Korean Medication Algorithm for Bipolar Disorder 2018: Comparisons with Other Treatment Guidelines

The objective of this study was to compare recommendations of the Korean Medication Algorithm Project for Bipolar Disorder 2018 (KMAP-BP 2018) with other recently published guidelines for treating bipolar disorder. We reviewed a total of five recently published global treatment guidelines and compared treatment recommendation of the KMAP-BP 2018 with those of other guidelines. For initial treatment of mania, there were no significant differences across treatment guidelines. All guidelines recommended mood stabilizer (MS) or atypical antipsychotic (AAP) monotherapy or a combination of an MS with an AAP as a first-line treatment strategy for mania. However, the KMAP-BP 2018 did not prefer monotherapy with MS or AAP for psychotic mania. Quetiapine, olanzapine and aripiprazole were the first-line AAPs for nearly all phases of bipolar disorder across guidelines. Most guidelines advocated newer AAPs as first-line treatment options for all phases while lamotrigine was recommended for depressive and maintenance phases. Lithium and valproic acid were commonly used as MSs in all phases of bipolar disorder. As research evidence accumulated over time, recommendations of newer AAPs (such as asenapine, cariprazine, paliperidone, lurasidine, long-acting injectable risperidone and aripiprazole once monthly) became prominent. KMAP-BP 2018 guidelines were similar to other guidelines, reflecting current changes in prescription patterns for bipolar disorder based on accumulated research data. Strong preference for combination therapy was characteristic of KMAP-BP 2018, predominantly in the treatment of psychotic mania and severe depression. Further studies were needed to address several issues identified in our review.

Korean Treatment Guideline on Pharmacotherapy of Co-existing Symptoms and Antipsychotics-related Side Effects in Patients with Schizophrenia / 대한정신분열병학회지

OBJECTIVES: The current study covers a secondary revision of the guidelines for the pharmacotherapy of schizophrenia issued by the Korean Medication Algorithm for Schizophrenia (KMAP-SCZ) 2001, specifically for co-existing symptoms and antipsychotics-related side-effects in schizophrenia patients. METHODS: An expert consensus regarding the strategies of pharmacotherapy for positive symptoms of schizophrenia, co-existing symptoms of schizophrenia, and side-effect of antipsychotics in patients with schizophrenia was retrieved by responses obtained using a 30-item questionnaire. RESULTS: For the co-existing symptoms, agitation could be treated with oral or intramuscular injection of benzodiazepine or antipsychotics; depressive symptoms with atypical antipsychotics and adjunctive use of antidepressant; obsessive-compulsive symptoms with selective serotonin reuptake inhibitors and antipsychotics other than clozapine and olanzapine; negative symptoms with atypical antipsychotics or antidepressants; higher risk of suicide with clozapine; comorbid substance abuse with use of naltrexone or bupropion/ varenicline, respectively. For the antipsychotics-related side effects, anticholinergics (extrapyramidal symptom), propranolol and benzodiazepine (akathisia), topiramate or metformin (weight gain), change of antipsychotics to aripiprazole (hyperprolactinemia and prolonged QTc) or clozapine (tardive dyskinesia) could be used. CONCLUSION: Updated pharmacotherapy strategies for co-existing symptoms and antipsychotics-related side effects in schizophrenia patients as presented in KMAP-SCZ 2019 could help effective clinical decision making of psychiatrists as a preferable option.

