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1.
J Psychiatr Pract ; 26(2): 153-159, 2020 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-32134890

RESUMO

BACKGROUND: Population-based surveys estimate that 0.7% of youth (13 to 17 y of age) in the United States identifies as transgender. Transgender youth are at an increased risk of anxiety, depression, and suicide attempts that often require inpatient care. Unfortunately, because of perceived insensitivity to gender identity from their providers, which includes incorrect use of names and/or pronouns, they may delay seeking necessary care. To date, there have been no specific documentation practice guidelines published by the International Association of Child and Adolescent Psychiatry and Allied Professions, American Academy of Child and Adolescent Psychiatry (AACAP), or other professional associations. The main goal of this study was to review documentation practices among multidisciplinary teams caring for hospitalized transgender youth on a child and adolescent inpatient psychiatry unit. METHODS: Retrospective chart reviews were completed for 44 transgender patients who were hospitalized between 2008 and 2017. The charts were reviewed for consistency in the documentation of name and gender by the multidisciplinary team. Members included child and adolescent staff psychiatrists, residents, fellows, nurses, nurse practitioners, physician assistants, and social workers. Inconsistency was defined as at least 2 members of the team referring to a patient by a different name and/or gender pronoun in separate notes or >2 interchanges of name and/or gender pronoun in a single note. Kappa coefficient was calculated between each team member role to estimate exact agreement statistics. RESULTS: In 43.2% (n=19) of cases, team members did not have a consistent approach to documenting a patient's name and/or gender pronoun and 18% (n=8) of discharge summaries were also inconsistent in this documentation. The greatest agreement in documentation practices was noted between the team and the staff psychiatrist (κ=0.446). CONCLUSIONS: Findings from this study suggest that inpatient treatment teams show inconsistency in documentation practices for youth transgender inpatients. Further work is necessary to understand the implications of these findings for patient satisfaction and clinical outcomes.

2.
BMC Neurol ; 20(1): 44, 2020 Feb 03.
Artigo em Inglês | MEDLINE | ID: mdl-32013931

RESUMO

BACKGROUND: Autoimmune encephalitis is characterized by neuropsychiatric symptoms associated with brain inflammation. The differential is usually broad and Psychiatry often collaborates with Neurology in diagnostic clarification and symptom management. At least 40% of neuroencephalitis cases are of unknown etiology which adds to difficulties in making the right diagnosis and deciding on the appropriate treatment (Granerod et al., Lancet Infect Dis 10:835-44, 2010). The aim of this case series was to present four cases with complicated psychiatric symptomatology and isolated neurologic signs and symptoms, evaluated at a large tertiary medical center and treated for suspected autoimmune encephalitis, demonstrating the complexity of diagnosis and treatment. CASE PRESENTATION: Four diagnostically challenging and heterogeneous cases displayed clinical symptomatology suggestive of autoimmune encephalitis. All cases presented with neurologic and psychiatric symptoms, but had negative autoantibody panels, normal or inconclusive magnetic resonance imaging results and non-specific cerebrospinal fluid changes. All were challenged with immunosuppressive/immunomodulatory treatments with overall poor response rates. CONCLUSIONS: There is a heterogeneous presentation of autoimmune encephalitis in pediatric populations. In the absence of positive findings on testing, individuals who do not meet proposed criteria for seronegative encephalitis may be misdiagnosed, and/or may not respond adequately to treatment. In those cases, comprehensive evaluation and stringent application of consensus guidelines is necessary.

