Managing dissociative symptoms following the use of esketamine nasal spray: a case report.

Patients with treatment-resistant depression (TRD) treated with esketamine nasal spray commonly experience transient symptoms of dissociation. Manifestations of dissociation, such as feelings of detachment from the environment, can cause considerable anxiety for patients. Nonpharmacologic interventions may help clinicians to manage associated anxiety and confusion due to dissociation following administration of esketamine nasal spray. We present the case of a 64-year-old woman with major depressive disorder who participated in a clinical trial evaluating the efficacy and safety of esketamine nasal spray in conjunction with an oral antidepressant for TRD. The patient received flexible doses of esketamine nasal spray (56 or 84 mg) twice weekly for 4 weeks. On treatment day 1, the patient was administered 56 mg of esketamine nasal spray using two nasal spray devices (28 mg per device). Twenty minutes after the first esketamine nasal spray device was administered, the patient experienced a dissociative episode lasting 40 minutes that caused anxiety and confusion. The patient was encouraged to listen to music during treatment sessions, which resulted in notable improvement of her symptoms. Listening to music of choice immediately following esketamine nasal spray administration along with reassurance from staff may help manage confusion and anxiety associated with dissociation.

Drop-out from adolescent and young adult inpatient treatment for anorexia nervosa.

We examined factors predictive of dropout from inpatient treatment for anorexia nervosa (AN) among adolescents in a prospective study of 359 consecutive hospitalizations for AN (DSM-IV). Patients were assessed at admission (clinical, socio-demographic, and psychological data). Multivariate analyses were performed. Drop-out (i.e. leaving hospital before the target weight is achieved) occurred in 24% (n=86) of hospitalizations; in 42.3% (n=30) of the cases, dropout was initiated by the treatment team and in 58.6% (n=41) by the patients and/or their parents. 18.6% (16/86) occurred during the first half of the inpatient program. Frequency of drop-out was significantly higher when the patient was living with only one parent, had been hospitalized previously, had a lower BMI at admission and was over 18 at admission. These elements should draw the attention of the clinician, so that he/she can prepare hospitalization with patients presenting lower admission BMI, particularly by motivational interventions for a better therapeutic alliance, and by the deployment of intensive accompaniment of single parents. Further studies aiming to replicate these results, and including the evaluation of other clinical dimensions such as impulsivity and other personality traits, are needed to elucidate this important topic.

A randomized controlled trial of adjunctive family therapy and treatment as usual following inpatient treatment for anorexia nervosa adolescents.

UNLABELLED: Research on treatments in anorexia nervosa (AN) is scarce. Although most of the therapeutic programs used in 'real world practice' in AN treatment resort to multidisciplinary approaches, they have rarely been evaluated. OBJECTIVE: To compare two multidimensional post-hospitalization outpatients treatment programs for adolescents with severe AN: Treatment as Usual (TAU) versus this treatment plus family therapy (TAU+FT). METHOD: Sixty female AN adolescents, aged 13 to 19 years, were included in a randomized parallel controlled trial conducted from 1999 to 2002 for the recruitment, and until 2004 for the 18 months follow-up. Allocation to one of the two treatment groups (30 in each arm) was randomised. The TAU program included sessions for the patient alone as well as sessions with a psychiatrist for the patient and her parents. The TAU+FT program was identical to the usual one but also included family therapy sessions targeting intra-familial dynamics, but not eating disorder symptoms. The main Outcome Measure was the Morgan and Russell outcome category (Good or Intermediate versus Poor outcome). Secondary outcome indicators included AN symptoms or their consequences (eating symptoms, body mass index, amenorrhea, number of hospitalizations in the course of follow-up, social adjustment). The evaluators, but not participants, were blind to randomization. RESULTS: At 18 months follow-up, we found a significant group effect for the Morgan and Russell outcome category in favor of the program with family therapy (Intention-to-treat: TAU+FT :12/30 (40%); TAU : 5/29 (17.2%) p = 0.05; Per Protocol analysis: respectively 12/26 (46.2%); 4/27 (14.8%), p = 0.01). Similar group effects were observed in terms of achievement of a healthy weight (i.e., BMI≥10(th) percentile) and menstrual status. CONCLUSIONS: Adding family therapy sessions, focusing on intra-familial dynamics rather than eating symptomatology, to a multidimensional program improves treatment effectiveness in girls with severe AN. TRIAL REGISTRATION: Controlled-trials.com ISRCTN71142875.

Dropout from inpatient treatment for anorexia nervosa: critical review of the literature.

