Clinical Predictors of Drug Response in Patients with Obsessive-Compulsive Disorder

OBJECTIVE: The aim of this study was to evaluate which clinical variables might influence the antiobsessional responses to proserotonergic drugs in a sample of patients with obsessive-compulsive disorder (OCD). METHODS: Two hundred forty-nine patients with DSM-IV OCD under-gone mean 13-month treatments with selective serotonin reuptake inhibitors. According to the treatment response, defined as a reductions of the Yale-Brown Obsessive Compulsive Scale (Y-BOCS) total score > or =35%, patients were divided into two groups. RESULTS: One hundred fourteen patients responded to the treatment and the other one hundred thirty five patients did not. Responders had a significant long duration of medication in YUMC OCD clinic, short total duration of past treatment in other institutes, and higher frequency of drug naive cases and lower baseline Y-BOCS scores. CONCLUSION: The pre-treatment factors including total duration of past treatment, drug naive or not, baseline OCD symptoms and the factor of duration of the treatment may influence drug treatment response in OCD patients.

Modern Psychiatric Understanding of the Psychopathology of Psychosis in Oriental Medicine / 신경정신의학

OBJECTIVES: Oriental medicine has affected the way in which Koreans seek psychiatric help and how they understand psychiatric symptoms and mental illnesses. In this study, we investigated the concept of psychosis in traditional oriental medicine and compared it with how modern western medicine understands the same concept. METHODS: We searched for descriptions of psychotic symptoms or illnesses in traditional medical documents of various periods. Four psychiatrists then analyzed the contents of these descriptions in terms of DSM-IV. RESULTS: The concept of psychosis in oriental medicine has two symptom domains: positive and negative symptoms, which are similar to the positive and negative symptoms of schizophrenia in modern psychiatry. However, there were differences in the basic concepts of disease entities and in the approaches to the illness. CONCLUSION: This descriptive study showed that, in oriental medicine, psychopathology is based on oriental philosophy, and that this creates wide differences between oriental and western medicine.

Erratum: Modern Psychiatric Understanding of the Psychopathology of Psychosis in Oriental Medicine / 신경정신의학

No abstract available.

The Characteristics of Suicide Attempts and Psychosocial Risk Factors in Correctional Institutions / 신경정신의학

OBJECTIVES: Suicide is one of the most common causes of deaths in correctional institutions. This study aimed to examine the characteristics of suicide attempts and its related psycho-social factors in correctional institutions. METHODS: This study examined the characteristics of 101 suicide attempts from 2006 to 2007 in the two regional correctional headquarters. Thirty-seven male inmates (43 suicide attempts) and 40 matched controls were included in interviews and reviews of personal records. Psychiatric illnesses were examined using the Structured Clinical Interview for DSM-IV and medical outcomes of their suicide attempts with the Lethality Scale of Diagnostic Interview for Genetic Studies. RESULTS: Over a half of suicide attempts occurred in solitary cells and the most common method was hanging. Medically, 70% of the suicide attempts were more than severe. Poor social support, a lifetime history of suicide attempts, and incarceration were associated with suicide attempts. Additionally, psychiatric illnesses were more likely to increase the risk of suicide. CONCLUSION: This study implies that mental health issues and monitoring systems are important to reduce suicides in the correctional system. Regular checks and management of suicide risk and mental illness are crucial to prevent suicide in correctional institutions.

Cognitive Deficits Associated with Posttraumatic Stress Disorder / 신경정신의학

OBJECTIVES: In addition to the main symptoms of posttraumatic stress disorder (PTSD), which include reexperience, avoidance and hyperarousal, many patients complain of cognitive deficits and especially in attention and memory. This study was conducted to evaluate the cognitive deficits of survivors of a tragic shooting incident at a frontline guard post. All of the survivors experienced the same accident, and they were homogeneous in terms of age and education level, which are closely associated with cognitive performance. METHODS: We recruited 12 survivors who suffered from PTSD following the same traumatic incident and we also recruited 12 normal volunteers, and we assessed their neurocognitive functions with using a vigilance test, a continuous attention test, a reaction unit test and the Corsi block tapping test in the computerized Vienna Test System, as well as an auditory verbal learning test and complex figure test in the Rey-Kim Memory Test. Standardized clinical scales, including the Clinician-Administered PTSD Scale, the Hamilton Depression Rating Scale, the Hamilton Anxiety Scale and the State-Trait Anxiety Scale I and II, were used to assess the involved mental areas and the severity of the PTSD symptoms. RESULTS: The patient group showed significant impairments in continuous attention, and the visual and auditory information processing time on the Vienna test when compared to the control group. The patient group also showed significant impairments in the verbal memory, visual memory and visuospatial function on the Rey-Kim Memory Test. CONCLUSION: In this study, the author reports on the cognitive impairments in patients with PTSD as measured by computerized neurocognitive tests and memory tests. Future studies are needed to determine the changes in cognitive functioning that are related to symptom improvement, as well as the influence of the therapeutic effects on the cognitive improvement.

