Chee Hong Ng

The association between depression and isotretinoin use in acne

Objective: The association between isotretinoin and depression has received little attention in the psychiatric literature despite an increasing number of reports in medical journals. The purpose of this paper is to highlight this association, examine the possible link and review the clinical implications. Method: A critical review of the literature pertaining to depression in patients with acne who were treated with isotretinoin was conducted. Results and Conclusions: The causal relationship between isotretinoin therapy and depression has not been clearly established and needs further study. Isotretinoin is likely to have a positive psychological impact for the majority of patients who benefit from such a highly efficacious anti-acne treatment. However, it is important to recognize that depression can occur as an idiosyncratic side-effect that requires urgent and appropriate treatment. Therefore, having a low threshold for detection of this uncommon complication and early psychiatric referral to address both the depression and its contributing factors may prevent serious consequences.

Adjunctive minocycline treatment for major depressive disorder: A proof of concept trial

Objective: Conventional antidepressant treatments result in symptom remission in 30% of those treated for major depressive disorder, raising the need for effective adjunctive therapies. Inflammation has an established role in the pathophysiology of major depressive disorder, and minocycline has been shown to modify the immune-inflammatory processes and also reduce oxidative stress and promote neuronal growth. This double-blind, randomised, placebo-controlled trial examined adjunctive minocycline (200 mg/day, in addition to treatment as usual) for major depressive disorder. This double-blind, randomised, placebo-controlled trial investigated 200 mg/day adjunctive minocycline (in addition to treatment as usual) for major depressive disorder. Methods: A total of 71 adults with major depressive disorder (Diagnostic and Statistical Manual of Mental Disorders–Fourth Edition) were randomised to this 12-week trial. Outcome measures included the Montgomery–Asberg Depression Rating Scale (primary outcome), Clinical Global Impression–Improvement and Clinical Global Impression–Severity, Hamilton Anxiety Rating Scale, Quality of Life Enjoyment and Satisfaction Questionnaire, Social and Occupational Functioning Scale and the Range of Impaired Functioning Tool. The study was registered on the Australian and New Zealand Clinical Trials Register: www.anzctr.org.au, #ACTRN12612000283875. Results: Based on mixed-methods repeated measures analysis of variance at week 12, there was no significant difference in Montgomery–Asberg Depression Rating Scale scores between groups. However, there were significant differences, favouring the minocycline group at week 12 for Clinical Global Impression–Improvement score – effect size (95% confidence interval) = −0.62 [−1.8, −0.3], p = 0.02; Quality of Life Enjoyment and Satisfaction Questionnaire score – effect size (confidence interval) = −0.12 [0.0, 0.2], p < 0.001; and Social and Occupational Functioning Scale and the Range of Impaired Functioning Tool score – 0.79 [−4.5, −1.4], p < 0.001. These effects remained at follow-up (week 16), and Patient Global Impression also became significant, effect size (confidence interval) = 0.57 [−1.7, −0.4], p = 0.017. Conclusion: While the primary outcome was not significant, the improvements in other comprehensive clinical measures suggest that minocycline may be a useful adjunct to improve global experience, functioning and quality of life in people with major depressive disorder. Further studies are warranted to confirm the potential of this accessible agent to optimise treatment outcomes.

‘Omic’ Genetic Technologies for Herbal Medicines in Psychiatry

The field of genetics, which includes the use of ‘omic’ technologies, is an evolving area of science that has emerging application in phytotherapy. Omic studies include pharmacogenomics, proteomics and metabolomics. Herbal medicines, as monotherapies, or complex formulations such as traditional Chinese herbal prescriptions, may benefit from omic studies, and this new field may be termed ‘herbomics’. Applying herbomics in the field of psychiatry may provide answers about which herbal interventions may be effective for individuals, which genetic processes are triggered, and the subsequent neurochemical pathways of activity. The use of proteomic technology can explore the differing epigenetic effects on neurochemical gene expression between individual herbs, isolated constituents and complex formulae. The possibilities of side effects or insufficient response to the herb can also be assessed via pharmacogenomic analysis of polymorphisms of cytochrome P450 liver enzymes or P‐glycoprotein. While another novel application of omic technology is for the validation of the concept of synergy in individual herbal extracts and prescriptive formulations. Chronic administration of psychotropic herbal medicines may discover important effects on chromatin remodelling via modification of histone and DNA methylation. This paper focuses on the emerging field of herbomics, and is to our knowledge the first publication to explore this in the area of psychiatry. Copyright

The acute effects of kava and oxazepam on anxiety, mood, neurocognition; and genetic correlates: a randomized, placebo‐controlled, double‐blind study

Kava (Piper methysticum) is a psychotropic plant medicine with history of cultural and medicinal use. We conducted a study comparing the acute neurocognitive, anxiolytic, and thymoleptic effects of a medicinal dose of kava to a benzodiazepine and explored for the first time specific genetic polymorphisms, which may affect the psychotropic activity of phytomedicines or benzodiazepines.

