Korean Guidelines for the Pharmacological Treatment of Social Anxiety Disorder: Initial Treatment Strategies

OBJECTIVE: The aim of the present study was to provide clinical consensus and evidence regarding initial treatment strategies for the pharmacological treatment of social anxiety disorder (SAD) in Korea. METHODS: We prepared a questionnaire to derive a consensus from clinicians regarding their preference for the pharmacological treatment of SAD in Korea. Data regarding medication regimens and psychotropic drugs used during initial treatment, the doses used, and the pharmacological treatment duration were obtained. Responses were obtained from 66 SAD experts, and their opinions were classified into three categories (first-line, second-line, third-line) using a chi-square analysis. RESULTS: Clinicians agreed upon first-line regimens for SAD involving monotherapy with selective serotonin reuptake inhibitors (SSRIs) or the serotonin-norepinephrine reuptake inhibitor (SNRI) venlafaxine, or combined therapy using antidepressants with betablockers or benzodiazepines on a standing or as-needed basis. First-line psychotropic drug choices for initial treatment included the following: escitalopram, paroxetine, sertraline, venlafaxine, and propranolol. The medication dosage used by domestic clinicians was found to be comparable with foreign guidelines. Domestic clinicians tended to make treatment decisions in a shorter amount of time and preferred a similar duration of maintenance treatment for SAD when compared with foreign clinicians. CONCLUSION: This study may provide significant information for developing SAD pharmacotherapy guidelines in Korea, especially in the early stage of treatment.

Correlation between Luteal Eating Behavior Symptom and Trait Anxiety in Premenstrual Dysphoric Disorder : A Preliminary Study / 신경정신의학

OBJECTIVES: The aim of this study was to examine the correlation between anxiety and premenstrual eating symptoms in premenstrual dysphoric disorder (PMDD). METHODS: A total of 49 women in the late luteal phase participated in this study. The psychiatric symptoms were assessed by Hamilton Rating Scale for Depression, State Trait Anxiety Inventory, and Menstrual Distress Questionnaire. Eating symptoms were assessed using the Dutch Eating Behavior Questionnaire and cocoa intake experiment. Estradiol, progesterone, and leptin were collected through venous blood. RESULTS: Participants with PMDD (n=25) showed a higher level of depression (p<0.001), trait anxiety (p=0.012), restrained eating symptoms (p=0.039), and leptin (p=0.015). Among PMDD patients in the luteal phase, trait anxiety showed correlation with emotional eating (p=0.023), alcohol (p=0.022), and unrestricted intake of cocoa (p=0.001). CONCLUSION: Our data suggest that PMDD subjects showed higher trait anxiety, depression, and difficulty in eating behavior control. Trait anxiety plays an important role in increased and uncontrolled eating symptoms during the premenstrual period and chronic course of PMDD.

Early Improvement in One Week Predicts the Treatment Response to Escitalopram in Patients with Social Anxiety Disorder: A Preliminary Study

OBJECTIVE: Social anxiety disorder (SAD) shows relatively delayed responses to pharmacotherapy when compared to other anxiety disorders. Therefore, more effective early therapeutic decisions can be made if the therapeutic response is predictable as early as possible. We studied whether the therapeutic response at 12 weeks is predictable based on the early improvement with escitalopram at 1 week. METHODS: The subjects were 28 outpatients diagnosed with SAD. The subjects took 10-20 mg/day of escitalopram. The results of the Liebowitz social anxiety scale (LSAS), Hamilton anxiety rating scale, and Montgomery-Asberg depression rating scale were evaluated at 0, 1, 4, 8, and 12 weeks of treatment. Early improvement was defined as a ≥10% reduction in the LSAS total at 1 week of treatment, and endpoint response was defined as a ≥35% reduction in the LSAS total score. The correlation between clinical characteristics and therapeutic responses was analyzed by simple linear regression. The correlation between early improvement responses and endpoint responses was analyzed by multivariate logistic regression analysis and receiver operating characteristic curves. RESULTS: When we adjusted the influence of a ≥35% reduction in the LSAS total endpoint score on a ≥10% reduction of the LSAS total score at 1 week of treatment for the patients' age, the early improvement group at 1 week of treatment was expected to show stronger endpoint responses compared to the group with no early improvement. CONCLUSION: The results suggest that a ≥10% reduction in the LSAS total score in a week can predict endpoint treatment response.

