한국형 우울장애 약물 치료 알고리듬 2012(IV): 소아 청소년/노인/여성

왕희령,박원명,박영민,이황빈,송후림,정종현,서정석,임은성,홍정완,김원,전덕인,홍진표,민경준 대한정신약물학회 2013 대한정신약물학회지 Vol.24 No.1

새로운 항우울제의 도입 이후 다양한 임상상황에서 우울장애의 치료에 많은 변화가 있어왔다. 이에 국내에서는 이미 2002년과 2006년에 한국형 우울장애 약물 치료 알고리듬이 개발된 바 있다. 본 연구자들은 2006년 알고리듬 개발 이후 6년이 지난 현 시점에서 우울장애의 약물 치료에 대한 새로운 연구 결과와 최근의 임상 경향을 반영하여 한국형 우울장애 약물 치료 알고리듬을 개정하게 되었다. 우울장애에 대한 임상 경험이 풍부한 정신과 전문의 123명을 선정하여 설문지를 발송하였고, 이 중 67명이 설문지를 보내왔다. 설문지는 총 44문항으로 구성되었으며, 전반적인 치료전략으로부터 시작하여 구체적인 상황에서의 치료전략에 이르는 세부항목들로 이루어졌다. 각 치료 전략이나 치료적 선택은 9점 척도로 평가되었고, 각각의 95% 신뢰구간에 따라 1차, 2차, 3차 선택으로 구분하였다. 소아 청소년 주요우울장애에 있어서, 경도 및 중등도 삽화, 정신병적 양상이 없는 중증 삽화의 초기 약물 치료 전략으로 항우울제 단독치료가 1차 치료로 권장되었다. 정신병적 양상이 동반된 중증 삽화에서는 항우울제와 비정형 항정신병약물의 병합치료가 1차 치료로 권장되었다. 노인 주요우울장애에서 경도 및 중등도 삽화에서의 초기 약물 치료 전략으로는 항우울제 단독치료가 최우선 치료로 권장되었으며, 정신병적 양상이 없는 중증 삽화에서도 항우울제 단독치료가 1차 치료로 선택되었다. 정신병적 양상이 동반된 중증 삽화에서는 항우울제와 비정형 항정신병약물의 병합치료가 최우선 치료로 선택되었다. 노인 주요우울장애의 임상유형별 항우울제 선택에 있어서는, 경도 및 중등도, 정신병적 양상이 없는 중증 삽화에서 fluoxetine과 fluvoxamine을 제외한 SSRI, SNRI, mirtazapine이 1차 약물로 선택되었으며, 정신병적 양상이 동반된 중증 삽화에서는 fluvoxamine을 제외한 SSRI, SNRI, mirtazpine이 1차 약물로 권장되었다. 여성 우울장애의 약물치료에서, 월경전 불쾌기분장애의 치료에서는 항우울제 단독치료가 1차 치료로 권장되었으며, (es)citalopram, fluoxetine, paroxetine, sertraline, duloxetine, venlafaxine이 1차 약물로 선택되었다. 산후 우울증의 약물 치료 전략에 있어서, 경도 및 중등도 삽화에서는 항우울제 단독치료가 1차 치료로 선택되었다. 정신병적 양상이 없는 중증 삽화에서는 항우울제 단독치료, 항우울제와 비정형 항정신병약물의 병합치료가 1차 치료로 권장되었으며, 정신병적 양상이 있는 중증 삽화에서는 항우울제와 비정형 항정신병약물의 병합치료, 기분조절제와 비정형 항정신병약물의 병합치료가 1차 치료로 선호되었다. Korean Medication Algorithm for Depressive Disorder 2012에서는, KMAP-DD 2006에서는 다루지 않았던 소아 청소년 우울장애와 노인 주요우울장애의 약물 치료가 추가되어 현재 임상 상황에서의 치료 전략이 소개되었다. 여성 우울장애의 치료 전략에 있어서는 KMAP-DD 2006과 비교하여 초기 전략에 있어 큰 차이는 없었으나, 산후 우울증 치료에서 정신병적 양상이 없는 중증 삽화에서 항우울제 단독치료뿐만 아니라 항우울제와 비정형 항정신병약물의 병합치료가 1차 치료로 선택되었고, 정신병적 양상이 있는 중증삽화에서는 항우울제와 비정형 항정신병약물의 병합치료뿐만 아니라 기분조절제와 비정형 항정신병약물의 병합치료도 1차 치료로 추가로 선택되었다. Objective Since the introduction of selective serotonin reuptake inhibitor in 1980s, there have been many changes in the treatment strategies for depressive disorders. To be of help for clinicians to select appropriate treatment strategies, Korean Medication Algorithm Project for Major Depressive Disorder was developed in 2002 and revised in 2006. To reflect changes in treatment pattern for depressive disorders since 2006, we revised the previous algorithm and developed Korean Medication Algorithm Project for Depressive Disorder 2012 (KMAP-DD 2012). Methods 123 psychiatrists who have vast clinical experiences in treating depressive disorders are primarily selected, and the survey was sent to them via mails. Among them, 67 psychiatrists answered the survey. This survey was composed of 44 questionnaires of which the contents covered from overall treatment strategies to treatment strategies under the specific circumstances. Based on 95% confidence interval and overall scores, each treatment of option was classified into three categories of recommendation; first-line, second-line, and third-line treatment option. Results In child and adolescent, antidepressant monotherapy was selected as first-line treatment option for mild, moderate, and severe episode without psychotic features. The combination of antidepressant and atypical antipsychotics was advocated as first-line treatment option for severe episode with psychotic features. In geriatric depression, antidepressant monotherapy was advocated as treatment of choice for mild to moderate episode. For severe episode without psychotic features, antidepressant monotherapy was selected as first-line treatment option. For severe episode with psychotic features, combination of antidepressant and atypical antipsychotics was selected as treatment of choice. In premenstrual dysphoric disorder, antidepressant monotherapy was advocated as first-line treatment option. In postpartum depression, antidepressant monotherapy was selected as first-line treatment option for mild to moderate episode. For severe episode without psychotic features, both antidepressant monotherapy and combination of antidepressant and atypical antipsychotics were selected as first-line treatment option. For severe episode with psychotic features, both combination of antidepressant and atypical antipsychotics and combination of mood stabilizer and atypical antipsychotics were advocated as first-line treatment option. Conclusion In KMAP-DD 2012, the recommendations for treatment options in Child and Adolescent Depressive Disorder and Geriatric Depression were newly introduced. In aspects of treatment options for Female Depression, KMAP-DD 2006 and KMAP-DD 2012 had some similarities. But there were some changes of the treatment strategies in KMAP-DD 2012 which seemed to reflect recent study results.