3.
Artigo em Inglês | MEDLINE | ID: mdl-31634515

RESUMO

STUDY OBJECTIVES: Sleep disruption is a significant symptom of major depressive disorder (MDD). To our knowledge, no prior work has examined the impact of repetitive transcranial magnetic stimulation (rTMS) on sleep disturbances in adolescents with MDD. METHODS: Seventeen adolescents with treatment-resistant depression received 30 daily sessions of 10-Hz rTMS applied to the left dorsolateral prefrontal cortex (L-DLPFC). Clinical symptoms were assessed at baseline; after 10, 20, and 30 treatments; and at a 6-month follow-up visit. Insomnia was measured with a 3-item subscale of the Quick Inventory of Depressive Symptomatology-Adolescent (17 Item)-Self Report (QIDS-A17-SR). Hypersomnia was measured with a single QIDS-A17-SR item. Depression severity was rated with the Children's Depression Rating Scale, Revised (CDRS-R). The effect of rTMS on sleep was examined via linear mixed model analyses, with fixed effects of time (as a proxy of treatment), depression severity, age, and hypnotic medication use. RESULTS: No significant main effect of time was observed on the insomnia subscale (F4,43.442 = 1.078, p = 0 .379). However, there was a significant main effect of time on the QIDS-A17-SR hypersomnia score (F4,46.124 = 2.733, p = 0 .040), with significant improvement from baseline to treatment 10 (padj = 0.019) and from baseline to 6-month follow-up (padj = 0.044). In exploratory sensitivity analyses, response/nonresponse to rTMS for overall depressive symptoms had no significant effect on sleep outcomes. CONCLUSIONS: rTMS may have intrinsic effects on hypersomnia apart from its antidepressant effects in depressed adolescents. Future work should utilize sham controls and objective, quantitative measurements of sleep architecture to assess effects of rTMS in depressed adolescents. CLINICAL TRIAL REGISTRY: Clinicaltrials.gov identifiers are NCT00587639, NCT01502033, NCT01804270.

5.
Bipolar Disord ; 2019 Oct 23.
Artigo em Inglês | MEDLINE | ID: mdl-31643130

RESUMO

OBJECTIVE: The aim of this study was to evaluate the efficacy and safety of the dopaminergic-enhancing agent modafinil/armodafinil (MoArm) as adjunctive treatment for bipolar depression. METHODS: A comprehensive search of major electronic databases was conducted to identify randomized controlled trials (RCTs) of adjunctive MoArm that included patients with bipolar I (BP-I) or bipolar II (BP-II) depression. Data for response/remission and all-cause discontinuation were analyzed. Effect size was summarized by relative risk (RR) using a random effect model. RESULTS: Of 58 studies, five RCTs (N = 795 drug, N = 792 placebo) met inclusion criteria. Four armodafinil studies included only BP-I patients and one modafinil study included both bipolar subtypes with limited heterogeneity (I2  = 34%, P = .19; I2  = 18%, P = .30). Compared to placebo, augmentation with MoArm was associated with significantly greater rates of treatment response (RR, 1.18; 95% CI, 1.01-1.37; P = .03) and remission (RR, 1.38; 95% CI, 1.10-1.73; P = .005). All-cause discontinuation was not different than placebo (RR, 1.08; 95% CI, 0.89-1.30; P = .45) with no evidence of increased risk of mood switch or suicide attempts with MoArm (RR, 0.99; 95% CI, 0.39-2.5; P = .98; RR, 1.02; 95% CI, 0.37-2.85; P = .97). CONCLUSION: This narrower scope meta-analysis of one drug for one disease suggests that adjunctive MoArm may represent a novel therapeutic intervention. Further studies delineating the subtypes of bipolar depression responsive to these novel dopaminergic-enhancing agents are encouraged.

6.
Artigo em Inglês | MEDLINE | ID: mdl-31424700

RESUMO

Background: Opioid use is a significant national crisis impacting individuals struggling with addiction and their families. The majority of individuals who abuse opioids are of child-rearing age, and critical knowledge gaps remain regarding how this abuse impacts their offspring. Fortunately, treatment for opioid use disorders is available. The primary goal of this study was to evaluate both physical and psychiatric diagnoses of children who have at least 1 parent participating in a buprenorphine-assisted treatment program. Methods: This retrospective study is based on chart review (January 1, 2010, through June 30, 2018). Children with parents receiving care in a buprenorphine clinic were identified and matched on sex, race, and age in a ratio of 1:5 with controls from the general pediatric clinic population. Data related to health outcomes were extracted from the medical records. Results: Compared to controls (n = 120), children of parents receiving buprenorphine-assisted treatment (n = 24) were more likely to have been born premature (odds ratio [OR] = 3.3, P = .035), had jaundice after birth (OR = 2.7, P = .034), had enuresis/encopresis (P < .001), and had been the victims of abuse or neglect (OR = 19.7, P = .0005). Children of parents with opioid use disorders were also more likely to utilize emergency services (ie, being seen in the emergency department for fussiness; OR = 4.0, P = .046) and were less likely to be covered by private insurance compared to state-funded insurance (OR = 0.2, P = .0013). Conclusions: Parental opioid use disorder impacts children. More research is needed to better describe long-term effects of treatment of parental opioid use on their offspring and to help design addiction treatment programs to support whole family units.