Korean Medication Algorithm for Bipolar Disorder 2014: Overview / 대한정신약물학회지

OBJECTIVE: The Korean Medication Algorithm for Bipolar Disorder (KMAP-BP) was firstly published in 2002, with updates in 2006 and 2010. This third update reviewed the experts' consensus of opinion on the pharmacological treatments of bipolar disorder. METHODS: The newly revised questionnaire composed of 55 key questions about clinical situations including 223 sub-items was sent to the experts. Sixty-four of 110 experts replied. For the newly added section (treatment guideline for child and adolescent bipolar disorders) in KMAP-BP 2014, 23 of 38 experts replied to this special section. Data were analyzed according to the same methods to be used in conjunction with the previous publications. RESULTS: The recommendations for the management of acute mania remained largely unchanged. Combination of mood stabilizer (MS) and atypical antipsychotic (AAP) was the first-line treatment option in acute mania. Valproic acid (VP), lithium (Li), and several AAPs continued to be first-line treatments. MS or AAP monotherapy was the first-line treatment in hypomania. More frequent use of AAP as a first-line agent was noted in KMAP-BP 2014. For management of mild to moderate bipolar depression, MS monotherapy, combination of MS and AAP, combination of AAP and lamotrigine (LTG) was the first-line treatments. In severe non-psychotic depression, combination of MS and AAP, combination of AAP and LTG, and combination of MS and antidepressant (AD) was the first-line treatments. For the management of severe psychotic bipolar depression, combination of MS and AAP, combination of AAP and LTG, combination of MS, AAP and AD or LTG, combination of AAP and AD, and combination of AAP, AD and LTG was the first-line treatments. Li, VP, LTG, aripiprazole (ARP), olanzapine (OLZ) and quetiapine (QT) were the first-line treatment for bipolar depression. Although many treatment options were recommended, there were few consensus of opinion in bipolar depression. Treatment of mixed features was firstly added in KMAP-BP 2014. Combination of MS and AAP was the treatment of choice for management of mixed features. AAP monotherapy was also the first-line treatment. VP, Li, ARP, OLZ and QT were the first-line treatment for management of all phases of mixed features. Risperidone was added in mixed mania and LTG in mixed depressive features. There have been many treatment options for management of rapid cycling in bipolar disorder, when considered the combination of MS and AAP was only first-line treatment in KMAP-BP 2014. Combination of MS and AAP, MS or AAP monotherapy was the first-line options for management of maintenance phase after manic episode. For maintenance treatment after bipolar I depression, combination of MS and AAP, combination of MS and LTG, combination of AAP and LTG, MS or LTG monotherapy, and combination of MS, AAP and LTG were the first-line options. For management of maintenance phase of bipolar II depression, combination of AAP and LTG, combination of MS and LTG, combination of MS and AAP, AAP or LTG monotherapy were recommended as the first-line options. CONCLUSION: The experts' opinion of consensus was markedly changed in KMAP-BP 2014 than in previous publications. Preferred treatment with AAP and LTG was especially noted for management of bipolar disorder. We confirmed the treatment options recommended in KMAP-BP 2014 were much in concordance with current updated treatment guidelines for bipolar disorder. Despite the limitations of expert consensus guideline, KMAP-BP 2014 may reflect the current patterns of clinical practice and recent researches.

Korean Medication Algorithm for Depressive Disorder 2012 (III): The Subtypes of Depression / 대한정신약물학회지

OBJECTIVE: Recently, the pharmacotherapy including antidepressants in treating depression is widely used. However, as a result of newer agents that are continuously introduced, pharmacological treatment strategy is also changing. To catch up this trend, Korean Medication Algorithm Project for Depressive Disorder was developed in 2002 and revised in 2006. Since the last revision, the third revision reflected the new research result and the latest trends in the areas of pharmacological treatment. METHODS: One hundred and twenty three psychiatrists who have vast clinical experiences in depressive disorder are primarily selected then survey was sent to them via mail, 67 surveys were retried. This survey is constructed with 44 questionnaires in which contained from overall treatment strategies to treatment strategies under the specific circumstances. Each treatment strategy or treatment option is evaluated with the overall score of nine and the following 95% confidence interval result treatment option were divided into three phases of recommendation; primary, secondary, tertiary. RESULTS: For dysthymic disorder, antidepressant monotherapy including selective serotonin reuptake inhibitor (SSRI) [(es)citalopram, fluoxetine, sertraline, paroxetine], serotonin-norepinephrine reuptake inhibitor (SNRI) (venlafaxine, duloxetine, milacipran), and mirtazapine, was recommended as the first line medications. For melancholic type, SSRI, SNRI, and mirtazapine were recommended as the first line medications. For atypical type and seasonal pattern, bupropion as well as SSRI, SNRI, and mirtazapine, were recommended as the first line medications. CONCLUSION: The preferences of antidepressants in experts were different according to the subtype of depression. These results suggest that clinicians have to consider the subtype of depression in the treatment of depressive disorders.

Korean Medication Algorithm for Depressive Disorder (IV): Child and Adolescent/The Elderly/Female / 대한정신약물학회지

