The Trauma Recovery Clinic: A Stepped Collaborative Care Model for Trauma Surgery Patients to Address Health Disparities.

Background: The Trauma Recovery Clinic (TRC) was developed to meet the psychiatric, psychological, and psychosocial needs of traumatically injured patients following discharge from a level-I trauma center. The objective of this study is to demonstrate the efficacy of the TRC as an application of the stepped collaborative care model in order to address health disparities.Methods: Patients with a history of inpatient treatment for a physically traumatic injury at this level-I trauma center were approached and enrolled at initial TRC outpatient appointments. Data was collected, including the PTSD Checklist-Civilian Version (PCL-C), the Patient Health Questionnaire (PHQ-9), the Attitudes towards Guns scale, and the Youth Behavior Risk Survey (questions about weapon carrying practices).Results: A total of 80 patients were included in this study. Patients expressed several social determinants of health risk factors, with 60% of the sample reporting witnessing someone being wounded or killed. Results demonstrated a significant decrease in trauma symptoms (T24 = 3.33; P = .001, d = 0.67) and depressive symptoms (T24 = 2.23, P = .02, d = 0.45) by their 6th clinic visit. Additionally, patients reported significant improvements in role limitations due to emotional problems (T25 = 1.74; P = .04; d = 0.34) and social functioning (T25 = 2.23; P = .02; d = 0.43). Interestingly, patients who reported carrying a weapon in the last 30 days reported significantly higher trauma symptoms (T64 = 3.21, P = .002) and depressive symptoms (T64 = 2.77, P = .007).Discussion: This evaluation of services at the recently implemented Trauma Recovery Clinic demonstrated that the clinic is successfully treating individuals who have experienced traumatic injuries. More specifically, the clinic services are effectively engaging a vulnerable, hard-to-reach patient population.

The COVID-19 pandemic and associated increases in experiences of assault violence among black men with low socioeconomic status living in Louisiana.

Background: The COVID-19 pandemic has had mental health, social, and economic implications among communities with high levels of social disadvantage; this may have impacted community violence rates. The objective of this study was to characterize overall trends in assault and social disadvantage of patients experiencing assault before and during the COVID-19 pandemic. Methods: All trauma activations at a level one trauma center serving the entire southeast Louisiana region were included during March-August pre-COVID (2018-2019) and during COVID (2020). ICD-10 E-codes were used to identify trauma intent (assault vs. other). Assaults in this context are defined as physical injuries caused by an act of violence wherein the perpetrator was suspected or confirmed to have intended harm, injury, or death to the victim. Social disadvantage was assessed using the Area Deprivation Index (ADI). Change in the monthly rate of assault-trauma activations was assessed using negative binomial regression with adjustment for race, gender, and injury intent. The study was reviewed and approved by the Louisiana State University Health Sciences Institutional Review Board. Results: A total of 4,233 trauma activations were included. The majority of activations occurred among men. Assaults increased from 27.5% of all activations pre-Covid to 35.6% during the pandemic. Penetrating trauma similarly increased from 29.5% to 35.7% of all activations. Negative binomial regression demonstrated that in addition to this increase in proportion of assaults relative to all activations, the monthly assault rate also increased by 20% during the pandemic. These increases were driven primarily by increased assaults among Black men. ADI rank did not change between study periods. Conclusions: Health disparities in violence worsened during the pandemic: increased cases of assault occurred disproportionately among Black men, and assaults persisted in occurring primarily among low-ADI communities where burden had been high pre-pandemic. There is a critical need for resources and support to Black men, to mitigate violence and improve racial heath equity.

PTSD treatment reduces risk of trauma recidivism in a diverse community at a safety-net hospital: A propensity score analysis of data from a level one trauma center.

