A Pilot Study of Adjunctive Group Therapy to Enhance Coping With Cognitive Challenges and Support Cognitive Health After Electroconvulsive Therapy.

OBJECTIVES: Concerns about the cognitive adverse effects of electroconvulsive therapy (ECT) are common among recipients of the treatment despite its relatively small adverse effects on cognitive functioning. Interventions aimed at remediating or improving coping with cognitive adverse effects of ECT have not been developed. The Enhancing Cognitive Domains after ECT (ENCODE) program is a new group intervention aimed at teaching self-management strategies to cope with the cognitive challenges and associated anxiety that often accompanies ECT. METHODS: This pilot study used a pretest-posttest design to examine the feasibility and clinical utility of delivering ENCODE to 20 adults who had received ECT in a hospital-based ECT program. RESULTS: The program was found to be both feasible and acceptable as indicated by the attainment of recruitment targets, high rates of attendance (85% of participants attended at least 5 of the 6 group sessions), and high participant satisfaction ratings (88% reported that ENCODE helped or helped very much to manage their cognitive challenges). The clinical utility of the program was suggested by reductions in depressive symptom severity and subjective memory complaints. Nonsignificant improvements were observed in global cognitive function and cognitive self-efficacy. CONCLUSIONS: This study provides preliminary evidence for the feasibility and clinical utility of ENCODE based on program demand, strong participant satisfaction, and postgroup reductions in distress and subjective memory complaints.

Neurocognitive effects of repeated ketamine infusion treatments in patients with treatment resistant depression: a retrospective chart review.

BACKGROUND: Ketamine has emerged as a rapid-acting antidepressant in treatment-resistant depression (TRD) increasingly used in non-research, clinical settings. Few studies, however, have examined neurocognitive effects of repeated racemic ketamine infusion treatments in patients with TRD. In an effort to identify potential effects after serial infusions, we conducted a retrospective chart review to identify statistically significant changes in cognition in patient undergoing serial intravenous infusions; concomitantly, we examined baseline cognition as potential predictor of anti-depressant potential. METHODS: Twenty-two patients with TRD were examined after they finished the induction phase of 8-10 repeated intravenous ketamine infusions and completed the assessments of their depressive symptoms (measured by the 16-item Quick Inventory of Depressive Symptomatology-Self Report Scale: QIDS-SR16) and cognitive function (measured by the Montreal Cognitive Assessment: MoCA) before the first and the last ketamine treatments. RESULTS: Repeated ketamine infusions administered through an escalating dose protocol with 8-10 infusion sessions produced a 47.2% reduction response in depression; there was no evidence of impairment as reflected in MoCA testing. There was a moderate association between baseline cognition and antidepressant response with a Pearson correlation of 0.453. CONCLUSION: In this naturalistic sample of patients with TRD in our clinical service, repeated ketamine infusions significantly decreased depression symptoms without impairing cognitive performance. The baseline cognition may positively predict antidepressant responses of repeated ketamine treatment.

First Acute-Course Electroconvulsive Therapy for Moderate-to-Severe Depression Benefits Patients With or Without Accompanying Baseline Cognitive Impairment.

BACKGROUND: Researchers are increasingly investigating therapeutic response associated with new patient subgroups as a way to improve electroconvulsive therapy (ECT) treatment outcomes and reduce adverse events. This study is the first to examine baseline cognitive impairment status as a predictor of clinical outcome in first acute-course ECT patients. METHODS: Baseline cognitive function at various thresholds and serial depressive symptom severity data from first-time ECT patients were examined using generalized linear mixed-effects models. RESULTS: Of 1345 patients who met the inclusion criteria, 617 had available data at their third assessment visit (~15th treatment visit). There was a robust improvement in depression symptoms over time (P < 0.0001), and cognitive function was not associated with baseline levels of depressive symptoms or serially measured change in self-reported symptom severity during acute-phase ECT. CONCLUSIONS: These results indicate that an acute course of ECT for the treatment of moderate-to-severe depression benefits patients with or without accompanying baseline cognitive impairment. These findings may be useful in informing shared decision-making discussions about ECT risks and expected benefits.

Acute Phase Treatment Outcomes of Electroconvulsive Therapy in Adolescents and Young Adults.