OBJECTIVE: Since the introduction of selective serotonin reuptake inhibitor in 1980s, there have been many changes in the treatment strategies for depressive disorders. To be of help for clinicians to select appropriate treatment strategies, Korean Medication Algorithm Project for Major Depressive Disorder was developed in 2002 and revised in 2006. To reflect changes in treatment pattern for depressive disorders since 2006, we revised the previous algorithm and developed Korean Medication Algorithm Project for Depressive Disorder 2012 (KMAP-DD 2012). METHODS: 123 psychiatrists who have vast clinical experiences in treating depressive disorders are primarily selected, and the survey was sent to them via mails. Among them, 67 psychiatrists answered the survey. This survey was composed of 44 questionnaires of which the contents covered from overall treatment strategies to treatment strategies under the specific circumstances. Based on 95% confidence interval and overall scores, each treatment of option was classified into three categories of recommendation; first-line, second-line, and third-line treatment option. RESULTS: In child and adolescent, antidepressant monotherapy was selected as first-line treatment option for mild, moderate, and severe episode without psychotic features. The combination of antidepressant and atypical antipsychotics was advocated as first-line treatment option for severe episode with psychotic features. In geriatric depression, antidepressant monotherapy was advocated as treatment of choice for mild to moderate episode. For severe episode without psychotic features, antidepressant monotherapy was selected as first-line treatment option. For severe episode with psychotic features, combination of antidepressant and atypical antipsychotics was selected as treatment of choice. In premenstrual dysphoric disorder, antidepressant monotherapy was advocated as first-line treatment option. In postpartum depression, antidepressant monotherapy was selected as first-line treatment option for mild to moderate episode. For severe episode without psychotic features, both antidepressant monotherapy and combination of antidepressant and atypical antipsychotics were selected as first-line treatment option. For severe episode with psychotic features, both combination of antidepressant and atypical antipsychotics and combination of mood stabilizer and atypical antipsychotics were advocated as first-line treatment option. CONCLUSION: In KMAP-DD 2012, the recommendations for treatment options in Child and Adolescent Depressive Disorder and Geriatric Depression were newly introduced. In aspects of treatment options for Female Depression, KMAP-DD 2006 and KMAP-DD 2012 had some similarities. But there were some changes of the treatment strategies in KMAP-DD 2012 which seemed to reflect recent study results.

Korean Medication Algorithm for Bipolar Disorder 2010: Introduction / 대한정신약물학회지

OBJECTIVE: Psychopharmacological treatment of bipolar disorder is quite complex because of its clinical features of different episodes and various course. We published Korean Medication Algorithm Project for Bipolar Disorder (KMAP-BP) in 2002, that appeared to be helpful in clinical situation by feasibility study in 2005, and revised KMAP-BP in 2006. New papers in which some drugs are effective in treating bipolar disorder have been published, and the demand for revision of KMAP-BP are increased. METHODS: The questionnaire was sent to 94 experts, 65 of whom replied. It was composed of 40 questions about clinical situations, and each question includes various sub-items. Based on KMAP-BP 2006 and new data, some questions sub-items are amended. Safety issues and consideration on special populations were added in this revision. Each option was categorized on three parts (the first-line, the second-line, or the third-line) by its 95% confidence interval. RESULTS: In acute manic episode, even though it is euphoric, mixed, or psychotic, combination of a mood stabilizer (MS) with an atypical antipsychotic (AAP) is recommended as first-line strategy. Mood stabilizer monotherapy is first-line in hypomanic episode. Among the mood stabilizers, valproic acid and lithium are selected as first-line. Monotherapy with mood stabilizer is recommended in mild to moderate bipolar depression. However, triple combination of a mood stabilizer, an atypical antipsychotic and an antidepressant (AD), is the first-line strategy in non-psychotic severe depression. Also combination of MS and AAP (MS+AAP) and combination of MS and AD (MS+AD) are recommended as first-line. In psychotic bipolar depression, combination of MS, AAP, and AD (MS+AAP+AD), combination of MS and AAP (MS+AAP), and combination of AAP and AD (AAP+AD) are first-line strategies. In bipolar depression, lithium, lamotrigine, and valproic acid are selected as first-line mood stabilizer, and quetiapine, olanzapine and aripiprazole are preferred antipsychotics. Bupropion and (es)citalopram are first-line antidepressant in moderated depression, and (es)citalopram, bupropion, and paroxetine are recommended as firstline in severe depression. Preferred strategy for rapid cycling patients is combination of MS with AAP. In maintenance treatment, combination of MS with AAP and monotherapy of MS are recommended as first-line. CONCLUSION: In treating bipolar disorder, even the first step of treatment, consensus of experts are changed from our studies in 2002 and 2006. This medication algorithm, with some limitations, may reflect the clinical practice and recent researches.