Association Study between Obsessive-Compulsive Disorder and Val-158-Met Catechol-O-Methyltransferase Gene Polymorphism in Korea / 신경정신의학

OBJECTIVES: The definite cause of obsessive-compulsive disorder (OCD) is still unknown. Evidences from familial, twin and segregation studies support the role of a genetic factor. There are also growing evidence indicating that OCD has specific neurochemical and neuroanatomical basis. Derived from the effectiveness of treatment with dopamine receptor blocker in certain part of OCD patients (eg. SSRI treatment-resistant OCD), several candidate genes related to dopamine dysregulation have been hypothesized to play an important role in the development of OCD. One of them is the Catechol-O-Methyltransferase (COMT) gene. The aim of this study was to investigate the association between COMT and OCD in Korean population. METHODS: 124 OCD patients and 170 normal controls participated in this study. Genomic DNA was extracted from their blood. The genotypes and allele frequencies of the COMT polymorphism between OCD group and control group were compared. We investigated the association between severity of OCD assessed by Yale-Brown obsessive compulsive symptom scale (YBOCS) and Hamilton depression rating scale (HDRS) scores and COMT polymorphism. RESULTS: In this case-control study, we could not find any association between COMT gene polymorphism and development of OCD. In OCD group, patients with H/H genotype had significantly higher scores for the HDRS than those with H/L or L/L genotype. CONCLUSION: In this study, there was no difference in genotype distributions of COMT between OCD and control groups. However, H/H genotype of COMT gene polymorphism might be related to depressive symptoms in OCD patients.

Lack of Association between Polymorphisms of the Dopamine Receptor D4 and Dopamine Transporter Genes and Personality Traits in a Korean Population

Human personality traits have a considerable genetic component. Cloninger et al. were the first to postulate that certain personality traits, such as novelty seeking, are related to the dopamine neurotransmitter system. In this study, we investigated the associations between dopamine receptor D4 (DRD4) exon III and dopamine transporter (DAT1) polymorphisms and personality traits. The DRD4 and DAT1 gene polymorphisms were genotyped in 214 healthy Korean subjects, whose personality traits were assessed with the Temperament and Character Inventory (TCI). There were no significant differences between scores of TCI temperament dimensions (novelty seeking, harm avoidance, reward dependence, and persistence) and DRD4 gene polymorphism. The DAT1 gene polymorphisms also showed no significant association with any of the temperament subscales of the TCI. These data suggest that DRD4 and DAT1 gene polymorphism may not associated with personality traits in a Korean population.

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.

The Feasibility Test of Korean Medication Algorithm for the Treatment with Schizophrenic Patients(IV): Influences of a History of Antipsychotic Treatment on Effectiveness and Algorithm Application / 대한정신약물학회지

OBJECTIVE: The Korean Medication Algorithm for the Treatment of Schizophrenia was developed by the extensive review and questionnaires. To evaluate the impact of a history of antipsychotic treatments on clinical response and algorithm application, using the data derived from the feasibility study of the Medication Algorithm for patients with schizophrenia. METHOD: Outcomes of treatment with the Medication Algorithm for 108 schizophrenics up to 4 months are presented. Measures of changes included clinical symptoms, functioning, and side effects. Comparison was done between patients with and without a history of antipsychotic treatments. RESULTS: 100 individuals (with a history=71 ; without a history=29) were analyzed for the comparison. Most of subjects without a history of antipsychotic treatments were administered on risperidone in the initial treatment. When compared with the subjects with a treatment history, the subjects without a history showed better treatment effects on clinical symptoms at the first evaluation. At 4-month, there were similar effects between the two groups except negative symptoms, in which the group with a history showed significantly more improvement than without a history. There were no significant differences in assessment of subjective opinion and well-being to drugs and quality of life, and objective evaluation of drug side effects. Among the subjects with a history, the ones starting with stage 1 showed higher positive symptoms, anxiety scores, and briefer duration of antipsychotic exposure than the ones starting with stage 2 or more advanced. CONCLUSION: This study suggests that despite some limitation, an antipsychotic treatment history may have an impact on application of medication algorithm and these data will be helpful for revision of the Medication Algorithm for the Treatment of Schizophrenia.