BACKGROUND: Physically-traumatic injuries result in PTSD for approximately 10% of Americans, and this rate is higher among individuals of color and those living in poverty. Individuals of color living in poverty experience lower access to PTSD and other mental health services. Untreated PTSD is associated with increased risk of trauma recidivism, but it is unknown if provision of treatment is actually associated with a subsequent reduction in recidivism risk. METHODS: For this observational cross-sectional study, data were collected retrospectively from the Trauma Registry of a level one trauma center, safety-net hospital in New Orleans between 2018 and 2020. Receipt of outpatient PTSD treatment at this same hospital was evaluated via chart review of the electronic health record. Propensity score matching was used to balance confounding variables of trauma type (assault vs. non-assault), gender, and race. McNemar test and Cox proportional hazard model were used with the propensity-balanced dataset to assess differences in trauma recidivism according to PTSD treatment status. RESULTS: Among 5916 trauma activations that occurred in the study period, 92 instances of recidivism occurred. 91 pairs were established after balancing with the propensity score. 1-year recidivism was 2.2% (n = 2) of all treated individuals versus 15.4% (n = 14) of non-treated individuals (p < 0.0001). The marginal risk from the Cox proportional hazard model demonstrated an 82% reduction in risk of recidivism (p = 0.02). CONCLUSIONS: This study demonstrated that mental health treatment can be used to reduce trauma recidivism. These data were shown among a high-risk population of disproportionately Black men living in a low-income community. Ensuring access to quality mental health care is one way to address the health disparities associated with physically-traumatic injuries.

Alcohol Consumption and COVID-19-Related Stress Among Health Care Workers: The Need for Continued Stress-Management Interventions.

OBJECTIVES: Although a known association exists between stress and alcohol consumption among health care workers (HCWs), it is not known how the COVID-19 pandemic has affected this association. We assessed pandemic work-related stress and alcohol consumption of HCWs. METHODS: We emailed a cross-sectional, anonymous survey in June 2020 to approximately 550 HCWs at an academic hospital in New Orleans, Louisiana. HCWs from all departments were eligible to complete the survey. Questions measured work-related stress and emotional reactions to the pandemic (using the Middle East Respiratory Syndrome [MERS-CoV] Staff Questionnaire), depressive symptoms (using the Patient Health Questionnaire-9 [PHQ-9]), coping habits (using the Brief COPE scale), and pre-COVID-19 (March 2020) and current (June 2020) alcohol consumption. We measured alcohol consumption using the Alcohol Use Disorders Identification Test-Consumption (AUDIT-C), with scores >3 considered positive. We asked 4 open-ended questions for in-depth analysis. RESULTS: One-hundred two HCWs participated in the survey. The average AUDIT-C scores for current and pre-COVID-19 alcohol consumption were 3.1 and 2.8, respectively. The level of current alcohol consumption was associated with avoidant coping (r = 0.46, P < .001). Relative increases in alcohol consumption from March to June 2020 were positively associated with PHQ-9 score and greater emotional reactions to the pandemic. Availability of mental health services was ranked second to last among desired supports. Qualitative data demonstrated high levels of work-related stress from potential exposure to COVID-19 and job instability, as well as social isolation and negative effects of the pandemic on their work environment. CONCLUSIONS: Ongoing prevention-based interventions that emphasize stress management rather than mental or behavioral health conditions are needed.

Violent trauma as an indirect impact of the COVID-19 pandemic: A systematic review of hospital reported trauma.

INTRODUCTION: The COVID-19 pandemic has exacerbated many social conditions associated with violence. The objective of this systematic review was to examine trends in hospital reported violent trauma associated with the pandemic. METHODS: Databases were searched in using terms "trauma" or "violence" and "COVID-19," yielding 4,473 records (2,194 de-duplicated). Exclusion criteria included non-hospital based studies and studies not reporting on violent trauma. 44 studies were included in the final review. RESULTS: Most studies reported no change in violent trauma incidence. Studies predominately assessed trends with violent trauma as a proportion of all trauma. All studies demonstrating an increase in violent trauma were located in the United States. CONCLUSIONS: A disproportionate rise in violence has been reported within the US. However, most studies examined violent trauma as a proportion of all trauma; results may reflect relative changes from lockdowns. Future studies should examine rates of violent trauma to provide additional context.

