Alcohol and substance use in older adults with treatment-resistant depression.

INTRODUCTION: Alcohol and substance use are increasing in older adults, many of whom have depression, and treatment in this context may be more hazardous. We assessed alcohol and other substance use patterns in older adults with treatment-resistant depression (TRD). We examined patient characteristics associated with higher alcohol consumption and examined the moderating effect of alcohol on the association between clinical variables and falls during antidepressant treatment. METHODS: This secondary and exploratory analysis used baseline clinical data and data on falls during treatment from a large randomized antidepressant trial in older adults with TRD (the OPTIMUM trial). Multivariable ordinal logistic regression was used to identify variables associated with higher alcohol use. An interaction model was used to evaluate the moderating effect of alcohol on falls during treatment. RESULTS: Of 687 participants, 51% acknowledged using alcohol: 10% were hazardous drinkers (AUDIT-10 score ≥5) and 41% were low-risk drinkers (score 1-4). Benzodiazepine use was seen in 24% of all participants and in 21% of drinkers. Use of other substances (mostly cannabis) was associated with alcohol consumption: it was seen in 5%, 9%, and 15% of abstainers, low-risk drinkers, and hazardous drinkers, respectively. Unexpectedly, use of other substances predicted increased risk of falls during antidepressant treatment only in abstainers. CONCLUSIONS: One-half of older adults with TRD in this study acknowledged using alcohol. Use of alcohol concurrent with benzodiazepine and other substances was common. Risks-such as falls-of using alcohol and other substances during antidepressant treatment needs further study.

A randomized controlled pilot study of daily intravenous ketamine over three days for treatment-resistant depression.

BACKGROUND: Studies have confirmed the rapid antidepressant action of ketamine in depressive episodes. Nevertheless, a standardized procedure for the delivery of ketamine infusion in individuals suffering from treatment-resistant depression, particularly in terms of infusion frequency and total dosage, remains undetermined. In addition, an efficacious ketamine regimen for persistent pain management involved a continuous 10-day infusion period with no notable adverse effects. Consequently, the primary objective of this study was to evaluate the antidepressant capacity of consecutive ketamine infusions spanning over three successive days, the duration of therapeutic response, and the overall safety profile of the treatment. METHODS: In this randomized controlled trial, participants aged 18-64 with treatment-resistant depression were randomized to receive either intravenous ketamine or midazolam (used as an active placebo) for 40 min daily over three consecutive days. Statistical analysis using repeated measures ANOVA was employed to assess the changes in the total score of the Montgomery-Åsberg Depression Rating Scale (MADRS) and the clinical global impression-Severity from the initial assessment to 10 and 31 days post-infusion. Additionally, the duration of response and remission was evaluated using Kaplan-Meier survival analysis. RESULTS: Out of 33 randomized participants, 20 underwent the treatment as planned. By day 10th, the ketamine group had a mean reduction in MADRS score of 12.55 (95% CI = 6.70-18.09), whereas the midazolam group had a decrease of 17.22 (95% CI = 11.09-23.36). This pattern continued to day 31, with ketamine showing a mean score decrease of 13.73 (95% CI = 7.54-19.91) and midazolam a fall of 12.44 (95% CI = 5.61-19.28). Both treatments were well tolerated, with dissociative symptoms in the ketamine group being temporary and ceasing by the end of each infusion. CONCLUSION: Intravenous ketamine given for three consecutive days did not show a notable antidepressant advantage when compared to the active placebo midazolam, highlighting the need for further research into effective treatments schedules for treatment-resistant depression. TRIAL REGISTRATION: NCT05026203, ClinicalTrials.gov, registered on 24/08/2021.

Perioperative Anxiety and Depression in Older Adults: Epidemiology and Treatment.

The intervals before and after major surgery is a high-risk period for older adults; in this setting, anxiety and depression are common and serious problems. We comprehensively reviewed current evidence on perioperative anxiety and depression in older adults, focusing on epidemiology, impact, correlates, medication risks, and treatment. Principles of perioperative mental healthcare are proposed based on the findings. Prevalence estimates of clinically significant anxiety and depression range from 5% to 45% for anxiety and 6% to 52% for depression, depending on surgical populations and measurement tools. Anxiety and depression may increase risk for surgical complications and reduce patient participation during rehabilitation. Medical comorbidities, pain, insomnia, cognitive impairment, and delirium are common co-occurring problems. Concomitant uses of central nervous system acting medications (benzodiazepines, anticholinergics, and opioids) amplify the risks of delirium and falls. Based on these findings, we propose that anxiety and depression care should be part of perioperative management in older adults; components include education, psychological support, opioid-sparing pain management, sleep management, deprescribing central nervous system active medications, and continuation and optimization of existing antidepressants. More research is needed to test and improve these care strategies.

