Increased Attendance During Rapid Implementation of Telehealth for Substance Use Disorders During COVID-19 at the Largest Public Hospital System in the United States.

OBJECTIVE: The objective of this study is to examine differences between; telehealth and in-person visits during COVID-19 and in a pre-COVID-19 reference period; COVID-19 televisit completion for patients with varying engagement in treatment during the reference period. METHODS: Electronic medical record data were collected and analyzed with chi-squared or t-tests to compare patient demographics. Generalized estimating equations for estimating the odds of outcomes were used, controlling for demographics. RESULTS: Patients were 3.34 and 1.74 times more likely to complete a telehealth visit (n = 11,839) compared with an in-person visit during (n = 7,917) and prior (n = 15,497) to COVID-19. For patients on buprenorphine, patients with no prior in-person visits during the pre-televisit period were 2.26 more likely to complete televisits compared with patients with two or more prior in-person visits. For all patients, those with two or more prior in-person visits in the reference period were 1.27 times more likely to complete a televisit compared with a patient with no in-person visits during the pre-televisit period. There was no significant difference when comparing with patients who had only one prior in-person visit to those patients with no prior visits. CONCLUSIONS: In this study, outpatient substance use disorder (SUD) telehealth appointments were associated with higher odds of visit completion compared with in-person visits during and prior to COVID-19. Patients receiving buprenorphine, without prior in person visits, were more likely to attend if they did not have in-person visits prior to COVID-19. Regulators should consider permanently adopting telehealth flexibilities for SUD treatment once the federal emergency status has ended.

Development of Geriatric Mental Health Learning Objectives for Medical Students: A Response to the Institute of Medicine 2012 Report.

America is aging as the population of older adults increases. The shortage of geriatric mental health specialists means that most geriatric mental healthcare will be provided by physicians who do not have specialty training in geriatrics. The Institute of Medicine Report of 2012 highlighted the urgent need for development of national competencies and curricula in geriatric mental health for all clinicians. Virtually all physicians can expect to treat older patients with mental health symptoms, yet currently there are no widely accepted learning objectives in geriatric mental health specific for medical students. The authors describe the development of a set of such learning objectives that all medical students should achieve by graduation. The iterative process included initial drafting by content experts from five medical schools with input and feedback from a wider group of geriatric psychiatrists, geriatricians, internists, and medical educators. The final document builds upon previously published work and includes specific knowledge, attitudes and skills in six key domains: Normal Aging, Mental Health Assessment of the Geriatric Patient, Psychopharmacology, Delirium, Depression, and Dementia. These objectives address a pressing need, providing a framework for national standards and curriculum development.

Automatic implantable cardioverter defibrillator in electroconvulsive therapy.

As the number of patients with implantable cardiac devices increases so too does the frequency with which these individuals present for electroconvulsive therapy (ECT). The rationale for deactivating an automatic implantable cardioverter defibrillator before ECT has been made based on the concern that artifacts generated during treatment could be interpreted as a treatable rhythm by the internal device, resulting in a discharge. We believe that the risk of inappropriate discharge during ECT is very low and outweighed by the considerable benefit of an active device being able to more quickly treat a malignant dysrhythmia.

Depression severity in electroconvulsive therapy (ECT) versus pharmacotherapy trials.

OBJECTIVE: We sought to compare the level of severity of depressive symptoms on entry into electroconvulsive therapy (ECT) clinical trials versus pharmacotherapy clinical trials. DATA SOURCES: English-language MEDLINE/PubMed publication databases were searched for ECT literature (search terms: ECT, electroconvulsive therapy, depression, and Hamilton) for clinical trials in which depressed patients had baseline Hamilton Rating Scale for Depression (HRSD) scores. For comparison, we used a convenience sample of 7 large pharmacotherapy trials in major depression (N = 3677). The search included articles from 1960 to 2011. STUDY SELECTION: We included 100 studies that met the following criteria: ECT trial for depression, patients adequately characterized by diagnosis at baseline, and patients rated at baseline by 15-item HRSD (HRSD15), HRSD17, HRSD21, HRSD24, or HRSD28, with mean (SD) and sample size (n) reported. For the comparator pharmacotherapy trials, we chose to use a subset of the studies (excluding one study of minor depression) in the widely publicized meta-analysis of Fournier et al, as well as the STAR*D study and one additional study by Shelton et al. This provided 7 studies of major depression using HRSD17 (total N = 3677). DATA EXTRACTION: Data extracted included number of subjects and baseline and final HRSD scores, with mean (SD) values. RESULTS: Of 100 ECT studies, 56 studies (N = 2243) used the HRSD17 version. The mean baseline HRSD17 score in the ECT trials was 27.6, the mean in the pharmacotherapy trials was 21.94, a statistically, and clinically, significant difference. In a subanalysis of the 16 ECT studies that used the HRSD24 version, the mean baseline score was 32.2. CONCLUSIONS: This selective literature review confirms that patients who entered ECT clinical trials were more severely ill than those who entered the selected comparator pharmacotherapy trials. Such data highlight the critical role of ECT in the treatment of severe and treatment-resistant mood disorders.