8.
Front Pharmacol ; 10: 83, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-30837869

RESUMO

Background: Pharmacogenomic testing, specifically for pharmacokinetic (PK) and pharmacodynamic (PD) genetic variation, may contribute to a better understanding of baseline genetic differences in patients seeking treatment for depression, which may further impact clinical antidepressant treatment recommendations. This study evaluated PK and PD genetic variation and the clinical use of such testing in treatment seeking patients with bipolar disorder (BP) and major depressive disorder (MDD) and history of multiple drug failures/treatment resistance. Methods: Consecutive depressed patients evaluated at the Mayo Clinic Depression Center over a 10-year study time frame (2003-2013) were included in this retrospective analysis. Diagnoses of BP or MDD were confirmed using a semi-structured diagnostic interview. Clinical rating scales included the Hamilton Rating Scale for Depression (HRSD24), Generalized Anxiety Disorder 7-item scale (GAD-7), Patient Health Questionnaire-9 (PHQ-9), and Adverse Childhood Experiences (ACE) Questionnaire. Clinically selected patients underwent genotyping of cytochrome P450 CYP2D6/CYP2C19 and the serotonin transporter SLC6A4. PK and PD differences and whether clinicians incorporated test results in providing recommendations were compared between the two patient groups. Results: Of the 1795 patients, 167/523 (31.9%) with BP and 446/1272 (35.1%) with MDD were genotyped. Genotyped patients had significantly higher self-report measures of depression and anxiety compared to non-genotyped patients. There were significantly more CYP2C19 poor metabolizer (PM) phenotypes in BP (9.3%) vs. MDD patients (1.7%, p = 0.003); among participants with an S-allele, the rate of CYP2C19 PM phenotype was even higher in the BP (9.8%) vs. MDD (0.6%, p = 0.003). There was a significant difference in the distribution of SLC6A4 genotypes between BP (l/l = 28.1%, s/l = 59.3%, s/s = 12.6%) and MDD (l/l = 31.4%, s/l = 46.1%, s/s = 22.7%) patients (p < 0.01). Conclusion: There may be underlying pharmacogenomic differences in treatment seeking depressed patients that potentially have impact on serum levels of CYP2C19 metabolized antidepressants (i.e., citalopram / escitalopram) contributing to rates of efficacy vs. side effect burden with additional potential risk of antidepressant response vs. induced mania. The evidence for utilizing pharmacogenomics-guided therapy in MDD and BP is still developing with a much needed focus on drug safety, side effect burden, and treatment adherence.

9.
Artigo em Inglês | MEDLINE | ID: mdl-30651753

RESUMO

Background: Between 2009 and 2014, nearly 3% of US children (age ≤ 17 years) lived in households with at least 1 parent with substance use disorder. The present systematic review aimed to evaluate effects of parental opioid use disorder on the parent-child relationship and child developmental and behavioral outcomes. Methods: Several databases were comprehensively searched for studies published from January 1980 through February 2018 that reviewed effects of parental opioid addiction on parent-child relationships and outcomes of children (age, 0-16 years). Results: Of 304 unique studies, 12 evaluated effects of parental opioid addiction on the parent-child relationship as the primary outcome and on children's outcomes, including behaviors and development. Observation of mother-child interaction showed that mothers with opioid use disorders are more irritable, ambivalent, and disinterested while showing greater difficulty interpreting children's cues compared with the control group. Children of parents with opioid use disorders showed greater disorganized attachment; they were less likely to seek contact and more avoidant than children in the control group. The children also had increased risk of emotional and behavioral issues, poor academic performance, and poor social skills. Younger children had increased risk of abuse or neglect, or both, that later in life may lead to such difficulties as unemployment, legal issues, and substance abuse. Conclusions: Current evidence shows association between parental opioid addiction and poorer mother-child attachment and suboptimal child developmental and behavioral outcomes. Further research and treatment targeting children and families with parental opioid use are needed to prevent difficulties later in life.