Association between Obsessive-Compulsive Disorder and Serotonin Transporter Gene Polymorphism / 신경정신의학

OBJECTIVES: The definite cause of obsessive-compulsive disorder (OCD) is still unknown. Evidences from familial, twin and segregation studies support the role of a genetic factor. There also are growing evidences indicating that OCD has specific neurochemical and neuroanatomical basis. Derived from the effectiveness of serotonin reuptake inhibitors in OCD treatment, several candidate genes related to serotonin regulation have been hypothesized to play on important role in the development of OCD. One of them is the serotonin transporter gene. The aim of this study was to investigate the association between serotonin transporter gene and OCD. METHODS: 124 OCD patients and 119 normal controls participated in this study. Genomic DNA was extracted from their blood. The genotypes and allele frequencies of the 5-HTTLPR polymorphism between OCD group and control group were compared. And we investigated the association between 4 factors derived from YBOCS checklists and 5-HTTLPR polymorphism. RESULTS: In this case-control study, we could not find any association between 5-HTRLPR polymorphism and development of OCD. In OCD group, patients with L (l/s+s/s) genotype had higher scores for the religious/somatic factor than those with S genotype. CONCLUSION: In this study, there was no difference in genotype distributions of 5-HTTLPR between OCD and control groups. But, L genotype of 5-HTTLPR polymorphism had negative effects on some factors of the obsessive-compulsive symptoms.

Association between Obsessive-Compulsive Disorder and Serotonin Transporter Gene Polymorphism / 신경정신의학

OBJECTIVES: The definite cause of obsessive-compulsive disorder (OCD) is still unknown. Evidences from familial, twin and segregation studies support the role of a genetic factor. There also are growing evidences indicating that OCD has specific neurochemical and neuroanatomical basis. Derived from the effectiveness of serotonin reuptake inhibitors in OCD treatment, several candidate genes related to serotonin regulation have been hypothesized to play on important role in the development of OCD. One of them is the serotonin transporter gene. The aim of this study was to investigate the association between serotonin transporter gene and OCD. METHODS: 124 OCD patients and 119 normal controls participated in this study. Genomic DNA was extracted from their blood. The genotypes and allele frequencies of the 5-HTTLPR polymorphism between OCD group and control group were compared. And we investigated the association between 4 factors derived from YBOCS checklists and 5-HTTLPR polymorphism. RESULTS: In this case-control study, we could not find any association between 5-HTRLPR polymorphism and development of OCD. In OCD group, patients with L (l/s+s/s) genotype had higher scores for the religious/somatic factor than those with S genotype. CONCLUSION: In this study, there was no difference in genotype distributions of 5-HTTLPR between OCD and control groups. But, L genotype of 5-HTTLPR polymorphism had negative effects on some factors of the obsessive-compulsive symptoms.

Development of Korean Version of Schizotypal Ambivalence Scale(K-SAS) / 신경정신의학

OBJECTIVES: The present study investigated the reliability and validity of Korean version of schizotypal ambivalence scale, which was developed to measure ambivalence in schizotypy, a latent personality organization that provides the liability for the development of schizophrenia. METHODS: The psychometric properties of the K-SAS in a sample of 348 normal healthy controls were obtained. Subjects with various range of age and education level of male and female were included in order to investigate the correlation of these demographic variables with the scores of K-SAS. RESULTS: The internal consistency of the scale was 0.85 and split-half reliability was 0.84. The factor analysis revealed four factors which were labeled as ambivalence on identity, decision, love and outcome, respectively. There were significant main effects for age, gender, and education level. In other words, being older, male, and having more years of education had negative effects on the scale score (p<0.05). These main effects were also valid after the interaction between these demographic factors was excluded through ANCOVA. CONCLUSION: The Korean version of schizotypal ambivalence scale was a valid tool for measuring ambivalence in schizophrenia. It was found that being older, male, and having more years of education had negative effects on the scale score, and these effects should be considered when using this scale.