Korean Medication Algorithm Project for Generalized Anxiety Disorder 2009 (II) : Medication Algorithm & Long-Term Medication Treatment Strategy / 신경정신의학

OBJECTIVES: This study was performed to investigate the consensus about medication algorithms, including long-term medication treatment strategies, in the treatment of generalized anxiety disorder (GAD). METHODS: The executive committee of the Korean Medication Algorithm Project for GAD developed questionnaires about the psychopharmacologic treatment strategies for patients with GAD. Fifty-five (65%) of 84 experts of a reviewing committee answered the questionnaires. The consensus of expert opinion was classified into three categories, and the treatments of choice were selected by use of 95% confidence intervals and chi-square-tests. RESULTS: The consensus on the first-line treatment strategy for GAD was as follows. Step 1 is the use of the one of a selective serotonin reuptake inhibitor (SSRI), a serotonin and noradrenaline reuptake inhibitor (SNRI) and buspirone for at least four to six weeks. Step 2 is to switch from a SSRI to a SNRI or buspirone or vice versa. Step 3 is to augment medication with an atypical antipsychotic or add a benzodiazepine or antihistamine. Step 4 is to switch to another combination, which includes a SSRI, a SNRI, mirtazapine or a tricyclic antidepressant Step 6 is to review the diagnosis, and 'benzodiazepines including clonazepam and alprazolam can be combined with another drug even from the initial period'. In terms of long-term medication treatment, the consensus first-line tr-eatment strategy involved the use of venlafaxine XR, escitalopram, fluoxetine, paroxetine CR, sertraline and buspirone. CONCLUSION: This study provided information about the consensus among Korean experts regarding medication algorithms, including long-term medication treatment strategies, in the treatment of GAD.

Korean Medication Algorithm for Depressive Disorder 2006 (I) / 신경정신의학

OBJECTIVES: Since the publication of Korean Medication Algorithm Project for Major depressive Disorder (KMAP-MD) in 2002, there has been a substantial need for a revision due to rapid progress in the pharmacological management for depressive disorder. We revised KMAP-MD to Korean Medication Algorithm Project for Depressive Disorder (KMAP-DD) in 2006. This paper is one of the following 4 papers consisting of Korean pharmacological algorithm for depressive disorder. METHODS: The questionnaire consisted of 4 parts; initial treatment of 1) non-psychotic depressive disorder, 2) psychotic depressive disorder, 3) treatment strategy for clinical subtypes and drug choice considering adverse effects, and 4) treatment for depressive disorder in women. It was composed of 22 questions, and each question had 54 sub-items. The questionnaire was completed by the review committee consisting of 101 experienced Korean psychiatrists. We classified the expert opinion to 3 categories (the first-line, the second-line, or the third-line). RESULTS: For non-psychotic major depression, regardless of the severity of an episode, the antidepressant (AD) monotherapy was the optimal first-line treatment. SSRI, venlafaxine, and mirtazapine were the 1st-line AD. In case of a partial or no response to initial strategy, adding another AD was recommended. For psychotic major depression, combination of an AD and an atypical antipsychotic (AAP) was the treatment of choice. Among AAPs, quetiapine, risperidone, olanzapine were preferred. For non-responder to initial strategy, the next step was adding or changing AD before changing AAP. For women with premenstrual dysphoric syndrome or postpartum depression without psychotic features, AD monotherapty was a preferred strategy while for psychotic postpartum depression, combination of AD and AAP was recommended. Experts recommended various ADs according to adverse effect. CONCLUSION: These results suggest that the medication strategies for depressive disorder are rapidly changing and reflect the recent studies and clinical experiences.

Korean Medication Algorithm for Depressive Disorder 2006 (III): Major Depressive Episode with Psychotic Feature / 신경정신의학

OBJECTIVES: Since the publication of Korean Medication Algorithm Project for Major Depressive Disorder (KMAP-MD) in 2002, there has been a substantial need for a revision due to rapid progress in the pharmacological management of depressive disorder. We revised KMAP-MD 2002 and developed the Korean Medication Algorithm Project for Depressive Disorder (KMAP-DD) 2006. METHODS: We developed a questionniare for surveying the opinion of experts on pharmacotherapy of depressive disorder. The questionnaire consisted of 4 parts; 1) treatment of non-psychotic depressive disorder, 2) treatment of psychotic depressive disorder, 3) treatment according to clinical subtypes and drugs choice considering adverse effects, and 4) treatment of depressive disorder in women. The questionnaire was completed by the review committee consisting of 101 experienced Korean psychiatrists. It is composed of 22 questions, and each question includes 54 sub-items. We classified the expert opinion to 3 categories (the first-line, the second-line, or the third-line) by Chi2-test. RESULTS: For depressive disorder with psychotic features, most reviewers prefer the combination of antidepressant and atypical antipsychotics. Electroconvulsive therapy and the combination of antidepressant and typical antipsychotics were the second-line treatment. Among antidepressants, venlafaxine was the most preferred, and SSRI and mirtazapine followed. Among atypical antipsychotics, quetiapine, risperidone and olanzapine were the most preferred, in this order. In patients who have no response to the first-line treatment, many reviewers recommended switching to another antidepressant or adding another atypical antipsychotics. CONCLUSION: For severe depressive disorder with psychotic features, the combination of antidepressant and atypical antipsychotics was preferred for the first-line treatment. These results suggest that the medication strategies of depressive disorder are rapidly changing and reflects the recent studies and clinical experiences.