10.
J Child Adolesc Psychopharmacol ; 29(1): 34-40, 2019 02.
Artigo em Inglês | MEDLINE | ID: mdl-30388048

RESUMO

OBJECTIVES: The Patient Health Questionnaire-9 Modified (PHQ-9M) is a self-report tool used to assess the presence and severity of depressive symptoms in teenagers. Despite widespread use in primary care clinics and psychiatric settings, the PHQ-9M has not been validated nor are its psychometric properties adequately understood for the adolescent population. This study sought to examine the psychometrics of the PHQ-9M in treatment-seeking, depressed adolescents at a psychiatric psychopharmacology clinic who were concurrently assessed with the Children's Depression Rating Scale Revised (CDRS-R) and Quick Inventory of Depressive Symptomatology-Adolescent (17-item) Self-Report (QIDS-A17-SR). METHODS: Adolescents (N = 160) aged 13 through 18 years with a diagnosis of major depressive disorder, determined on the basis of a clinical interview and semi-structured interview using the Kiddie Schedule for Affective Disorders and Schizophrenia-Present and Lifetime Version, were assessed for severity of depressive symptoms with the PHQ-9M, CDRS-R (adolescent interview only), and QIDS-A17-SR assessments at baseline, 4, and 8 weeks. Classical test theory analysis was used to evaluate the internal consistency and dimensionality of the PHQ-9M. Convergent validity was evaluated via intraclass correlations of the PHQ-9M with the CDRS-R and QIDS-A17-SR. Sensitivity to treatment response was also evaluated. RESULTS: The internal consistency (Cronbach's coefficient α) at baseline, 4, and 8 weeks was 0.879, 0.859, and 0.827 for the PHQ-9M; 0.739, 0.835, and 0.867 for CDRS-R; and 0.712, 0.777, and 0.804 for QIDS-A17-SR, respectively. The PHQ-9M had moderate convergent validity with the CDRS-R but good convergent validity with the QIDS-A17-SR. The PHQ-9M was less sensitive to changes in symptom severity than the CDRS-R and QIDS-A17-SR. CONCLUSIONS: The PHQ-9M appears to be a valid and reliable assessment tool for the severity of depressive symptoms in a psychiatric clinic setting. However, its utility as a treatment outcome measure may be limited compared with other available rating scales.

11.
J Child Adolesc Psychopharmacol ; 28(9): 615-619, 2018 11.
Artigo em Inglês | MEDLINE | ID: mdl-30358422

RESUMO

OBJECTIVES: Clozapine is the drug of choice for treatment-resistant schizophrenia. While pediatric clozapine use is not contraindicated, the literature describing its clinical application is limited. The primary objective of this study was to assess the use of clozapine in a child and adolescent population by characterizing the documented safety and clinical benefits of the medication. METHODS: A multicenter retrospective study at sites in the United States and Australia included children and adolescents admitted to a psychiatric unit who were administered at least one dose of clozapine. Information related to demographics, patient history, past treatments, clozapine, and adverse events was collected. RESULTS: Eighty-two patients from eight sites were included in this study. Patients were predominantly clozapine naive (76.8%), and most had a discharge diagnosis of a primary psychotic disorder (61%) or bipolar disorder (25.6%). Four clozapine discontinuations occurred during hospitalization due to severe neutropenia, ileus, need for diagnostic clarification, and significant psychomotor retardation. The remainder (n = 78) were discharged on a mean clozapine dose of 218.1 ± 142.2 mg. Sedation (26.8%) and sialorrhea (17.1%) were the most common documented adverse events. The mean number of previously trialed antipsychotics before clozapine was 3.5 ± 1.4 (range 1-10). Improvement with clozapine was documented as significant (31.7%), moderate (32.9%), minimal (12.2%), no improvement (2.4%), and not described (20.7%). CONCLUSIONS: In this cohort, 95% of pediatric patients admitted with or started on clozapine during an acute psychiatric hospitalization were discharged on the medication. The high incidence of adverse events should reinforce to clinicians the need for vigilant monitoring. Pediatric guidelines recommend clozapine for refractory schizophrenia but stress the critical need to ensure an accurate diagnosis. Limited data exist for the use of clozapine in pediatric patients with other diagnoses.


