Clozapine Withdrawal Catatonia: A Case Report.

Catatonia, which is associated with gamma-aminobutyric acid (GABA) hypoactivity, often responds robustly to benzodiazepines. It has been reported to be a consequence of abrupt discontinuation of clozapine, an antipsychotic used for treatment-resistant schizophrenia. Clozapine discontinuation, sometimes necessitated by medical concerns, can carry the risk of adverse outcomes, including catatonia. We present the case of a 66-year-old African-American male with schizoaffective disorder (depressive subtype) and a complex medical history. He discontinued clozapine abruptly due to medication unavailability, and, seven days later, presented with catatonic symptoms, initially unrecognized by emergency room clinicians. His symptoms included self-neglect, auditory hallucinations, isolation, psychomotor retardation, fixed gaze, and thought blocking. An attempt to reinstate clozapine led to orthostatic hypotension, prompting admission to an inpatient psychiatry unit. Attempt to initiate risperidone for psychosis worsened the catatonia, which then responded rapidly to intravenous lorazepam challenge. This facilitated the re-introduction of clozapine with slow re-titration.

Kratom use and mental health: A systematic literature review and case example.

OBJECTIVE: This review aims to synthesize and critically evaluate the existing literature on kratom use and its possible association with induction of psychotic and manic symptoms, in order to identify potential areas for future research that would improve our understanding of the risks of kratom consumption. METHODS: An electronic search was performed using five major databases: including PubMed, Scopus, Google Scholar, Web of Science, and PsycINFO. keywords such as kratom, Mitragyna speciosa, mania, psychosis, bipolar disorder, schizophrenia, schizoaffective, case report, and case series. The retrieved articles on initial search were screened based on predefined inclusion and exclusion criteria for this study, and then data synthesis was performed to analyze relevant information from the included studies. RESULTS: Six prior papers were found using (1 case series and 5 case reports). These included 10 cases, involving kratom use association with mania and psychosis. The ages of patients ranged from 28 to 55 years mean age was 38, and (SD 13.74), the majority were males (8 out of 11). Patients had durations of kratom use ranging from 2 wk to 15 years. Significant association was found between kratom use and the worsening of psychotic and manic symptoms in individuals with psychiatric conditions. CONCLUSIONS: Our research highlights the possibility of worsening preexisting psychiatric conditions in the context of kratom use. This study emphasizes the need for clinical evaluation of patients for kratom use. Additional research is required to gain a deeper understanding of the potential mental health implications of kratom use, especially among vulnerable populations.

Ketamine Augmentation of Electroconvulsive Therapy: A Scoping Review of Dose-Dependent Effects in Major Depressive Disorder.

Intravenous ketamine infusions in subanesthetic doses have been shown to rapidly alleviate depressive symptoms. However, the efficacy of ketamine as an anesthetic during electroconvulsive therapy (ECT) for major depression has not yet been answered by a large randomized control trial (RCT). This scoping review aims to examine the available literature to determine whether the dose of ketamine used during ECT influences the response to treatment. A literature search was conducted on PubMed to identify all published RCTs within the last 10 years which compared ketamine anesthesia during ECT for major depression with another anesthetic. Studies using low (<0.8 mg/kg) versus high (≥0.8 mg/kg) doses of ketamine during ECT were evaluated for the differences in outcomes using depression rating scales. Studies that examined ketamine as a standalone treatment for depression or focused primarily on the anesthetic benefits of ketamine were excluded from our review. Fifteen studies were utilized for this literature review. Overall, the studies showed inconsistent results in terms of the speed and magnitude of response to ketamine-assisted ECT in patients with major depression. Limitations of the available literature are discussed, including the lack of head-to-head comparisons, differences in methodology, inclusion/exclusion criteria, and primary and secondary endpoints.

Parents' Awareness of Bullying Involvement in Relation to Physician Practices: Implications for Practice Modifications.

Background Bullying is a complex abusive behavior with potentially serious consequences. Persons who bully and those who are bullied have consistently been found to have higher levels of depression, suicidal ideation, physical injury, distractibility, somatic problems, anxiety, poor self-esteem, and school absenteeism than those not involved with bullying. Objectives To our knowledge, no study has compared physicians' practices of bullying prevention across different hospital settings and the effect of these practices on parents' level of awareness. This article represents a subset (phase I) of the inter-departmental quality improvement study for comparing practices of healthcare professionals regarding bullying prevention between the pediatric outpatient clinic and child & adolescent psychiatry outpatient clinic, and parents' awareness about provider's anti-bullying practices. Methods Phase I was conducted as a cross-sectional study with the target population of adolescents (age 12-17 yrs) and corresponding guardians, seeking care from healthcare providers (residents, fellows and attendings) in the child & adolescent outpatient psychiatry clinic and pediatric outpatient clinic. It targeted both patients and providers, with adolescents/guardians completing questionnaire about bullying experiences, physician's anti-bullying practices during past healthcare visits and adolescent Peer Relations Instrument. Providers answered questions about bullying assessing practices, level of self-preparedness and limitations. Results Data were analyzed in SAS 9.2 (SAS Institute Inc., Cary, NC) and SPSS (IBM Corp., Armonk, NY) and Chi-square tests were used for analyses of variables, and cross-comparing results for particular subsets. A total of 150 questionnaires were distributed. Among the provider surveys, self-reported level of preparedness (on a scale of 1-5; 1- least, 5-most) for assessing bullying was more in Psychiatry providers (Median 4, Mean 4.1) as compared to Pediatric providers (Median 3, Mean 2.9). In the first evaluation, very unprepared, unprepared and neutral (1, 2, 3) responses were contrasted with prepared to very prepared responses (4,5). The second evaluation excludes the neutral responses (3) and tests responses for the unprepared group (1,2) with the prepared group (4,5). The first evaluation resulted in Chi-Squared = 6.810, significant at p = 0.05 and the second evaluation resulted in Chi-squared = 4.774, also significant at p = 0.05. Conclusions This study identifies differences in healthcare professional's anti-bullying practices and helps in identifying limiting factors. This identification of the practice gap helps in developing interventional strategies to improve the assessment of bullying situations across specialties.

An Audit of Inpatient Consultation-Liaison Psychiatry Services at an Inner New York City Safety Net Hospital.

Background Our study's primary objective is to audit the resource utilization of a consultation-liaison (CL) psychiatry service in an inner New York City safety net hospital. This cross-sectional, observational study was conducted as a subset of a quality improvement project at the hospital to investigate the characteristics of the emergent nature of consults, types, and the specialty from which the referral was placed to the CL services. This study aims to improve the efficacy of our consult process by improving the appropriateness and precision of consult requests. Methodology This cross-sectional, observational study was reviewed and approved by the Institutional Review Board under a quality improvement exemption. The study investigated the EPIC electronic medical record data for characteristics of consult referrals in the third quarter of 2019 from July 1, 2019, to September 30, 2019. A total of 629 consults were recorded during this period. We excluded follow-up calls, duplicate data rows, and patients with missing data points; the final consults were 421. Patients who required more than one new consult (follow-up excluded) within 90 days were considered; thus, the total number of patients who were included in the study was 327. Results Of the 421 consults identified in the dataset for review, only 45.8% were valid consults, 32.8% were not valid, and 21.4% were uncertain. Further, the most common department from which consults were placed was Medicine (73.2%), followed by Surgery (12.8%), Obstetrics/Gynecology (9%), Critical Care (3.6%), and, finally, Pediatrics (1.4%). Conclusions The study overviews the quality of general consults for the CL psychiatry service and how the CL staff manages it. It also provides an idea about the number of consults that can be comprehensively addressed.