Medical events in SARS-Cov-2 infected psychiatric inpatients with and without pre-existing co-morbid medical conditions.

SARS-CoV-2 (COVID-19) infection can be associated with significant medical complications. This risk could be even higher in psychiatric patients due to an increased risk of medical co-morbidity. In addition, psychiatric patients are also vulnerable to acquiring SARS-CoV2 infection due to homelessness, living in crowded areas, and poor adherence to recommended preventive measures. This retrospective study aims to compare two groups of patients, namely COVID-19 positive inpatient psychiatric patients with and without preexisting medical comorbidity on specific clinical and socio-demographic features and more importantly how many patients in the two groups subsequently developed medical complications. All COVID-19 positive psychiatric patients who were admitted to acute psychiatric inpatient units over a one-year period during the peri-pandemic phase were included for this study. Data was collected from the electronic medical records of 174 patients admitted to the inpatient psychiatric facility between January and December 2020. Among the COVID-19 positive patients, twenty individuals out of eighty-nine in the WC (with pre-existing medical comorbidity) group and two individuals out of eighty-five in the WOC (without pre-existing medical comorbidity) group developed COVID-related pneumonia. Ten WC patients and two WOC patients required supplemental oxygen, while only one patient in the WC group developed critical illness and required ventilatory support. The WC group had longer stay in both psychiatric and medical units compared to the WOC group. Consistent with existing literature that patients with comorbid medical condition are higher risk of COVID-19 complications, this study replicates the finding that in psychiatric inpatients pre-existing comorbid medical conditions create a higher risk of experiencing COVID-19 related medical complications. More interestingly, however that increased risk of developing new medical complications was not significantly different from the published rates observed in the general population which is surprising given how vulnerable psychiatric patients are, both medical, psychiatrically and psychosocially. In fact, in some ways and for reasons as yet unclear, the medical complication rate was slightly better in the WC compared to published data in the general population groups.

Polysomnographic identification of anxiety and depression using deep learning.

Anxiety and depression are common psychiatric conditions associated with significant morbidity and healthcare costs. Sleep is an evolutionarily conserved health state. Anxiety and depression have a bidirectional relationship with sleep. This study reports on the use of analysis of polysomnographic data using deep learning methods to detect the presence of anxiety and depression. Polysomnography data on 940 patients performed at an academic sleep center during the 3-year period from 01/01/2016 to 12/31/2018 were identified for analysis. The data were divided into 3 subgroups: 205 patients with Anxiety/Depression, 349 patients with no Anxiety/Depression, and 386 patients with likely Anxiety/Depression. The first two subgroups were used for training and testing of the deep learning algorithm, and the third subgroup was used for external validation of the resulting model. Hypnograms were constructed via automatic sleep staging, with the 12-channel PSG data being transformed into three-channel RGB (red, green, blue channels) images for analysis. Composite patient images were generated and utilized for training the Xception model, which provided a validation set accuracy of 0.9782 on the ninth training epoch. In the independent test set, the model achieved a high accuracy (0.9688), precision (0.9533), recall (0.9630), and F1-score (0.9581). Classification performance of most other mainstream deep learning models was comparable. These findings suggest that machine learning techniques have the potential to accurately detect the presence of anxiety and depression from analysis of sleep study data. Further studies are needed to explore the utility of these techniques in the field of psychiatry.

Impact of SARS-CoV-2 infection and implementation of infection prevention and control (IPC) measures on inpatient psychiatric units.

Psychiatric inpatients are at high risk of acquiring and transmitting communicable diseases such as SARS-CoV-2 (COVID-19). Via chart review, the authors examined a cohort of COVID-positive psychiatric inpatients admitted between March and June of 2020, early in the pandemic, to Valleywise Health Medical Center (VMHC), in Arizona, USA. The goal was to assess the ways in which the virus itself as well as infection prevention and control (IPC) measures affected psychiatric inpatients. Variables examined included demographics, psychiatric diagnoses, COVID-19 symptoms, medical comorbidities, and length of stay. Behavioral health faciltiies encountered significant challenges in blalancing the need for a therapeutic milieu and compliance with IPC measures. During the study period, 39 patients and 15 staff members contracted COVID. All but one COVID-positive staff member provided direct patient care. During the study period, VMHC behavioral health facilities were largely successful in identifying and quarantining COVID-positive patients. The hospital's IPC policies/procedures were constantly updated to incorporate new guidelines and address emerging knowledge about the virus, which may have lowered transmission rates and mitigated potential complications. To preserve quallity and safety of psychiatric care, the therapeutic milieu was altered, which may have adversely affected patient care and/or lengthened hospital stay.