Development of Korean Version of Schizotypal Ambivalence Scale(K-SAS) / 신경정신의학

OBJECTIVES: The present study investigated the reliability and validity of Korean version of schizotypal ambivalence scale, which was developed to measure ambivalence in schizotypy, a latent personality organization that provides the liability for the development of schizophrenia. METHODS: The psychometric properties of the K-SAS in a sample of 348 normal healthy controls were obtained. Subjects with various range of age and education level of male and female were included in order to investigate the correlation of these demographic variables with the scores of K-SAS. RESULTS: The internal consistency of the scale was 0.85 and split-half reliability was 0.84. The factor analysis revealed four factors which were labeled as ambivalence on identity, decision, love and outcome, respectively. There were significant main effects for age, gender, and education level. In other words, being older, male, and having more years of education had negative effects on the scale score (p<0.05). These main effects were also valid after the interaction between these demographic factors was excluded through ANCOVA. CONCLUSION: The Korean version of schizotypal ambivalence scale was a valid tool for measuring ambivalence in schizophrenia. It was found that being older, male, and having more years of education had negative effects on the scale score, and these effects should be considered when using this scale.

Association between Obsessive-Compulsive Disorder and Dopamine Receptor D4 Gene / 대한정신약물학회지

OBJECTIVE: The definite causes of obsessive-compulsive disorder (OCD) are still unknown. Evidences from familial, twin and segregation studies support the role of a genetic component in the etiology of OCD. There are growing evidences that OCD has specific neurochemical and neuroanatomical basis. It has been shown that serotonergic neurons play the predominant pathophysiological role in OCD. Recently, it has also been proposed that neurotransmitters other than serotonin play a role in the pathophysiology of OCD, and a series of studies have provided evidence that dopamine is involved in some OCD patients. Therefore, the aims of this study were to investigate the association between dopamine receptor D4 (DRD4) and OCD. METHODS: One hundred and fifteen OCD patients and 160 normal controls participated in this study. Genomic DNA was extracted from their blood. The genotypes and allele frequencies of the DRD4 polymorphism between OCD group and control group were compared. OCD patients were classified into early onset group (age of onset or =17) according to their onset age and the genotype and allele frequency were compared between two groups. Using principal component analysis, we had already derived 4 factors from 13 main contents of YBOCS checklist in the previous study and in this study, we investigated the association between these three factors and DRD4 genotypes. RESULTS: In this case-control study, we could find that the L-genotype frequencies of DRD4 were significantly higher in OCD than in normal control groups (chi2 test, p=0.04). There were no difference in genotype frequencies between early onset OCD group and late onset OCD group. In OCD group, patients with L-genotype had higher scores for the religious/somatic factor than the other groups (t test, p=0.009). CONCLUSIONS: The L-genotype of DRD4 may have negative effects on the development of OCD and religious/somatic factor of the obsessive-compulsive symptoms.

Validity and Reliability of the Korean Version of the Hamilton Depression Rating Scale(K-HDRS) / 신경정신의학

OBJECTIVES: The reliability and validity of the Korean version of Hamilton Depression Rating Scale (K-HDRS) were examined in Korean patients depressive symptoms. METHODS: 33 inpatients and 70 outpatients diagnosed as major depressive disorder or depressive episode of bipolar I disorder according to the DSM-IV criteria were assessed with K-HDRS, Clinical Global Impression score(CGI), Beck Depression Inventory (BDI) and Montgomery-Aberg Depression Rating Scale (MADRS). RESULTS: Internal consistency (Cronhach's alpha coefficeint=0.76) and interrater reliability (r=0.94, p<0.001) were statistically significant. Principal axis factoring analysis revealed 4 factors that accounted for 50.4% of the total variance. The correlations of K-HDRS with CGI, BDI and MADRS were 0.84, 0.54, 0.58 respectively. CONCLUSION: These results showed that the K-HDRS could be a reliable and valid tool for the assessment of depressive Korean patients. The K-HDRS will be a useful tool for assessing depressive symptoms in Korea.

The Clinical Meanings of the Hippocampal Metabolites of Female Patients with Major Depressive Disorder / 대한정신약물학회지

OBJECTIVE: Stress and elevated levels of glucocorticoids in patients with major depressive disorder (MDD) have been hypothesized to be associated with damage to the hippocampus. However the relationship between depression and hippocampal structure is unconfirmed. We investigated whether the chemical changes will occurr in the hippocampus of patients with MDD by using 1H-magnetic resonance spectroscopy (MRS) and explored the clinical meanings of hippocampal metabolites. METHODS: Fourteen female, right-handed patients with major depressive disorder and 12 healthy controls (age, sex, education and their dextrality matched) were included. We measured variables of time course of illness, severity of illness, levels of NAA, Cho and Cr in both hippocampus using 1HMRS. In addition, we performed neuropsychological tests in depressed subjects. RESULTS: There were no significant difference in the NAA/Cr, Cho/Cr, Cho/NAA between depressed and control subjects. In depressed subjects, significant negative correlations were observed between hippocampal NAA/Cr and duration of illness, duration of unmedication, severity of illness, respectively. Right hippocampal NAA/Cr was correlated with RCFT scores. CONCLUSION: These findings indicate damage to the hippocampus may not be a common feature in all depressed patients. However the results suggest that the illness burden and past treatment may influence hippocampal neurons and neuronal network in patients with MDD. Also, chemical changes in hippocampus may be associated with severity of illness and memory function.