양극성 장애 환자에서 퇴원 이후 외래 치료 유지에 영향을 미치는 예측인자 : 일 대학병원 후향적 의무기록 조사연구

왕희령,정영은,송후림,전태연,김광수,박원명 대한우울조울병학회 2011 우울조울병 Vol.9 No.2

Background and Objectives : This study aims to identify sociodemographic and disease-related variables which predicts continuity of outpatient treatment after discharge among bipolar patients. Materials and Method : The medical records of patients who discharged with the diagnosis of bipolar disorder from Department of Psychiatry, St. Mary’s hospital from 2005 to 2009 were reviewed. Data on sociodemographic and disease-related variables were analyzed. Results : It showed older age, higher rate of male and higher rate of being married in 1-year follow-up group than in non-follow-up group. And it showed longer duration of index hospitalization, higher rate of previous psychiatric outpatient treatment within 3 months before index hospitalization, higher rate of involuntary admission in 1-year follow-up group than in non-follow-up group. The univariate logistic regression analysis revealed that older age, being male, previous psychiatric treatment and longer duration of index hospitalization were significantly related to an increased likelihood of 1-year follow-up visits. Conclusion : Age, sex, history of previous psychiatric treatment, and duration of hospitalization seems to have influence on continuity of outpatient treatment after discharge. (J of Kor Soc for Dep and Bip Disorders 2011;9:126-132)

Korean Medication Algorithm for Depressive Disorder: Comparisons with Other Treatment Guidelines

왕희령,박원명,박영민,이황빈,송후림,정종현,서정석,임은성,홍정완,김원,전덕인,홍진표,우영섭,민경준 대한신경정신의학회 2014 PSYCHIATRY INVESTIGATION Vol.11 No.1

