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.

Substance Use Disorders in the Geriatric Population: a Review and Synthesis of the Literature of a Growing Problem in a Growing Population.

Purpose of review: Substance use disorders are becoming increasingly prevalent in the geriatric population, necessitating an updated understanding of the existing literature. This review aims to describe the epidemiology, special considerations, and management of substance use disorders in older adults. Recent findings: PubMed, Ovid MEDLINE, and PsychINFO databases were searched from their inception through June 2022 using the following keywords: "substance use disorder," "substance abuse," "abuse," "illicit substances," "illicit drugs," "addiction," "geriatric," "elderly," "older adults," "alcohol," "marijuana," "cannabis," "cocaine," "heroin," "opioid," and "benzodiazepine." Our findings suggest an increasing trend in substance use in older adults despite medical and psychiatric consequences when using such substances. The majority of older patients admitted to substance abuse treatment programs were not referred by healthcare providers, suggesting room for improvement in the screening and discussion of substance use disorders. Our review also suggests that there should be careful consideration of COVID-19 and racial disparities when screening, diagnosing, and treating substance use disorders in the older population. Summary: This review provides updated information on epidemiology, special considerations, and management of substance use disorders in older adults. As substance use disorders become more prevalent in older adults, primary care physicians must be prepared to recognize and diagnose substance use disorders as well as collaborate with and refer patients to geriatric medicine, geriatric psychiatry, and addiction medicine.

Case report: Diagnostic challenges in a patient with alcohol use disorder that developed following a stroke.

Patients with comorbid neurological and psychiatric diseases often face considerable impairment, causing challenges that pervade many aspects of their lives. Symptoms can be especially taxing when one or more of these conditions is severely disabling, as the resulting disability can make it more challenging to address comorbidities. For clinicians, such patients can be quite difficult to both diagnose and treat given the immense potential for overlap between the underlying psychiatric and neurologic causes of their symptoms-as well as the degree to which they might exacerbate or, conversely, mask one another. These intricate relationships can also obscure the workup of more acute pathologies, such as alcohol withdrawal and delirium. This report details the complex history and clinical challenges in a 54-year-old man who was no longer able to work after developing multiple neurologic deficits from a left MCA stroke a decade earlier. The intellectual and motor disabilities he faced in the aftermath of his stroke were subsequently compounded by a steady increase in alcohol consumption, with his behavior ultimately progressing to severe alcohol use disorder. The coinciding neurologic and psychiatric manifestations obfuscate the workup-and therefore the management-of his major depressive disorder. In pursuit of the optimal approach to address these comorbid conditions and promote recovery, an investigation into possible mechanisms by which they are interconnected revealed several potential neuropsychiatric explanations that suggest targets for future therapeutic strategies.

Switch to Hypomania After Discontinuation of Tamoxifen: A Case Report.

Tamoxifen is a synthetic, nonsteroidal antiestrogen widely used in the treatment of hormone-sensitive breast cancer that has also been shown to inhibit the enzyme protein kinase C (PKC). Upregulation of PKC is associated with disruption of prefrontal cortical regulation of thinking and behavior, which can lead to mania-like symptoms in animal models. Lithium and valproate, 2 mood stabilizers that are widely used in the treatment of bipolar disorder, have also been shown to inhibit PKC. We describe the case of a 48-year-old woman who entered a hypomanic state after discontinuation of tamoxifen while remaining on unopposed venlafaxine prescribed for depression. This case highlights the risk of misdiagnosing unipolar depression in breast cancer patients with undiagnosed bipolar disorder who are being treated with tamoxifen and subsequently started on antidepressants. The use of antidepressants in this population should be carefully monitored to avoid the development of manic, hypomanic, or mixed symptoms in patients with underlying bipolar disorder once tamoxifen is discontinued.

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.

Cannabis use and psychiatric illness in the context of medical marijuana legalization: A clinical perspective.

OBJECTIVE: More than half of the U.S. states have legalized medical marijuana. Emerging evidence suggests that medical marijuana legalization may increase marijuana use and cannabis use disorder (CUD). CUD is comorbid with, and exacerbates, numerous psychiatric conditions, including misuse of other substances. It is unclear if marijuana is a gateway to other drug use, if it is simply a marker of another variable or shared experiences. Thus, we aim to present a perspective of the potential impact of medical marijuana legalization on CUD, focusing on the relationship of CUD to other psychiatric disorders. FINDINGS: Medical marijuana legalization may lead to problematic cannabis use in patients with depressive symptoms, individuals with genetic predispositions, and those with certain early life stressors or who use in order to cope. Past positive experience with marijuana use may contribute to patient desire to seek medical marijuana treatment. Despite approved indications, medical marijuana often only leads to partial relief of its intended target symptom. While recreational marijuana use increases likelihood of using other drugs and is detrimental to recovery from other substance use disorders, the relationship between medical marijuana use and polysubstance use or risk of addiction relapse is uncertain. CONCLUSIONS AND RELEVANCE: Legalized medical marijuana use may increase rates of CUD, although further research is needed to clarify this association. Based on the literature, it is our perspective that patients with affective symptoms and those with other substance use disorders are at increased risk of developing CUD and its sequelae. Given the uncertainty surrounding how prescribed marijuana may interact with other disorders, it is paramount that clinicians make patient-specific judgments as to the risks and benefits of the treatment.