The importance of adverse childhood experiences during the perinatal period.

The Adverse Childhood Experiences (ACEs) study (Felitti et al., 1998) has led to an understanding of how exposure to abuse, neglect, and family dysfunction in childhood are related to subsequent physical and mental health problems. These issues are important to consider during the perinatal period, with studies indicating that pregnant women who report adverse experiences in childhood may be at risk of experiencing mental health and substance use problems. This study examined the association of pregnant women's ACEs with symptoms of depression, anxiety, posttraumatic stress, and substance use, and examined the potential buffering effect of women's resilience against the deleterious effects of ACES on mental health and substance use. Women reported on ACES, mental health symptoms, substance use, and resilience when they were screened for participation in a perinatal psychosocial support intervention, which was integrated into obstetrical clinics in a Southern academic medical center. Almost a quarter of the 303 women in this sample reported four or more ACEs, indicating significant risk. Those reporting more overall ACEs also reported more symptoms of depression, posttraumatic stress, and increased risk of tobacco use. Unique effects of specific ACEs subtypes were also found. Women exposed to child maltreatment reported more anxiety, depression, and posttraumatic stress symptoms, and were at risk for tobacco, cannabis, or opioid use during pregnancy. Women exposed to household dysfunction reported more posttraumatic stress symptoms and were at increased risk of tobacco and alcohol use during pregnancy. Women's resilience attenuated effects of household dysfunction on posttraumatic stress symptoms. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Treatment of a Complex Case of Catatonia and Conversion Features With Electroconvulsive Therapy in a 14-Year-Old Male.

Background: Pediatric catatonia is a rare and poorly understood phenomenon. The majority of reported cases have a psychiatric etiology. Because of the heterogeneous presentation and treatment issues unique to the pediatric population, identification and management can be challenging. Additionally, few definitive guidelines or practice parameters are available for pediatric patients. The first-line treatment for catatonia is pharmacologic, and when treatment fails or is inadequate, electroconvulsive therapy (ECT) has been shown to be safe and effective. Case Report: A previously healthy, 14-year-old male presented with acute onset of catatonia that resolved at 4 weeks after a short course of ECT with adjunctive lorazepam and risperidone. An interesting feature of this case was the resolution of autonomic symptoms and the emergence of conversion features. The resolution of the catatonia (negativism, mutism, and withdrawal) made it possible for the team to identify a thought disorder and initiate appropriate pharmacologic treatment for the precipitating etiology. Conclusion: ECT was a safe and effective treatment for the resolution of catatonia symptoms in this patient. Conversion and catatonia features may exist on a continuum.

Implementing an intensive care unit (ICU) diary program at a large academic medical center: Results from a randomized control trial evaluating psychological morbidity associated with critical illness.

