Is Transcranial Magnetic Stimulation Appropriate For Treating Adolescents with Depression?

Children who are inadequately treated for depression often experience greater dysfunction. Problems can include conduct disorders, substance abuse, physical illness, and poor performance at school, work, or in psychosocial contexts. Depression can lead to a greater risk of suicide. Suicide is the third most common cause of death among adolescents, with more than 500,000 attempts made by children each year. Suicide is the third most frequent cause of death among young people ages 10 to 19 years old. Thus, proper treatment is important. Major depressive disorder in adolescents is often followed by frequent recurrences in adulthood. Imaging studies document underactivity in the left dorsolateral prefrontal cortex in subjects suffering from depression. Activation of the brain with high-frequency transcranial magnetic stimulation increases neuronal excitability and induces the growth of new connections. Though larger, randomized, controlled trials with more patients and longer follow-up are needed, the favorable side effect profile and efficacy of TMS seen so far in the literature support the use of TMS as a therapeutic intervention in children and adolescents with depression.

Suicide Among Transgender and Gender-Nonconforming People.

Suicide rates are higher in those who identify as transgender or gender nonconforming (TGNC) compared to the overall population. Suicide risk factors include discrimination, family rejection, internalized transphobia, and being denied appropriate bathroom or housing access. It is important to assess the risk of suicide among transgender and gender-nonconforming patients and discuss past experiences of prejudice or maltreatment to prevent further victimization. This narrative review includes the most pertinent literature from the past 17 years on issues related to suicide among individuals who identify as TGNC. ​.

Is Electroconvulsive Therapy a Treatment for Depression Following Traumatic Brain Injury?

Traumatic brain injury (TBI) can be caused by blunt or penetrating injury to the head. The pathophysiological evolution of TBI involves complex biochemical and genetic changes. Common sequelae of TBI include seizures and psychiatric disorders, particularly depression. In considering pharmacologic interventions for treating post-TBI depression, it is important to remember that TBI patients have a higher risk of seizures; therefore, the benefits of prescribing medications that lower the seizure threshold need to be weighed against the risk of seizures. When post-TBI depression is refractory to pharmacotherapy, electroconvulsive therapy (ECT) could provide an alternative therapeutic strategy. Data remain sparse on using ECT in this seizure-prone population, but three case reports demonstrated good outcomes. Currently, not enough evidence exists to provide clinical recommendations for using ECT for treating post-TBI depression, and more research is needed to generate guidelines on how best to treat depression in TBI patients. However, the preliminary data on using ECT in patients with TBI are promising. If proven safe, ECT could be a powerful tool to treat post-TBI depression.

Electroconvulsive Therapy During Pregnancy.

Women often experience worsening mood disorder symptoms during pregnancy. Women with mood disorders have an increased risk for suboptimal prenatal care, inadequate weight gain, and more substance abuse during pregnancy. It is often difficult to balance pharmacotherapy risks to a developing fetus versus not medicinally treating maternal mental health conditions. Electroconvulsive therapy (ECT) is a rapid and effective treatment option that can be an appropriate intervention in some women during pregnancy. This report presents an overview of ECT in pregnancy and the case of a 28-year-old pregnant woman with bipolar mania who responded well to ECT.

The Biological Basis to Personality Disorders.

OBJECTIVE: To provide understanding into the biological basis of thinking and behavior in people with personality disorders, explain anatomic findings, and appraise therapeutic options. DATA SOURCES: PubMed was searched with no date restrictions using the terms personality disorders DSM-5, cluster B personality disorders, biological psychiatry of personality disorders, neurobiology of personality disorders, and neurobiology of cluster B personality disorders. STUDY SELECTION/DATA EXTRACTION: We identified 2,790 English-language articles and utilized 18 in this report. RESULTS: There are anatomic features typical to the brains of individuals with cluster B personality disorders, for example, abnormalities in the superior frontal cortex and amygdala and enlarged striatal volumes. Emotional dysregulation and impulsiveness are 2 prominent symptoms. Hereditary factors may contribute to the development of such conditions. CONCLUSION: Understanding the neurobiology of cluster B personality disorders expands knowledge that hopefully results in better clinical management and development of improved treatments. Psychotherapy is currently the most effective intervention for borderline personality disorders. Symptomatic pharmacotherapies may be prescribed adjunctively on an individualized basis if clinically indicated (eg, with a coexistant depression).

Benefits of Dexmedetomidine in Management of Post-ECT Agitation.