Non-suicidal self-injury in developing countries: A review.

BACKGROUND: Non-suicidal self-injury (NSSI) may be understood as a physical and behavioral expression of emotional distress. Over the past 70 years, it has been variably formulated as a type of emotional reaction to various stressors. NSSI has complex goals, sometimes implicit, but overall it serves as a transient psychological relief. Many believe that NSSI is a maladaptive behavior and is not related to suicide, with the primary differentiating factor between suicide and NSSI being the 'intention' to die. NSSI is an important mental health problem in current modern societies, and it is part of a trend in current psychiatric and mental health practice to medicalize maladaptive behaviors or psychological distress. AIMS: To review the prevalence, associated factors, purpose, and psychological and social significance of NSSI in developing countries. METHOD: This article is a narrative review. However, of the total 1,094 articles, 13 articles were included to derive information on the prevalence and methods of NSSI in the developing country. RESULTS: NSSI rates are very variable, ranging from 11.5% to as high as 33.8%, depending on the nature of the sample and study design, but data show an increasing trend globally, including in developing countries. CONCLUSION: The recent emerging data does not support the notion that it is common in developed Western countries, though the meaning, context and reason for NSSI might differ in developing and developed countries. NSSI is almost equally prevalent in both developing and developed countries.

Hybrid Telepsychiatry: A United States Perspective with Relevance to India.

Telepsychiatry provides a platform for mental health care delivery in rural and remote areas. Hybrid Telepsychiatry model combines home-based telepsychiatry with domiciliary visits by community mental health workers. This involves use of different modes of teledevices which ensures safe and secure clinical platform. Research evidence supports that incorporating this model seems to use the specialist time efficiently where the resources are limited and services need to be catered for larger geographical community. The current telepsychiatry practice in the United States, specifically the hybrid model, has indisputably shown significant benefits in caring for psychiatric patients. Such valuable clinical model and its relevance to current mental practice and also its application in the Indian scenario can be helpful in providing comprehensive multidisciplinary treatment. This review evaluates and highlights the potential risks and benefits of adopting the hybrid telepsychiatry model in the Indian mental health system.

Inflammation, Antipsychotic Drugs, and Evidence for Effectiveness of Anti-inflammatory Agents in Schizophrenia.

In recent years, there is a new optimism in schizophrenia therapeutics with the emergence of immunomodulation as a potential treatment approach. Current evidence points to various immunological abnormalities in schizophrenia, including cell-mediated processes, acute phase proteins, cytokines, and intracellular mediators. Trait- and state-related immune dysfunction appears to exist, and a strong case can therefore be made for immunomodulation therapies in the prevention, treatment, and/or moderating the course of schizophrenia.Immunomodulation approaches include use of nonsteroidal anti-inflammatory agents to stop or moderate an over-activated inflammatory process, anti-oxidants, nutrients, vitamins, herbal products, and other neuroprotection agents that inhibit pro-inflammatory processes, optimal use of antipsychotic drugs (APDs) that may have anti-inflammatory actions or in certain cases such as clozapine may enhance blunted inflammatory responses, and biological agents to antagonize specific immune mediators such as the cytokines. A combination of two or more of the above approaches is also worthy of consideration.In this chapter, the available data for each of the above approaches is reviewed and discussed. Strengths and limitations of current studies are identified, and suggestions are made for future studies. For example, identifying patients with high levels of specific biomarkers such as C-Reactive Protein, IL-6, IFN-γ, TNF-α, and genetic polymorphisms of cytokines, and match them with clinical subgroups such as prodromal, first episode psychosis, chronic psychosis, and negative symptoms with the aim of developing targeted treatment approaches and more personalized medicine. Meanwhile, since the science and trial data are not advanced enough to make definitive recommendations, clinicians should stay up to date with the literature, obtain detailed immunological histories, and review the risk-benefit ratio of adding available immune modulating agents to standard therapies, to provide optimal and state-of-the-art care to patients.

Successful Management of Psychotropics Induced Stuttering Priapism with Pseudoephedrine in a Patient with Schizophrenia.

