A missed case of lurasidone induced laryngospasm: A case study and overview of extrapyramidal symptom identification and treatment.

OBJECTIVE: Many patients with bipolar disorder are treated exclusively in primary care settings, and the use of atypical antipsychotics as primary treatment for bipolar depression is increasing. Extrapyramidal symptoms (EPS) are common side effects of antipsychotic medications, and clinicians should actively monitor for these symptoms when prescribing antipsychotic medications. Accurate diagnosis of EPS is especially important as the symptoms can be highly distressing, and in some cases, life threatening. Our aim is to familiarize primary care providers and other clinicians prescribing antipsychotic medications with EPS and to aid in its rapid diagnosis and treatment. METHOD: We describe a case of lurasidone induced dystonia with prominent laryngospasm and oculogyric crisis which was missed for many years in the primary care setting, largely due to misdiagnosis of symptoms as being related to anxiety and panic attacks. RESULTS: In addition to summarizing this illustrative case, we present the most common forms of EPS and summarize the primary therapies for each type of EPS. CONCLUSIONS: With increased management of bipolar disorder in the primary care setting and increased use of atypical antipsychotics as the primary therapy for bipolar disorder, it is essential that all practitioners are prepared to actively monitor for EPS, followed by its rapid diagnosis and treatment.

Clinical Case Vignettes: A Promising Tool to Assess Competence in the Management of Agitation.

OBJECTIVE: While standardized patients (SPs) remain the gold standard for assessing clinical competence in a standardized setting, clinical case vignettes that allow free-text, open-ended written responses are more resource- and time-efficient assessment tools. It remains unknown, however, whether this is a valid method for assessing competence in the management of agitation. METHODS: Twenty-six psychiatry residents partook in a randomized controlled study evaluating a simulation-based teaching intervention on the management of agitated patients. Competence in the management of agitation was assessed using three separate modalities: simulation with SPs, open-ended clinical vignettes, and self-report questionnaires. RESULTS: Performance on clinical vignettes correlated significantly with SP-based assessments (r = 0.59, p = 0.002); self-report questionnaires that assessed one's own ability to manage agitation did not correlate with SP-based assessments (r = -0.06, p = 0.77). CONCLUSIONS: Standardized clinical vignettes may be a simple, time-efficient, and valid tool for assessing residents' competence in the management of agitation.

Baseline physical health-related quality of life and subsequent depression outcomes in cardiac patients.

Among 137 depressed cardiac patients, lower baseline physical health-related quality of life (HRQoL) was independently associated with greater depression persistence at 6 months among patients randomized to collaborative care, but not usual care. Low physical HRQoL may impact collaborative care effectiveness and indicate a need for alternate depression treatment.

Risk factors for positive depression screens in hospitalized cardiac patients.

BACKGROUND: Depression is common in patients with cardiac illness and is independently associated with elevated morbidity and mortality. There are screening guidelines for depression in cardiac patients, but the feasibility and cost-effectiveness of screening all cardiac patients is controversial. This process may be improved if a subset of cardiac patients at high risk for depression could be identified using information readily available to clinicians and screened. OBJECTIVE: To identify risk factors for a positive depression screen at the time of admission in hospitalized cardiac patients. METHODS: A total of 561 consecutively screened cardiac inpatients underwent the Patient Health Questionnaire-2 (PHQ-2). A prospective chart review was performed to assess potential risk factors for depression that would be readily available to front-line clinicians. Rates of risk factors were compared between patients with positive and negative PHQ-2 depression screens, and multivariate logistic regression was performed to assess whether specific risk factors were independently associated with positive screens. RESULTS: Of the 561 patients screened, 13.5% (n=76) had a positive depression screen (PHQ-2≥2). In the univariate analyses, several variables were associated with a positive depression screen. On multivariate analysis, an elevated white blood cell (WBC) count (>10×10(9) cells per liter) and prescription of an antidepressant on admission were independently associated with a positive depression screen, while current smoking showed a trend toward significance. CONCLUSION: Information on these three identified risk factors (WBC count, antidepressant use, and smoking) is readily available to clinicians, and patients with these diagnoses may represent a cohort who would benefit from targeted depression screening in certain settings.

A collaborative care depression management program for cardiac inpatients: depression characteristics and in-hospital outcomes.