Depression, Attachment and Addiction Problems in Runaway Youths

OBJECTIVES: This study investigated the relationship between depression, attachment and addiction problems in runaway youths. METHODS: We sent a questionnaire package to 187 runaway youths in 18 adolescent shelters. The questionnaire package collected their sociodemographic data and included the Patient Health Questionnaire-9, Inventory of Parent Attachment (IPA), Korean Internet Addiction Self-Scale (K-Scale), Korean version of Alcohol Use Disorders Identification Test, and Korean version of the Fagerström Test for Nicotine Dependence. RESULTS: The percentage of youth with depression was 28.8% (N=54). In the depression group, there were significantly more problematic alcohol users (53.06%, p=.0199) and significantly lower IPA scores (p=.0064). There was a significant negative correlation between depression and a IPA, and significant positive correlation between depression and the K-Scale. CONCLUSION: These results suggest that runaway youths with depression have more problematic alcohol drinking and attachment problems.

The Effect of Group Musical Therapy on Depression and Activities on Daily Living in Patients with Cognitive Decline

BACKGROUND: Beside pharmacological treatment, non-pharmacological interventions are a great deal of interest resides on ways that allow modulation of brain plasticity in the elderly. Music therapy is a potential non-pharmacological treatment for the behavioral and psychological symptoms of dementia, but a few studies reported it to be helpful. The aim of this study was to evaluate the effect of structured musical intervention therapy in patient with cognitive decline. METHODS: The subjects of the study were a total of fifty elderly with cognitive decline (K-MMSE: 21+/-3.99, CDR: 0.80+/-0.38). The musical therapy was applied to the group twice a week, fifty minutes per session for eight weeks. The data were analyzed by using chi-square and paired t-test before and after musical intervention. RESULTS: The study showed a significant reduction in depression and anxiety after musical therapy measured with short form-GDS and BDI (p<0.001). Activities daily living (ADL) markedly improved after the all session of musical interventions (p<0.001). CONCLUSION: Group music therapy is a safe and effective method for treating depression and anxiety, and also improving ADL in patients with cognitive decline.

Comparison of Antidepressants Tolerability in Cancer Patients Referred for Psychiatric Consultation / 정신신체의학

OBJECTIVES: Many patients diagnosed with cancer suffer from various psychiatric symptoms such as depression, anxiety and insomnia as well as cancer itself. Patients with cancer are more vulnerable to possible adverse events of psychotropic medications. Although antidepressants are widely used among cancer patients, there is little information about tolerability of antidepressants. This study was conducted to compare tolerability of antidepressants in cancer patients referred for psychiatric consultation. METHODS: The participants were cancer patients who had been referred to psychiatrist for their psychiatric symptoms. We retrospectively analyzed the data of patients diagnosed with cancer from 9 general hospitals in Korea. The discontinuation rate for a 6 months period after treatment initiation for three antidepressants(Escitalopram, Mirtazapine, Paroxetine) were compared. RESULTS: Antidepressants were prescribed for 96.3% of subjects and Escitalopram 150(47.2%), Mirtazapine 92 (28.9%) and Paroxetine 76(23.9%) were prescribed frequently in order There were no significant differences in discontinuation rates among the three antidepressants during the 6 month period after initiation of pharmacotherapy. But there was a difference in discontinuation rates between inpatients versus outpatients(p<0.0001). CONCLUSIONS: In a naturalistic setting for the antidepressant treatment for cancer patients, it seems that there are no differences in discontinuation rates among these three antidepressants. It is therefore essential that such interactions are carefully considered when treating patients of antidepressants who already have cancer.

Clinical Characteristics and Use of Antidepressants among Cancer Patients Referred for Psychiatric Consultation : A Korean Multicenter Survey / 신경정신의학

OBJECTIVES: Antidepressants are frequently used for treatment of psychological distress among cancer patients. The aim of this study is to investigate the characteristics of psychiatric consultations and antidepressant use for cancer patients. METHODS: Participants in the study included cancer patients who had been referred for psychiatric consultation. A total of 488 patients were recruited from nine general hospitals in Korea. Questionnaires based on medical records, including antidepressants prescribed, were investigated by psychiatrists. RESULTS: The most common psychiatric diagnosis of subjects was depressive disorders (72.4%), followed by anxiety disorders (13.0%), and adjustment disorders (7.3%). Antidepressants were prescribed for 96.3% of subjects and escitalopram, mirtazapine, and paroxetine were prescribed frequently, in order. Anxiolytics and hypnotics were used for 58.2% of the subjects, for which lorazepam and alprozolam were preferred. During the study period, 226 (46.8%) subjects discontinued treatment and the most common cause was improvement of symptoms (123, 54.4%). CONCLUSION: Our results showed a tendency of prescription of antidepressants and anxiolytics and common psychiatric problems in Korean cancer patients. We suppose that these data would be helpful to clinicians who manage psychiatric symptoms of cancer patients.