Assuntos
Antipsicóticos/uso terapêutico , Transtorno Bipolar/tratamento farmacológico , Clozapina/uso terapêutico , Unidade Hospitalar de Psiquiatria , Transtornos Psicóticos/tratamento farmacológico , Adolescente , Austrália , Criança , Clozapina/efeitos adversos , Feminino , Humanos , Masculino , Neutropenia/induzido quimicamente , Estudos Retrospectivos , Sialorreia/induzido quimicamente
12.
Front Psychiatry ; 9: 427, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-30258371

RESUMO

Parent-child interaction therapy (PCIT) is an evidence-based, behavioral dyadic treatment for caregivers and their children aged 2-7 years old with emotional and behavioral disorders. Here we present a treatment course of a 3-years-old girl with leukoencephalopathy, dysgenesis of the brainstem, and associated global developmental delay who was diagnosed with muscular dystrophy after PCIT completion. At the beginning of PCIT she had the developmental level of an 18 months old with language skills of a 12-18 months old; both her vocabulary and verbal expression were very limited. She had slow, unco-ordinated gait with limited fine motor skills. She was referred to Psychiatry with concerns regarding disruptive behaviors including severe self-injury. PCIT was started with a focus on PRIDE skills (Praise, Reflection, Imitation, behavioral Description and Enjoyment); particularly behavioral description and reflection with simple developmentally appropriate labeled praise. Modifications to treatment included using non-verbal actions (e.g., "high fives" as praises), sign language and using only one-step basic commands, which greatly improved compliance. In a matter of weeks, the patient demonstrated remarkable improvement in her disruptive behavior as evidenced by parent/daycare report and clinical observation. Surprisingly her vocabulary more than doubled and her ability of self-expression also increased; she was able to point to things and ask for them. This clinical experience suggests that PCIT principles are effective treatment interventions for other clinical presentations outside of the usual inclusion criteria. Implementation of targeted PCIT interventions greatly benefited the development of language skills and communication in a young child with global developmental delay.

13.
Gen Hosp Psychiatry ; 55: 10-14, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-30193205

RESUMO

OBJECTIVE: Psychiatric rehospitalizations results in a significant burden to patients, families, and health care systems. Understanding psychiatric rehospitalizations offers an opportunity to identify weaknesses in current systems of care. The objective of this study was to test the hypothesis that a history of trauma or ongoing bullying increases the risk of psychiatric rehospitalization. METHOD: Retrospective cohort study of 366 individual patients (71% female) admitted to a pediatric psychiatry unit between 1/1/2015 and 12/31/2015. The primary outcome measure was rehospitalization to the same psychiatric hospital unit within one year of first discharge. Trauma was defined as having a history of Post-Traumatic Stress Disorder, Reactive Attachment Disorder, or a filed Suspected Abuse and Neglect of a Child report by the end of first hospitalization. Ongoing bullying was identified by medical record review. RESULTS: History of trauma (Odds Ratio (OR) = 3.2, 95% Confidence Interval (CI) = 1.8-5.6, p < 0.0001) and ongoing bullying (OR = 2.2, CI = 1.2-3.9, p = 0.009) were significantly associated with increased rates of rehospitalizations. We controlled for the following covariates: Patient Health Questionnaire-9 Modified (PHQ-9M) score, gender, age, relative age, initial length of stay, disrupted family system, and sexual orientation/identity. CONCLUSION: History of trauma or ongoing bullying are important risk factors for pediatric psychiatric rehospitalization.


Assuntos
Bullying/estatística & dados numéricos , Vítimas de Crime/estatística & dados numéricos , Hospitais Psiquiátricos/estatística & dados numéricos , Readmissão do Paciente/estatística & dados numéricos , Trauma Psicológico/epidemiologia , Trauma Psicológico/terapia , Adolescente , Criança , Feminino , Humanos , Masculino , Minnesota , Estudos Retrospectivos
14.
J Am Acad Child Adolesc Psychiatry ; 57(5): 351-352, 2018 05.
Artigo em Inglês | MEDLINE | ID: mdl-29706165

RESUMO

Suicide remains one of the leading causes of death among 25- to 49-year-olds in the United States, and each year roughly 30,000 children are victims of parental suicide in the United States (Center for Disease Control and Prevention, 2005).1 We report a case of a young child who lost both of his parents to suicide.