We aimed to compare the recommendations of the Korean Medication Algorithm Project for Depressive Disorder 2012 (KMAP-DD2012) with other recently published treatment guidelines for depressive disorder. We reviewed a total of five recently published global treatment guidelines and compared each treatment recommendation of the KMAP-DD 2012 with those in other guidelines. For initialtreatment recommendations, there were no significant major differences across guidelines. However, in the case of nonresponse or incompleteresponse to initial treatment, the second recommended treatment step varied across guidelines. For maintenance therapy,medication dose and duration differed among treatment guidelines. Further, there were several discrepancies in the recommendationsfor each subtype of depressive disorder across guidelines. For treatment in special populations, there were no significant differences inoverall recommendations. This comparison identifies that, by and large, the treatment recommendations of the KMAP-DD 2012 aresimilar to those of other treatment guidelines and reflect current changes in prescription pattern for depression based on accumulatedresearch data. Further studies will be needed to address several issues identified in our review. We aimed to compare the recommendations of the Korean Medication Algorithm Project for Depressive Disorder 2012 (KMAP-DD2012) with other recently published treatment guidelines for depressive disorder. We reviewed a total of five recently published globaltreatment guidelines and compared each treatment recommendation of the KMAP-DD 2012 with those in other guidelines. For initialtreatment recommendations, there were no significant major differences across guidelines. However, in the case of nonresponse or incompleteresponse to initial treatment, the second recommended treatment step varied across guidelines. For maintenance therapy,medication dose and duration differed among treatment guidelines. Further, there were several discrepancies in the recommendationsfor each subtype of depressive disorder across guidelines. For treatment in special populations, there were no significant differences inoverall recommendations. This comparison identifies that, by and large, the treatment recommendations of the KMAP-DD 2012 aresimilar to those of other treatment guidelines and reflect current changes in prescription pattern for depression based on accumulatedresearch data. Further studies will be needed to address several issues identified in our review.

양극성 장애 환자에서 한국어판 Bipolar Spectrum Diagnostic Scale의 타당성 연구

왕희령,김상억,강시현,주연호,김창윤 大韓神經精神醫學會 2008 신경정신의학 Vol.47 No.6

본 연구는 한국어판 BSDS의 민감도와 특이도, 최적의 절단값을 조사하기 위해 시행되었다. SCID를 사용하여 DSM-IV에 의거하여 진단된 양극성 장애 및 주요우울장애 환자들을 대상으로 본 연구를 시행하였고, 가장 적절한 절단값은 10점, 이 때의 특이도, 민감도는 각각 0.85, 0.73 수준으로 나왔다. 본 연구 결과를 통해, 한국어판 BSDS는 양극성 장애에 선별에 있어서 높은 민감도와 특이도를 지닌 타당성 있는 자가보고형 선별도구임이 밝혀졌다. Objectives : Because bipolar spectrum disorders frequently go unrecognized in clinical practice, sensitive screening tools for bipolar spectrum disorders are much needed. This study was conducted to confirm the validity of the Korean version of the Bipolar Spectrum Diagnostic Scale (BSDS), which was originally designed by Ronald Pies. Methods : The BSDS, which was translated into Korean by the authors, was dministered to patients with known bipolar disorders (N=60) and unipolar depressive disorders (N=27). Using various cut-off scores, we calculated the sensitivities and specificities of the Korean version of the BSDS in order to determine the optimal cut-off score. Results : In this study,a cut-off score of 10 was shown to be optima1, with a sensitivity of 0.73 and a specificity of 0.85, although a cut-off score of 13 was proposed to be optima1 by the original authors of the BSDS. Conclusion : These results indicate that the Korean version of the BSDS is a valid screening tool for bipolar spectrum disorder.

한국형 우울장애 약물치료 알고리듬 2017(II) : 정신병적 양상을 동반한 우울장애

왕희령,우영섭,서정석,박영민,김원,정종현,심세훈,이정구,홍진표,전덕인,민경준,박원명 대한우울조울병학회 2017 우울조울병 Vol.15 No.1

Objectives : The Korean Medication Algorithm Project for Depressive Disorder 2017 (KMAP-DD 2017) was developed to revise the previous version, the Korean Medication Algorithm Project for Depressive Disorder 2012 (KMAP-DD 2012), to reflect accumulated new findings regarding pharmacotherapy for depression. Methods : A total of 144 psychiatrists with numerous clinical experiences and academic achievements in treating depression were selected. The KMAP-DD 2017 survey was sent to them through e-mail. Of these, 79 answered the survey. The survey consists of seven parts and 44 questions. Each treatment strategy was categorized into three recommendation classifications ; first-line, second-line, and third-line, based on a 95% confidence interval. Results : For psychotic depression, an antidepressant augmented with atypical antipsychotics was selected as the first-line initial treatment. In case of an inadequate treatment response after the first treatment step, switching to another antidepressant, switching to another atypical antipsychotic agent, and adding another antidepressant were selected as first-line treatments. In case of an inadequate treatment response at the second treatment step, switching to another antidepressant, switching to another atypical antipsychotic agent, and adding another antidepressant were selected as first-line treatment options for third step treatment. Conclusion : The KMAP-DD 2017 is expected to provide useful guidance for treating psychotic depression, based on expert consensus and formulated recommendations, enabling clinicians to effectively choose treatment options in clinical practice.

