The Potential Usefulness of Magnetic Resonance Guided Focused Ultrasound for Obsessive Compulsive Disorders

Obsessive compulsive disorder is a debilitating condition characterized by recurrent obsessive thoughts and compulsive reactions. A great portion of the obsessive compulsive disorder (OCD) patients are managed successfully with psychiatric treatment such as selective serotonin-reuptake inhibitor and cognitive behavioral psychotherapy, but more than 10% of patients are remained as nonresponder who needs neurosurgical treatments. These patients are potential candidates for the neurosurgical management. There had been various kind of operation, lesioning such as leucotomy or cingulotomy or capsulotomy or limbic leucotomy, and with advent of stereotaxic approach and technical advances, deep brain stimulation was more chosen by neurosurgeon due to its characteristic of reversibility and adjustability. Gamma knife radiosurgery are also applied to make lesion targeting based on magnetic resonance (MR) imaging, but the complication of adverse radiation effect is not predictable. In the neurosurgical field, MR guided focused ultrasound has advantage of less invasiveness, real-time monitored procedure which is now growing to attempt to apply for various brain disorder. In this review, the neurosurgical treatment modalities for the treatment of OCD will be briefly reviewed and the current state of MR guided focused ultrasound for OCD will be suggested.ope

Effects of Ziprasidone on Cognitive Function in Patients with Schizophrenia

Cognitive impairments are a fundamental characteristic of schizophrenia which can limit patients' function in daily lives. Cognitive impairments are among the most important determinant of functional disability of schizophrenia. Typical antipsychotics seem to have minimal effect on the enhancement of cognitive functioning in patients with schizophrenia. It seems that atypical antipsychotics have benefit of improving the cognitive function to a greater degree than typical antipsychotics. In 3 studies where patients were switched to ziprasidone because of suboptimal efficacy or adverse effects, patients demonstrated significant improvements of multiple cognitive domains. Path analysis of switch study showed that improvement of cognitive function and affective symptom were associated improvement of social function. In comparison of cognitive effects of ziprasidone versus olanzapine, both demonstrated substantial and comparable cognitive enhancing effects relative to previous treatment.ope

Prognostic Factors in Bulimia Nervosa

OBJECTIVE: Over the last few years there has been growing concern about bulimia nervosa in Korea, but there was only a few clinical study, especially about outcome and predictors. CBT combined with pharmacotherapy has been recognized as the most effective short-term treatment modality, but there was nonresponders. The purpose of this paper is to examine the factors that influence treatment response and outcome in patients with bulimia nervosa. The identification of prognostic factors in bulimia nervosa will help clinicians to deliver the most appropriate type of initial treatment to patients. METHOD: The subjects were 62 patients from the outpatients of Mind & Mind psychiatric clinic, who had been previously evaluated by EDI-2 and MMPI. The sociodemographic data, disease progress, past history, family history, BMI, EDI-2 and MMPI were variables assessed. All patients received a 12-week course of CBT combined with pharmacotherapy (fluoxetine 20-60mg/d). Responders and non-responders group ware compared with each variables. Responders were defined as patients who had maximum symptom frequencies of three or less during the last 4 weeks of treatment. RESULT: Among 62 patients, responders were 32 and non-responders were 30. There was no difference in sociodemographic variables such as age, education level, job, marriage. As a result of comparing the two groups, non-responders were differentiated by their higher frequency of binge eating vomiting, history of suicide attempt, family history of psychiatric illness and use of laxatives or diuretics. And among the subscale of EDI-2, there were significant high scores in bulimia, ineffectiveness, interoceptive awareness. CONCLUSION: The findings suggest that frequency of binge eating, vomiting, history of suicide attempt, family history of psychiatric illness, and use of laxatives or diuretics could be prognostic factors in patients with bulimia nervosa.ope

Psychotropics Metabolism：Gender-Related Issues

There are significant gender differences in pharmacokinetics and pharmacodynamics of psychotropic medications. Gender differences in pharmacokinetics such as drug absorption, bioavailability, drug distribution, drug metabolism, and elimination have clinical implications in terms of plasma levels, drug half-lives, side effects and toxicity. Women and men also show different pharmacodynamic response to a variety of drugs. Additionally female-specific issues such as pregnancy, menopause, oral contraceptive use and menstruation may also have profound effects on drug metabolism. These and other gender-related issues are considered in this article. Gender differences in drug metabolism have the potential to affect appropriate dosing, effectiveness and toxicity. Further research is needed to determine the scope and significance of these sex differences.ope

