Moderating Effects of Informal Care on the Relationship Between ADL Limitations and Adverse Outcomes in Stroke Survivors.

BACKGROUND: Stroke survivors with limitations in activities of daily living (ADL) have a greater risk of experiencing falls, hospitalizations, or physical function decline. We examined how informal caregiving received in hours per week by stroke survivors moderated the relationship between ADL limitations and adverse outcomes. METHODS: In this retrospective cohort, community-dwelling participants were extracted from the National Health and Aging Trends Study (2011-2020; n=277) and included if they had at least 1 formal or informal caregiver and reported an incident stroke in the prior year. Participants reported the amount of informal caregiving received in the month prior (low [<5.8], moderate [5.8-27.1], and high [27.2-350.4] hours per week) and their number of ADL limitations (ranging from 0 to 7). Participants were surveyed 1 year later to determine the number of adverse outcomes (ie, falls, hospitalizations, and physical function decline) experienced over the year. Poisson regression coefficients were converted to average marginal effects and estimated the moderating effects of informal caregiving hours per week on the relationship between ADL limitations and adverse outcomes. RESULTS: Stroke survivors were 69.7% White, 54.5% female, with an average age of 80.5 (SD, 7.6) years and 1.2 adverse outcomes at 2 years after the incident stroke. The relationships between informal caregiving hours and adverse outcomes and between ADL limitations and adverse outcomes were positive. The interaction between informal caregiving hours per week and ADL limitations indicated that those who received the lowest amount of informal caregiving had a rate of 0.12 more adverse outcomes per ADL (average marginal effect, 0.12 [95% CI, 0.005-0.23]; P=0.041) than those who received the highest amounts. CONCLUSIONS: Informal caregiving hours moderated the relationship between ADL limitations and adverse outcomes in this sample of community-based stroke survivors. Higher amounts relative to lower amounts of informal caregiving hours per week may be protective by decreasing the rate of adverse outcomes per ADL limitation.

Coding for Physical Restraint Status Among Hospitalized Patients: a 2019 National Inpatient Sample Analysis.

BACKGROUND: The reduction of physical restraint utilization in the hospital setting is a key goal of high-quality care, but little is known about the rate of restraint use in general hospitals in the USA. OBJECTIVE: This study reports the rate of physical restraint coding among acute care hospital discharges in the USA and explores associated demographic and diagnostic factors. DESIGN: The National Inpatient Sample, a de-identified all-payors database of acute care hospital discharges in the USA, was queried for patients aged 18 and older with a diagnosis code for physical restraint status in 2019. PARTICIPANTS: Hospitalized patients aged 18 and older. MAIN MEASURES: Demographics, discharge diagnoses, in-hospital mortality, length of stay, total hospital charges. KEY RESULTS: In total, 220,470 (95% CI: 208,114 to 232,826) hospitalizations, or 0.7% of overall hospitalizations, included a discharge code for physical restraint status. There was a 700-fold difference in coding for restraint utilization based on diagnosis, with 7.4% of patients with encephalitis receiving restraint diagnosis codes compared to < 0.01% of patients with uncomplicated diabetes. In an adjusted model, male sex was associated with an odds ratio of 1.4 (95% CI: 1.4 to 1.5) for restraint utilization coding, and Black race was associated with an odds ratio of 1.3 (95% CI: 1.2 to 1.4) relative to white race. CONCLUSIONS: In the general hospital setting, there is variability in physical restraint coding by sex, race, and clinical diagnosis. More research is needed into the appropriate utilization of restraints in the hospital setting and possible inequities in restraint utilization.

Risk Stratification of QTc Prolongation in Critically Ill Patients Receiving Antipsychotics for the Management of Delirium Symptoms.