Assuntos
Filho de Pais Incapacitados/psicologia , Pais/psicologia , Suicídio , Revelação da Verdade , Fatores Etários , Ansiedade de Separação/psicologia , Transtorno do Deficit de Atenção com Hiperatividade/psicologia , Criança , Humanos , Masculino , Transtornos de Estresse Pós-Traumáticos/psicologia , Estados Unidos
15.
Neuropsychopharmacology ; 43(9): 1822-1831, 2018 08.
Artigo em Inglês | MEDLINE | ID: mdl-29703993

RESUMO

Although suicide is the second-leading cause of death in adolescents and young adults worldwide, little progress has been made in developing reliable biological markers of suicide risk and suicidal behavior. Converging evidence suggests that excitatory and inhibitory cortical processes mediated by the neurotransmitters glutamate and γ-aminobutyric acid (GABA) are dysregulated in suicidal individuals. This study utilized single- and paired-pulse transcranial magnetic stimulation (TMS) to assess excitatory and inhibitory cortical functioning in healthy control adolescents (n = 20), depressed adolescents without any history of suicidal behavior ("Depressed", n = 37), and depressed adolescents with lifetime history of suicidal behavior ("Depressed+SB", n = 17). In a fixed-effects general linear model analysis, with age, sex, and depression severity as covariates, no significant group main effects emerged for resting motor threshold, intracortical facilitation, short-interval intracortical inhibition, or cortical silent period. However, group main effects were significant for long-interval intracortical inhibition (LICI) at interstimulus intervals (ISIs) of 100 ms and 150 ms, but not 200 ms. Depressed+SB adolescents demonstrated impaired LICI compared to healthy control and Depressed adolescents, while healthy control and Depressed participants did not differ in LICI. Multiple linear robust regression revealed significant positive linear relationships between lifetime suicidal behavior severity and impairment in LICI at 100-ms and 150-ms ISIs. In a post hoc receiver operating characteristic analysis, LICI significantly discriminated Depressed from Depressed+SB youth in 100-ms and 150-ms paradigms. These findings suggest that GABAB receptor-mediated inhibition is distinctly dysregulated in depressed adolescents with histories of suicidal behavior. Further research is warranted to establish the utility of cortical inhibition in the assessment of suicide risk and as a target for treatment interventions.


Assuntos
Córtex Cerebral/fisiopatologia , Transtorno Depressivo/fisiopatologia , Inibição Neural/fisiologia , Suicídio , Adolescente , Criança , Transtorno Depressivo/diagnóstico , Potencial Evocado Motor , Feminino , Humanos , Masculino , Curva ROC , Receptores de GABA-B/metabolismo , Estimulação Magnética Transcraniana , Adulto Jovem
16.
J Affect Disord ; 232: 34-40, 2018 05.
Artigo em Inglês | MEDLINE | ID: mdl-29477096

RESUMO

BACKGROUND: Item 9 of the Patient Health Questionnaire (PHQ) evaluates passive thoughts of death or self-injury within the last two weeks, and is often used to screen depressed patients for suicide risk. We aimed to validate the PHQ-9 item 9 with a brief electronic version of the Columbia Suicide Severity Rating Scale (eC-SSRS). METHODS: We analyzed data from 841 patients enrolled in the National Network of Depression Centers Clinical Care Registry. We performed a validation analysis of PHQ-9 item 9 for suicide risk and ideation, using the eC-SSRS as a gold standard (defined as positive response to suicidal ideation with intent to act or recent suicidal behavior). RESULTS: Of the 841 patients, 13.4% and 41.1% were assessed as being positive for suicide risk by the eC-SSRS and PHQ-9 item 9, respectively. For the overall cohort, sensitivity was 87.6% (95%CI 80.2-92.5%), specificity was 66.1% (95%CI 62.6-69.4%), PPV was 28.6% (95%CI 24.1-33.6%), and NPV was 97.2% (95%CI 95.3-98.3%) for the PHQ-9 suicide item. These performance measures varied within subgroups defined by demographic and clinical characteristics. In addition, the validity of PHQ-9 item 9 (cutoff score of 1) with eC-SSRS-defined suicide ideation showed overall poor results. LIMITATIONS: The gold standard used in our study was a surrogate measure of suicidality based on eC-SSRS scores. CONCLUSIONS: The results of our study suggest that item 9 of the PHQ-9 is an insufficient assessment tool for suicide risk and suicide ideation, with limited utility in certain demographic and clinical subgroups that requires further investigation.