Geriatric psychiatry in the psychiatry clerkship: a survey of current education practices.

OBJECTIVE: The aging of the US population and shortage of geriatric psychiatrists mean that all medical students must be prepared to evaluate psychiatric symptoms in older patients. The authors sought to describe current geriatric psychiatry teaching practices during the psychiatry clerkship. METHODS: Psychiatry clerkship directors at 110 American medical schools were surveyed about didactic and clinical experiences of geriatric psychiatry. RESULTS: Sixty-two (56 %) of programs responded. One fifth of programs lacked specific instruction in geriatric psychiatry. Programs were more likely to include instruction on dementia than late-life depression. Increased geriatric psychiatry educational offerings were associated with the following: number of geriatric psychiatrists on faculty, presence of a geriatric psychiatrist on the medical education committee, and inclusion of geriatric psychiatry specific items in clerkship learning objectives. CONCLUSIONS: Current practices in some clerkships are inadequate to prepare medical students to care for older patients with psychiatric symptoms.

Low-dose right unilateral electroconvulsive therapy (ECT): effectiveness of the first treatment.

BACKGROUND: Electroconvulsive therapy (ECT) is a widely used, highly effective antidepressant treatment. Except for the most severely ill patients, right unilateral (RUL) electrode placement is the most frequent initial treatment choice. In current practice, RUL ECT is administered at several multiples of seizure threshold (ST) based on reports that lower stimulus intensity results in lower response/remission rates. Many patients, as part of an initial dose titration to determine ST, will receive a single treatment with low-dose RUL ECT and subsequent treatments with a stimulus at a multiple of ST. OBJECTIVE: To assess response to the first ECT. METHODS: A retrospective analysis of charts from clinical practice at Mount Sinai Medical Center was performed. RESULTS: A single treatment with low-dose (presumably near ST) RUL ECT had a significant and immediate antidepressant effect in our sample of patients with major depression. We determined that this response is similar to that of patients receiving a single initial treatment with high-dose RUL ECT (at a multiple of ST). CONCLUSIONS: These data suggest, contrary to commonly held belief, that RUL ECT may be effective at a low stimulus dose. This argues against restimulating at 6 times ST in the initial session, based on the belief that the near-threshold seizure has no antidepressant efficacy. Our findings suggest a need for further investigation of cases in which low-dose RUL ECT may be an effective antidepressant treatment. Further prospective studies, including larger numbers of patients who receive randomized treatment with low- or high-dose RUL with longer follow-up, are indicated.

The Telltale Heart or the importance of the "Tap Test" in electroconvulsive therapy (ECT).

The "Tap Test" is a maneuver used to test the functioning of the electroencephalogram and electromyogram leads just prior to electroconvulsive therapy. Here we present a brief case and image that reinforces the importance of this simple test.

Electroconvulsive therapy (ECT) after pulmonary edema.

We report a case of pulmonary edema after electroconvulsive therapy (ECT) in an 88-year-old man with controlled hypertension and treatment-refractory depression. Despite this unexpected episode of pulmonary edema, the patient was able to complete this course of ECT without further complications. Because the pulmonary edema was thought to be due to extremely elevated blood pressures, nitroglycerine and esmolol were used during subsequent treatments, and electrode placement was changed to bilateral to speed recovery.

Multiple episodes of intraictal cessation during electroconvulsive therapy.