BACKGROUND: Patients experiencing significant agitation or perceptual disturbances related to delirium in an intensive care setting may benefit from short-term treatment with an antipsychotic medication. Some antipsychotic medications may prolong the QTc interval, which increases the risk of potentially fatal ventricular arrhythmias. In this targeted review, we describe the evidence regarding the relationships between antipsychotic medications and QTc prolongation and practical methods for monitoring the QTc interval and mitigating arrhythmia risk. METHODS: Searches of PubMed and Cochrane Library were performed to identify studies, published before February 2023, investigating the relationships between antipsychotic medications and QTc prolongation or arrhythmias. RESULTS: Most antipsychotic medications commonly used for the management of delirium symptoms (eg, intravenous haloperidol, olanzapine, quetiapine) cause a moderate degree of QTc prolongation. Among other antipsychotics, those most likely to cause QTc prolongation are iloperidone and ziprasidone, while aripiprazole and lurasidone appear to have minimal risk for QTc prolongation. Genetic vulnerabilities, female sex, older age, pre-existing cardiovascular disease, electrolyte abnormalities, and non-psychiatric medications also increase the risk of QTc prolongation. For individuals at risk of QTc prolongation, it is essential to measure the QTc interval accurately and consistently and consider medication adjustments if needed. CONCLUSIONS: Antipsychotic medications are one of many risk factors for QTc prolongation. When managing agitation related to delirium, it is imperative to assess an individual patient's risk for QTc prolongation and to choose a medication and monitoring strategy commensurate to the risks. In intensive care settings, we recommend regular ECG monitoring, using a linear regression formula to correct for heart rate. If substantial QTc prolongation (eg, QTc > 500 msec) is present, a change in pharmacologic treatment can be considered, though a particular medication may still be warranted if the risks of discontinuation (eg, extreme agitation, removal of invasive monitoring devices) outweigh the risks of arrhythmias. AIMS: This review aims to summarize the current literature on relationships between antipsychotic medications and QTc prolongation and to make practical clinical recommendations towards the approach of antipsychotic medication use for the management of delirium-related agitation and perceptual disturbances in intensive care settings.

Changes in Inpatient Electroconvulsive Therapy Utilization Between 2019 and 2020: A National Inpatient Sample Analysis.

OBJECTIVES: Electroconvulsive therapy (ECT) is an essential procedure for a range of psychiatric conditions. Multiple single-center studies have documented reduction in ECT administration in 2020 because of the coronavirus disease 2019 pandemic, but there have been little nationally representative data from the United States. The aim of this study was to examine the demographics of patients receiving ECT in 2019 and 2020 and to characterize temporal and regional variations in ECT utilization. METHODS: The 2019 and 2020 National Inpatient Sample, an administrative database of inpatient hospitalizations in the United States, was queried for hospitalizations involving the delivery of ECT based on procedural codes. Overall number of ECT procedures was calculated based on the overall number of ECT procedural claims. RESULTS: In the 2019 NIS, 14,230 inpatient hospitalizations (95% confidence interval, 12,936-15,524) involved the use of ECT, with a cumulative 52,450 inpatient ECT procedures administered. In 2020, the number of inpatient hospitalizations with ECT decreased to 12,055 (95% confidence interval, 10,878-13,232), with a 10.0% reduction in overall procedures to 47,180. Whereas January and February ECT hospitalizations were comparable in both years, ECT hospitalizations decreased by more than 25% in March through May 2020 relative to 2019 volume. There was regional variability in the change in ECT utilization between 2019 and 2020. CONCLUSIONS: Electroconvulsive therapy use among general hospital inpatients declined between 2019 and 2020, with regional variability in the magnitude of change. Further study is warranted into the root causes and optimal responses to these changes.

Senior Resident as Junior Supervisor: Case Report of an Apprenticeship Model for Training Psychotherapy Supervisors.

Psychotherapy supervision is an essential component of graduate medical education in psychiatry. However, most psychotherapy supervisors have never had training specific to supervision, and the requisite skills have received little attention in the literature. The authors of this article describe the first year of a pilot project that was aimed at fostering interest and skill in psychotherapy supervision among senior residents. In this model, a postgraduate year (PGY)-4 resident supervised a PGY-2 resident's psychodynamic psychotherapy while receiving supervisory support from a senior faculty member. Feedback from the two residents and the residency program director was positive. The PGY-2 resident reported benefiting from near-peer supervision. The PGY-4 resident continued to supervise residents after graduation and felt well prepared to assume that role. The residency program continued to use this model after the pilot period. Other training programs can replicate this model to nurture the next generation of psychotherapy supervisors.

Novel methods for assessment of vulnerability to financial exploitation (FE).