Assuntos
Testes Neuropsicológicos , Suicídio/psicologia , Inquéritos e Questionários , Adulto , Idoso , Estudos de Coortes , Estudos Transversais , Depressão/psicologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Gravidez , Padrões de Referência , Sistema de Registros , Reprodutibilidade dos Testes , Medição de Risco , Sensibilidade e Especificidade , Fatores Socioeconômicos , Ideação Suicida , Adulto Jovem
18.
J Clin Psychiatry ; 78(8): 1068-1074, 2017.
Artigo em Inglês | MEDLINE | ID: mdl-27929610

RESUMO

OBJECTIVE: Insomnia and disrupted sleep are associated with increased risk of suicide. The N-methyl-d-aspartate antagonist ketamine has been associated with reduced suicidal thoughts, but the mechanism of action is unknown. This study sought to evaluate differences in nocturnal wakefulness in depressed individuals who did and did not have an antisuicidal response to ketamine. METHODS: Thirty-four participants with baseline suicidal ideation diagnosed with either DSM-IV major depressive disorder (n = 23) or bipolar depression (n = 11) between 2006 and 2013 completed nighttime electroencephalography (EEG) the night before and the night after a single ketamine infusion (0.5 mg/kg over 40 minutes). Suicidal ideation was assessed at baseline and the morning after ketamine infusion via several measures, including the Hamilton Depression Rating Scale suicide item, the suicide item of the Montgomery-Asberg Depression Rating Scale, and the first 5 items of the Scale for Suicide Ideation. A generalized linear mixed model evaluated differences in nocturnal wakefulness, as verified by EEG, between those who had an antisuicidal response to ketamine and those who did not, controlling for baseline nocturnal wakefulness. Results were also compared to the sleep of healthy controls (n = 22). RESULTS: After analyses adjusted for baseline sleep, participants with an antisuicidal response to ketamine showed significantly reduced nocturnal wakefulness the night after ketamine infusion compared to those without an antisuicidal response (F1,22 = 5.04, P = .04). Level of nocturnal wakefulness after antisuicidal response to ketamine did not differ significantly from nocturnal wakefulness in the control sample but did differ at a trend level (F1,40 = 3.15, P = .08). CONCLUSIONS: Reductions in wakefulness following ketamine may point to a biological mechanism underlying the effect of ketamine on suicidal ideation. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT00088699.


Assuntos
Transtorno Bipolar , Transtorno Depressivo Maior , Ketamina , Suicídio , Vigília/efeitos dos fármacos , Administração Intravenosa , Adulto , Transtorno Bipolar/complicações , Transtorno Bipolar/diagnóstico , Transtorno Bipolar/tratamento farmacológico , Transtorno Bipolar/psicologia , Transtorno Depressivo Maior/complicações , Transtorno Depressivo Maior/diagnóstico , Transtorno Depressivo Maior/tratamento farmacológico , Transtorno Depressivo Maior/psicologia , Manual Diagnóstico e Estatístico de Transtornos Mentais , Monitoramento de Medicamentos/métodos , Resistência a Medicamentos , Eletroencefalografia/métodos , Antagonistas de Aminoácidos Excitatórios/administração & dosagem , Antagonistas de Aminoácidos Excitatórios/efeitos adversos , Feminino , Humanos , Ketamina/administração & dosagem , Ketamina/efeitos adversos , Masculino , Pessoa de Meia-Idade , Escalas de Graduação Psiquiátrica , Ideação Suicida , Suicídio/prevenção & controle , Suicídio/psicologia , Resultado do Tratamento
19.
Front Neural Circuits ; 10: 98, 2016.
Artigo em Inglês | MEDLINE | ID: mdl-27965544

RESUMO

Introduction: Transcranial magnetic stimulation (TMS) research has suggested dysfunction in cortical glutamatergic systems in adolescent depression, while proton magnetic resonance spectroscopy (1H-MRS) studies have demonstrated deficits in concentrations of glutamatergic metabolites in depressed individuals in several cortical regions, including the anterior cingulate cortex (ACC). However, few studies have combined TMS and MRS methods to examine relationships between glutamatergic neurochemistry and excitatory and inhibitory neural functions, and none have utilized TMS-MRS methodology in clinical populations or in youth. This exploratory study aimed to examine relationships between TMS measures of cortical excitability and inhibition and concentrations of glutamatergic metabolites as measured by 1H-MRS in depressed adolescents. Methods: Twenty-four adolescents (aged 11-18 years) with depressive symptoms underwent TMS testing, which included measures of the resting motor threshold (RMT), cortical silent period (CSP), short-interval intracortical inhibition (SICI), and intracortical facilitation (ICF). Fourteen participants from the same sample also completed 1H-MRS in a 3 T MRI scanner after TMS testing. Glutamate + glutamine (Glx) concentrations were measured in medial ACC and left primary motor cortex voxels with a TE-optimized PRESS sequence. Metabolite concentrations were corrected for cerebrospinal fluid (CSF) after tissue segmentation. Pearson product-moment and Spearman rank-order correlations were calculated to assess relationships between TMS measures and [Glx]. Results: In the left primary motor cortex voxel, [Glx] had a significant positive correlation with the RMT. In the medial ACC voxel, [Glx] had significant positive correlations with ICF at the 10-ms and 20-ms interstimulus intervals (ISIs). Conclusion: These preliminary data implicate glutamate in cortical excitatory processes measured by TMS. Limitations included small sample size, lack of healthy control comparators, possible age- and sex-related effects, and observational nature of the study. Further research aimed at examining the relationship between glutamatergic metabolite concentrations measured through MRS and the excitatory and inhibitory physiology measured through TMS is warranted. Combined TMS-MRS methods show promise for future investigations of the pathophysiology of depression in adults as well as in children and adolescents.