Korean Medication Algorithm for Depressive Disorder 2006 (IV): The Choice of Antidepressant According to the Subtypes of Depression, Adverse Effects of Antidepressant and Treatment Strategies in Women / 신경정신의학

OBJECTIVES: In 2002, the Korean Medication Algorithm Project for Major depressive Disorder (KMAP-MD) was published, but there has been a need for a guideline about detailed issues of depressive disorder. We revised KMAP-MDD and reestablished Korean Medication Algorithm Project for Depressive Disorder (KMAP-DD) in 2006. METHODS: A questionnaire had been developed by the executive committee for KMAP-DD. The review committee consisted of 101 experienced psychiatrists. From the total of 22 questions in the questionnaire, 7 questions were evaluated for these subjects . We classified the expert opinions to 3 categories according to its confidence interval; first, second and third line. RESULTS: SSRI and venlafaxine were the first line antidepressants (AD) for atypical and melancholic depression. For dysthymic disorder and minor depressive disorder, SSRI was recommended as the first line medications. Only AD medications was a preferred initial strategy for treating premenstrual dysphoric disorder, mild to moderate and severe non-psychotic postpartum depression. In severe psychotic postpartum depression, combination therapy of AD and atypical antipsychotics was the treatment of choice. SSRI was preferred when considering sedation, anticholinergic and cardiovascular adverse effects. Also, experts recommended mirtazapine against gastrointestinal adverse effects and bupropion in avoiding sexual dysfunction. CONCLUSION: These results suggest that clinicians have to consider both clinical situations and drug adverse effects in the choice of antidepressant medications.

The Feasibility Test of Korean Medication Algorithm for the Treatment with Schizophrenic Patients(III): The Influence of Therapeutic Environment on Application of Korean Medication Algorithm Project for Schizophrenia / 대한정신약물학회지

OBJECTIVE: Korean Medication Algorithm Project(KMAP) for schizophrenia was started in 2001. Phase II of this algorithm project for schizophrenia was a feasibility trial and was done to investigate suitability of the algorithm. The purpose of this paper was to evaluate the influence of the therapeutic environment in application of Korean medication algorithm project for schizophrenia. METHOD: A total 108 schizophrenic patients were enrolled at 16 general hospitals and at 3 mental hospitals. All subjects were treated and evaluated according to the algorithm. After the application of the algorithm, clinical effects, switching tendency of antipsychotics and degree of satisfaction for algorithm were compared between general hospitals and mental hospitals. RESULT: There were no significant demographic differences in the two hospital groups. But, cognitive and obsessive symptoms were significantly more severe in mental hospital patients. In general hospital, transitions between each treatment stages were more frequent than in mental hospital. After 4 months of antipsychotic medications trial, most patients were still in the stage 1 (83.3%) in mental hospital group compared to 51.85% of patients in general hospital group. After 4 months of algorithm trial, changes in PANSS (32.85+/-18.87) and CGI (3.47+/-1.81) in general hospital group were significantly greater than those in mental hospital group. Necessities of treatment algorithm were more emphasized by clinician working at the mental hospitals. Overall, degrees of satisfaction for treatment algorithm were not significantly different between two hospital groups. CONCLUSION: These results could be due to the different characteristics of patients or therapeutic environment between the two groups. Also, the resources needed to implement the algorithm may be different between the two groups. To use the Korean Medication Algorithm for schizophrenia with treatment as usual, the difference between therapeutic environments should be considered.

Korean Medication Algorithm for Bipolar Disorder 2006(III): Depressive Episode / 대한정신약물학회지