Financial exploitation (FE) is a complex problem influenced by many factors. This article introduces two novel methods for assessment of FE vulnerability: (1) performance-based measures of financial skills using web-based simulations of common financial tasks; (2) scam vulnerability measures based on credibility ratings of common scam scenarios. Older adults who were male, younger, Hispanic, more educated, with higher incomes performed better on the simulated financial tasks. Better performance was also related to higher cognitive function and numeracy, and more experience with technology. On the scenario-based measures, older adults who were male, younger, African American, less educated, and lower income showed higher FE vulnerability. Higher scam vulnerability was also related to poorer performance on the simulated financial tasks, lower cognitive function, less experience with technology, more financial conflict/anxiety, more impulsivity, and more stranger-initiated FE. Findings indicate that these novel measures show promise as valid indicators of vulnerability to FE.

Caregiving Factors as Predictors of Care Recipient Mortality.

OBJECTIVE: Assess a conceptual model linking caregiving factors to care recipient mortality in a large representative sample of older adults with disability. DESIGN: Descriptive longitudinal study with 5-year mortality follow-up among older adults with disability. Baseline in person and telephone interviews/assessments of older adults with disability and their family caregivers carried out in 2011. SETTING: Representative samples of older US population and their family caregivers. PARTICIPANTS: US representative samples of older adults with disability aged 65 and over (National Health and Aging Study) and their family caregivers (National Study of Caregiving; www.nhats.org; N = 1,262). MEASUREMENT: Controlling for known risk factors for mortality in older adults, including age, gender, race, education, socioeconomic status, disability, and cognitive status, we assess the role of three caregiving factors (depression, anxiety, and burden) and three mediating factors (care recipient depression, anxiety, and unmet needs for care) as predictors of care recipient mortality. RESULTS: Caregiver burden, care recipient depression, and care recipient unmet needs are independent predictors of care recipient mortality. CONCLUSION: Caregiving factors may play an important role in the survival of their care recipients. This is a relatively unexplored research area that calls for fine-grained studies capturing caregiver-care recipient health-related interactions over time.

Family Caregiving for Older Adults.

Family members are the primary source of support for older adults with chronic illness and disability. Thousands of published empirical studies and dozens of reviews have documented the psychological and physical health effects of caregiving, identified caregivers at risk for adverse outcomes, and evaluated a wide range of intervention strategies to support caregivers. Caregiving as chronic stress exposure is the conceptual driver for much of this research. We review and synthesize the literature on the impact of caregiving and intervention strategies for supporting caregivers. The impact of caregiving is highly variable, driven largely by the intensity of care provided and the suffering of the care recipient. The intervention literature is littered with many failures and some successes. Successful interventions address both the pragmatics of care and the emotional toll of caregiving. We conclude with both research and policy recommendations that address a national agenda for caregiving.

Effect of Antithrombotic Therapy on Clinical Outcomes in Outpatients With Clinically Stable Symptomatic COVID-19: The ACTIV-4B Randomized Clinical Trial.

Importance: Acutely ill inpatients with COVID-19 typically receive antithrombotic therapy, although the risks and benefits of this intervention among outpatients with COVID-19 have not been established. Objective: To assess whether anticoagulant or antiplatelet therapy can safely reduce major adverse cardiopulmonary outcomes among symptomatic but clinically stable outpatients with COVID-19. Design, Setting, and Participants: The ACTIV-4B Outpatient Thrombosis Prevention Trial was designed as a minimal-contact, adaptive, randomized, double-blind, placebo-controlled trial to compare anticoagulant and antiplatelet therapy among 7000 symptomatic but clinically stable outpatients with COVID-19. The trial was conducted at 52 US sites between September 2020 and June 2021; final follow-up was August 5, 2021. Prior to initiating treatment, participants were required to have platelet count greater than 100 000/mm3 and estimated glomerular filtration rate greater than 30 mL/min/1.73 m2. Interventions: Random allocation in a 1:1:1:1 ratio to aspirin (81 mg orally once daily; n = 164), prophylactic-dose apixaban (2.5 mg orally twice daily; n = 165), therapeutic-dose apixaban (5 mg orally twice daily; n = 164), or placebo (n = 164) for 45 days. Main Outcomes and Measures: The primary end point was a composite of all-cause mortality, symptomatic venous or arterial thromboembolism, myocardial infarction, stroke, or hospitalization for cardiovascular or pulmonary cause. The primary analyses for efficacy and bleeding events were limited to participants who took at least 1 dose of trial medication. Results: On June 18, 2021, the trial data and safety monitoring board recommended early termination because of lower than anticipated event rates; at that time, 657 symptomatic outpatients with COVID-19 had been randomized (median age, 54 years [IQR, 46-59]; 59% women). The median times from diagnosis to randomization and from randomization to initiation of study treatment were 7 days and 3 days, respectively. Twenty-two randomized participants (3.3%) were hospitalized for COVID-19 prior to initiating treatment. Among the 558 patients who initiated treatment, the adjudicated primary composite end point occurred in 1 patient (0.7%) in the aspirin group, 1 patient (0.7%) in the 2.5-mg apixaban group, 2 patients (1.4%) in the 5-mg apixaban group, and 1 patient (0.7%) in the placebo group. The risk differences compared with placebo for the primary end point were 0.0% (95% CI not calculable) in the aspirin group, 0.7% (95% CI, -2.1% to 4.1%) in the 2.5-mg apixaban group, and 1.4% (95% CI, -1.5% to 5.0%) in the 5-mg apixaban group. Risk differences compared with placebo for bleeding events were 2.0% (95% CI, -2.7% to 6.8%), 4.5% (95% CI, -0.7% to 10.2%), and 6.9% (95% CI, 1.4% to 12.9%) among participants who initiated therapy in the aspirin, prophylactic apixaban, and therapeutic apixaban groups, respectively, although none were major. Findings inclusive of all randomized patients were similar. Conclusions and Relevance: Among symptomatic clinically stable outpatients with COVID-19, treatment with aspirin or apixaban compared with placebo did not reduce the rate of a composite clinical outcome. However, the study was terminated after enrollment of 9% of participants because of an event rate lower than anticipated. Trial Registration: ClinicalTrials.gov Identifier: NCT04498273.