BACKGROUND: Psychological morbidity in both patients and family members related to the intensive care unit (ICU) experience is an often overlooked, and potentially persistent, healthcare problem recognized by the Society of Critical Care Medicine as Post-intensive Care Syndrome (PICS). ICU diaries are an intervention increasingly under study with potential to mitigate ICU-related psychological morbidity, including ICU-related post-traumatic stress disorder (PTSD), depression and anxiety. As we encounter a growing number of ICU survivors, in particular in the wake of the coronavirus pandemic, clinicians must be equipped to understand the severity and prevalence of significant psychiatric complications of critical illness. METHODS: We compared the efficacy of the ICU diary, written by family and healthcare workers during the patient's intensive care course, versus education alone in reducing acute PTSD symptoms after discharge. Patients with an ICU stay >72 h, who were intubated and mechanically ventilated over 24 h, were recruited and randomized to either receive a diary at bedside with psychoeducation or psychoeducation alone. Intervention patients received their ICU diary within the first week of admission into the intensive care unit. Psychological symptom screening with IES-R, PHQ-8, HADS and GAD-7 was conducted at baseline within 1 week of ICU discharge and at weeks 4, 12, and 24 after ICU discharge. Change from baseline in these scores was assessed using Wilcoxon rank sum tests. RESULTS: From September 26, 2017 to September 25, 2018, our team screened 265 patients from the surgical and medical ICUs at a single large academic urban hospital. 60 patients were enrolled and randomized, of which 35 patients completed post-discharge follow-up, (n = 18) in the diary intervention group and (n = 17) in the education-only control group. The control group had a significantly greater decrease in PTSD, hyperarousal, and depression symptoms at week 4 compared to the intervention group. There were no significant differences in other measures, or at other follow-up intervals. Both study groups exhibited clinically significant PTSD symptoms at all timepoints after ICU discharge. Follow-up phone interviews with patients revealed that while many were interested in getting follow-up for their symptoms, there were many barriers to accessing appropriate therapy and clinical attention. CONCLUSIONS: Results from psychological screening tools demonstrate no benefit of ICU diaries versus bedside education-alone in reducing PTSD symptoms related to the intensive care stay. However, our study finds an important gap in clinical practice - patients at high risk for PICS are infrequently connected to appropriate follow-up care. Perhaps ICU diaries would prove beneficial if utilized to support the work within a program providing wrap-around services and close psychiatric follow up for PICS patients. This study demonstrates the high prevalence of ICU-related PTSD in our cohort of survivors, the high barrier to accessing care for appropriate treatment of PICS, and the consequence of that barrier-prolonged psychological morbidity. TRIAL REGISTRATION: NCT04305353. GRANT IDENTIFICATION: GH-17-022 (Arnold P. Gold Foundation).

Childhood trauma exposure and gun violence risk factors among victims of gun violence.

OBJECTIVE: Gun violence is a serious public health concern, yet risk factors for gun violence involvement remain understudied. Childhood trauma exposure, such as domestic violence (DV) and community violence (CV), may increase the risk for aggression, although this relationship has not been examined in the context of gun violence. The aim of the current study was to investigate whether different childhood trauma ecologies are related to increased gun violence involvement and gun violence risk factors among individuals hospitalized for a gun injury. METHOD: Seventy-two gun violence victims reported on their gun violence involvement and gun violence risk factors (e.g., gun ownership, gun carrying, gun arrests, impulsivity, perceptions regarding violence) at hospital bedside. RESULTS: Childhood DV and CV exposure were both associated with increased gun violence involvement as well as numerous gun violence risk factors. Effect sizes were generally medium to large (M d = .53). CONCLUSION: Childhood traumatic events, such as DV and CV, may be important antecedent risk factors for gun violence. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

Motivational Interviewing for Victims of Armed Community Violence: A Nonexperimental Pilot Feasibility Study.

OBJECTIVE: The present study aimed to develop a novel, hospital-based motivational interviewing (MI) intervention for victims of armed community violence (MI-VoV) targeting patient-specific risk factors for future violence or violent victimization. METHOD: This uncontrolled pilot feasibility study examined a sample of patients (n = 71) hospitalized due to violent injury at a Level 1 Trauma Center in [Location Redacted for Masked Review] between January 2013 and May 2014. Patients first participated in a brief assessment to identify risk factors for violence/violent injury. A single MI session then targeted risk behaviors identified for each patient. Proximal outcomes, including motivation for change and behaviors to reduce risk, were examined at 2 weeks and 6-12 weeks post-discharge. Distal outcomes, including fighting, weapon-carrying, and gun-carrying, and other violence risk factors were examined at 6-12 week follow-up. RESULTS: Ninety-five patients were offered participation, 79 (83.2%) agreed to participate, and 73 (76.8%) completed the risk assessment. Of these, 71 had at least one violence/violent injury risk factor. Behaviors to reduce risk were significantly greater at two-week and 6-12 week follow-up (ps < .05). Fighting, weapon-carrying, gun-carrying were significantly reduced at 6-12 week follow-up (p < .05). CONCLUSIONS: This intervention appears to be feasible to implement and acceptable to patients. A randomized controlled trial evaluating efficacy appears warranted.

