Ketamine for major depressive disorder during an inpatient psychiatric admission: Effectiveness, adverse events, and lessons learned.

OBJECTIVE: Most studies examining the efficacy of ketamine for Major Depressive Disorder (MDD) have been conducted in outpatient or mixed inpatient/outpatient settings. Less is known about effectiveness and tolerability of ketamine for psychiatrically hospitalized patients. Efficacy and tolerability data from a naturalistic sample of acute inpatients may help inform institutions considering ketamine therapy for inpatient services. METHODS: We performed a retrospective chart review of inpatients with non-psychotic MDD treated during the initial 3 years of a ketamine infusion program. Treatment effectiveness was defined using change in Montgomery Asberg Depression Rating Scale (MADRS) scores over five infusions. MDD treatment response was defined by a 50 % reduction of MADRS score, and remission was defined as MADRS score ≤ 10 at any point during the treatment. We also report the frequency of adverse events. RESULTS: 41 patients with MDD were treated and had outcome data. 19 patients (46.5 %) met criteria for response and 15 patients (26.5 %) met criteria for remission during treatment. Four patients (10 %) had adverse psychological or behavioral outcomes. LIMITATIONS: MADRS scales were administered by psychiatrists, psychologists, and trainees in each discipline who did not undergo standardized training in scale administration. Consistent data regarding the race/ethnicity of the patients was not available. CONCLUSION: Twice weekly racemic ketamine infusion is an effective treatment option for patients hospitalized with MDD. Unmonitored or at home ketamine therapy may pose substantial risks.

Rehabilitation of Neuropsychiatric Symptoms in Patients With Long COVID: Position Statement.

Long COVID, a term used to describe ongoing symptoms after COVID-19 infection, parallels the course of other postviral syndromes. Neuropsychiatric symptoms of long COVID can be persistent and interfere with quality of life and functioning. Within the biopsychosocial framework of chronic illness, rehabilitation professionals can address the neuropsychiatric sequelae of long COVID. However, current practice models are not designed to address concurrent psychiatric and cognitive symptoms in adults living with long COVID. Thus, we present a biopsychosocial framework for long COVID and provide treatment strategies based on evidence from current literature of postviral chronic illness. These recommendations will guide rehabilitation professionals in identifying common neuropsychiatric symptoms in long COVID that can be targeted for intervention and addressing these symptoms via integrative interventions taking into account the biopsychosocial presentation of long COVID symptoms.

Low COVID-19 Vaccination Rates Among Psychiatric Inpatients: Implications for Institutional Settings and Outreach Efforts.

OBJECTIVE: This study sought to determine COVID-19 vaccination rates for individuals with serious mental illness admitted to a large health system in New York State. METHODS: Vaccination rates among 12,714 patients admitted to psychiatric units and to medical and surgical units were compared between April 6, 2021, and September 30, 2021. RESULTS: Only 40% (N=416 of 1,029) of patients admitted to psychiatric services had at least one COVID-19 vaccination, whereas 64.4% (7,523 of 11,685) of patients admitted to medical and surgical services had at least one vaccination. After adjustment for differences in key demographic and clinical characteristics, patients admitted to psychiatric services had a significantly lower likelihood of vaccination during the study period (risk ratio=0.78, 95% confidence interval=0.73-0.85, p<0.001). Black psychiatric patients had the lowest vaccination rate (28%). CONCLUSIONS: Psychiatric patients with acute illness had low COVID-19 vaccination rates. Targeted outreach for COVID-19 vaccination is necessary to reach this population.

Patient and provider experiences of telemental health during the COVID-19 pandemic in a New York City academic medical center.