Practical Issues in the Psychopharmacotherapy during Pregnancy and Lactation

Although the pregnancy period has typically been viewed as a time of emotional well-being, recent data do not substantiate this optimistic view for women with prior histories of depression. This paper will review the natural history of depression in pregnancy. The potential risks to the mother and the fetus when the psychiatric illness goes untreated will be reviewed. Also to be discussed are: the potential teratogenicity of each class of psychotropic medication, the treatment dilemmas, the possible alternatives when prescribing psychotropic medications and the decision-making guidelines regarding the discontinuation of medications. The risk of major depression in the postpartum period in the overall population and the likelihood of recurrence will be reviewed, and prophylactic strategies will be covered alsoope

Effectiveness and Tolerability of Long-Acting Risperidone：A 12 Weeks, Multi-center Switching Study from Oral Antipsychotics

Objective：To evaluate maintained effectiveness and tolerability when treated with long-acting risperidone compared to the previous antipsychotics in patients with schizophrenia or other psychotic disorders and to compare maintained effectiveness between oral risperidone and non-risperidone subgroups. Methods：Subjects aged at least 18 years who required long-term antipsychotic therapy and who have been symptomatically stable on a stable dose of antipsychotics during the last month were enrolled in the non-randomized, single-arm, multi-center, 12 weeks duration study. Antipsychotic medications were switched from oral antipsychotics to long-acting risperidone. Injections were administered every 2 weeks. Most patients were started on 25mg long-acting risperidone injection or 37.5mg in some patients. The dosage were adjusted according to the patients' symptoms and responses to treatment at the discretion of investigators. Oral antipsychotics were continued at the same dose as before for 2 weeks and then were stopped or tapered off within next 7days. Results：A total of 204 patients with schizophernia (N=192) and other psychotic disorder (N=12) from 20 sites in Korea were enrolled. The drop-out rate was 22.5% at 12 weeks. LOCF analysis has been performed. At 12 weeks after switching from oral antipsychotics to long-acting risperidone, statistically significant improvement was observed from baseline across all symptom domains including PANSS total, positive, negative, general subscale, CGI-S(Clinical Global Impression-Severity) scores and GAF(Global Assessment of Functioning) scores. The proportion of responders was 36.8% where response was defined as ≥20% reduction from baseline PANSS total score. The proportion of symptom worsening at 12 weeks was 7.4%(N=15) where symptom worsening was defined as ≥20% increase from baseline in PANSS total score or drop-out due to insufficient response or any 2 points change on any of 4 PANSS psychotic items(delusion, conceptual disorganization, hallucinatory behavior, suspiciousness/persecution) excluding changes in which the ratings remained at nonpsychotic levels (i.e ＞3). Significant improvement from baseline was also observed in the measure of parkinsonism assessed using Extrapyramidal Symptom Rating Scale (ESRS). In addition, overall, patients were satisfied with long-acting risperidone injection on a single item measure of satisfaction. When subgroup analysis was performed on the basis of previous antipsychotics before switching to long-acting risperidone, no statistically significant differences were detected between oral risperidone(N=139) and non-risperidone subgroup(N=65) on all measures of effectiveness and tolerability including baseline demographic and clinical characteristics, symptom improvements, proportion of symptom improvement or worsening and ESRS score changes. Conclusion：Our study results demonstrated maintained effectiveness and tolerability of long-acting risperidone microsphere and also could confirm successful switching from not only oral risperidone but also non-risperidone to long-acting risperidone injection.ope

The Effectiveness of 6-Month Treatment with Venlafaxine Extended Release in Generalized Anxiety Disorder : Prospective, Multi-Center, Open-Labeled Trial