Depression in Kidney Transplant Recipients: Prevalence, Risk Factors, and Association With Functional Disabilities.

This study examined the prevalence, risk factors, and disability associated with depression. We conducted a cross-sectional, observational study in 217 consecutive kidney transplant (KT) recipients routinely followed-up at a Kidney Transplantation Clinic in Northern Thailand. Participants were assessed using the Charlson Comorbidity Index (CCI), the nine-item Patient Health Questionnaire (PHQ-9), and the 12-item self-report of World Health Organization Disability Assessment Scale, Version 2.0 (WHODAS). Twenty-eight (12.9%) patients had depression (PHQ-9 score, ≥10). A binary logistic regression analysis found that the CCI score was significantly higher in KT recipients with depression (ß = 0.54, p < 0.01). After the adjustment of education and glomerular filter rates, an ordinal logistic regression analysis revealed that the PHQ-9 scores were positively correlated with the WHODAS scores (ß = 0.39, p < 0.01). In KT recipients, physical comorbidity is associated with depression, and depression is correlated with functional disability.

What Do LGBTQ+ Medical Students Experience and Need in Medical School? A Multicenter Qualitative Study in Thailand.

PURPOSE: This study evaluated the experiences and needs of lesbian, gay, bisexual, transgender, queer, and other sexual and gender minorities (LGBTQ+) attending medical schools in Thailand. METHOD: Medical students from 4 medical schools in Thailand were recruited in 2022. LGBTQ+ participants were selected via purposive sampling and invited for semistructured interviews. Verbatim transcripts were analyzed using reflexive thematic analysis. RESULTS: Interviews were conducted with 39 students identifying as lesbian, gay, bisexual, transgender, queer, questioning, nonbinary, asexual, or androgynous, with a mean age of 21. The experiences of these LGBTQ+ individuals in medical school had 4 themes: (1) normalization of LGBTQ+ identity among friends, or not openly identifying as LGBTQ+ (because it was viewed as unnecessary), facilitated everyday life; (2) fear of negative judgments from being LGBTQ+ by attending physicians and patients; (3) authenticity to sexual or gender identity provided relief; and (4) personal histories of discrimination affected self-disclosure and social dynamics. Overall, approximately 17% of reported stressors were directly associated with participants' LGBTQ+ identity. The identified needs within medical schools comprised 2 themes: (1) treat each other with equal respect (with 3 subthemes: nonjudgmental attitudes supported by effective discrimination reporting systems; more LGBTQ+-related education and extracurricular activities; and activities driven by voluntariness without gender-based selection); and (2) abolishment or amendment of regulations that strictly enforce gender binaries. These amendments could include implementing flexible dress codes, establishing gender-neutral restrooms and dormitories, and introducing gender-neutral titles. Transgendered participants reported experiencing the most significant disparities due to binary regulations and infrastructures. CONCLUSIONS: LGBTQ+ medical students in Thailand reported fear of negative perceptions by attending physicians and patients. Exposing everyone, particularly attending physicians, to examples of unintentional discrimination is recommended. There is also a need to promote LGBTQ+-related education and extracurricular activities and to ensure activities and regulations are not gender-divided.

Optimizing treatment for older adults with depression.

This review presents a comprehensive guide for optimizing medication management in older adults with depression within an outpatient setting. Medication optimization involves tailoring the antidepressant strategy to the individual, ensuring the administration of appropriate medications at optimal dosages. In the case of older adults, this process necessitates not only adjusting or changing antidepressants but also addressing the concurrent use of inappropriate medications, many of which have cognitive side effects. This review outlines various strategies for medication optimization in late-life depression: (1) Utilizing the full dose range of a medication to maximize therapeutic benefits and strive for remission. (2) Transitioning to alternative classes (such as a serotonin and norepinephrine reuptake inhibitor [SNRI], bupropion, or mirtazapine) when first-line treatment with selective serotonin reuptake inhibitors [SSRIs] proves inadequate. (3) Exploring augmentation strategies like aripiprazole for treatment-resistant depression. (4) Implementing measurement-based care to help adjust treatment. (5) Sustaining an effective antidepressant strategy for at least 1 year following depression remission, with longer durations for recurrent episodes or severe presentations. (6) Safely discontinuing anticholinergic medications and benzodiazepines by employing a tapering method when necessary, coupled with counseling about the benefits of stopping them. Additionally, this article explores favorable medications for depression, as well as alternatives for managing anxiety, insomnia, allergy, overactive bladder, psychosis, and muscle spasm in order to avoid potent anticholinergics and benzodiazepines.

