users with RIE. The short-term clinical outcome of RIE is not different from that of LIE.

Characteristics of Telepresence by Multisensory Feedback and Related Neural Mechanism in Patients with Schizophrenia : A Functional MRI Study

OBJECTIVES: The multimodal telepresence systems have been adopted in a variety of applications, such as telemedicine, space or underwater teleoperation and videoconference. Multimedia, one of the telepresence systems, has been used in various fields including entertainment, education and communication. The degree of subjective telepresence is defined as the probability that a person perceives to be physically in the remote place when he/she experiences a multisensory feedback from the multimedia. The current study aimed to explore the neural mechanism of telepresence related to multisensory feedback in patients with schizophrenia. METHODS: Brain activity was measured using functional magnetic resonance imaging while fifteen healthy controls and fifteen patients with schizophrenia were experiencing filmed referential conversation at various distances (1 m, 5 m and 10 m). Correlations between the image contrast values and the telepresence scores were analyzed. RESULTS: Subjective telepresence was not significantly different between the two groups. Some significant correlations of brain activities with the telepresence scores were found in the left postcentral gyrus, bilateral inferior frontal gyri, right fusiform gyrus, and left superior temporal sulcus. There were no main effects of group and distance. CONCLUSION: These results suggest that patients with schizophrenia experience telepresence as appropriately as healthy people do when exposed to multimedia. Therefore, patients with schizophrenia would have no difficulty in immersing themselves in multimedia which may be used in clinical training therapies.

Risk Factors Associated with the Development and the Course of Alcohol Withdrawal Delirium / 신경정신의학

OBJECTIVES: The aim of this study was to analyze the clinical variables associated with the occurrence, duration, and severity of alcohol withdrawal delirium (AWD) in patients with alcohol dependence. METHODS: We conducted a retrospective case-control study in alcohol dependent inpatients admitted to the psychiatric department, between 2006 and 2012 (n=863). Multivariable logistic and linear regression models were used for analysis of risk factors associated with development of AWD and the duration of illness, respectively. And multivariable logistic regression models were applied for assessment of risk factors associated with seclusions or physical restraints, which reflect the severity of AWD. RESULTS: Significant predictors for the occurrence of AWD included higher body temperature, lower platelet count, lower serum potassium, higher drinking amount, history of AWD, and history of head trauma or structural brain lesion. Variables associated with prolongation of delirium included higher body temperature, higher drinking amount, and less use of benzodiazepine during the AWD episode. Significant predictors for severe AWD included higher systolic blood pressure, longer duration of harmful alcohol use, and higher drinking amount. CONCLUSION: Easily determinable parameters, such as vital signs and past history related to drinking are significantly associated with not only development of AWD, but also its severity and duration. Therefore, when initially assessing alcohol dependent patients, clinicians should keep these parameters in mind in order to prevent occurrence of risky withdrawal delirium and behavioral problems.

Understanding of Neuroimaging and Its Perspectives in Mental Illnesses

Neuroimaging in psychiatry encompasses the powerful tools available for the in vivo study of brain structure and function. MRI including the volumetry, voxel-base morphometry(VBM) and diffusion tensor imaging (DTI) are useful for assessing brain structure, whereas function MRI, positron emission tomography(PET) and magnetoencephalography(MEG) are well established for probing brain function. These tools are well tolerated by the vast majority of psychiatric patients because they provide a powerful but noninvasive means to directly evaluate the brain. Although neuroimaging technology is currently used only to rule in or rule out general medical conditions as opposed to diagnosing primary mental disorders, it may be used to confirm or make psychiatric diagnoses in the future. In addition, neuroimaging may be valuable for predicting the natural course of psychiatric illness as well as treatment response.

Periprocedural Myocardial Infarction After Retrograde Approach for Chronic Total Occlusion of Coronary Artery: Demonstrated by Cardiac Magnetic Resonance Imaging

A retrograde approach through the collateral channels was recently proposed as one of the most promising current techniques for percutaneous coronary intervention of chronic total occlusion in coronary arteries (CTO). This report describes the case of a 68-year-old man in whom CTO was successfully crossed with a wire by the retrograde approach using septal collateral, but the patient suffered from a complication with septal myocardial infarction demonstrated by cardiac magnetic resonance imaging.