Stuttering Priapism is a recurrent, persistent penile erection in the absence of sexual desire due to altered genital hemodynamics, affecting the arterial component (high flow, non-ischemic) or the veno-occlusive mechanism (low flow, ischemic). Both typical and atypical antipsychotics increase the risk for priapism with greater implications in typicals than atypicals. Prompt recognition and treatment are important as 40% to 50% of patients with stuttering priapism may develop an erectile dysfunction if left untreated. There are several case reports in the literature about the association between psychotropic agents and priapism. However, there are no reports of successfully treating stuttering priapism using pseudoephedrine (sudafed) in the adult population. Here we present successful management of psychotropics induced stuttering priapism with pseudoephedrine in a male patient with schizophrenia.

A Case of Concomitant Pseudocyesis and Couvade Syndrome Variant.

Per DSM-V, pseudocyesis is included under the category "other specified somatic symptom and related disorder" and is defined as a false belief of being pregnant that is associated with objective signs and reported symptoms of pregnancy. The male counterpart of pseudocyesis is Couvade syndrome, also called "sympathetic pregnancy" where a man experiences symptoms of pregnancy when his female partner is pregnant. There are extensive reports on pseudocyesis and Couvade syndrome in psychiatric literature but none with features of both, in a single case. Here we present a unique case of a fifty-eight-year-old mother who presented with symptoms of concomitant pseudocyesis and Couvade syndrome concurrently when her daughter was pregnant. This case report discusses the epidemiology, course of symptoms and common comorbidities associated with this interesting diagnosis.

Caffeine Sodium Benzoate for Electroconvulsive Therapy Augmentation.

OBJECTIVES: Because of an ongoing manufacturer shortage of injectable caffeine sodium benzoate (CSB), patients at our health system were given CSB compounded in-house to increase seizure response during electroconvulsive therapy (ECT). Therefore, we aimed to evaluate its effectiveness and safety as an ECT augmentation agent. METHODS: Medical records of patients who received compounded CSB at Virginia Commonwealth University Health System were reviewed to identify adults receiving it as part of an index ECT treatment course between June 2012 and December 2016. The primary outcome was change in electroencephalogram seizure duration from pre-caffeine session to initial caffeine session. Data were also collected on demographics, motor seizure duration, maximum heart rate, mean arterial pressure, and concurrent medication use for these sessions and the last caffeine session. RESULTS: Seven-one patients were included in the study, predominantly white females with a mean age of 58.6 years. The most common indication for ECT was major depressive disorder resistant to pharmacotherapy (71.8%), followed by catatonia associated with another mental disorder (19.7%). Electroencephalogram seizure duration increased by 24.1 seconds on average with first CSB use (P < 0.0001), allowing 24 more patients overall to achieve goal of at least 30 seconds (P < 0.0001). No clinically significant changes in maximum heart rate or mean arterial pressure were observed, nor did any patients require an abortive agent for prolonged seizure. Five patients (7%) discontinued CSB prematurely: 4 related to adverse effects and 1 secondary to ineffectiveness. CONCLUSIONS: We confirm results of prior studies of the utility of CSB and add that compounded CSB is effective for ECT augmentation, maintaining effectiveness throughout the index course with minimal safety concerns.

Subcallosal cingulate deep brain stimulation for treatment-resistant depression: a multisite, randomised, sham-controlled trial.

BACKGROUND: Deep brain stimulation (DBS) of the subcallosal cingulate white matter has shown promise as an intervention for patients with chronic, unremitting depression. To test the safety and efficacy of DBS for treatment-resistant depression, a prospective, randomised, sham-controlled trial was conducted. METHODS: Participants with treatment-resistant depression were implanted with a DBS system targeting bilateral subcallosal cingulate white matter and randomised to 6 months of active or sham DBS, followed by 6 months of open-label subcallosal cingulate DBS. Randomisation was computer generated with a block size of three at each site before the site started the study. The primary outcome was frequency of response (defined as a 40% or greater reduction in depression severity from baseline) averaged over months 4-6 of the double-blind phase. A futility analysis was performed when approximately half of the proposed sample received DBS implantation and completed the double-blind phase. At the conclusion of the 12-month study, a subset of patients were followed up for up to 24 months. The study is registered at ClinicalTrials.gov, number NCT00617162. FINDINGS: Before the futility analysis, 90 participants were randomly assigned to active (n=60) or sham (n=30) stimulation between April 10, 2008, and Nov 21, 2012. Both groups showed improvement, but there was no statistically significant difference in response during the double-blind, sham-controlled phase (12 [20%] patients in the stimulation group vs five [17%] patients in the control group). 28 patients experienced 40 serious adverse events; eight of these (in seven patients) were deemed to be related to the study device or surgery. INTERPRETATION: This study confirmed the safety and feasibility of subcallosal cingulate DBS as a treatment for treatment-resistant depression but did not show statistically significant antidepressant efficacy in a 6-month double-blind, sham-controlled trial. Future studies are needed to investigate factors such as clinical features or electrode placement that might improve efficacy. FUNDING: Abbott (previously St Jude Medical).