Efficacy and acceptability of vitamin D supplements for depressed patients: A systematic review and meta-analysis of randomized controlled trials.

OBJECTIVES: This systematic review and meta-analysis synthesized the evidence from randomized controlled trials comparing vitamin D and placebo in reducing depressive symptoms and contributing to all-cause dropout rates. METHODS: Inclusion criteria were randomized controlled trials comparing reduced depression between depressed patients receiving vitamin D and those receiving placebo. We searched PubMed, Embase, Web of Science, and the Cochrane Central Register of Controlled Trials through January 2022. RESULTS: Eighteen trials (1980 participants, median age 39 y) were included in the meta-analysis. Vitamin D supplements were significantly superior to placebo in reducing depression (standardized mean difference = -0.49; 95% confidence interval [CI], -0.75 to -0.23; I2 = 81%). Depressed adults (standardized mean difference = -0.70; 95% CI, -1.09 to -0.31) responded to vitamin D significantly better than children and adolescents (standardized mean difference = 0.10; 95% CI -0.27 to 0.47). Vitamin D administered as bolus doses (oral intermittent high doses or intramuscular single high dose) appeared to be more effective than that taken daily by the oral route (P < 0.01). Patients with more severe depression tended to respond better than those with less severity (P = 0.053). We found no moderating effect of concurrent antidepressant use, presence of major depressive disorder diagnosis, physical comorbidity, sex, duration and doses of vitamin D supplement, serum 25-hydroxyvitamin D levels at baseline, and changes in serum 25-hydroxyvitamin D levels in the vitamin D group. Dropout rates were indifferent between the groups (17 trials; risk ratio = 0.84; 95% CI, 0.6-1.16; I2 = 0). CONCLUSIONS: Heterogeneous data suggested that vitamin D supplements are effective and safe for depressed patients.

Sexual Behaviors Among Lesbian, Gay, Bisexual, Transgender, and Other Sexual and Gender Diverse Medical Students: A National Study of Thai Medical Schools.

Objective: This study aims to investigate sexual behaviors among gender diverse (LGBT and other sexual/gender minorities) and nongender-diverse medical students. Methods: In 2021 academic year, medical students from five Thai medical schools completed questionnaires identifying demographic data, psychosexual factors, sexual experiences, and risks. Results: Among 1,322 students, 32.1% were gender-diverse students who had lower age at first sexual intercourse and more experiences in solitary and partnered sexual activity. Conclusions: Use of hookup applications was more frequent among gay and bisexual males. Risky sexual behaviors were significantly higher among bisexual females. Gender-diverse medical students showed higher involvement in sexual activities. Future studies should be addressing sexual health in Thai medical education.

Mental problems and risk factors for depression among medical students during the COVID-19 pandemic: A cross-sectional study.

Prevalence of depression is high among medical students and several mental problems are identified as risk factors. Coronavirus disease 2019 (COVID-19) pandemic causes difficulties that could adversely affect mental health. However, data concerning prevalence of mental problems, and whether or not these problems remain risk factors for depression during the COVID-19 pandemic in medical students are scarce. To investigate the prevalence of depression, social media addiction, game addiction, sleep quality, eating disorder risk, and perceived stress among Thai medical students, risk factors for depression were investigated. Online surveys via our faculty's learning portals were advertized to medical students who engaged online learning and 224 respondents provided complete data. Study-related medical students' data were collected using the Patient Health Questionnaire-9 for depression, the Social-Media Addiction Screening Scale for social media addiction, the Game Addiction Screening Test for game addiction, the Pittsburgh Sleep Quality Index for sleep quality, the Eating Attitudes Test for eating disorder risk, and the Perceived Stress Scale for perceived stress. Depression was reported in 35.7% of medical students, social-media addiction in 22.3%, game addiction in 4.5%, eating disorder risk in 4.9%, poor sleep quality in 80.8%, and moderate-to-high perceived stress in 71.4%. The independent predictors of depression were lower grade point average, social media addiction, and moderate-to-high perceived stress. A high prevalence of depression, stress, and poor sleep was found among medical students during the COVID-19 pandemic. Medical students who are stressed, have lower grades, and/or who are addicted to social media warrant depression screening.

Impact of the COVID-19 pandemic on older adults living in long-term care centers in Thailand, and risk factors for post-traumatic stress, depression, and anxiety.