Optimizing Fit: Targeting a Residency Psychiatry Consultation-Liaison Rotation to Various Levels of Training.

BACKGROUND: Determining the optimal timing and structure for a core residency rotation in consultation-liaison psychiatry (CLP) remains a key challenge for program directors and rotation leaders. Previous surveys have been conducted regarding these questions, and guidelines from national organizations have been issued, but practices remain varied among institutions. METHODS: We conducted a narrative review of the literature related to the timing of CLP rotations and generated consensus recommendations based on our experience as program directors, rotation leaders, and residents. RESULTS: Explicit goals of CLP training in residency include identifying and treating psychiatric manifestation of medical illness and communicating effectively with primary teams. Implicit goals of training may includeconflict management, limit setting, and "thinking dirty." DISCUSSION: Although CLP rotations earlier in residency often create a better fit within the overarching curriculum and allow for generating early interest in the field, significant amounts of supervision are required, and consultees may look to attendings as the primary consultant. Conversely, while later rotations are sometimes challenging to structure with other outpatient responsibilities, they allow for greater autonomy and may map better onto the informal curriculum. A hybrid model, with training spread across multiple years, is another approach that may mitigate some of the disadvantages of confining consultation-liaison training to a single year. Compelling arguments can be made for placing the core CLP rotation in postgraduate year 2 or 3 or using a hybrid model. Regardless of placement, program directors and rotation leaders should be mindful of tailoring the rotation to the trainees' developmental stage.

The Educational Value of Outpatient Consultation-Liaison Rotations: A White Paper From the Academy of Consultation-Liaison Psychiatry Residency Education Subcommittee.

BACKGROUND: As mental health services in outpatient medical clinics expand, psychiatrists must be trained to practice in these settings. OBJECTIVES: The Academy of Consultation-Liaison Psychiatry residency education subcommittee convened a writing group with the goal of summarizing the current evidence about outpatient consultation-liaison psychiatry (CLP) training and providing a framework for CLP educators who are interested in developing outpatient CLP rotations within their programs. METHOD: MEDLINE (via PubMed), Embase, and PsycINFO (via OVID) were reviewed each from inception to December 2019, for psychiatric CLP services in ambulatory settings that involved residents or fellows. The CLP education guidelines were reviewed for recommendations relevant to outpatient CLP. We also searched MedEd portal for published curriculums relevant to CLP. The group held 2 conferences to reach consensus about recommendations in setting up outpatient CLP rotations. RESULTS: Seventeen articles, 3 Academy of Consultation-Liaison Psychiatry-supported guidelines, and 8 online didactic resources were identified as directly reporting on the organization and/or impact of an outpatient CLP rotation. These manuscripts indicated that residents found outpatient CLP rotations effective and relevant to their future careers. However, the literature provided few recommendations for establishing formal outpatient CLP training experiences. CONCLUSIONS: Outpatient CLP rotations offer multiple benefits for trainees, including exposure to specific clinical scenarios and therapeutic interventions applicable only in the outpatient setting, increased continuity of care, and the unique experience of providing liaison and education to non-mental health providers. The article outlines recommendations and examples for developing outpatient CLP rotations which CLP educators can incorporate in their programs.