A recent case reported an episode of a "stop-start-stop" phenomenon during an electroconvulsive therapy treatment. We report an example of multiple stop-start-stop episodes during several electroconvulsive therapy treatments of a 16-year-old boy.

Electrocardiographic "bleed through" to the electroencephalogram on an electroconvulsive therapy (ECT) tracing: the return of the tell-tale heart.

Improper recording electrode placement can cause artifacts on electroconvulsive therapy tracings. This shows an example of electrocardiogram artifact in the electroencephalogram.

Febrile reaction with elevated CPK after a single electroconvulsive therapy (ECT) in an adolescent patient with severe bipolar disorder.

This report describes the electroconvulsive therapy (ECT) course of a 15-year-old male with severe bipolar disorder unresponsive to medical management. After his first treatment, the patient exhibited fever, elevated creatine phosphokinase levels, and leukocytosis. Treatment was halted although the patient reported an improvement in symptoms, which was not maintained with pharmacotherapy alone. Subsequent treatments were completed without adverse reactions, and the patient entered remission. We discuss the possible causes of this reaction and remind the reader that a single adverse event does not always require the abandonment of a treatment modality.

Methohexital and succinylcholine dosing for electroconvulsive therapy (ECT): actual versus ideal.

This report compares the actual doses of methohexital and succinylcholine used for optimal anesthesia and muscle relaxation in electroconvulsive therapy with written guidelines for dosing. The initial doses of methohexital and succinylcholine in milligrams per kilogram were reviewed and compared with subsequent doses of each agent after adjustments were made for individual patient responses during treatment. The dose of methohexital required to induce general anesthesia for most patients is 1.0 mg/kg. The dose of succinylcholine required to provide adequate muscle relaxation during electroconvulsive therapy is 0.9 mg/kg, although there is considerable variability in patient response to this drug.

Cases of catatonia on an academic electroconvulsive therapy service: lessons to learn.

Catatonia is a well-described neuropsychiatric syndrome that has been the subject of several texts. We present 4 cases seen on our academic service in the past 18 months and discuss significant features of each case.

Tinnitus as a symptom of psychotic depression successfully treated with electroconvulsive therapy.

We present the case of a 51-year-old woman with recurrent major depression with psychotic features including severe tinnitus. Her tinnitus resolved with successful treatment of her depressive episode with electroconvulsive therapy. We review the literature on electroconvulsive therapy and tinnitus.

Resolution of severe suicidality with a single electroconvulsive therapy.

Electroconvulsive therapy is a rapid and effective treatment of severe depression that has been shown to quickly decrease or eliminate suicidal thoughts and behaviors. We describe the case of an 88-year-old man hospitalized for a carefully premeditated suicide attempt with highly lethal means. He was treated with a single electroconvulsive therapy (ECT) and improved markedly. His suicidal ideation remitted, and the patient was still free of suicidal ideation at 5 months of follow-up. We discuss the effect of ECT on suicidal ideation, the benefit of minimizing the number of total ECT treatments, and the possible biological markers of change after a single treatment in an ECT-naive patient.

Left unilateral electroconvulsive therapy (ECT) after oligodendroglioma resection.

A 44-year-old man with a previously resected right parietal oligodendroglioma received left unilateral electroconvulsive therapy (ECT). We present images of his brain magnetic resonance imaging, ECT electrode placement, and the electroencephalogram tracing from his ECT.

Prolonged succinylcholine action during electroconvulsive therapy (ECT) after cytarabine, vincristine, and rituximab chemotherapy.

Succinylcholine is a depolarizing neuromuscular blocker frequently used during electroconvulsive therapy. In most patients, the duration of paralysis is brief, allowing for spontaneous respiration shortly after the therapy. We report a case of delayed return of neuromuscular function after succinylcholine administered during electroconvulsive therapy in a 72-year-old man receiving cytarabine, vincristine, and rituximab chemotherapy for chronic lymphocytic leukemia. We hypothesize that an interaction between succinylcholine and one of the chemotherapeutic agents caused the prolongation of paralysis and believe that this is the first reported case of prolonged duration of succinylcholine following this regimen of chemotherapy. Despite this unexpected prolonged neuromuscular blockade, the patient could be treated uneventfully, with attention paid to his respiratory support and with subsequent succinylcholine dose titration to effect.