정신분열병 환자에서 퇴원 이후 외래 치료 유지에 영향을 미치는 요인: 일 대학병원 후향적 의무기록 조사연구

왕희령,우영섭,정영은,송후림,전태연,박원명 대한정신약물학회 2010 대한정신약물학회지 Vol.21 No.4

Objective This study aims to identify sociodemographic and disease-related variables associated with continuity of outpatient treatment after discharge of patient with schizophrenia in a university hospital. Methods The medical records of patients who discharged with the diagnosis of schizophrenia from department of psychiatry, St. Mary’s Hospital in 2008, 2009, and 2010 were reviewed. Data on sociodemographic and disease-related variables were an-alyzed. Results Comparing sociodemographic variables, 6-month follow-up group showed higher rate of family history (p=0.034), and lower rate of divorce and bereavement (p=0.037) than non-follow-up group. Comparing disease-related variables, 6-month follow-up group showed higher rate of previous psychiatric outpatient treatment within 3 months before index hospitalization (p=0.013), higher scores in Global Assessment of Functioning (GAF) at discharge (p=0.002), but lower rate of prescription of risperidone at discharge (p=0.007). The univariate logistic regression analysis revealed that previous psychiatric outpatient treatment within 3 months before index hospitalization, GAF scores at discharge, family history, absence of divorce and bereavement, and not being prescribed of risperidone at discharge were significantly related to an increased likelihood of 6-month follow-up visits. Conclusion The previous psychiatric outpatient treatment before hospitalization, psychosocial functioning, family history, divorce, bereavement, and antipsychotics prescription at discharge appeared to have influence on continuity of outpatient treatment after discharge of patients with schizophrenia. 본 연구에서 최근 2년간 정신분열병으로 입원치료를 받고 퇴원한 환자들의 6개월 이상 외래 치료 지속률은 77.9%였으며, 외래 치료 지속과 관련된 요인들을 분석한 결과 정신과 질환의 가족력이 없을수록, 이혼이나 사별인 경우, 퇴원시 risperidone을 처방받은 경우, 입원 전 3개월 이내 외래 통원 치료를 받지 않은 경우, 퇴원시 전반적 기능수준 척도의 점수가 낮은 경우에서 6개월 이전 외래 치료의 조기 중단율이 높은 것으로 나타났다. 정신분열병의 경우 꾸준한 외래 통원 치료를 받지 않으면, 증상의 악화 및 재발의 위험성이 높아지며 이로 인한 재입원율 및 사회 경제적 부담이 증가하는 여러 병폐가 있음을 감안할 때, 외래 치료 조기 중단의 고위험군들을 입원 기간 중에 잘 선별하여 이들 대상 집단에 대한 신중한 퇴원 계획을 수립하여 입원에서 외래 치료로의 이행이 원활히 이루어지도록 하는 관리 대책이 마련되어야 할 것으로 여겨진다. 아울러 외래 치료 지속 및 치료 순응도에 영향을 미치는 영향 요인에 대한, 보다 대규모, 전향적 연구와 함께 외래 치료 유지율 향상을 위한 퇴원 관리 프로그램 등의 개발이 향후 필요할 것으로 사료된다.

거주형태에 따른 노인 우울증과 자살경향성 비교 연구

왕희령,최용성,조명제,최윤미,신희숙,제수경,최재원,홍진표,Wang, Hee-Ryung,Choi, Yong-Sung,Cho, Myeong-Je,Choi, Yun-Mi,Shin, Hee-Sook,Je, Su-Kyung,Choi, Jae-Won,Hong, Jin-Pyo 대한불안의학회 2010 대한불안의학회지 Vol.6 No.1