BACKGROUND: Depression in cardiac patients is common, under-recognized, and independently associated with mortality. OBJECTIVES: Our objectives in this initial report from a 6-month longitudinal trial were to determine whether a collaborative care program improves rates of depression treatment by discharge among patients hospitalized with acute cardiovascular disease, and to assess key clinical characteristics of depression in this cohort. METHOD: This was a prospective, randomized trial comparing collaborative care and usual care interventions for depressed cardiac patients who were admitted to cardiac units in an urban academic medical center. For collaborative care subjects, the care manager performed a multi-component depression intervention in the hospital that included patient education and treatment coordination; usual care subjects' inpatient providers were informed of the depression diagnosis. RESULTS: The mean Patient Health Questionnaire-9 for subjects (N = 175) was 17.6 (SD 3.5; range 11-26), consistent with moderate-severe depression. The majority of subjects had depression for over one month (n = 134; 76.6%) and a prior depressive episode (n = 124; 70.8%); nearly one-half (n = 75; 42.9%) had thoughts that life was not worth living in the preceding 2 weeks. Collaborative care subjects were far more likely to receive adequate depression treatment by discharge (71.9% collaborative care vs. 9.5% usual care; p < 0.001). CONCLUSION: Depression identified by systematic screening in hospitalized cardiac patients appears was prolonged, and of substantial severity. A collaborative care depression management model appears to vastly increase rates of appropriate treatment by discharge.

The impact of mental illness on cardiac outcomes: a review for the cardiologist.

Traditional cardiac risk factors, such as smoking, hypertension and obesity, are widely accepted contributors to the onset and progression of cardiovascular disease (CVD), one of the foremost causes of morbidity and mortality worldwide. Largely overlooked, however, is the impact of mental health on cardiac disease. From extensive MEDLINE and PsycINFO searches, we have reviewed the association between specific psychiatric disorders and CVD-related morbidity and mortality, the efficacy and safety of their treatments, and plausible behavioral and biological mechanism through which these associations may occur. The preponderance of evidence suggests that depression, anxiety disorders, bipolar disorder and schizophrenia are all important cardiac risk factors, and patients with these disorders are at significantly higher risk for cardiac morbidity and mortality than are their counterparts in the general population. Antidepressants, antipsychotics, mood stabilizers and benzodiazepines are effective therapeutic interventions, and many are safe to use in cardiac populations. Some, such as selective serotonin reuptake inhibitors and atypical antipsychotics, may even improve cardiac outcomes in healthy individuals and patients with CVD, although more work is needed to confirm this hypothesis. A combination of behavioral and biological mechanisms underlies the association between cardiac disease and mental illness, many of which are shared across disorders. With further research, it may be learned that psychiatric treatments definitively reverse the detrimental effects of mental illness on cardiac health. Currently, however, the challenge lies in raising awareness of mental health issues in cardiac patients, so that basic but critical treatments may be initiated in this population.

Oxyntomodulin increases intrinsic heart rate in mice independent of the glucagon-like peptide-1 receptor.

Oxyntomodulin (OXM), a postprandially released intestinal hormone, inhibits food intake via the glucagon-like peptide-1 receptor (GLP-1R). Although OXM may have clinical value in treating obesity, the cardiovascular effects of OXM are not well understood. Using telemetry to measure heart rate (HR), body temperature (Tb), and activity in conscious and freely moving mice, we tested 1) whether OXM affects HR and 2) whether this effect is mediated by the GLP-1R. We found that peripherally administered OXM significantly increased HR in wild-type mice, raising HR by >200 beats/min to a maximum of 728 +/- 11 beats/min. To determine the extent to which the sympathetic nervous system mediates the tachycardia of OXM, we delivered this hormone to mice deficient in dopamine-beta-hydroxylase [Dbh(-/-) mice], littermate controls [Dbh(+/-) mice], and autonomically blocked C57Bl mice. OXM increased HR equally in all groups (192 +/- 13, 197 +/- 21, and 216 +/- 11 beats/min, respectively), indicating that OXM elevated intrinsic HR. Intrinsic HR was also vigorously elevated by OXM in Glp-1R(-/-) mice (200 +/- 28 beats/min). In addition, peripherally administered OXM inhibited food intake and activity levels in wild-type mice and lowered Tb in autonomically blocked mice. None of these effects were observed in Glp-1R(-/-) mice. These data suggest multiple modes of action of OXM: 1) it directly elevates murine intrinsic HR through a GLP-1R-independent mechanism, perhaps via the glucagon receptor or an unidentified OXM receptor, and 2) it lowers food intake, activity, and Tb in a GLP-1R-dependent fashion.