OBJECTIVE: We aimed to evaluate patient and provider experiences with telemental health (TMH) at an academic outpatient psychiatry department in New York City during the first wave of the COVID-19 pandemic. METHODS: Patients and providers completed online surveys evaluating their experience with TMH during the first wave of the COVID-19 pandemic. Surveys were distributed to 1,178 patients and 287 providers from July 2020 through October 2020. RESULTS: 42.5% of providers and 21% of patients responded to the survey. The majority of patient and provider respondents rated the quality of phone and video visits as "equally good" or "somewhat worse" than in-person visits, while the majority of respondents were "somewhat satisfied" or "very satisfied" with video visits. Patients and providers preferred a hybrid model for future care. Common barriers to TMH included privacy, technical difficulties, and wi-fi access. CONCLUSIONS: Patients and providers appeared willing to exchange some degree of quality for satisfaction with TMH. This study did not demonstrate with statistical significance any specific patient populations that would benefit more or less from TMH, suggesting that TMH may be a successful model for diverse patient populations. Our results suggest that providers, payors, and regulators should facilitate hybrid care delivery models that incorporate TMH beyond the pandemic.

The Structural and Functional Neuroanatomy of Post-Stroke Depression and Executive Dysfunction: A Review of Neuroimaging Findings and Implications for Treatment.

Post-stroke depression and executive dysfunction co-occur and are highly debilitating. Few treatments alleviate both depression and executive dysfunction after stroke. Understanding the brain network changes underlying post-stroke depression with executive dysfunction can inform the development of targeted and efficacious treatment. In this review, we synthesize neuroimaging findings in post-stroke depression and post-stroke executive dysfunction and highlight the network commonalities that may underlie this comorbidity. Structural and functional alterations in the cognitive control network, salience network, and default mode network are associated with depression and executive dysfunction after stroke. Specifically, post-stroke depression and executive dysfunction are both linked to changes in intrinsic functional connectivity within resting state networks, functional over-connectivity between the default mode and salience/cognitive control networks, and reduced cross-hemispheric frontoparietal functional connectivity. Cognitive training and noninvasive brain stimulation targeted at these brain network abnormalities and specific clinical phenotypes may help advance treatment for post-stroke depression with executive dysfunction.

Modifiable predictors of suicidal ideation during psychotherapy for late-life major depression. A machine learning approach.

This study aimed to identify subgroups of depressed older adults with distinct trajectories of suicidal ideation during brief psychotherapy and to detect modifiable predictors of membership to the trajectories of suicidal ideation. Latent growth mixed models were used to identify trajectories of the presence of suicidal ideation in participants to a randomized controlled trial comparing Problem Solving Therapy with "Engage" therapy in older adults with major depression over 9 weeks. Predictors of membership to trajectories of suicidal ideation were identified by the convergence of four machine learning models, i.e., least absolute shrinkage and selection operator logistic regression, random forest, gradient boosting machine, and classification tree. The course of suicidal ideation was best captured by two trajectories, a favorable and an unfavorable trajectory comprising 173 and 76 participants respectively. Members of the favorable trajectory had no suicidal ideation by week 8. In contrast, members of the unfavorable trajectory had a 60% probability of suicidal ideation by treatment end. Convergent findings of the four machine learning models identified hopelessness, neuroticism, and low general self-efficacy as the strongest predictors of membership to the unfavorable trajectory of suicidal ideation during psychotherapy. Assessment of suicide risk should include hopelessness, neuroticism, and general self-efficacy as they are predictors of an unfavorable course of suicidal ideation in depressed older adults receiving psychotherapy. Psychotherapeutic interventions exist for hopelessness, emotional reactivity related to neuroticism, and low self-efficacy, and if used during therapy, may improve the course of suicidal ideation.

The CopeNYP program: A model for brief treatment of psychological distress among healthcare workers and hospital staff.

In the midst of the Spring 2020 initial surge of the COVID-19 pandemic in New York, members of the Psychiatry Department of Weill Cornell Medicine/NewYork-Presbyterian Hospital rapidly created and implemented a brief, behavioral skills-based intervention program, "CopeNYP", to address the immediate mental health needs of the employees of the hospital and medical school. We describe the development, implementation and evolution of this telehealth-delivered program staffed primarily by in-house clinical psychologists, postdoctoral fellows, pre-doctoral interns and counselors who were redeployed or volunteered their time to provide urgent support for employees. We discuss the challenges and lessons learned in providing brief, skills-based psychological interventions for employees subjected to chronic stress. As the impact of the pandemic became prolonged, employees faced compounding stressors including social isolation, fear of infection, grief and loss, and sequelae of COVID-19-related illness combined with work-related demands. Our goal is to present our program design, implementation, and utilization as a blueprint for other institutions that would like to develop an evidence-based clinician-staffed psychological intervention program to support ongoing employee mental health needs.