OBJECTIVE: High dropout rates from inpatient treatment for Anorexia Nervosa (AN) pose a serious obstacle to successful treatment. Because dropping out of inpatient treatment may have a negative impact on outcome, it is important to understand why dropout occurs so that treatment can be targeted toward keeping patients in care. We therefore conducted a critical literature review of studies on dropout from inpatient treatment for AN. METHOD: Searches of Medline and PsycINFO revealed nine articles on this subject. Two were excluded because they did not differentiate AN from other eating disorders in analyses. RESULTS: Results were scarce and conflicting, with methodological issues complicating comparisons. Weight on admission, AN subtype, eating disorder symptoms, greater psychiatric difficulty in general, and the absence of depression were related to dropout in multivariate analyses. DISCUSSION: Authors should use a common definition of dropout and continue research on the identified predictors as well as potential predictors such as impulsivity and family factors.

Decreased immune response in alexithymic women: a cross-sectional study.

It has been reported in a few studies that alexithymia is associated with impaired immune response but results are still contradictory. The present study investigates whether alexithymia is associated with lower cell-mediated (Th-1) immune response. Fifty-one healthy 18-27-year-old women were selected from healthy subjects on the basis of high or low cut-off scores on the 20-item Toronto Alexithymia Scale (TAS-20). They were evaluated using standardized psychiatric rating scales notably the Hospital Anxiety Depressive Scale (HAD) and the Mini Neuropsychiatric Interview (MINI). None of the subjects were suffering from psychiatric disorders. Twenty-seven were classified as alexithymics and 24 as non-alexithymics according to the TAS-20. Blood was drawn for lymphocyte subset counts (CD4, CD8), in vitro production of interleukin 1 (IL-1beta), IL-2, IL-4, and IL-10 by phytohaemagglutinin stimulated peripheral lymphocytes, and cortisol. Women with alexithymia exhibited decreased interleukin 1beta, IL-2 and IL-4 production with reduced ratios of Th1/Th2 (IL-2/IL-10) and of CD4/CD8, as well as reduced CD4 percentages. IL-2 and IL-4 production remained significantly diminished in the alexithymic group, even after adjusting for between-group differences in anxiety and depression levels on the HAD. This study further demonstrates that alexithymic women have altered immune function, with a predominance of depressed cell-mediated immunity and a skewed Th1/Th2 ratio towards Th2 response.

Predictive factors of length of inpatient treatment in anorexia nervosa.

OBJECTIVE: To identify clinical variables influencing the length of stay (LOS) of inpatient treatment for anorexia nervosa (AN). METHOD: We analyzed structured clinical charts of 300 consecutive hospitalizations for AN in a specialized eating disorder unit. The sample included patients from 12 to 22 years old. Factors related to the patient and events occurring during the stay were investigated as possible predictors of LOS. RESULTS: Mean LOS was 135 days. The best model of linear regression revealed that the following factors were significantly related to LOS: duration of AN at admission, use of tube feeding during the stay, accomplishment of the therapeutic weight contract and presence of a comorbid disorder. CONCLUSIONS: The identification of factors influencing duration of stay, both at the outset and during the hospitalization, could help clinicians to optimize and individualize treatments, as well as increase patient and family compliance.

Predictive value of alexithymia in patients with eating disorders: a 3-year prospective study.

OBJECTIVE: Several cross-sectional studies have reported high levels of alexithymia in populations with eating disorders. However, only few studies, fraught with multiple methodological biases, have assessed the prognostic value of alexithymic features in these disorders. The aim of the present study was to investigate the long-term prognostic value of alexithymic features in a sample of patients with eating disorders. METHODS: Within the framework of a European research project on eating disorders (INSERM Network No. 494013), we conducted a 3-year longitudinal study exploring a sample of 102 DSM-IV eating disorder patients using the Toronto Alexithymia Scale (TAS-20) and the Beck Depression Inventory. RESULTS: At the 3-year assessment, 74% (n=76) of the sample still presented a syndromal or subsyndromal eating disorder (unfavorable outcome: score of > or =3 on the Psychiatric Status Rating Scale for anorexia nervosa or bulimia nervosa). In logistic and hierarchical regression analyses, the Difficulty Identifying Feelings factor of the TAS-20 emerged as a significant predictor of treatment outcome, independent of depressive symptoms and eating disorder severity. CONCLUSIONS: The results of this study indicate that difficulty in identifying feelings can act as a negative prognostic factor of the long-term outcome of patients with eating disorders. Professionals should carefully monitor emotional identification and expression in patients with eating disorders and develop specific strategies to encourage labeling and sharing of emotions.