OBJECTIVE: Electroconvulsive therapy (ECT) is a highly efficacious, well-tolerated treatment in adults. Little is known, however, about its effectiveness in adolescents and young adults. Our objectives were to assess clinical outcomes after acute phase ECT in adolescents and young adults and determine whether screening positive or negative for a substance use disorder (SUD) is associated with differences in treatment outcomes. METHODS: Study sample consisted of all patients 16 to 25 years old who received ECT from May 2011 to August 2016 and who completed self-reported SUD screens and the Behavior and Symptom Identification Scale-24 (BASIS-24) initially and completed the BASIS-24 again after the fifth ECT treatment. For 5 BASIS-24 domains, longitudinal changes in mean domain scores were assessed; mean changes by SUD screening status were also examined using linear mixed models. RESULTS: One hundred ninety adolescents and young adults, with mean age 21.0 ± 2.6 years, met inclusion criteria. Electroconvulsive therapy was associated with significant clinical improvement (score decreases) in all 5 BASIS-24 domains during the acute phase treatment (P < 0.001). Sixty-four percent (122/190) screened positive for SUD. Compared with adolescents and young adults screening negative for SUD, those screening positive for co-occurring SUD had greater improvement in depression/functioning (-0.37 ± 0.14, P = 0.009), interpersonal relationships (-0.27 ± 0.13, P = 0.045), and emotional lability (-0.27 ± 0.14, P = 0.044) domains after the fifth ECT treatment. CONCLUSIONS: Electroconvulsive therapy in adolescents and young adults was associated with significantly improved clinical outcomes during acute phase treatment. Adolescents and young adults screening positive for SUD had better acute phase ECT outcomes in self-reported depression/functioning, interpersonal relationships, and emotional lability than those screening negative. More research is needed to clarify adolescents and young adult patient characteristics that may be associated with differential ECT outcomes.

Providing Physical Care to Persons With Serious Mental Illness: Attitudes, Confidence, Barriers and Psychological Empowerment.

The prevalence of metabolic syndrome (MetS) in people with serious mental illness (SMI) has been well documented in the mental health literature. Despite the adoption of various guidelines for monitoring risk factors for diabetes and cardiovascular risk in this population, limited translation has occurred in actual practice (Hermes, Sernyak, & Rosenheck, 2013). The Institute of Medicine (IoM) (2009) has noted a lag time in the application of knowledge within clinical settings. Evidence-based practice was deemed as a means of improving healthcare outcomes through the use of science supported standards of care. Evidence-based practice (EBP) is a process to guide clinical decision making that involves the clinician's experience, well documented research findings, and the patient's values and choices (Sackett, Rosenberg, Gray, Haynes, & Richardson, 1996). The IoM has established that by the year 2020, 90% of clinical decisions should be based upon current and scientifically based information (IoM, 2009). Psychiatric-mental health nurses are challenged to utilize EBP for clients with MetS in assessing their health status and discussing the findings, educating them about their current risk and life style modifications to mitigate risk, and finally, partnering with them to maximize health and quality of life.

Metabolic Syndrome: Psychiatric-Mental Health Nurses' Knowledge of Risks and Care Practices.

Comorbidity of serious mental illness (SMI) and metabolic syndrome contributes to the reduced lifespan of individuals with SMI. Integration of physical and mental health care has been slow. The current study explored the level of knowledge of metabolic syndrome and practices of psychiatric-mental health nurses related to metabolic syndrome risks. Using a knowledge survey and adapted Mental Health Nurse Physical Health Attitude Scale, the researchers surveyed 175 psychiatric nurses through an online social media website. Of respondents, 52% identified all five risk factors for metabolic syndrome. However, only 70.8% knew all recommended physiological monitoring markers. There was no significant relationship between knowledge score and integration of physical health care activities in practice; however, knowledge regarding metabolic syndrome risk factors was high. Currently, integration of this knowledge into care is lagging. Nurse educators must integrate assessment, planning, intervention, and evaluation of physical health status and related needs of individuals with SMI. [Journal of Psychosocial Nursing and Mental Health Services, 54(11), 44-53.].

Nursing Care for Lifestyle Behavioral Change.