Electroconvulsive therapy (ECT) is an intervention for patients with a variety of psychiatric conditions. Occasionally, people exhibit dangerous degrees of agitation after this treatment, and some do not respond well to conventional pharmacotherapies. Dexmedetomidine is a central α-2 agonist that can induce significantly calmative effects in persons with post-ECT agitation. The indication for it is in calming individuals with acute and/or recurrent posttreatment agitation. Dexmedetomidine is safe and effective when infused just before, or postictally, at ECT sessions.

Deep Brain Stimulation for Treatment-Refractory Depression.

Depression has a high lifetime prevalence and recurrence rate, with more than one-third of affected patients experiencing treatment-refractory depression. These individuals should benefit from additional treatment options such as deep brain stimulation (DBS), a research-grade intervention. DBS is being investigated for its efficacy in treatment-refractory cases. We reviewed the English-language literature published between the years 2010 and 2015 regarding the utility of DBS for patients with treatment-refractory depression. The literature review revealed that most DBS research is open label, with few large randomized, placebo-controlled trials to confirm results. Long-term response rates with DBS were between 40% and 70%, with clinical effects depending on location of electrode placement. Improvement was documented to last for months to years. Although DBS is potentially efficacious and a relatively safe option for patients with treatment resistance, it is invasive, costly, and still considered experimental. Understanding of the neurobiology of depression, the mechanism of DBS action, and biomarkers that may predict patient response remains obscure. Future research should contain careful design, including homogenous inclusion criteria and characterization of pretreatment patient mood, somatic complaints, and cognition; consistent outcome measures; monitoring of depressive symptoms at different brain-positioning targets across an adequate time course; and records of stimulus parameters.

Pharmacogenomics Can Enhance Prescribing of Psychiatric Medications.

Many psychiatric patients experience pharmaceutical intolerances, and some of them do not derive optimal efficacy from their pharmacotherapies. Clinical problems such as these may result in prolonged dysfunction, adverse consequences, and repeated changes in medication treatment regimens. Pharmacogenomics is a laboratory method that aids individualized medication selection by predicting drug efficacy and adverse effect profiles. It is a technique that involves the testing of patients' genetic makeup to improve medicinal response and tolerance. Pharmacogenomics aims to clarify pharmacokinetics and pharmacodynamics in addition to focusing on hepatic cytochrome enzyme metabolism. Ultimately, it facilitates optimal selection and adjustment of medications to enhance clinical outcomes. Pharmacogenomics is most useful in cases in which routinely prescribed pharmacotherapies are either suboptimally effective or have unacceptable adverse effects. Once there has been a failure of a therapeutic drug treatment, rather than "blindly" selecting an alternative medicine, pharmacogenomic test results can provide guidance for the selection of the most appropriate drug and its dose. The intent is to yield a greater likelihood of patient success in following a therapeutic intervention.

Pharmacotherapy for Insomnia in Primary Care.

Pharmacotherapy for insomnia in primary care settings can be challenging. Frequently, there are multiple coexisting medical and psychiatric conditions, drug interactions, concern regarding use of habit-forming sleep aids, and paucity of time in office visits to discuss management of sleep difficulties. This article reports the results of a literature search related to pharmacotherapy for insomnia and presents 4 clinical vignettes with corresponding treatment options.

Electroconvulsive Therapy Intervention for Parkinson's Disease.

BACKGROUND: Electroconvulsive therapy is an established means to improve function in a variety of psychiatric and neurologic conditions, particularly for patients who remain treatment-refractory. Parkinson's disease is a neurodegenerative disorder that sometimes does not respond well to conventional pharmacotherapies. Reports have indicated that electroconvulsive therapy may be an effective and safe treatment for those patients with Parkinson's disease who are not optimally responding to first-line treatments. Despite these reports, however, electroconvulsive therapy is not often used by clinicians in patients with treatment-resistant Parkinson's disease, perhaps due to stigma, lack of knowledge regarding its safety and efficacy, and/or inability to predict the duration of therapeutic benefit. OBJECTIVE: Our objective was to determine if the available literature on ECT supports it as a safe and effective treatment option in patients with treatment-refractory Parkinson's disease. CONCLUSION: Motoric improvement induced by electroconvulsive therapy has been documented for decades in persons with Parkinson's disease. Efficacy and safety are reported following electroconvulsive therapy in people with Parkinson's disease who have sub-optimal response to medicines or experience the "on/off" phenomenon to L-dopa. Electroconvulsive therapy is an effective option for acute and maintenance treatment of Parkinson's disease in select patients. Inability to predict how long the beneficial effects of ECT therapy will last in patients with Parkinson's disease may be a reason why this treatment is underutilized by clinicians. More research is warranted to clarify parameters for application and duration of therapeutic benefit in individuals with difficult-to-treat Parkinson's disease.