Neurocovid: Pharmacological Recommendations for Delirium Associated With COVID-19.

BACKGROUND: The pandemic of coronavirus disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has emerged as one of the biggest health threats of our generation. A significant portion of patients are presenting with delirium and neuropsychiatric sequelae of the disease. Unique examination findings and responses to treatment have been identified. OBJECTIVE: In this article, we seek to provide pharmacologic and treatment recommendations specific to delirium in patients with COVID-19. METHODS: We performed a literature search reviewing the neuropsychiatric complications and treatments in prior coronavirus epidemics including Middle Eastern respiratory syndrome and severe acute respiratory syndrome coronaviruses, as well as the emerging literature regarding COVID-19. We also convened a work group of consultation-liaison psychiatrists actively managing patients with COVID-19 in our hospital. Finally, we synthesized these findings to provide preliminary pharmacologic recommendations for treating delirium in these patients. RESULTS: Delirium is frequently found in patients who test positive for COVID-19, even in the absence of respiratory symptoms. There appears to be a higher rate of agitation, myoclonus, abulia, and alogia. No data are currently available on the treatment of delirium in patients with COVID-19. Extrapolating from general delirium treatment, Middle Eastern respiratory syndrome/severe acute respiratory syndrome case reports, and our experience, preliminary recommendations for pharmacologic management have been assembled. CONCLUSIONS: COVID-19 is associated with neuropsychiatric symptoms. Low-potency neuroleptics and alpha-2 adrenergic agents may be especially useful in this setting. Further research into the pathophysiology of COVID-19 will be key in developing more targeted treatment guidelines.

Psychiatry Resident Attitudes Toward Practice Habit Data.

OBJECTIVE: This descriptive study queries the attitudes of psychiatry residents regarding provision of practice habit data to trainees by residency programs, as required by the Accreditation Council for Graduate Medical Education (ACGME). Identifying trainee perspectives may assist program directors in tailoring practice habit data reporting to better engage residents and to increase resident-reported adherence to the ACGME requirement. METHODS: Residents at a large, hospital-based adult psychiatry training program completed an anonymous survey of attitudes regarding practice habit data, including perceptions of the residency program's current reporting, preferences toward mechanisms of delivering this data, and perceived relative utility of five hypothetical domains of practice habit data. RESULTS: Of 61 eligible residents, 52 (85%) completed surveys. Only 29 (56%) recalled receiving prior-year individual practice habit data, and only 10 (19%) recalled receiving team-based data. Seventy-five percent desired more practice habit data. Out of five hypothetical thematic domains for practice habit reporting, residents preferred patient-oriented domains as opposed to process-oriented domains. Resident concerns about dissemination of these data included confidentiality, effect on evaluations, and difficulty translating data to changes in clinical practice. CONCLUSIONS: Residents generally desire increased dissemination of practice habit data that focuses on patient-oriented measures such as adherence to disease-specific guidelines and is both individual and team-based. Residency programs may benefit their trainees and improve resident-reported adherence to the ACGME requirement both by taking resident preferences into account and by addressing concerns about confidentiality when providing practice habit data.

Association Between Endoscopist Personality and Rate of Adenoma Detection.

BACKGROUND & AIMS: There is significant variation among endoscopists in their adenoma detection rates (ADRs). We explored associations between ADR and characteristics of endoscopists, including personality traits and financial incentives. METHODS: We collected electronic health record data from October 2013 through September 2015 and calculated ADRs for physicians from 4 health systems. ADRs were risk-adjusted for differences in patient populations. Physicians were surveyed to assess financial motivations, knowledge and perceptions about colonoscopy quality, and personality traits. Of 140 physicians sent the survey, 117 responded. RESULTS: The median risk-adjusted ADR for all surveyed physicians was 29.3% (interquartile range, 24.1%-35.5%). We found no significant association between ADR and financial incentives, malpractice concerns, or physicians' perceptions of ADR as a quality metric. ADR was associated with the degree of self-reported compulsiveness relative to peers: among endoscopists who described themselves as much more compulsive, the ADR was 33.1%; among those who described themselves as somewhat more compulsive, the ADR was 32.9%; among those who described themselves as about the same as others, the ADR was 26.4%; and among those who described themselves as somewhat less compulsive, the ADR was 27.3%) (P = .0019). ADR was also associated with perceived thoroughness (much more thorough than peers, ADR = 31.5%; somewhat more, 31.9%; same/somewhat less, 27.1%; P = .0173). Physicians who reported feeling rushed, having difficulty pacing themselves, or having difficulty in accomplishing goals had higher ADRs. A secondary analysis found the same associations between personality and adenomas per colonoscopy. CONCLUSIONS: We found no significant association between ADR and financial incentives, malpractice concerns, or perceptions of ADR as a quality metric. However, ADRs were higher among physicians who described themselves as more compulsive or thorough, and among those who reported feeling rushed or having difficulty accomplishing goals.