Mobile Phone Use in Psychiatry Residents in the United States: Multisite Cross-Sectional Survey Study.

BACKGROUND: Mobile technology ownership in the general US population and medical professionals is increasing, leading to increased use in clinical settings. However, data on use of mobile technology by psychiatry residents remain unclear. OBJECTIVE: In this study, our aim was to provide data on how psychiatric residents use mobile phones in their clinical education as well as barriers relating to technology use. METHODS: An anonymous, multisite survey was given to psychiatry residents in 2 regions in the United States, including New Orleans and Boston, to understand their technology use. RESULTS: All participants owned mobile phones, and 79% (54/68) used them to access patient information. The majority do not use mobile phones to implement pharmacotherapy (62%, 42/68) or psychotherapy plans (90%, 61/68). The top 3 barriers to using mobile technology in clinical care were privacy concerns (56%, 38/68), lack of clinical guidance (40%, 27/68), and lack of evidence (29%, 20/68). CONCLUSIONS: We conclude that developing a technology curriculum and engaging in research could address these barriers to using mobile phones in clinical practice.

Combined Oral Contraceptive Pill Initiation in a Patient With Major Depressive Disorder, Premenstrual Dysphoric Disorder, Social Anxiety, Panic Disorder, and Histrionic Personality Disorder.

BACKGROUND: Comorbid psychiatric conditions present an added layer of challenge in managing patients, as each condition and associated set of symptoms exacerbate the complexity of the overall presentation. Premenopausal women may be at particular risk for inadequate care, as their comorbid conditions may present overlapping symptoms and mask independent premenstrual symptoms. The prevalence of premenstrual dysphoric disorder and associated conditions can be as high as 8% in women of reproductive age. Recognizing and assessing premenstrual symptoms that are comorbid with other psychiatric conditions can help contribute to a comprehensive treatment strategy and potentially improve the treatment response for the comorbid conditions. Combined oral contraceptive pills (COCPs) have been approved for premenstrual conditions and should be considered by the psychiatrist as an available treatment option. CASE REPORT: A 34-year-old Caucasian female patient with comorbid major depressive disorder, premenstrual dysphoric disorder, social anxiety, panic disorder, and histrionic personality disorder, with persistent suicidal ideation and distress intolerance, was treated with norgestimate-ethinyl estradiol with improvement in mood, anxiety, and menstrual cramping and with associated diminished suicidal ideation and improved distress tolerance. CONCLUSION: In this case, Beck Depression Inventory and Beck Anxiety Inventory scores, as well as self- and peer-reported functionality, all suggested improvement in symptoms following the introduction of COCPs. The neurohormonal contribution to psychiatric conditions continues to be studied and is becoming increasingly important. An understanding of the presence and etiology of premenstrual symptoms should be part of a comprehensive psychiatric assessment of female patients, and consideration of COCPs in the treatment plan adds a potentially potent option for symptom mitigation and remission.

Criminal Behavior and Repeat Violent Trauma: A Case-Control Study.

INTRODUCTION: Repeat violent injury is common among young urban men and is increasingly a focus of trauma center-based injury prevention efforts. Though understanding risk factors for repeat violent injury may be critical in designing such interventions, this knowledge is limited. This study aims to determine which criminal behaviors, both before and after the initial trauma, predict repeat violent trauma. Gun, violent, and drug crimes are expected to increase risk of subsequent violent injury among victims of violence. METHODS: A case-control design examined trauma registry and publicly available criminal data for all male patients aged <40 years presenting for violent trauma between April 2006 and December 2011 (N=1,142) to the sole Level 1 trauma center in a city with high rates of violence. Logistic regression was used to determine criminal behaviors predictive of repeat violent injury. Data were obtained and analyzed between January 2013 and June 2014. RESULTS: Regarding crimes committed before the first injury, only drug crime (OR=5.32) predicted repeat violent trauma. With respect to crimes committed after the initial injury, illegal gun possession (OR=2.70) predicted repeat victimization. Initiating gun (OR=3.53) or drug crime (OR=5.12) was associated with increased risk. CONCLUSIONS: Prior drug involvement may identify young male victims of violence as at high risk of repeat violent injury. Gun carrying and initiating drug involvement after the initial injury may increase risk of repeat injury and may be important targets for interventions aimed at preventing repeat violent trauma.

