Hae Kook Lee

Mirtazapine for patients with alcohol dependence and comorbid depressive disorders: A multicentre, open label study

Major depressive disorder and alcohol dependence are common and serious mental illnesses. There is a great interest in discovering useful treatments for both mood symptoms and alcohol abuse in those patients with depressive disorders and comorbid alcohol dependence. The primary purpose of this study was to evaluate the effectiveness and tolerability of mirtazapine for the treatment of patients with alcohol dependence comorbid with a depressive disorder in an open label, naturalistic multicentre treatment setting. The 17-item Hamilton Depression Rating Scale (HDRS), the Hamilton Anxiety Rating Scale (HARS) and the Clinical Global Impression-Severity (CGI-S) scale were measured at baseline and at weeks 4 and 8 for the assessment of treatment effectiveness. Alcohol craving was measured using the Obsessive Compulsive Drinking Scale (OCDS) and the Visual Analog Scale for Craving (VAS). This study showed a statistically significant reduction of the scores on the HDRS (13.9+/-7.3, p<0.0001), HARS (10.8+/-7.2, p<0.0001) and the CGI-S (1.7+/-1.0, p<0.0001) from baseline to the endpoint (week 8). The OCDS and VAS scores were also decreased significantly by 42.3% and 53.2% (9.0+/-10.0, p<0.0001; 2.5+/-2.4, p<0.0001, respectively). The number of patients with a 50% reduction or more in the HDRS and HARS scores was 103 (72.0%) and 106 (74.1%) at the endpoint, respectively. Adverse events related to mirtazapine were observed in 10% or more of the patients in this study. In conclusion, the results from this naturalistic study suggest that the use of mirtazapine for the patients with alcohol dependence comorbid with depressive disorder is accompanied by clinical improvement in their mood and alcohol craving.

Association study of catechol-O-methyltransferase gene polymorphism in Korean male alcoholics.

Objective Catechol-O-methyltransferase, which has a functional genetic polymorphism, plays an important role in dopamine metabolism. The study analyzed the association between the catechol-O-methyltransferase gene polymorphism and alcohol dependence in the Korean population. Methods Ninety-seven male alcoholics and 94 male age-matched normal controls were enrolled in this study. Polymerase chain reaction-based genotyping was used to verify the presence of the catechol-O-methyltransferase gene polymorphism. The patients were divided into two subtypes (violent group and non-violent group) according to their history of violent behavior. Results No difference in the distribution of the catechol-O-methyltransferase genotypes (H/H, H/L, L/L) and alleles (H, L) was observed between the patients and the controls. However, the differences between the violent and non-violent groups were significant in terms of the frequencies of the COMT genotypes (χ2=7.977, df=2, P=0.019) and the alleles (χ2=6.832, df=1, P=0.012). In addition, significant differences in the frequencies of the catechol-O-methyltransferase allele (χ2=4.481, df=1, P=0.040) were observed between the non-violent group and the controls. Conclusions This suggests that the catechol-O-methyltransferase gene polymorphism is not associated with the development of alcohol dependence, but may affect the susceptibility to a clinical heterogeneity of alcohol dependence, at least in the Korean population.

Gaming disorder: Its delineation as an important condition for diagnosis, management, and prevention

Online gaming has greatly increased in popularity in recent years, and with this has come a multiplicity of problems due to excessive involvement in gaming. Gaming disorder, both online and offline, has been defined for the first time in the draft of 11th revision of the International Classification of Diseases (ICD-11). National surveys have shown prevalence rates of gaming disorder/addiction of 10%–15% among young people in several Asian countries and of 1%–10% in their counterparts in some Western countries. Several diseases related to excessive gaming are now recognized, and clinics are being established to respond to individual, family, and community concerns, but many cases remain hidden. Gaming disorder shares many features with addictions due to psychoactive substances and with gambling disorder, and functional neuroimaging shows that similar areas of the brain are activated. Governments and health agencies worldwide are seeking for the effects of online gaming to be addressed, and for preventive approaches to be developed. Central to this effort is a need to delineate the nature of the problem, which is the purpose of the definitions in the draft of ICD-11.

Characteristics of Drug Overdose in Young Suicide Attempters

Objective Few studies have focused on the characteristic features of drug overdose in children and adolescents who have attempted suicide in Korea. The present study examined the characteristics of drug overdose in children and adolescents who visited the emergency room following drug ingestion for a suicide attempt. Methods The medical records of 28 patients who were treated in the emergency room following a drug overdose from January 2008 to March 2011 were analyzed. Demographic and clinical variables related to the suicide attempts were examined. Results The mean age of the patients was 16.6±1.7 years (range 11-19 years), and 20 of the patients (71.4%) were female. Most of the patients (n=23, 82.1%) overdosed on a single drug; acetaminophen-containing analgesics were the most common (n=12, 42.9%). Depression was the most common psychiatric disorder (n=22, 78.6%), and interpersonal conflict was the most common precipitating factor of the suicide attempts (n=11, 39.3%). This was the first suicide attempt for approximately 80% of the patients. About one fourth of the patients (n=7, 25%) had follow-up visits at the psychiatric outpatient clinic. Conclusion Early screening and psychiatric intervention for depression may be an important factor in preventing childhood and adolescent suicide attempts. Developing coping strategies to manage interpersonal conflicts may also be helpful. Moreover, policies restricting the amount and kind of drugs purchased by teenagers may be necessary to prevent drug overdose in this age group.