Universal COVID-19 testing and a three-space triage protocol is associated with a nine-fold decrease in possible nosocomial infections in an inpatient psychiatric facility.

In May of 2020, the Substance Abuse and Mental Health Service Administration (SAMSA) issued guidelines for state psychiatric hospitals, recommending that these facilities adopt universal testing for COVID-19 and "three-space" triage protocols for dedicated COVID-19 positive, negative, and quarantine spaces to mitigate the risk of nosocomial infection. The Westchester Behavioral Health Center of New York Presbyterian Hospital (WBHC-NYP) adopted a comprehensive infection control protocol consistent with these recommendations in April, 2020. We reviewed the records of 1,139 patients treated on the inpatient service at WBHC-NYP between March 14th and June 10th, 2020, dates corresponding to the first COVID-19 surge in the New York City metropolitan region. The incidence of detected nosocomial or possible nosocomial infections before and during the implementation of the protocol was 0.096 (16/167), or 0.96 infections per 10 at-risk patients. The incidence of nosocomial or possible nosocomial infections after complete implementation was 0.0110 (2/182), or 1.1 infections per 100 at-risk patients. The difference in incidence between the two time points was statistically significant (p<.0003) and represents a 9-fold decrease.  Our findings support the institutional use of a combined testing and space allocation protocol to mitigate risk of outbreaks in confined settings.

A systematic review of neuropsychological and psychiatric sequalae of COVID-19: implications for treatment.

PURPOSE OF REVIEW: COVID-19 impacts multiple organ systems and is associated with high rates of morbidity and mortality. Pathogenesis of viral infection, co-morbidities, medical treatments, and psychosocial factors may contribute to COVID-19 related neuropsychological and psychiatric sequelae. This systematic review aims to synthesize available literature on psychiatric and cognitive characteristics of community-dwelling survivors of COVID-19 infection. RECENT FINDINGS: Thirty-three studies met inclusion/exclusion criteria for review. Emerging findings link COVID-19 to cognitive deficits, particularly attention, executive function, and memory. Psychiatric symptoms occur at high rates in COVID-19 survivors, including anxiety, depression, fatigue, sleep disruption, and to a lesser extent posttraumatic stress. Symptoms appear to endure, and severity of acute illness is not directly predictive of severity of cognitive or mental health issues. The course of cognitive and psychiatric sequelae is limited by lack of longitudinal data at this time. Although heterogeneity of study design and sociocultural differences limit definitive conclusions, emerging risk factors for psychiatric symptoms include female sex, perceived stigma related to COVID-19, infection of a family member, social isolation, and prior psychiatry history. SUMMARY: The extant literature elucidates treatment targets for cognitive and psychosocial interventions. Research using longitudinal, prospective study designs is needed to characterize cognitive and psychiatric functioning of COVID-19 survivors over the course of illness and across illness severity. Emphasis on delineating the unique contributions of premorbid functioning, viral infection, co-morbidities, treatments, and psychosocial factors to cognitive and psychiatric sequelae of COVID-19 is warranted.

COVID-19 infection rates in patients referred for psychiatric admission during a regional surge: The case for universal testing.