Clinical Case of the Month: A 48-Year-Old Man With Fever and Abdominal Pain of One Day Duration.

A 48-year-old man residing in a mental health department inpatient program with a history of schizoaffective disorder presented to the emergency department with a chief complaint of fever and intense abdominal pain for one day. The patient stated he initially fell in the shower and afterwards experienced back pain. He was transferred to an acute care unit within the facility for further evaluation. The facility physician noted that the patient had a mild temperature elevation and abdominal rigidity on exam. At that time, he was given two doses of benztropine intramuscularly, and transferred to our hospital for further evaluation. The patient exhibited fever, diffuse abdominal pain and a nonproductive cough, but denied chills, dysuria, urinary frequency, hematuria, weakness, diarrhea, melena or hematochezia. He did have a one-week history of constipation for which he was given sodium phosphate enemas, magnesium citrate and docusate sodium, eventually resulting in a bowel movement. He also complained of new onset dysphagia. There were no recent changes to his medications, which included clonazepam, divalproex sodium extended release, olanzapine and risperidone. He denied use of tobacco, alcohol or illicit drugs.

Patient Smartphone Ownership and Interest in Mobile Apps to Monitor Symptoms of Mental Health Conditions: A Survey in Four Geographically Distinct Psychiatric Clinics.

BACKGROUND: Despite growing interest in mobile mental health and utilization of smartphone technology to monitor psychiatric symptoms, there remains a lack of knowledge both regarding patient ownership of smartphones and their interest in using such to monitor their mental health. OBJECTIVE: To provide data on psychiatric outpatients' prevalence of smartphone ownership and interest in using their smartphones to run applications to monitor their mental health. METHODS: We surveyed 320 psychiatric outpatients from four clinics around the United States in order to capture a geographically and socioeconomically diverse patient population. These comprised a state clinic in Massachusetts (n=108), a county clinic in California (n=56), a hybrid public and private clinic in Louisiana (n=50), and a private/university clinic in Wisconsin (n=106). RESULTS: Smartphone ownership and interest in utilizing such to monitor mental health varied by both clinic type and age with overall ownership of 62.5% (200/320), which is slightly higher than the average United States' rate of ownership of 58% in January 2014. Overall patient interest in utilizing smartphones to monitor symptoms was 70.6% (226/320). CONCLUSIONS: These results suggest that psychiatric outpatients are interested in using their smartphones to monitor their mental health and own the smartphones capable of running mental healthcare related mobile applications.

Assessment of psychiatric symptoms at a level I trauma center surgery follow-up clinic: a preliminary report.

At Level I trauma centers, psychiatric consultation is readily available to inpatient surgical services. This study sought to characterize the psychiatric symptoms present in the surgical follow-up clinic. Patients aged 18 years and older were assessed over one month for symptoms of posttraumatic stress disorder (PTSD) with the Short PTSD Rating Interview (SPRINT), depression with the Patient Health Questionnaire (PHQ-9), alcohol abuse with the Alcohol Use Disorder Identification Test (AUDIT), and the presence of violence using the MacArthur Community Violence Instrument (MCVIa [victimization] MCVIb [perpetration]). Twenty-five individuals participated. Using the SPRINT, 13 (52.0%) met the cutoff for PTSD. For PHQ-9 depression, 11 (44%) were in the moderate to severe range. For AUDIT, five (20.0%) likely had an alcohol problem. Using the MCVI, 15 (60.0%) reported victimization and 12 (48.0%) reported perpetration. Elevated levels of psychiatric symptoms were found in the trauma surgery follow-up clinic. Psychiatric care embedded in this setting may be warranted.

Psychiatry consultation during disaster preparedness: Hurricane Gustav.