Functional impairment matters in the screening and diagnosis of gaming disorder

This commentary responds to Aarseth et al.’s (in press) criticisms that the ICD-11 Gaming Disorder proposal would result in “moral panics around the harm of video gaming” and “the treatment of abundant false-positive cases.” The ICD-11 Gaming Disorder avoids potential “overpathologizing” with its explicit reference to functional impairment caused by gaming and therefore improves upon a number of flawed previous approaches to identifying cases with suspected gaming-related harms. We contend that moral panics are more likely to occur and be exacerbated by misinformation and lack of understanding, rather than proceed from having a clear diagnostic system.This commentary responds to Aarseth et al.’s (in press) criticisms that the ICD-11 Gaming Disorder proposal would result in “moral panics around the harm of video gaming” and “the treatment of abundant false-positive cases.” The ICD-11 Gaming Disorder avoids potential “overpathologizing” with its explicit reference to functional impairment caused by gaming and therefore improves upon a number of flawed previous approaches to identifying cases with suspected gaming-related harms. We contend that moral panics are more likely to occur and be exacerbated by misinformation and lack of understanding, rather than proceed from having a clear diagnostic system.

Characteristic Risk Factors Associated with Planned versus Impulsive Suicide Attempters.

Objective The present study aimed to investigate predictors for planned suicide attempters. Methods This study included 1,003 patients who attempted suicide and visited emergency department. They were divided into two groups, planned suicide attempters (SAs; n=133 [13.3%]) and impulsive SAs (n=870, [86.7%]), and the demographic variables, clinical characteristics, factors related to suicide, and psychiatric resources of the groups were compared. Results Major depressive disorder and substance use disorders were more common among planned SAs than among impulsive SAs. Additionally, the planned SAs were older, more likely to be divorced, separated or widowed, and more likely to have comorbid medical illnesses, severe depression, higher suicidality, and self-blaming tendencies than the impulsive SAs. Financial problems and physical illnesses were more common in planned SAs but interpersonal conflicts were more frequent in impulsive SAs. Planned SAs had fewer previous suicide attempts but these were more serious suicide attempts. The presence of the hope to die, a written will, and suicidal ideation of a repetitive, intense, and continuous nature were predictive of planned SAs. Conclusion The present findings demonstrated that planned SAs had more severe psychopathology and medical illnesses than impulsive SAs. Therefore, screening for depression, substance use disorders, and suicidal plans among old and medically ill patients may be important for preventing suicide attempts.

Sleep and cognitive problems in patients with attention-deficit hyperactivity disorder.

Objectives Attention-deficit hyperactivity disorder (ADHD) is characterized by inattentive and impulsive behavior. Many ADHD patients reportedly have cognitive dysfunction and sleep problems, including longer sleep latency, lower sleep efficiency, and shorter total sleep time. The purpose of this study was to examine neurocognitive functions and nocturnal sleep parameters in patients with ADHD, using a cognitive function test and actigraphy. Methods Subjects included 37 male patients with ADHD and 32 controls (7–12 years of age). For each participant, we determined intelligence quotient (IQ) and administered the Matching Familiar Figures Test (MFFT) and 72-hour actigraphy. The relationships between sleep parameters and cognitive functions were assessed. Results ADHD patients significantly differed from controls in several cognitive functions and sleep variables. In the MFFT, response error rate (P<0.001) and error counts (P=0.003) were significantly increased in ADHD patients compared with control children. MFFT response latency was significantly shorter in ADHD patients than in controls (P<0.001). In addition, sleep latency (P=0.01), wake after sleep onset (WASO) (P<0.001), and fragmentation index (P<0.001) were evaluated by actigraphy and found to be significantly increased in patients with ADHD compared with controls. However, no significant differences in total sleep time or sleep efficiency were observed. WASO and response error rates were positively correlated in patients with ADHD (rho =0.52, P=0.012). Furthermore, fragmentation index sleep variables were significantly positively correlated with response error (rho =0.44, P=0.008) and response latency rates (rho =0.4, P=0.018) in the MFFT. Reaction error rate was significantly associated with the fragmentation index (beta =0.94, P=0.024). Conclusion Patients with ADHD had more sleep problems, including significantly increased sleep latency, WASO, and fragmentation index, and poorer cognitive function, compared with controls. Some of these sleep problems, including WASO and the fragmentation index, were positively correlated with impulsivity, illustrated by the cognitive function tests in patients with ADHD. However, further studies with large sample sizes and the addition of polysomnography and determination of ADHD subtypes should be performed to confirm our results regarding sleep and cognitive problems in patients with ADHD.