Some psychiatric hospitals have instituted mandatory COVID-19 testing for all patients referred for admission. Others have permitted patients to decline testing. Little is known about the rate of COVID-19 infection in acute psychiatric inpatients. Characterizing the proportion of infected patients who have an asymptomatic presentation will help inform policy regarding universal mandatory versus symptom-based or opt-out testing protocols. We determined the COVID-19 infection rate and frequency of asymptomatic presentation in 683 consecutively admitted patients during the surge in the New York City region between April 3rd, 2020 and June 8th, 2020. Among these psychiatric inpatients, there was a 9.8 % overall rate of COVID-19 infection. Of the COVID-19 infected patients, approximately 76.1 % (51/67) either had no COVID-19 symptoms or could not offer reliable history of symptoms at the time of admission. Had they not been identified by testing and triaged to a COVID-19 positive unit, they could have infected others, leading to institutional outbreak. These findings provide justification for psychiatric facilities to maintain universal mandatory testing policies, at least until community infection rates fall and remain at very low levels.

Modifiable predictors of nonresponse to psychotherapies for late-life depression with executive dysfunction: a machine learning approach.

The study aimed to: (1) Identify distinct trajectories of change in depressive symptoms by mid-treatment during psychotherapy for late-life depression with executive dysfunction; (2) examine if nonresponse by mid-treatment predicted poor response at treatment end; and (3) identify baseline characteristics predicting an early nonresponse trajectory by mid-treatment. A sample of 221 adults 60 years and older with major depression and executive dysfunction were randomized to 12 weeks of either problem-solving therapy or supportive therapy. We used Latent Growth Mixture Models (LGMM) to detect subgroups with distinct trajectories of change in depression by mid-treatment (6th week). We conducted regression analyses with LGMM subgroups as predictors of response at treatment end. We used random forest machine learning algorithms to identify baseline predictors of LGMM trajectories. We found that ~77.5% of participants had a declining trajectory of depression in weeks 0-6, while the remaining 22.5% had a persisting depression trajectory, with no treatment differences. The LGMM trajectories predicted remission and response at treatment end. A random forests model with high prediction accuracy (80%) showed that the strongest modifiable predictors of the persisting depression trajectory were low perceived social support, followed by high neuroticism, low treatment expectancy, and low perception of the therapist as accepting. Our results suggest that modifiable risk factors of early nonresponse to psychotherapy can be identified at the outset of treatment and addressed with targeted personalized interventions. Therapists may focus on increasing meaningful social interactions, addressing concerns related to treatment benefits, and creating a positive working relationship.

Minocycline augmentation in older adults with persistent depression: an open label proof of concept study.

Less than 40% of depressed older adults treated with an antidepressant achieve remission. Incomplete response to treatment is common. Current augmentation strategies have limited efficacy, and many have side effects that restrict their utilization in older adults. We conducted the first open pilot trial of minocycline augmentation in older adults who had failed to achieve remission after adequate psychopharmacologic treatment. Subjects older than 55 years of age with major depression and failure to achieve substantial improvement of depressive symptoms after at least 6 weeks of antidepressant treatment were given augmentation with minocycline 100 mg twice daily over an 8-week period. At the end of 8 weeks of augmentation with minocycline, 31% (4/13) patients achieved remission. Remitters had higher baseline ratings of hopelessness and apathy. Minocycline was well tolerated with no reported adverse events or discontinuation due to intolerance. Larger placebo-controlled studies are needed to evaluate the effects of minocycline augmentation in older adults who had failed to achieve remission after adequate treatment with antidepressants.

A COVID-19 testing and triage algorithm for psychiatric units: One hospital's response to the New York region's pandemic.

Psychiatric patients are at high risk for contracting COVID-19, and inpatient psychiatric units face substantial risks of institutional outbreaks. Here, the authors describe an algorithm for testing and triage in a large psychiatric facility designed to prevent local COVID-19 transmission. The algorithm is based on expert opinion and clinical experience between March and April of 2020, during which the institution cared for 47 COVID-19 positive psychiatric inpatients. The implementation of the algorithm is designed to mitigate COVID-19 transmission, preserve the safest and least restrictive treatment environment for psychiatric inpatients, and provide a model adaptable to other institutional settings.

Dimensions of Poststroke Depression and Neuropsychological Deficits in Older Adults.