OBJECTIVES: Little is known about patient populations that remain during or after the mandatory evacuation of a city and use hospital services. This study sought to characterize the population that presented to an emergency department during Hurricane Gustav in 2008. METHODS: This was a retrospective chart review of patients who presented to the Interim Louisiana State University Hospital emergency department in New Orleans during the 72-hour activation phase of Hurricane Gustav. RESULTS: Of the 104 patients, 51 (49%) had a psychiatric diagnosis. Among the psychiatric patients, 34 (67%) had a substance use disorder diagnosis, 16 (31%) had a mood disorder, 13 (25%) had a psychotic disorder, and 4 (8%) had an anxiety disorder. The psychiatry service was the most used consultation service. CONCLUSIONS: To our knowledge, this is the first report to characterize the patient population presenting to an emergency department during a hurricane evacuation. Data suggest that disaster preparedness should include psychiatric consultation services. The consultation psychiatrist may anticipate patients with high levels of substance use disorders and the need for ongoing psychiatric management until the event ends.

A double-blind placebo-controlled trial of lamotrigine as an antidepressant augmentation agent in treatment-refractory unipolar depression.

BACKGROUND: Previous reports have suggested that lamotrigine is effective as an antidepressant augmentation agent in patients with treatment-resistant unipolar depression. This study is the largest double-blind placebo-controlled study conducted to date of lamotrigine in this role. METHOD: In this multicenter trial, conducted at 19 sites, patients aged 18-65 years with a DSM-IV/ICD-10 diagnosis of unipolar, nonpsychotic major depressive disorder (confirmed by the Mini-International Neuropsychiatric Interview) who had failed at least 1 adequate trial of an antidepressant (N = 183) were first treated for 8 weeks with open-label paroxetine or paroxetine controlled-release in dosages up to 50 mg/d or 62.5 mg/d, respectively. Individuals with a 17-item Hamilton Depression Rating Scale (HDRS-17) score ≥ 15 (n = 96) were then randomized on a double-blind basis to receive either placebo or lamotrigine in dosages titrated upward to a maximum of 400 mg/d for 10 weeks. Sixty-five patients completed the study. The primary outcome measure was the Montgomery-Asberg Depression Rating Scale (MADRS), and the main secondary outcome measures were the HDRS-17 and Clinical Global Impressions-Severity of Illness (CGI-S) and Clinical Global Impressions-Improvement (CGI-I) ratings. Data were collected from 2003 to 2006. RESULTS: Results of the primary efficacy analysis of the randomized patients using the MADRS, HDRS-17, CGI-S, and CGI-I did not demonstrate a statistically significant difference between lamotrigine and placebo groups, although some secondary analyses were suggestive of efficacy, particularly in those patients who completed the study (completer analysis) and in more severely ill patients (HDRS-17 ≥ 25). CONCLUSIONS: This add-on study of patients with treatment-resistant depression failed to detect a statistically significant difference between lamotrigine and placebo given for 10 weeks. However, post hoc analyses suggest that future studies of lamotrigine's efficacy might focus on specific subgroups with depression. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00901407.

Update on anesthesia considerations for electroconvulsive therapy.

Depression is diagnosed in 14 million Americans every year, and pharmacotherapy is the standard treatment. However, in approximately 50% of patients, pharmacology intervention does not resolve depression. Electroconvulsive therapy (ECT) has been a mainstay as a treatment option for treatment-resistant major depression since its inception in the 1930s. It has also been shown to be effective in treatment-resistant mania and catatonic schizophrenia. The complication rate of ECT has improved from 50% in the 1960's to almost anecdotal adverse events, similar to the morbidity and mortality seen in minor surgery and childbirth. Although anesthetic agents are administered briefly, many patients experience significant fluctuations in physiologic parameters. The clinical anesthesiologist must be aware of these changes as well as have an understanding of perioperative pharmacological interventions. ECT is a proven therapy for select psychiatric patients, and appropriate anesthesia is a critical part of successful ECT. Careful review of the patient's medical history may reveal pertinent anesthetic considerations.