Association between Serotonin Transporter Linked Promoter Region(5-HTTLPR) Polymorphism and Age of Onset of Obsessive-Compulsive Disorder / 대한정신약물학회지

OBJECTIVE: Many researches strongly suggest that early- and late-onset obsessive-compulsive disorder (OCD) represent separate subtypes of the disorder, possibly with distinct underlying pathogeneses. The aim of this study was to determine the association between 5-HTTLPR genotypes and the onset of OCD. METHODS: We recruited 124 OCD patients and classified them into an early-onset group (age of onset or= 18 years). From the blood, DNA was isolated using standard techniques and the 5-HTTLPR polymorphism was genotyped by polymerase chain reaction and electrophoresis. We classified the subject as s/s, s/l, and l/l group according to their genotype. We also combined the s/l and l/l genotypes (l allele non-carrier) and compared these with the s/s genotype (l allele non-carrier) for our analysis. Genotype and allele frequencies of early- and late-onset OCD were analyzed by chi-square statistics. RESULTS: The frequencies of s/l+l/l genotype and l allele in early-onset OCD group were significantly higher than late-onset OCD group. CONCLUSION: These results suggest that a 5-HTTLPR polymorphism is an important factor in the onset of OCD.

Polymorphisms in 5-HT1Dbeta Receptor Gene and Personality Traits in a Korean Population / 신경정신의학

OBJECTIVES: Recently, there has been a growing enthusiasm in biological approach to personality; the identification of genes responsible for particular personality traits. The aim of this study was to investigate the association between the 5-HT1Dbeta G861C polymorphism and personality traits. METHODS: We recruited 218 normal subjects. The Korean version of the Temperament and Character Inventory (TCI) was used to assess personality traits. From blood samples taken from the subjects, DNA was isolated using standard techniques and the HT1Dbeta G861C polymorphism was genotyped by means of polymerase chain reaction and Homogeneous MassEXTEND method. We classified the subject into the GG, CG, and GG groups according to their genotypes. The differences in the temperament factors of the TCI between homozygote group (GG+CC genotype) and heterozygote group (CG genotype) were tested. RESULTS: The heterozygote group had significantly lower Harm avoidance (HA) scores and higher Self-directedness scores (SD) than the homozygote group. CONCLUSION: In conclusion, we found some associations between the 5-HT1Dbeta G861C polymorphism and the personality dimension HA and SD in a normal population.

Effects of Mirtazapine on Hippocampal Metabolites of Female Patients with Major Depression / 대한정신약물학회지

OBJECTIVE: Recent studies suggested that the neurotrophic effects might be a major therapeutic mechanism of antidepressants. However, these effects have not been confirmed yet in depressed patients. We investigated whether mirtazapine treatment has the neurotrophic effects in depressed patient by using (1)H-MRS and explored the relationship between these effects and clinical improvements and neuropsychological functions. METHODS: Fourteen female, right-handed patients with major depressive disorder and 12 healthy controls participated in the study. Before the treatment with mirtazapine, we measured severity of illness, neuropsychological functions, and the levels of NAA, Cho and Cr in both hippocampi using (1)H-MRS in the depressed subjects. After the treatment with mirtazapine for 6 weeks, we repeated the measures of the pretreatment condition in the depressed subjects. We also measured variables of severity of illness and hippocampal metabolites with (1)H-MRS in the control group. RESULTS: There were no significant differences in NAA/Cr, Cho/Cr, and Cho/NAA between the depressed subjects and the control group. However, after the treatment with mirtazapine, there were significant improvements in severity of illness, immediate memory, and delayed memory. The posttreatment ratio of the total hippocampal Cho/Cr was significantly lowered than the ratio of the pretreatment Cho/Cr. However, the percent changes of the hippocampal Cho/Cr from the pretreatment Cho/Cr ratio were not correlated with the changes of severity of illness or neuropsychological functions from the pretreatment condition. CONCLUSIONS: These findings indicate that mirtazapine may reduce the level of choline metabolites by stabilizing the effect on the cholinergic neurons, reducing turnover or metabolism of neuronal membranes, or modulating the neuroendocrine systems in the depressed patients. However, this effect is not necessarily related to clinical improvements. Further studies on the therapeutic action of mirtazapine are needed.