Opana(®) ER induced thrombotic thrombocytopenic purpura.

We present the case of a patient who developed thrombotic thrombocytopenic purpura (TTP) following intravenous injection of Opana(®) ER. TTP reemerged after three months of abstinence with Opana misuse. This case report brings awareness to the possibility of developing TTP in those who misuse Opana, which is a growing concern.

Problem adaptation therapy for older adults with major depression and cognitive impairment: a randomized clinical trial.

IMPORTANCE: Problem adaptation therapy (PATH) is a treatment for older adults with major depression, cognitive impairment (from mild cognitive deficits to moderate dementia), and disability. Antidepressants have limited efficacy in this population and psychosocial interventions are inadequately investigated. OBJECTIVE: To test the efficacy of 12-week PATH vs supportive therapy for cognitively impaired patients (ST-CI) in reducing depression and disability in 74 older adults with major depression, cognitive impairment, and disability. DESIGN, SETTING, AND PARTICIPANTS: A randomized clinical trial at the Weill Cornell Institute of Geriatric Psychiatry from April 1, 2006, to September 31, 2011. Interventions were administered at the participants' homes. Participants included 74 older individuals (age ≥ 65 years) with major depression and cognitive impairment to the level of moderate dementia. They were recruited through collaborating community agencies of Weill Cornell Institute of Geriatric Psychiatry and were randomly assigned to 12 weekly sessions of PATH or ST-CI (14.8% attrition rate). INTERVENTIONS: Home-delivered PATH vs home-delivered ST-CI. Problem adaptation therapy integrates a problem-solving approach with compensatory strategies, environmental adaptations, and caregiver participation to improve patients' emotion regulation. Supportive therapy for cognitively impaired patients focuses on expression of affect, understanding, and empathy. MAIN OUTCOMES AND MEASURES: Mixed-effects models for longitudinal data compared the efficacy of PATH with that of ST-CI in reducing depression (Montgomery-Asberg Depression Rating Scale) and disability (World Health Organization Disability Assessment Schedule II) during 12 weeks of treatment. RESULTS: Participants in PATH had significantly greater reduction in depression (Cohen d, 0.60; 95% CI, 0.13-1.06; treatment × time, F(1,179) = 8.03; P = .005) and disability (Cohen d, 0.67; 95% CI, 0.20-1.14; treatment × time, F(1,169) = 14.86; P = .001) than ST-CI participants during the 12-week period (primary outcomes). Furthermore, PATH participants had significantly greater depression remission rates than ST-CI participants (37.84% vs 13.51%; χ(2) = 5.74; P = .02; number needed to treat = 4.11) (secondary outcome). CONCLUSIONS AND RELEVANCE: Problem adaptation therapy was more efficacious than ST-CI in reducing depression and disability. Problem adaptation therapy may provide relief to a large group of depressed and cognitively impaired older adults who have few treatment options. TRIALS REGISTRATION: Clinicaltrials.gov Identifier: NCT00368940.

Self-injurious behavior in the nursing home setting.

BACKGROUND: Self-injurious behavior (SIB) in older adults is defined as harm inflicted on oneself without conscious suicidal intent. SIB as a separate entity distinct from suicidal intent is poorly understood. However, it is of great concern to the patients' families and caregivers and it poses serious clinical challenges for clinicians. METHODS: We searched the database of PubMed, Ovid Medline, and ScienceDirect for reports published between 1970 and 2009 using combination of the following keywords: "self-injurious behavior", "self-destructive behavior", "self-mutilating behavior", "older adults", "geriatric population", and "nursing homes". The term "self-harm behavior" which also appears in the literature is broader in scope than "self-injurious behavior". It encompasses high suicide intent and failed suicide attempts; therefore, we excluded this term in order to focus purely on "self-injurious behavior". Our search yielded 10 publications concerning SIB in older adults, four of which included studies investigating SIB in nursing homes. RESULTS: Clinical studies of SIB in older adult nursing home residents are sparse. This limited literature suggests that SIB is a prevalent phenomenon and is reported to be as high as 14% in one study of nursing home subjects aged 65 and older. It is reported to be strongly associated with dementia and a risk of accidental death. It has been suggested that SIB among demented patients occurs in the context of poor impulse control and physical isolation. CONCLUSION: SIB is likely a common phenomenon in older adult nursing home residents. There is little evidence-based treatment guidance for SIB in older population.