BACKGROUND: There is a lack of data concerning impact of COVID-19 among older adults (OA) living at long-term care (LTC) centers. This study investigated how COVID-19 has affected this population. The prevalence of and risk factors for post-traumatic stress, depression, and anxiety were investigated. METHODS: A semi-structured interview to determine the effect of COVID-19 was conducted to 200 OA at two government LTC centers. The 17-item Post-traumatic Stress Disorder Checklist, the 9-item Patient Health Questionnaire, and the 7-item Generalized Anxiety Disorder Scale were used to evaluate post-traumatic stress, depression, and anxiety, respectively. RESULTS: Most OA reported moderate or severe impact of COVID-19. The most impacted area was financial due to decreased support from outside the center. Seventy percent of OA reported no or mild psychological stress from COVID-19; however, 5.5% had post-traumatic stress, 7.0% had depression, and 12.0% had anxiety. Higher psychological stress from COVID-19 and having respiratory tract infection symptoms were independently associated with post-traumatic stress, depression, and anxiety. Receiving COVID-19 news via social media was independently associated with post-traumatic stress and depression. Having psychiatric comorbidity was independently associated with depression. CONCLUSIONS: OA living in LTC centers reported moderate or severe impact from COVID-19, especially financial, but relatively low psychological stress. Psychological stress from COVID-19, having respiratory tract infection symptoms, and receiving COVID-19 news via social media were risk factors for psychological disorders. LIMITATIONS: The data reflected the post-outbreak period. There is limitation in the generalizability of the results for other countries with different health care systems.

Paliperidone palmitate-induced facial angioedema: A case report.

BACKGROUND: Paliperidone palmitate is a once-monthly injectable, atypical antipsychotic. To our knowledge, there has been only one report of paliperidone palmitate-induced angioedema presenting with acute laryngeal edema with subsequent respiratory arrest. Here, we present a case report of paliperidone palmitate-induced angioedema with a relatively mild clinical presentation compared with the previously reported case, and the patient's condition was not complicated by life-threatening anaphylaxis. CASE SUMMARY: A 79-year-old female, who had a major neurocognitive disorder due to Alzheimer's disease with behavioral disturbances. Paliperidone palmitate was off-label used to control her aggression, irritability, and psychosis. After induction doses (150 mg and 100 mg intramuscularly, given 1 wk apart), she developed intermittent swelling of the face, eyelids, and lips on day 17 after the initial dose, and the edema was explicitly seen on day 20. The diagnosis was paliperidone palmitate-induced angioedema. The monthly injection dose was discontinued on day 33 after the initial dose. The angioedema was subsequently alleviated, and it had completely resolved by day 40 after the initial dose. CONCLUSION: Paliperidone palmitate-induced angioedema is a rare condition and can present with a mild, intermittent facial edema, which may be overlooked in clinical practice.

Restless legs syndrome in children and adolescents with attention-deficit/hyperactivity disorder: prevalence, mimic conditions, risk factors, and association with functional impairment.

OBJECTIVES: To determine the prevalence of restless legs syndrome (RLS) and RLS-mimic conditions, the risk factors for RLS, and whether RLS contributes to functional impairment in children and adolescents with attention-deficit/hyperactivity disorder (ADHD). METHODS: ADHD children and adolescents were prospectively studied at the outpatient psychiatric clinic. A trained registered nurse used the 2012 Revised International Restless Legs Syndrome Study Group diagnostic criteria to diagnose RLS. Sociodemographic data and medical records were reviewed. Weiss Functional Impairment Rating Scale-Parent Report (WFIRS-P) Thai version was used to identify association between RLS and 6 domains of function [family, school (learning), school (behavior), life skills, child self-concept, social activities, and risky activities]. RESULTS: A total of 217 patients were included. Of those, 23 (11%) patients met the criteria for RLS, and 49 (23%) had RLS-mimic conditions. Those conditions included myalgia (30/49), habitual foot tapping (23/49), positional discomfort (20/49), leg ulcer/bruise (1/49), and arthralgia/arthritis (1/49). Binary logistic regression revealed first-degree relative having RLS symptom to be significantly associated with RLS in study patients (OR: 5.06, p < 0.01). Multivariate linear regression showed RLS to be independently associated with school (behavior) (Β = 1.18, p = 0.05) and life skills (Β = 2.36, p = 0.05) impairment. CONCLUSIONS: RLS was found to be common in ADHD children and adolescents. RLS-mimic conditions were found in two-thirds of patients who previously met 4 essential RLS criteria. First-degree relative with RLS symptom was associated with RLS, and RLS was associated with functional impairment in the life skills and school (behavior) domains.