Medication attitudes and beliefs in patients with psychotic and affective disorders on maintenance treatment

Patient attitudes and beliefs regarding the cost‐benefits of medications may influence treatment adherence. However, beliefs and attitudes about psychotropic medications have not been well studied across different clinical populations.

Implementation of psychiatric-focused lifestyle medicine programs in Asia

Lifestyle‐focused health programs are growing in interest throughout Western society, and a range of lifestyle factors are known to enhance both physical and mental health. However, it remains largely unknown as to whether this approach is salient for the Asian context. The major components of integrative lifestyle‐focused health programs to enhance mental and physical health are considered to include the evidence‐based adoption of physical activity and exercise, dietary modification, general psychoeducation, adequate relaxation/sleep and social interaction, use of mindfulness techniques, the reduction of substance use, attention of intersecting environmental factors, and the potential use of motivation and goal‐setting techniques. This paper outlines an overview of the evidence underpinning these elements, and discusses potential barriers and challenges, and what logistical considerations may need to be addressed in the implementation of such programs within the context of Asian cultures.

Effects of persisting emotional impact from child abuse and norepinephrine transporter genetic variation on antidepressant efficacy in major depression: a pilot study

Objective Previous studies suggest child abuse and serotonergic polymorphism influence depression susceptibility and anti-depressant efficacy. Polymorphisms of the norepinephrine transporter (NET) may also be involved. Research in the area is possibly clouded by under reporting of abuse in researcher trials. Methods Adults (n=51) with major depressive disorder has 8 weeks treatment with escitalopram or venlafaxine. Abuse history was obtained, the ongoing emotional impact of which was measured with the 15-item impact of event scale (IES-15). The 17-item Hamilton Depression Rating Scale (HDRS) was applied serially. Two NET polymorphisms (rs2242446 and rs5569) were assayed, blinded to HDRS ratings and abuse history. Results No subjects reporting abuse with high impact in adulthood (IES-15 ≥26, n=12) remitted; whereas 77% reporting low impact (IES-15 <26; n=26) remitted (p<0.001). Subjects reporting high impact abuse (n=12) had a 50-fold (95% confidence interval=4.85–514.6) greater odds of carrying rs2242446-TT genotype, but the small sample size leaves this finding vulnerable to type I error. Conclusion The level of persisting impact of child abuse appears relevant to antidepressant efficacy, with susceptibility to such possibly being influence by NET rs2242446 polymorphism. Larger studies may be merited to expand on this pilot level finding given potential for biomarker utility.

An Overview of the Management of Treatment Resistant Depression in Late Life

Abstract: Treatment resistant depression (TRD) significantly contributes to the morbidity and mortality associated with depression occurring in late life. Yet, depression in the elderly population remains largely under‐recognised and under‐treated. This paper aims to provide an overview of the contributing factors and current treatment approaches in TRD in late life. Consensus on the operational criteria for TRD is still emerging due to unresolved issues on different criteria of definition and diagnosing TRD. If there is treatment failure, a comprehensive diagnostic evaluation along with the assessment of treatment adequacy should be undertaken. Reasons for the lack of treatment response need to be adequately explored including non‐compliance, misdiagnosis and co‐morbid physical, psychiatric and cognitive disorders. Stabilising co‐existing medical conditions as well as addressing the psychological and social issues may be necessary to achieve optimal outcome. Other strategies including increasing the dose and duration of treatment, switching antidepressant, augmentation and combination treatments, and electroconvulsive therapy (ECT) may be appropriate. There is a growing range of treatment options available including newer agents and treatment strategies that may offer improved efficacy and safety for the elderly depressed patients. However, considerable research into such treatment approaches in TRD in late life is still needed. A systematic consideration of all the treatment options with the associated risks and benefits is recommended, together with close monitoring of symptoms, progress and adverse effects.