A Newly Developed Pericardial Tuberculoma During Antituberculous Therapy

Tuberculosis generally affects the respiratory tract. In developing nations, the pericardium is the most common location of extrapulmonary tuberculosis; however, tuberculous pericarditis rarely appears as a localized mass or tuberculoma. We present here a case of a 62-year-old woman with pericardial tuberculoma. She had a history of effusive tuberculous pericarditis and drainage. Because she had taken regular medication over a period of six months, the pericardial mass with an adjacent lung nodule newly detected on the chest radiogram was initially suspected of being invasive lung cancer. Prior to pathologic confirmation, precise information from imaging tests, including computed tomography, magnetic resonance imaging, and positron emission tomography-computed tomography are helpful when making decisions regarding which methods should be used for surgical approach and treatment. Through imaging, our case showed typical features of pericardial tuberculoma and a favorable clinical course after two months with a change in antituberculous therapy.

Flash Pulmonary Edema in a Patient With Unilateral Renal Artery Stenosis and Bilateral Functioning Kidneys

Flash pulmonary edema typically exhibits sudden onset and resolves rapidly. It generally is associated with bilateral renal artery stenosis or unilateral stenosis in conjunction with a single functional kidney. We describe a patient who presented with flash pulmonary edema treated by percutaneous therapy with stent implantation. Our case is unique in that the flash pulmonary edema occurred in the setting of unilateral renal artery stenosis with bilateral functioning kidneys.

Deglutition Syncope Associated With Ventricular Asystole in a Patient With Permanent Atrial Fibrillation

Deglutition syncope is a situational syncope that is diagnosed only by a detailed history. We report deglutition syncope in a 62-year-old man, who had permanent atrial fibrillation. The patient had no structural or functional abnormalities of the esophagus. During syncopal attacks, his electrocardiography showed ventricular asystole that was sustained for 12 seconds. The patient was successfully treated by implantation of a permanent pacemaker.

Comparison of the Characteristics of Anhedonia between Patients with Schizophrenia and Depressive Disorder / 신경정신의학

OBJECTIVES: Anhedonia, defined as an inability to experience pleasure, has been considered to be a core feature of schizophrenia and depression. The purpose of the present study was to compare the specific characteristics of anhedonia in patients with the two illnesses by examining hedonic capacity during phased hedonic experience. METHODS: Hedonic rating tasks, using the film clips of physical and social hedonic stimuli and neutral stimuli, were performed by 29 patients with schizophrenia, 20 patients with depression, and 29 normal controls. Each task consisted of 'preview phase' with insufficient emotional information, and a subsequent 'theme phase' with sufficient emotional information. RESULTS: In normal controls, the mean hedonic score was increased in the theme phase compared with the preview phase, suggesting an appropriate augmentation of the hedonic response. In patients with schizophrenia, hedonic scores in the preview phase were comparable with those in normal controls, but showed deficient augmentation in the theme phase. In patients with depressive disorder, the range of increments in scores between the preview and theme phases was normal, but the scores themselves were lower in both phases than in the other two groups. CONCLUSION: The results indicate that patients with schizophrenia show a deficient augmentation of the hedonic response, whereas patients with depressive disorder have a pervasive lack of hedonic capacity.

Characteristics of Eye Gaze Distribution of Patients with Schizophrenia during the Emotion-Provoking Conversation with Several Virtual Persons / 신경정신의학

OBJECTIVES: Impairment of social cognition affects the social functioning of patients with schizophrenia. For example, patients with schizophrenia have been shown to display abnormal eye contact during a one-on-one conversation. This study was designed to investigate the behavioral characteristics of patients with schizophrenia while talking with two people. METHODS: Twenty six patients with schizophrenia and 26 normal controls performed virtual reality conversation tasks, in which they talked with main and assistant avatars under positive or negative emotional conditions. While listening and speaking, the durations of eye gaze with the main and minor avatars were measured from the head orientations of the participants using a positional tracker. RESULTS: Compared with normal controls, the patient group showed a shorter duration of gaze towards the main avatar and a longer duration of gaze towards the assistant avatar. This pattern was more apparent in the negative situation. CONCLUSION: The results suggest a defect in social cognition, in which patients with schizophrenia fail to distribute their gaze appropriately during a conversation with more than one other person.

Intravascular Ultrasound-Guided Troubleshooting in a Large Hematoma Treated With Fenestration Using a Cutting Balloon

Intramural hematoma formation is not a well-studied complication of percutaneous coronary intervention. We describe a patient with stable angina who developed an intramural hematoma during elective percutaneous coronary intervention (PCI) in the right coronary artery (RCA). Total occlusion with dense dye staining developed a long way from the distal RCA, near the posterior descending artery bifurcation site. The true lumen was compressed by the enlarged, tense, false lumen. The patient was successfully treating with intravascular ultrasound-guided fenestration using a cutting balloon, and a stent was implanted in the distal RCA.