Assuntos
Transtorno Depressivo , Potencial Evocado Motor/fisiologia , Ácido Glutâmico/metabolismo , Glutamina/metabolismo , Giro do Cíngulo , Espectroscopia de Ressonância Magnética/métodos , Córtex Motor , Inibição Neural/fisiologia , Estimulação Magnética Transcraniana/métodos , Adolescente , Criança , Transtorno Depressivo/diagnóstico por imagem , Transtorno Depressivo/metabolismo , Transtorno Depressivo/fisiopatologia , Feminino , Giro do Cíngulo/diagnóstico por imagem , Giro do Cíngulo/metabolismo , Giro do Cíngulo/fisiopatologia , Humanos , Masculino , Córtex Motor/diagnóstico por imagem , Córtex Motor/metabolismo , Córtex Motor/fisiopatologia
20.
J Affect Disord ; 206: 300-304, 2016 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-27656788

RESUMO

BACKGROUND: Little is known about the antidepressive effects of repeated intravenous ketamine infusions beyond the acute phase of treatment in patients with refractory depression. METHODS: Twelve subjects with treatment-resistant non-psychotic unipolar or bipolar major depression and suicidal ideation were given repeated (up to 6) thrice-weekly acute-phase intravenous infusions of ketamine (0.5mg/kg, administered over 100min). Those who remitted during acute-phase treatment received continuation-phase treatment that consisted of 4 weekly ketamine infusions, followed by 4 weeks of post-continuation phase follow-up (during which no further ketamine infusions were administered). Clinical measures were assessed at baseline, at 24h following each infusion, at the last acute-phase observation, and during continuation and post-continuation follow-up (acute phase remitters only). RESULTS: Of the 12 enrollees, 5 (41.7%) remitted and 7 (58.3%) responded to ketamine treatment during the acute-phase. All five subjects who remitted during the acute-phase experienced further depressive symptom improvement during continuation-phase treatment. Four subjects lost remission status during the post-continuation phase, but all were still classified as positive treatment responders at the end of the post-continuation phase. Adverse effects were generally mild and transient during acute- and continuation-phase treatment; however, one subject developed behavioral outbursts and suicide threats during follow-up while hospitalized, and one subject died by suicide several weeks after the end of follow-up. LIMITATIONS: This was an uncontrolled feasibility study with a small sample size. CONCLUSIONS: The continuation-phase administration of ketamine at weekly intervals to patients with treatment-resistant depression who remitted during acute-phase ketamine treatment can extend the duration of depressive symptom remission. The antidepressive effect of ketamine persisted for several weeks after the end of continuation-phase treatment. Our results highlight the need for close monitoring of subjects who are at high baseline risk for suicide but do not respond clinically to ketamine. CLINICALTRIALS. GOV IDENTIFIER: NCT02094898.


Assuntos
Antidepressivos/uso terapêutico , Transtorno Bipolar/tratamento farmacológico , Transtorno Depressivo Maior/tratamento farmacológico , Transtorno Depressivo Resistente a Tratamento/tratamento farmacológico , Ketamina/uso terapêutico , Adulto , Relação Dose-Resposta a Droga , Feminino , Humanos , Infusões Intravenosas , Masculino , Pessoa de Meia-Idade , Indução de Remissão , Tamanho da Amostra , Ideação Suicida , Adulto Jovem
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