OBJECTIVE: In 2002, the Korean Medication Algorithm Project for Bipolar Disorder (KMAP-BP 2002) was published to make clinical guidelines to understand and treat bipolar disorder, but due to recent reports of various studies and application of new drugs, the revision of treatment algorithm was inevitable. Therefore, we revised the KMAP-BP 2002 focused on the treatment strategies of bipolar depression. METHOD: The methods of this survey were similar to those of the KMAP-BP 2002. The review committee consisted of 70 experienced psychiatrists. Among the total 37 questions, 15 questions for bipolar depression were evaluated. We classified the expert opinions to 3 categories according to its confidence interval; first, second, and third line. Results: Compared to the previous algorithm, combination of mood stabilizers (MS) or atypical antipsychotics (AAP) and antidepressants is generally more recommended than antidepressant monotherapy for bipolar depression. Lithium and divalproex are the first-line treatment choices as well as MS. The preference for lamotrigine is increased, while that for carbamazepine is decreased. Olanzapine and quetiapine are preferred as the first-line AAP. Most antidepressants are not recommended as the first-line drug. The strategy for breakthrough of depression is changed into adding an antidepressant and/or AAP after combination of 2 MS. CONCLUSION: These results suggest that treatment of bipolar depression should be different from that of unipolar depression. The advanced new algorithm is considered to be useful and practical in the treatment of bipolar depression.

Korean Medication Algorithm for Bipolar Disorder 2006(IV): Rapid Cycling / 대한정신약물학회지

OBJECTIVE: The development of treatment guidelines has emerged as an important element so as to standardize treatment and to provide clinicians with algorithms. From the previous publication of Korean Medication Algorithm Project for Bipolar Disorder (KMAP-BP): rapid cycling in 2002, we revised that in 2006. METHODS: The questionnaire to survey the expert opinion of medication for rapid cycling was completed by the review committee consisting of 53 experienced Korean psychiatrists. It is composed of 7 questions, and each question includes various options. We classified the expert opinion to 3 categories based on the lowest category in which the confidence interval fell (6.5 < or = for first-line and 3.5< or = for second-line treatment). RESULTS: Generally, 'treatment of choice' for rapid cycling was not demonstrated. The first-line treatment is the combination of a mood stabilizer and an atypical antipsychotic. Combination of two mood stabilizers was preferred as next strategy. Divalproex and lithium were the first-line choice as mood stabilizer. Compared to the surveys in 2002, the preference for lamotrigine and atypical antipsychotics has increased while that of carbamazepine and antidepressant has decreased. CONCLUSION: With the result of the survey, the discussion in executive committee, and the evidences from clinical studies, we have revised KMAP-BP for rapid cycling.

The Feasibility Test of Korean Medication Algorithm for the Treatment with Schizophrenic Patients(I): Analysis Focusing on the Effectiveness of Treatment / 대한정신약물학회지

OBJECTIVES: The Korean College of Neuropsychopharmacology and the Korean Academy of Schizophrenia developed the Korean algorithm project for schizophrenia to aid clinical decisions. The purpose of this study was to assess the feasibility of Korean Medication Algorithm for Schizophrenia patients in clinical settings in Korea. METHODS: A total of 108 schizophrenia and schizophreniform disorder patients were enrolled at 19 centers and treated according to the algorithm. PANSS (Positive and Negative Symptom Scale) and CGI (Clinical Global Impression) were used to evaluate symptom severity. Also UKU (UKU side effect rating scale) and LUNSERS (Liverpool University Neuroleptic Side Effect Rating Scale), DAI-10 (Drug Attitude Inventory-10), PPS (Patient Preference Scale), SWN (Subjective Well-Being under Neuroleptic treatment) and WHOQOL (World Health Organization Quality of Life) were used to evaluate tolerability and satisfaction of patient respectively. RESULTS: Overall ratings including symptom severity, compliance of medication, side effect of medication, quality of life were favorable. The treatment response (PANSS improvement > or = 20%) rate was 63%, 75% at the first Clinical decision point (CDP) and 4 month respectively. CONCLUSION: Symptom improvement, tolerability and quality of life were all favorable. These results suggest that this algorithm can be useful in clinical practices.

The Feasibility Test of Korean Medication Algorithm for the Treatment with Schizophrenic Patients(II): The Problem for Applying Algorithm to the Real Clinical Situation and Opinion of Revision / 대한정신약물학회지