Typology of Internet gaming disorder and its clinical implications

Various perspectives exist regarding Internet gaming disorder. While the concept of behavioral addiction is gaining recognition, some view the phenomenon as merely excessive indulgence in online pastimes. Still, in recent years, complaints from patients or their family members about problems related to Internet use, particularly Internet gaming, have become more common. However, the clinical picture of Internet gaming disorder could be obscured by its heterogeneous manifestations with other intertwined factors, such as psychiatric comorbidities, neurodevelopmental factors, sociocultural factors, and game‐related factors, which may influence the pathogenesis as well as the clinical course. To mitigate such problems, clinicians should be able to consider diverse aspects related to Internet gaming disorder. Classifying such a heterogeneous problem into subtypes that share a similar etiology or phenomenology may provide additional clues in the diagnostic process and allow us to designate available clinical resources for particularly vulnerable factors. In this review paper, we suggest a typology of ‘impulsive/aggressive,’ ‘emotionally vulnerable,’ ‘socially conditioned,’ and ‘not otherwise specified’ as subtypes of the heterogeneous phenomena of pathological Internet gaming. The implications of these subtypes for assessment and treatment planning will also be highlighted.

The Hierarchical Implications of Internet Gaming Disorder Criteria: Which Indicate more Severe Pathology?

Objective To explore the structure of Internet gaming disorder (IGD) criteria and their distribution according to the different severity level of IGD. The associations of psychiatric comorbidities to each IGD symptom and to the IGD severity were also investigated. Methods Consecutively recruited 330 Korean middle school students underwent face-to-face diagnostic interviews to assess their gaming problems by clinicians. The psychiatric comorbidities were also evaluated with a semi-structured instrument. The data was analyzed using principal components analysis and the distribution of criteria among different severity groups was visualized by plotting univariate curves. Results Two principal components of ‘Compulsivity’ and ‘Tolerance’ were extracted. ‘Decrease in other activities’ and ‘Jeopardizing relationship/career’ may indicate a higher severity of IGD. While ‘Craving’ deserved more recognition in clinical utility, ‘Tolerance’ did not demonstrate much difference in distribution by the IGD severity. Internalizing and externalizing psychiatric disorders differed in distribution by the IGD severity. Conclusion A hierarchic presentation of IGD criteria was revealed. ‘Decrease in other activities’ and ‘Jeopardizing relationship/career’ may represent a higher severity, thus indicating more clinical attention to such symptoms. However, ‘Tolerance’ was not found to be a valid diagnostic criterion.

Study protocol of the internet user Cohort for Unbiased Recognition of gaming disorder in Early adolescence (iCURE), Korea, 2015–2019

Introduction In 2013, the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) proposed nine internet gaming disorder (IGD) diagnostic criteria as a condition warranting further empirical and clinical research. The aim of this study is to clarify the natural and clinical courses of IGD proposed DSM-5 in adolescents and to evaluate its risk and protective factors. Methods and analysis The Internet user Cohort for Unbiased Recognition of gaming disorder in Early Adolescence (iCURE) study is an ongoing multidisciplinary, prospective, longitudinal cohort study conducted in 21 schools in Korea. Participant recruitment commenced in March 2015 with the goal of registering 3000 adolescents. The baseline assessment included surveys on emotional, social and environmental characteristics. A parent or guardian completed questionnaires and a structured psychiatric comorbidity diagnostic interview regarding their children. Adolescents with the Internet Game Use-Elicited Symptom Screen total scores of 6 or higher were asked to participate in the clinical diagnostic interview. Two subcohorts of adolescents were constructed: a representative subcohort and a clinical evaluation subcohort. The representative subcohort comprises a randomly selected 10% of the iCURE to investigate the clinical course of IGD based on clinical diagnosis and to estimate the false negative rate. The clinical evaluation subcohort comprised participants meeting three or more of the nine IGD criteria, determined by clinical diagnostic interview, to show the clinical course of IGD. Follow-up data will be collected annually for the 3 years following the baseline assessments. The primary endpoint is 2-year incidence, remission and recurrence rates of IGD. Cross-sectional and longitudinal associations between exposures and outcomes as well as mediation factors will be evaluated. Ethics and dissemination This study is approved by the Institutional Review Board of the Catholic University of Korea. Results will be published in peer-reviewed journals. Trial registration number ClinicalTrials.gov (identifier: NCT02415322).