Objective：We aimed to examine the efficacy and the safety of venlafaxine extended release (venlafaxine-XR), and its effect on the quality of life in patients with generalized anxiety disorder. Methods : Fifty three patients who had generalized anxiety disorder were recruited for this study. They showed scores of 18 or higher on the Hamilton Rating Scale for Anxiety (HAMA) and did not have major depression. They were scheduled to be examined 5 times (at baseline, 4, 8, 16 and 24 weeks) and took venlafaxine-XR for 24 weeks with a flexible dosing schedule. The primary efficacy variables were the response and remission rates (response : more than 50% reduction from baseline in HAMA total score ; remission : HAMA total score≤7). Other variables were the Hamilton Rating Scale for Depression, Beck Anxiety Inventory, Sheehan Disabilities Scale (SDS), and World Health Organization Quality of Life Assessment Instrument-Brief Form (WHOQOL-BREF). Also, the evaluation on adverse effects was performed. Results : The number of patients who completed 24 weeks of treatment was 32 (60.4%). Twenty one patients who were dropped out included 8 patients with intolerable adverse effects and 7 patients with unsatisfactory treatment response. Response/remission rates were 43.4/32.1% in the last-observation-carried-forward methods and 71.9/53.1% in the observed case data. Treatment with venlafaxine-XR improved anxiety and depressive symptoms during 24 weeks on all efficacy measures. By a completed patient analysis, venlafaxine-XR also significantly improved the disability scores on SDS and the quality of life scores on WHOQOL-BREF. In this study, nausea, palpitation, and severe tremor were common reasons of venlafaxine-XR discontinuation in GAD patients, but any serious adverse effect did not occur. Conclusion : Treatment with venlafaxine-XR was effective and well-tolerated for the patients with GAD, and also improved quality of life in the GAD patients.ope

Korean Medication Algorithm for Panic Disorder 2008 : Diagnosis, Treatment Response and Remission of Panic Disorder in Korea

Objective : This article is a part of the Korean Medication Algorithm Project for Panic Disorder, which aims to build consensus regarding the diagnosis, treatment response and achievement of clinical remission for patients with panic disorder in Korea. Methods : The questionnaire used in this article had parts : 1) diagnosis, 2) treatment response, and 3) remission for patients with panic disorder. The questionnaire was completed by each of 54 Korean psychiatrists who had much experience in treating patients with panic disorder. We classified the experts' opinions into 3 categories (first-line, second-line, and third-line) using the ${\chi}^2$-test. Results : Five factors were considered in this research : panic attack, anticipatory anxiety, phobic avoidance, severity of illness, and psychosocial disability. Most reviewers agreed that the presence of a panic attack was the most important factor in the diagnosis of patients with panic disorder. Phobic avoidance was included in the first-line category, whereas the severity of illness and psychosocial disability were included in the second-line category. Most reviewers also agreed that the presence of a panic attack was the most important factor in determining the appropriate treatment response, and it was included in the first-line category along with several other items. To determine remission status, the patients' scores on tests pertaining to the severity of panic attack, anticipatory anxiety, phobic avoidance, severity of illness and psychosocial disability should be less than 3.0-3.3 on a 9-point Likert scale. Conclusion : We suggest useful information for making a diagnosisof panic disorder, determining the appropriate treatment response and identifying remission in panic disorder patients on the basis of the results of a nationwide survey of experts in Korea.ope

Gender-Related Clinical Differences in Obsessive-Compulsive Disorder

Objective：Some reports have shown the gender-related clinical differences in Obsessive-compulsive disorder (OCD), but no study has yet been done in Korea. The purpose of this study was to investigate the gender-related differences of clinical features in the obsessive-compulsive patients in Korea. Methods：Two hundred forty nine patients with OCD were included in this study；180 subjects were male and 69 subjects were female. The two groups were analyzed in terms of demographic data including clinical variable, Y-BOCS (Yale-Brown Obsessive Compulsive Scale) scores, clinical course and treatment response. Results：We found the earlier age at onset of OC symptoms in males and the more frequent washing and somatization type in female. There were no gender difference in comorbidity, clinical course and the treatment response. Conclusion：We could observe some of the gender-related clinical differences in Korean OCD patients. The further studies would be required to evaluate the gender difference in the long-term clinical course and therapeutic response of Korean OCD patients.ope

Newer Antipsychotics : Serotonin and Glutamate Receptor Related Drugs

Several decades of research attempting to explain schizophrenia regarding dopamine hyperactivity hypothesis have produced disappointing results. New hypotheses focusing on serotonin-dopamine interactions and hypofunction of the NMDA glutamate transmitter system have been emerging as potentially more promising concepts. The next generation of treatments for schizophrenia, whether they are based on dopamine, serotonin, or glutamate etc., should be effective on negative symptoms and cognitive deficits as well as positive symptoms. In this article, I review the brief overview of these hypotheses and new drugs based on the hypotheses.ope