Comparison of Treatment Adherence between Selective Serotonin Reuptake Inhibitors and Moclobemide in Patients with Social Anxiety Disorder

OBJECTIVE: With respect to the pharmacotherapy of social anxiety disorder (SAD), it has been suggested that treatment duration is an important factor that can significantly predict responses. The present study aimed to compare the treatment adherence of SAD patients who were taking either SSRIs or reversible inhibitors of MAO-A (moclobemide) by measuring treatment duration and all-cause discontinuation rates of pharmacotherapy in a natural clinical setting. METHODS: We retrospectively analysed the data of 172 patients diagnosed with SAD. Depending on their medication, we divided the patients into two groups, SSRI (n=54) or moclobemide (n=118). The expected number of all-cause discontinuation every 2 weeks after starting treatment was calculated by life table survival methods. A multi-variable Cox proportional hazard regression was used to analyze the potential influence of explanatory variables. RESULTS: Treatment duration was significantly longer in the SSRI group [46.41+/-56.96, median=12.0 (weeks)] than in the moclobemide group [25.53+/-34.74, median=12.0 (weeks), Z=2.352, p=0.019]. Overall, all-cause discontinuation rates were significantly lower with SSRIs (81%) than moclobemide (96%, chi2=4.532, p=0.033). CONCLUSION: The SSRI group had a longer treatment duration and lower all-cause discontinuation rate than moclobemide. Further, only the type of medication had a significant effect on all-cause discontinuation rates and therefore, we could predict better treatment adherence with the SSRIs in the treatment of SAD.

Lack of Association between Brain-Derived Neurotrophic Factor Gene Val66Met Polymorphisms and Generalized Social Anxiety Disorder in Korean Population

OBJECTIVE: Several lines of evidence suggest that brain-derived neurotrophic factor (BDNF) plays a role in the pathophysiology of anxiety. We analyzed the association of the BDNF gene polymorphism, G196A (val66met), in the coding region of exon XIIIA in chromosome 11p13, and generalized social anxiety disorder (GSAD). METHODS: Patients with GSAD (n=73) and age-matched control subjects (n=152) were tested for the BDNF (val66met) polymorphism. A clinical interview and a Mini-International Neuropsychiatric Interview were conducted by trained psychiatrists in order to diagnose GSAD. The symptomatic characteristics of the GSAD patients were assessed with the Hamilton Anxiety Rating Scale, the Beck Anxiety Inventory, the Retrospective Self Report of Inhibition, the Spielberger State-Trait Anxiety Inventory, and the Liebowitz Social Anxiety Scale. RESULTS: There were no significant differences in the frequencies of the genotypes (chi2=0.961, degree of freedom [df]=2, p=0.619), alleles (chi2=0.415, df=1, p=0.519), or allele (methionine) carriers (chi2=0.019, df=1, p=0.889) between the patients and controls. In addition, when we compared the severity of social anxiety symptom as determined by the clinical scales with the genotypes of the BDNF gene, we could not find any significant differences between the genotypes or allele carriers. CONCLUSION: These results do not support the hypothesis that the BDNF gene might be a candidate gene for susceptibility or severity of GSAD in the Korean population in this study.

Sleep in Panic Disorder and Nocturnal Panic Attack / 수면정신생리

Sleep disturbance is a one of common complaints among patients with panic disorder. However, clinicians and researchers did not give much attention to the sleep symptoms of panic disorder yet. Several previous studies suggested that the sleep disturbance in panic disorder is mediated by nocturnal panic attack. In terms of the pathophysiology of panic disorder, nocturnal panic attack seems to be closely associated with the sleep problems in panic disorder. In this article, the authors reviewed various previous studies about sleep of panic disorder and intended to give importance of evaluating sleep disturbances and nocturnal panic attack in panic disorder for both clinical and research purpose.