OBJECTIVE: Poststroke depression (PSD) has a heterogeneous presentation and is often accompanied by cognitive impairment. This study aimed to identify distinct dimensions of depressive symptoms in older adults with PSD and to evaluate their relationship to cognitive functioning. DESIGN: Cross-sectional factor and correlational analyses of patients with poststroke depression. SETTING: Patients were recruited from the community and from acute inpatient stroke rehabilitation hospitals. PARTICIPANTS: Participants had suffered a stroke and met DSM-IV criteria for major depression (≥18 Montgomery Åsberg Depression Scale; MADRS). INTERVENTION: None. MEASUREMENTS: MADRS was used to quantify depression severity at study entry. Neuropsychological assessment at the time of study entry consisted of measures of Global Cognition, Attention, Executive Function, Processing Speed, Immediate Memory, Delayed Memory, and Language. RESULTS: There were 135 (age ≥50) older adult participants with PSD and varying degrees of cognitive impairment (MMSE Total ≥20). Factor analysis of the MADRS identified three factors, that is sadness, distress, and apathy. Items comprising each factor were totaled and correlated with neuropsychological domain z-score averages. Symptoms of the apathy factor (lassitude, inability to feel) were significantly associated with greater impairment in executive function, memory, and global cognition. Symptoms of the sadness and distress factors had no relationship to cognitive impairment. CONCLUSION: PSD consists of three correlated dimensions of depressive symptoms. Apathy symptoms are associated with cognitive impairment across several neuropsychological domains. PSD patients with prominent apathy may benefit from careful attention to cognitive functions and by interventions that address both psychopathology and behavioral deficits resulting from cognitive impairment.

CADASIL presenting as late-onset mania with anosognosia.

The diagnosis of cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL) should be considered in patients with late-onset personality change and mania. However, neuropsychological deficits precipitated by the disorder pose significant challenges to recognition and appropriate management of CADASIL in susceptible patients.

Depression, cognitive, and functional outcomes of Problem Adaptation Therapy (PATH) in older adults with major depression and mild cognitive deficits.

OBJECTIVES: Antidepressants have limited efficacy in older adults with depression and cognitive impairment, and psychosocial interventions for this population have been inadequately investigated. Problem Adaptation Therapy (PATH) is a psychosocial intervention for older adults with major depression, cognitive impairment, and disability. DESIGN: This study tests the efficacy of PATH versus Supportive Therapy for Cognitively Impaired Older Adults (ST-CI) in reducing depression (Montgamery Asberg Depression Rating Scale [MADRS]) and disability (World Health Organization Disability Assessments Schedule-II [WHODAS-II]) and improving cognitive outcomes (Mini Mental State Examination [MMSE]) over 24 weeks (12 weeks of treatment and 12-week post-treatment follow-up). SETTING: Participants were recruited through collaborating community agencies of Weill Cornell Institute of Geriatric Psychiatry. Both interventions and all research assessments were conducted at home. PARTICIPANTS: Thirty-five older adults (age ≥ 65 years) with major depression and cognitive impairment no dementia (CIND). INTERVENTIONS: PATH aims to increase emotion regulation by incorporating a problem-solving approach, teaching compensatory strategies, and inviting caregiver participation. Supportive Therapy aims to facilitate the expression of affect, as well as promote empathy. MEASUREMENTS: Depression was measured using the MADRS, disability using the WHODAS-II, and cognition using the MMSE. RESULTS: PATH participants showed significantly greater reduction in MADRS total score (7.04 points at 24 weeks, treatment group by time interaction: F[1,24.4] = 7.61, p = 0.0108), greater improvement in MMSE total score (2.30 points at 24 weeks, treatment group by time interaction: F[1,39.8] = 13.31, p = 0.0008), and greater improvement in WHODAS-II total score (2.95 points at 24 weeks, treatment group by time interaction: F[1,89] = 4.93, p = 0.0290) than ST-CI participants over the 24-week period. CONCLUSIONS: PATH participants had better depression, cognitive, and disability outcomes than ST-CI participants over 6 months. PATH may provide relief to depressed older adults with CIND who currently have limited treatment options.