The purpose of this pilot study was to determine if metabolic risk factors can be stabilized or improved with weekly motivational interviewing/coaching and medical follow-up care focused on lifestyle behavioral change in individuals with serious mental illness. Individuals were followed for 18 weeks following discharge from an inpatient psychiatric service. All individuals were prescribed an antipsychotic medication and had at least two risk factors for metabolic syndrome. Weight, waist circumference, blood pressure, LDLs, triglycerides, and blood glucose levels were evaluated during the study period. In addition, each individual selected a lifestyle behavior to improve over the 18-week period. Weekly motivational interviewing, and staggered health promotion appointments were designed to keep individuals focused on health and behavior change. While some individuals showed improvement, others showed deterioration in the physiological markers for metabolic syndrome. Only a small number completed the 18-week study. The nature of current psychiatric care is focused on rapid stabilization and discharge; individuals with serious mental illness may have difficulty focusing on lifestyle behavioral change while transitioning to independent living following an acute exacerbation of mental illness.

Electroconvulsive therapy for the acute management of severe agitation in dementia (ECT-AD): A modified study protocol.

OBJECTIVE: This study began as a single-blind randomized controlled trial (RCT) to investigate the efficacy and safety of electroconvulsive therapy (ECT) for severe treatment-refractory agitation in advanced dementia. The aims are to assess agitation reduction using the Cohen-Mansfield Agitation Inventory (CMAI), evaluate tolerability and safety outcomes, and explore the long-term stability of agitation reduction and global functioning. Due to challenges encountered during implementation, including recruitment obstacles and operational difficulties, the study design was modified to an open-label format and other protocol amendments were implemented. METHODS: Initially, the RCT randomized participants 1:1 to either ECT plus usual care or simulated ECT plus usual care (S-ECT) groups. As patients were enrolled, data were collected from both ECT and simulated ECT (S-ECT) patients. The study now continues in an open-label study design where all patients receive actual ECT, reducing the targeted sample size from 200 to 50 participants. RESULTS: Study is ongoing and open to enrollment. CONCLUSION: The transition of the ECT-AD study design from an RCT to open-label design exemplifies adaptive research methodologies in response to real-world challenges. Data from both the RCT and open-label phases of the study will provide a unique perspective on the role of ECT in managing severe treatment-refractory agitation in dementia, potentially influencing future clinical practices and research approaches.

An adjunct exercise program for serious mental illness: who chooses to participate and is it feasible?

Despite evidence that exercise is beneficial for serious mental illness, it continues to be an under utilized adjunct treatment strategy. Thus, the aims of this study were to examine if self-selected or volunteer exercise programs are feasible in a structured outpatient program and who might choose to participate in such a program. Individuals with serious mental illness admitted to a partial hospital program were offered an adjunct exercise group or a control, psychoeducation group. The exercise group (N = 38) met three times a week for 50 min. Individuals who chose not to exercise (N = 28), attended a psychoeducational control group. Those who self-selected the exercise group tended to have a higher level of education, employment rate and to be Caucasian. The control group had more medical problems, a higher body mass index and alcohol intake. The groups did not differ on age, sex, or use of cigarettes and caffeine. The exercise group was regularly attended. Both groups improved equally on all outcomes symptom and psychological well-being outcomes. These data highlight that certain individuals with serious mental illness may be more likely to exercise based on demographic opposed to clinical features, or illness characteristics. Thus, adjunct exercise programs for individuals with serious mental illness seem to be feasible, but certain groups of individuals (i.e., ethnic minorities, unemployed) should be targeted for recruitment as they are less likely to volunteer for such adjunct exercise programs.

The incidence of metabolic risk factors in an inpatient psychiatric setting.

Our study examines risk factors for metabolic syndrome on admission to an acute psychiatric facility and the incidence of medical referrals at discharge. Data on demographics, risk factors for metabolic syndrome, other health risk factors, medications, related diagnoses, and primary care providers and referrals were collected from 125 psychiatric patient charts. Comparison analysis was done for two groups: those with two or more risk factors for metabolic syndrome and those with less than two risk factors. Differences between groups were statistically significant for age, waist circumference, body mass index, high-density lipoprotein, triglycerides, and fasting glucose levels. Few patients were referred to their primary care provider for follow-up care. This study has clinical implications for improving assessment of psychiatric patients at risk for developing metabolic syndrome, for designing interventions to help patients adopt lifestyle changes to mitigate these risks, and for working toward fuller integration of psychiatric and primary care.