A pilot study of body image perceptions, and attitudes toward obesity in hospitalized psychotic and non-psychotic patients.

OBJECTIVE: Body image perceptions, and attitudes toward obesity were examined and compared between psychotic and non-psychotic patients with a mood disorder. METHODS: 80 psychotic patients and 36 non-psychotic patients with a mood disorder admitted to an acute inpatient psychiatric unit participated in the study. On admission, each patient completed a visual silhouettes scale of actual self and ideal self, as well as the Attitudes Toward Obese Persons (ATOP) scale. RESULTS: Analogous to the general population, psychotic and non-psychotic patients had similar body image perceptions, and experienced discrepancy between actual and ideal body image. Female patients with serious mental illness (SMI) picked a heavier actual self body image, and experienced greater discrepancy between actual and ideal body image compared to male patients with SMI. Psychotic and non-psychotic patients experienced similar mostly neutral attitudes toward obese persons, however there was a trend for depressed patients to have more negative attitudes toward obese persons compared to non-depressed patients. DISCUSSION: The presence of an acute psychotic episode did not affect body perceptions, or obesity attitudes; however depressed patients had more negative obesity attitudes. Similar to the general population, females with SMI overassessed their body size, and experienced more body dissatisfaction compared to males with SMI.

Reversal of cerebral glucose hypometabolism on positron emission tomography with electroconvulsive therapy in an elderly patient with a psychotic episode.

AB, a 74-year-old Caucasian woman, was admitted for acute onset of psychosis, anxiety, and cognitive impairment. Pharmacotherapy was unsuccessful and the patient was referred for electroconvulsive therapy (ECT). Pre-ECT, 18 F-fluorodeoxyglucose-positron emission tomography (PET)/computed tomography showed extensive frontal, parietal, and temporal cortical hypometabolism suggestive of a neurodegenerative disease. After eight ECT sessions, the psychotic and anxiety symptoms as well as the cognitive impairment resolved. The rapid improvement in symptoms was more suggestive of a psychotic episode rather than dementia. Two days after the ECT course, 18 F-fluorodeoxyglucose-PET/computed tomography showed improvements in cerebral cortical hypometabolism, especially in the left parietal cortex, left temporal/occipital cortex. and bifrontal regions. At a follow-up visit 2 months after the ECT course, the psychotic episode was still in remission, and 18 F-fluorodeoxyglucose-PET/computed tomography continued to show improved cerebral cortical hypometabolism in these areas. This case illustrated the effect of ECT in reversing cerebral glucose hypometabolism on PET. The improvement in cerebral glucose hypometabolism may represent the neurophysiological mechanism of ECT in the treatment of a psychotic episode. Improved cerebral glucose hypometabolism was present 2 months post-ECT, which suggests that ECT caused sustained functional neural changes.

Augmentation Therapy With Serial Intravenous Ketamine Over 18 Months in a Patient With Treatment Resistant Depression.

Major depressive disorder is a severe illness that affects 3% to 7% of adults annually in the United States. About 30% of these individuals are refractory to multiple treatment trials. Recent reports have found a significant and almost immediate improvement in depressive symptoms after single or multiple ketamine intravenous infusions (IVIs) in such patients. We present the case of A.B., a patient with treatment-resistant depression (TRD) including to subgenual deep brain stimulation, who went into remission after augmentation with 6 ketamine IVIs (0.5 mg/kg) over a 3-week period. However, she had a reemergence of depressive symptoms 4 months later and received a second series of 3 ketamine IVIs over the course of a week. A.B. again went into remission and maintained this for the next 8 months. At this time, she experienced a reemergence of depressive symptoms and was treated with the third series of ketamine IVIs (3 infusions over the course of a week). Because A.B. has now been in remission for 6 months. A.B. has received a total of 12 ketamine IVIs over the course of 18 months. No significant adverse events have occurred. To our knowledge, this is the first case of long-term ketamine efficacy as augmentation therapy in TRD over the course of 18 months. There is a need for studies examining the long-term management of TRD with IV ketamine. Guidelines for maintenance ketamine IVIs in TRD also need to be developed.

QTc Prolongation in Veterans With Heroin Dependence on Methadone Maintenance Treatment.