OBJECTIVES: The Korean College of Neuropsychopharmacology and the Korean Academy of Schizophrenia developed the Korean medication algorithm project for schizophrenia (KMAP) to aid clinical decisions. The purpose of this study was to investigate problems and revision of Korean Medication Algorithm for Schizophrenia after feasibility test. METHODS: A total of 108 schizophrenia patients were enrolled at 19 centers and treated according to the algorithm. Prescribing investigators were able to change the recommended treatment strategies of the algorithm if necessary. All subjects were assessed over a 4-month period. Appropriateness of choice, dosage, duration and switch of antipsychotics and definition of treatment response were examined. RESULTS: Compliance of 1(st) choice antipsychotics in KMAP was favorable. Atypical antipsychotics which is a 1(st) stage drug selected first was above 84%, especially in case of no previous medical history was nearly all. In case that shift of stage was needed, there is a trend that combination treatment stage (6(th) stage) and clozapine treatment stage (5(th) stage) were preferred to rather than 3(rd) stage and 4(th) stage (typical antipsychotics and atypical antipsychotics treatment stage). The rates of switching antipsychotics at the time points other than CDP (critical decision points) was low and the reason was almost the side effects. So the compliance of CDPs in KMAP was good in case of insufficiency of treatment response. Also the reasons why many investigators continued using current antipsychotics without switching despite insufficiency of treatment response were definition of treatment response, discrepancy between brief symptom rating scale for negative symptom and decision of clinicians. In addition, compliance of co-existence symptoms and side effect of medication in KMAP was favorable. CONCLUSION: It is some difference from clinical practice such as stage of antipsychotics, definition of treatment response and usefulness of brief symptom rating scale for negative symptom. But the majority apart from points of preceding paragraph is feasible in clinical practice. These results are essential to revise the next version of KMAP.

Korean Medication Algorithm for Bipolar Disorder 2006(I) / 대한정신약물학회지

OBJECTIVE: Since the publication of Korean Medication Algorithm Project for Bipolar Disorder (KMAP-BP) in 2002, there has been a substantial need for the revision due to rapid progress in the management for bipolar disorder. We revised KMAP-BP in 2006. METHODS: The questionnaire to survey the expert opinion of medication for bipolar disorder was completed by the review committee consisting of 53 experienced Korean psychiatrists. It is composed of 37 questions, and each question includes various sub-items. A part regarding treatment strategies for hypomanic episode and maintenance was newly investigated in this revision. We classified the expert opinion to 3 categories (the first-line, the second-line, or the third-line) by chi-square-test. RESULTS: For acute manic episode, the combination of a mood stabilizer (MS) and an atypical antipsychotic (AAP) is the optimal first-line treatment. Most reviewers recommended divalproex or lithium as a MS. Among AAPs, olanzapine, quetiapine and risperidone were most preferred. On breakthrough manic episode, the optimization of MS or adding AAP was recommended. For moderate bipolar depressed patients, a MS monotherapy or MS with an antidepressant was preferred. Combination of a MS and an antidepressant was recommended as a first-line treatment in severe non-psychotic depression. MS with an AAP and the triple combination of MS, AAP and an antidepressant were recommended for severe bipolar depression with psychotic features. Lithium and divalproex were the first-line choice as MS. Most antidepressants were recommended as a second-line drug. The strategy for breakthrough depression was changed to adding antidepressant after combination of two MS. The combination therapy (MS+AAP or MS+MS) was the most preferred treatment for rapid cycling bipolar patients. There was no 'treatment of choice' in maintenance treatment. In case of bipolar I mania without history of depression, a MS monotherapy was a firstline treatment. In maintenance management for bipolar II disorder, a MS monotherapy or the combinations of a MS and an AAP was preferred. Overall, the preference for lamotrigine and AAP was increased compared to the KMAP-BP 2002. Olanzapine and quetiapine were preferred as the first-line AAP. The carbamazepine and typical antipsychotics were markedly less favored in KMAP-2006 than KMAP-BP 2002. CONCLUSION: These results suggest that the medication strategies of bipolar disorder are rapidly changing and it reflects the recent studies and clinical experiences.

Korean Medication Algorithm for Bipolar Disorder 2006(II): Manic Episode / 대한정신약물학회지

OBJECTIVE: As clinician, it is very difficult to choose the pharmacotherapeutic strategies of bipolar disorder because of various clinical feature according to each episode, recurrence, breakthroughs, treatment resistance, switching and worsening of its course. Recently, rapid development in the research of bipolar disorder and psychopharmacology, including atypical antipsychotics and new anticonvulsants, make it more difficult to choose the appropriate pharmacological options. Therefore, we decided to revise the Korean Medication Algorithm Project for Bipolar Disorder 2002 (KMAP-BP 2002) in order to provide more proper guideline for clinicians. METHODS: Like the previous version, KMAP-BP 2002, we performed the first survey using questionnaire comprising 37 special clinical situations and 645 selection items. Fifty-three members of the review committee completed the first survey. After the discussion of the results at the review committee meeting, we performed the second adjunctive survey. Finally, the executive committee analyzed the results and discussed the final production of algorithm considering scientific evidences. RESULTS: The first-line pharmacotherapeutic strategy for acute manic episode is combination of mood stabilizer and atypical antipsychotics, monotherapy of mood stabilizer, or monotherapy of atypical antipsychotics. As mood stabilizers, divalproex and lithium are accepted as the first-line agents. As atypical antipsychotics, quetiapine, olanzapine and risperidone are recommended as the first-line. Overall, atypical antipsychotics and combination therapy are accepted more widely than before. Among mood stabilizers, the preference of divalproex are increasing and that of carbamazepine are decreasing. CONCLUSION: Based on the results of two surveys, the discussion in executive committee and review of evidences, we developed new algorithm presented here for manic episode. We expect this algorithm may provide clinicians good informations and advices about the treatment of bipolar disorder, manic episode.