본 연구는 이천시에 거주하는 65세 이상의 인구를 대상으로, 우울증의 유병률과 자살경향성, 우울증과 자살경향성에 영향을 미치는 위험요인을 살펴본 연구이다. 전체적으로 우울증의 유병률은 28% 정도로 파악되어 실제로 65세 이상의 연령대에서 상당수의 노인들이 임상적으로 의미 있는 우울증을 경험하고 있는 것으로 관찰되었다. 또한 자살경향성은 전체 조사대상자의 약 20%에서 자살생각, 자살의도, 자살계획, 자해의도, 자살시도 중 한 가지 이상을 지난 한 달 동안 경험했던 것으로 나타났다. 거주 형태별로 구분하여 비교 분석한 결과, 혼자 생활하거나 시설에서 생활하는 노인들에서 동거가족이 있는 노인들보다 우울증의 유병률이 높고, 증상도 심한 것으로 나타났으며, 이들에게서 자살경향성 역시 높은 것으로 파악되어 이들 고위험군에 대한 보다 집중적인 우울증의 조기 발견 및 자살예방사업이 필요할 것으로 판단되었다. 위험요인 분석에서는 고령, 시설거주, 낮은 사회적 지지 수준은 우울증의 위험요인으로, 독거생활, 시설거주, 낮은 사회적 지지 수준, 두통의 기왕력은 자살경향성의 위험요인인 것으로 파악되었다. Objective : This study aimed to investigate and compare the prevalence of depression and suicidality among the elderly in a rural city according to their residence type. Methods : Participants were 311 elderly people (109 male and 202 female) in Icheon City, whom trained researchers interviewed and examined Geriatric Depression Scale, Social Support Scale, Instrumental Activities of Daily Living, Activities of Daily Living, Quality of Life Scale, and Mini International Neuropsychiatric Interview (MINI), module C. Using these data, we analyzed participants' risk factors associated with depression and suicidality. Results : The prevalence of depression was 28.0%. The prevalence in the elderly living alone and those admitted to residential facilities was significantly higher than that among the elderly living with family. Suicidality frequency was 19.6%. The suicidality frequency among the elderly living alone and those admitted to facilities was significantly higher than that among the elderly living with family. The risk factors for depression were age, admission to a facility, and low economic status. The suicidality risk factors were living alone, admission to a facility, poor social support, and a history of headache. Conclusion : These results showed the prevalence of depression and frequency of suicidality among the elderly in such a city was quite high. The results of this study remind psychiatrists of the importance of early detection and therapeutic intervention for the elderly with a high risk of depression and suicidality.

한국형 우울장애 약물치료 알고리듬 2017(III) : 유지치료

김원,왕희령,우영섭,서정석,박영민,정종현,심세훈,이정구,전덕인,민경준,박원명 대한우울조울병학회 2017 우울조울병 Vol.15 No.1

Objectives : Pharmacological treatment of depression is common. Novel pharmacological agents are continuously being developed and introduced for use. The Korean Medication Algorithm Project for Depressive Disorder (KMAPDD) developed in 2002 and revised in 2006 and 2012 seeks to manage the burgeoning data to optimally benefit patients. The latest revision of KMAP-DD reflects new research results and the latest trends in the areas of pharmacological treatment. The current study focused on maintenance treatment. Methods : A 44-item questionnaire was used to obtain the consensus of experts regarding pharmacological treatment strategies for depressive disorder. The review committee included 144 psychiatrists who have vast clinical experiences in depressive disorder. Of the committee members, 79 psychiatrists responded to the survey. Each treatment strategy or treatment option was evaluated with the overall score of nine and the following 95% confidence interval result treatment options were divided into primary, secondary, and tertiary recommendations. Multiple response sets were used for the statistical analysis. Results : Most clinicians maintained use of antidepressants and antipsychotics in the treatment of patients with major depressive episodes with psychotic feature during remission. We questioned how to treat the patients in the maintenance phase according to history of depressive episode. For patients in remission from the first depressive episode, most clinicians maintained antidepressants from 19.8 to 46.8 weeks. For patients in remission of the second depressive episode, many clinicians maintained antidepressants from 34.8 to 78.4 weeks. For patients with history of three or more depressive episodes, most clinicians (83.5%) treated continuously and indefinitely. The preferred maintenance dose of antidepressants was about 75% of the acute treatment dose. Maintenance of antipsychotics in patients with psychotic depression in remission was similar to the antidepressants, although the agents were usedfor a shorter time and at a lower dose. Conclusion : The maintenance treatment strategy of KMAP-DD 2017 is similar to that of KMAP-DD 2012. Most clinicians prefer to maintain antidepressant medications for an extended time after achieving remission. For patients with a history of more depressive episodes, many clinicians prefer to maintain antidepressant therapy continuously. The maintenance of antipsychotics is also preferred, but the duration is shorter than for antidepressants. The dose of antidepressant in maintenance treatment is about 75% of the dose in acute treatment, and the dose of antipsychotics is about 50%.