"Call Me, Maybe": Supervisor and Resident Comfort With Indirect Supervision in Psychiatry Training.

BACKGROUND: Resident supervision is critical for education and ensuring patient safety. After hours, communication with attendings is variable. OBJECTIVE: The objective was to identify differences among psychiatry residents and attendings regarding the desired level of supervision for issues that arise overnight in the psychiatric emergency department (ED). METHODS: In a single-site psychiatric ED, an electronic survey containing 30 hypothetical scenarios was administered. For each scenario, residents were asked if they would call attendings and attendings whether they would want to be called. RESULTS: 35/44 psychiatry residents and 15/17 faculty participated, yielding a response rate of 82%. For five scenarios, faculty preferred that residents call for supervision more frequently than residents indicated they would. These included staff or house staff injuries (60% vs. 22.9%, p = 0.011; 93.3% vs. 62.9%, p = 0.039), a patient using heroin in the ED (53.3% vs. 5.7%, p < 0.001), a conflict with the medical ED attending (100% vs. 65.7%, p = 0.010), and a decision about calling in a backup resident (60% vs. 28.6%, p = 0.036). CONCLUSIONS: In a psychiatric ED, attendings prefer greater involvement in cases relating to psychosocial issues, legal concerns, and conflicts with patients. More work is needed to fully understand these differences and their potential impact on patient care and training.

After Hours: A Survey of Moonlighting Practices in Psychiatry Residents.

OBJECTIVE: The authors surveyed psychiatry residents to determine who participates in moonlighting and to understand their views and opinions on the necessity, importance, and educational value of moonlighting. METHODS: An electronic survey was distributed to psychiatry residents at 16 programs nationally. Descriptive characteristics were calculated. Logistic and linear regressions were performed to determine differences between those who moonlight and those who do not and to assess differences in measures of financial distress, quality of life, and work-life balance. RESULTS: A total of 173/624 (27.6%) residents participated. Within the subset allowed to moonlight, 50% (47/94) reported moonlighting during prior academic year, for an average of 17.4 ± 8.6 hoursh per month. Within those eligible to moonlight, there were no differences in perceived financial distress, quality of life, work-life balance, and confidence between residents who moonlighted and those who did not. Among moonlighters, 10.6% moonlighted overnight before working the next day, and only 68.1% included moonlighting when recording duty hours. 45% reported no supervision available while moonlighting. CONCLUSIONS: In the study sample, 50% of psychiatry residents eligible to moonlight opted to do so. Though most programs have policies in place regarding moonlighting, programs may benefit from ensuring that residents are reporting moonlighting in duty hours and that supervision is available to those moonlighting.

QT Prolongation, Torsades de Pointes, and Psychotropic Medications: A 5-Year Update.

BACKGROUND: Some psychotropic medications have been associated with prolongation of the QT interval and QT prolongation, especially in those with medical illness, and are linked to lethal ventricular arrhythmias, such as Torsades de Pointes (TdP). In 2013, we published a review of QT prolongation, TdP, and psychotropic medications. OBJECTIVE: We provide an update over the past 5 years on the specific concerns most relevant to clinicians who see medically ill patients. METHODS: In this nonsystematic review, we aimed to carefully and intensively identify new articles by utilizing a structured PubMed search from 2012-present. RESULTS: QT prolongation remains an imperfect, though well-established marker of risk for TdP. Among antidepressant medications, citalopram does appear to prolong the QT interval more than other selective serotonin reuptake inhibitors, though the clinical significance of this prolongation remains unclear. Escitalopram appears to prolong the QT interval to a lesser extent. Haloperidol carries a risk for QT prolongation, but the assertion that intravenous haloperidol is inherently riskier may be confounded by its primary use in medically ill populations. Among atypical antipsychotic agents, ziprasidone-and possibly iloperidone-is associated with the greatest QT prolongation, whereas aripiprazole appears safest from this standpoint. CONCLUSIONS: The evidence for clinically meaningful QT prolongation with most classes of psychiatric agents remains minimal. The most important risk-reducing intervention clinicians can make is undertaking a careful analysis of other QT risk factors when prescribing psychiatric medications.