Feasibility of Korean Medication Algorithm for Bipolar Disorder(I): Global Assessment / 대한정신약물학회지

OBJECTIVE: The Korean College of Neuro psychopharmacology and the Korean Academy of Schizophrenia developed the Korean algorithm project for bipolar disorder to aid clinical decisions. The purpose of this study was to assess the feasibility of Korean Medication Algorithm for Bipolar Disorder (KMAP-BP) in clinical settings in Korea. METHODS: A total of 126 bipolar patients were enrolled at 17 centers. Among them, 92 patients were treated according to the algorithm. All subjects were assessed over a 4-month period. Prescribing investigators were able to change the recommended treatment strategies of the algorithm if necessary. RESULTS: Overall ratings were favorable, with investigators stating that the overall quality of this algorithm was "good" or "no need to revise". Of manic patients, the majority (79%) showed treatment response (YMRS improvement > or =50%) at the first stage. CONCLUSION: These results suggest that this algorithm can be useful in clinical practices. However, some problems should be solved in the next version of KMAP-BP.

Feasibility of Korean Medication Algorithm for Bipolar Disorder(IV): Quality of Life / 대한정신약물학회지

OBJECTIVE: The Korean College of Neuropsychopharmacology and the Korean Academy of Schizophrenia developed the Korean Medication Algorithm Project for Bipolar Disorder (KMAP-BP) as a reference for clinical decisions. The purpose of this study was to investigate the effects of pharmacological treatments with the KMAP-BP on quality of life in patients with bipolar disorder. METHODS: Brief Form of World Health Organization Quality of Life assessment (WHOQOL-BREF), at baseline and 4 months after treatment, was used to evaluate the quality of life in this study. Also Young Mania Rating Scale (YMRS), Hamilton Rating Scale for Depression (HAM-D), Global Assessment of Functioning (GAF), and two scales of Clinical Global Impression (CGI-S, CGI-I) were rated by clinicians. Data from 76 of 92 bipolar patients, treated according to the algorithm, were attained at baseline, 55 at 4 months after treatment, and 47 at both. RESULTS: It was found that the treatments following the KMAP-BP for 4 months could not make improvement in all 4 domains of WHOQOL-BREF. There was no difference in change of QOL domains after treatment according to some variables such as sex, age, age of onset, age of first treatment, clinical feature of mania, and so on. Compared with mania, in which quality of life was aggravated a little after treatment, all domains of WHOQOL-BREF were improved in bipolar depressed patients. The improvement of YMRS score had a negative correlation with physical health domain. The decrease in HAM-D score was correlated positively with improvement in physical health and psychological domains. But there was no correlation between increase in quality of life and the improvement of GAF, CGI-S, and CGI-I scores. CONCLUSION: Quality of life was not improved in bipolar patients at 4 months after treatment, in which the KMAP-BP was applied. But it did not mean that the application of the algorithm to treat bipolar patients was not effective. Because their functions were not recovered yet, even though the symptoms were remitted. Long-term follow-up studies using various tools to estimate the quality of life are needed.

Korean Medication Algorithm for Bipolar Disorder: Revision and Further Suggestion / 대한정신약물학회지

The algorithms and guidelines are a synthesis of current scientific evidences with clinical issues of safety and tolerability. It is inevitable that pharmacological strategies of psychiatric treatment have to be based on evidence-based medicine. The first Korean Medication Algorithm for Bipolar Disorder was developed from the information and opinions gathered by wide surveys to Korean psychiatrists and then, in the first time, its feasibility study was done. The problems on appropriateness of the shift of step, full education of algorithm administration and procedure before implementation, and easy applicability of measuring scales were found. These problems must be fully considered for algorithm implementation in the near future. Rapid updates on new evidences of therapeutic effects of drugs and recent trends of diagnostic concepts about bipolar disorder may justify revision of the medication algorithm. Especially, addition of widespread use of novel antipsychotics in all phases of illness, evidences of new anticonvulsants' effects, and change of strategies in the acute depression and maintenance treatments will have to be considered. Moreover, modification of questionnaire for algorithm revision will be needed in the aspect of easy implementation.