Bioequivalence of Generic and Brand Name Clozapine in Korean Schizophrenic Patients: A Randomized, Two-Period, Crossover Study

우영섭,왕희령,윤보현,이상열,이광헌,서정석,박원명 대한신경정신의학회 2015 PSYCHIATRY INVESTIGATION Vol.12 No.3

ObjectiveaaClozapine is the treatment of choice for refractory schizophrenia. The aim of this study was to compare the pharmacokinetics of the brand name (Clozaril) formulation and a generic formulation (Clzapine) of clozapine in Korean schizophrenic patients. MethodsaaA prospective, randomized, crossover study was conducted to evaluate the steady-state pharmacokinetic profiles of Clozaril and Clzapine. Schizophrenic patients were randomized to receive either the brand name or generic formulation (100 mg twice daily) for 10 days, followed by the other formulation for 10 days. Plasma samples were collected on the last day of each treatment period. ResultsaaTwenty-two of 28 patients (78.6%) completed the study. The mean Cmax,ss values for Clzapine and Clozaril were 524.62 and 551.18 ng/mL, and the mean AUC0-12 values were 4479.90 hr·ng/mL and 4724.56 hr·ng/mL, respectively. The 90% CI values for the natural logarithmically transformed Cmax,ss and AUC0-12 ratios (Clzapine to Clozaril) after a single oral dose (100 mg) were 0.934 (0.849–1.028) and 0.936 (0.869–1.008), respectively. Five patients (20.8%) among 24 patients who took Clzapine reported 11 adverse events and six adverse events were reported by four patients (15.4%) among 26 who took Clozaril; there were no significant differences on physical examination or in vital signs, ECG, and laboratory tests between groups. ConclusionaaGeneric clozapine (Clzapine) appears to be bioequivalent to brand name clozapine (Clozaril).

한국형 우울장애 약물치료 알고리듬 2012(VI) : 비약물학적 생물치료

정종현,왕희령,이황빈,박영민,홍정완,김원,서정석,임은성,송후림,전덕인,홍진표,박원명,민경준 대한우울조울병학회 2013 우울조울병 Vol.11 No.1

Objectives: Pharmacological treatment of depression is widely used. As new medication for depression has been introduced continuously, pharmacological treatment strategy is also changing. To overcome problematic nature this trend, Korean Medication Algorithm Project for Depressive Disorder (KMAP-DD) was developed in 2002 and revised in 2006. Since the last revision six years ago, this revision reflected the new research result and the latest trends in the areas of pharmacological treatment. Methods: 123 psychiatrists who have vast clinical experiences in depressive disorder are primary selected then survey was sent to them via mail, 67 surveys were retried. This survey is constructed with 44 questionnaires in which contained from overall treatment strategies to treatment strategies under the specific circumstances. Each treatment strategy or treatment option is evaluated with the overall score of nine and the following 95% confidence interval result treatment option were divided into three phases of recommendation; primary, secondary, tertiary. Results: Electroconvulsive therapy(ECT) was recommended as an initial strategy for major depressive disorder, severe without psychotic features with urgent suicidal risk, and as a second strategy for non-responders on antidepressant combination therapy and combined with physical illness. In the patient of major depressive disorder, severe with psychotic features, ECT was preferred as an initial strategy for urgent suicidal risk patients, but as a second strategy for non-responders on antipsychotics and antidepressants combination therapy and combid with physical illness. Many experts have considered ECT (84.4%) as a good treatment strategy, and 53% of experts have execute ECT. TMS was not recommended as a initial treatment strategy for major depressive disorder, but could be a second strategy for non-responder on antidepressants combination therapy in severe episodes without psychotic features and non-responders on pharmacotherapy in moderate episodes. Light therapy, omega-3 and megavitamine combination therapy could be a second strategies for treatment refractory patients. Conclusions: ECT was an initial strategy in severe episode with/without psychotic features who has an urgent suicidal risks, and secondarily preferred in case of non-responders, comorbid with physical illness and pregnants. Combination with complementary therapy was a second strategy for treatment refractory patients.