BACKGROUND: QTc prolongation and Torsade de Ppointes have been reported in patients on methadone maintenance. OBJECTIVES: In this study, QTc was compared before and after the veteran (n = 49) was on a stable dosage of methadone for 8.72 ± 4.50 years to treat heroin dependence. Risk factors were correlated with the QTc once the veteran was on a stable dose of methadone. Differences in the clinical risk factors in subgroups of veterans with below and above mean QTc change was compared. PATIENTS AND METHODS: ECG data was obtained from a 12-lead electrocardiogram (pre-methadone and on methadone) on 49 veterans. Data and risk factors were retrospectively collected from the medical records. RESULTS: The mean QTc at baseline (pre-methadone) was 426 ± 34 msec and after being on methadone for an average of 8.72 ± 4.50 years was significantly higher at 450 ± 35 msec. No significant relationships were found between QTc prolongation and risk factors except for calcium. The methadone dosage was significantly higher in veterans with a QTc change above the mean change of ≥ 24 msec (88.48 ± 27.20 mg v.s 68.96 ± 19.84 mg). None of the veterans experienced cardiac arrhythmias. CONCLUSIONS: The low complexity of medical co-morbidities may explain the lack of a significant correlation between any risk factor with the QTc except calcium and methadone dosage. The absence of TdP may be explained by the low prevalence of QTc values > 500 msec as well as the retrospective design of the study. During long-term methadone treatment, there was a slight increase in the QTc interval but we did not find evidence of increased cardiac toxicity as a reason for treatment termination.

A brief analysis of suicide methods and trends in Virginia from 2003 to 2012.

BACKGROUND: The objective is to analyze and compare Virginia suicide data from 2003 to 2012 to US suicide data. METHODS: Suicide trends by method, age, gender, and race were obtained from Virginia's Office of the Chief Medical Examiner's annual reports. RESULTS: Similar to US suicide rates, suicide rates in Virginia increased between 2003 and 2012 from 10.9/100,000 people to 12.9/100,000 people. The most common methods were firearm, asphyxia, and intentional drug overdose, respectively. The increase in asphyxia (r = 0.77, P ≤ 0.01) and decrease in CO poisoning (r = -0.89, P ≤ 0.01) were significant. Unlike national trends, intentional drug overdoses decreased (r = -0.55, P = 0.10). Handgun suicides increased (r = 0.61, P = 0.06) and are the most common method of firearm suicide. Hanging was the most common method of asphyxia. Helium suicides also increased (r = 0.75, P = 0.05). Middle age females and males comprise the largest percentage of suicide. Unlike national data, the increase in middle age male suicides occurred only in the 55-64-year-old age group (r = 0.79, P ≤ 0.01) and decreased in the 35-44-year-old age group (r = -0.60, P = 0.07) and 10-14-year-old age group (r = -0.73, P = 0.02). Suicide in all female age ranges remained stable. Caucasians represent the highest percentage of suicide. CONCLUSION: There has been a rise in suicide in Virginia and suicide rates and trends have closely resembled the national average albeit some differences. Suicide prevention needs to be enhanced.

Quetiapine, QTc interval prolongation, and torsade de pointes: a review of case reports.

Recently, both the manufacturer of quetiapine and the US Food and Drug Administration warned healthcare providers and patients about quetiapine-induced QTc interval prolongation and torsade de pointes (TdP) when using this drug within the approved labeling. We reviewed the case-report literature and found 12 case reports of QTc interval prolongation in the setting of quetiapine administration. There were no cases of quetiapine-induced TdP or sudden cardiac death (SCD) among patients using quetiapine appropriately and free of additional risk factors for QTc interval prolongation and TdP. Among the 12 case reports risk factors included female sex (nine cases), coadministration of a drug associated with QTc interval prolongation (eight cases), hypokalemia or hypomagnesemia (six cases) quetiapine overdose (five cases), cardiac problems (four cases), and coadministration of cytochrome P450 3A4 inhibitors (two cases). There were four cases of TdP. As drug-induced TdP is a rare event, prospective studies to evaluate the risk factors associated with QTc prolongation and TdP are difficult to design, would be very costly, and would require very large samples to capture TdP rather than its surrogate markers. Furthermore, conventional statistical methods may not apply to studies of TdP, which is rare and an 'outlier' manifestation of QTc prolongation. We urge drug manufacturers and regulatory agencies to periodically publish full case reports of psychotropic drug-induced QTc interval prolongation, TdP, and SCD so that clinicians and investigators may better understand the clinical implications of prescribing such drugs as quetiapine.