Associations Between Psychological Constructs and Cardiac Biomarkers After Acute Coronary Syndrome.

OBJECTIVE: Psychological constructs are associated with cardiovascular health, but the biological mechanisms mediating these relationships are unknown. We examined relationships between psychological constructs and markers of inflammation, endothelial function, and myocardial strain in a cohort of post-acute coronary syndrome (ACS) patients. METHODS: Participants (N = 164) attended study visits 2 weeks and 6 months after ACS. During these visits, they completed self-report measures of depressive symptoms, anxiety, optimism, and gratitude; and blood samples were collected for measurement of biomarkers reflecting inflammation, endothelial function, and myocardial strain. Generalized estimating equations and linear regression analyses were performed to examine concurrent and prospective relationships between psychological constructs and biomarkers. RESULTS: In concurrent analyses, depressive symptoms were associated with elevated markers of inflammation (interleukin-17: ß = .047; 95% confidence interval [CI] = .010-.083]), endothelial dysfunction (endothelin-1: ß = .020; 95% [CI] = .004-.037]), and myocardial strain (N-terminal pro-B-type natriuretic peptide: ß = .045; 95% [CI] = .008-.083]), independent of age, sex, medical variables, and anxiety, whereas anxiety was not associated with these markers in multivariable adjusted models. Optimism and gratitude were associated with lower levels of markers of endothelial dysfunction (endothelin-1: gratitude: ß = -.009; 95% [CI] = -.017 to - .001]; optimism: ß = -.009; 95% [CI] = -.016 to - .001]; soluble intercellular adhesion molecule-1: gratitude: ß = -.007; 95% [CI] = -.014 to - .000]), independent of depressive and anxiety symptoms. Psychological constructs at 2 weeks were not prospectively associated with biomarkers at 6 months. CONCLUSIONS: Depressive symptoms were associated with more inflammation, myocardial strain, and endothelial dysfunction in the 6 months after ACS, whereas positive psychological constructs were linked to better endothelial function. Larger prospective studies may clarify the directionality of these relationships. CLINICAL TRIAL REGISTRATION: Clinicaltrials.gov identifier NCT01709669.

Brain Structural Markers and Caregiving Characteristics as Interacting Correlates of Caregiving Strain.

OBJECTIVE: To evaluate the association between brain structural markers and caregiving strain among older informal caregivers. DESIGN: A secondary data analysis combining data from the Caregiver Health Effects Study (1993-1994) and the Cardiovascular Health Study MRI examination (1992-1994). SETTING: Four United States communities. PARTICIPANTS: Co-residing spousal caregivers (N = 237; mean age: 76.2 years, SD: 2.2 years). MEASUREMENTS: Visually rated ventricular and white matter (WM) grades from magnetic resonance imaging, caregiving strain defined as "emotional or physical strain associated with providing care" for any of 12 activities of daily living (ADLs) and instrumental activities of daily living (IADLs), plus measures of caregiving characteristics and caregiver's health. RESULTS: Overall, 56% of caregivers reported strain. We detected an interaction where strain was very common (>82%) among caregivers who helped with four or more IADLs, regardless of WM grades, and among caregivers with the worst WM grades (WM grades ≥4), regardless of the number of IADLs they helped with. Among caregivers helping with fewer than four IADLs, having WM grade 4 or greater was associated with a 55% higher prevalence ratio for reporting strain. This association remained statistically significant but was most markedly attenuated by adjustments for: care recipient's memory and behavioral problems, caregiver's depression symptoms, and caregiver's ADL impairment. CONCLUSIONS: Caregiving strain is very common among older informal caregivers who provide help with many IADLs, and among caregivers who help with fewer IADLs, but have manifest signs of white matter pathology. Modern quantitative-neuroimaging studies are needed to evaluate whether more subtle variability in brain structure confers caregiving strain and the related health consequences.