Acute and Prophylactic Management of Postictal Agitation in Electroconvulsive Therapy.

ABSTRACT: Postictal agitation (PIA) is a common adverse effect of electroconvulsive therapy (ECT), a treatment used for a variety of psychiatric disorders. Because of risk of harm to patients and health providers when patients develop PIA, its acute management and prophylaxis are of vital importance for ECT practitioners. This article describes PIA risk factors, as well as practical steps to manage this ECT complication. Nonpharmacologic patient safety interventions are critical components of PIA management. Benzodiazepines, antipsychotics, and additional anesthetic doses are discussed as acute treatment interventions. Prophylactic pharmacologic choices described include antipsychotics, postseizure anesthetics, and dexmedetomidine. Exploratory choices such as melatonin and intranasal formulations of sedatives are also discussed. This review suggests that common medication like olanzapine and propofol are cost-effective considerations to decrease PIA incidence and/or severity after ECT. In addition, dexmedetomidine presents a management alternative for treatment-resistant PIA. This literature review outlines treatment choices while suggesting future directions for considering effective treatments of postictal agitation in clinical settings.

Ultrabrief Right Unilateral Electroconvulsive Therapy for the Treatment of the Neuropsychiatric Symptoms of Dementia with Lewy Bodies.

OBJECTIVES: Dementia with Lewy bodies (DLB) is a debilitating disorder associated with a number of distressing neuropsychiatric symptoms. There is currently limited guidance regarding the most effective strategies of managing these symptoms, and both pharmacologic and nonpharmacologic strategies are often used. Electroconvulsive therapy (ECT) has been reported as a potential nonpharmacologic method to alleviate some of these debilitating neuropsychiatric symptoms. However, there remains a paucity of evidence in current literature. This report aims to add to existing literature regarding ECT in DLB by highlighting successful treatment in seven cases. METHODS: Our study is a retrospective case series of 7 patients with DLB who received treatment with ultrabrief (UB) right unilateral (RUL) ECT for the treatment of agitation and depressive symptoms. Participants included patients with a diagnosis of DLB who were admitted to Emory University Hospital at Wesley Woods from 2011 to 2020 presenting with agitation and/or depressive symptoms after failing pharmacologic intervention. Patients underwent UB RUL ECT administered by a board-certified psychiatrist. After treatment, Pittsburg Agitation Scale and Clinical Global Impression-Improvement scales were recorded as measures of agitation and clinical improvement, respectively. RESULTS: All 7 patients responded to UB RUL ECT with marked improvement in their presenting symptoms of agitation and/or depression without significant adverse effects from treatment. CONCLUSIONS: Ultrabrief RUL ECT seems to be a safe and effective treatment of the agitative and depressive features of DLB.

Emotional Resilience of Older Adults during COVID-19: A Systematic Review of Studies of Stress and Well-Being.

OBJECTIVES: To examine post-traumatic stress, depression, anxiety, and well-being in older adults under quarantine. METHODS: A systematic review of CINAHL, Ovid EBM Reviews, Ovid Embase, Ovid Medline, Ovid PsycINFO, Scopus, and Web of Science from 2000 to 2020 was conducted. Keywords included coronavirus, epidemic, quarantine, stress, mental health, and similar terms. Included studies enrolled participants under quarantine, quantitatively measured mental health or well-being, and characterized outcomes by age. RESULTS: Of 894 initial results, 20 studies met the criteria and were included. Studies comprise 106,553 participants from eight countries, ages 6-100, two epidemics (COVID-19, SARS), and 27 assessment tools. One study found greater distress in older adults relative to younger adults, one found no significant differences, and 18 found lower negative outcomes in older participants in at least one metric. CONCLUSIONS: Older adults in this review generally have lower stress and less negative emotions under quarantine than younger adults. It is unknown how this compares to pre-pandemic measures. More representative and longitudinal studies are needed to measure the impact of quarantine on the mental health of older adults. CLINICAL IMPLICATIONS: As existing scales may not capture the full extent of pandemic psychological effects on older adults, clinicians must vigilantly monitor older adults' mental health.

Circadian and circannual timescales interact to generate seasonal changes in immune function.

Annual changes in day length enhance or suppress diverse aspects of immune function, giving rise to seasonal cycles of illness and mortality. The daily light-dark cycle also entrains circadian rhythms in immunity. Most published reports on immunological seasonality rely on measurements or interventions performed only at one point in the day. Because there can be no perfect matching of circadian phase across photoperiods of different duration, the manner in which these timescales interact to affect immunity is not understood. We examined whether photoperiodic changes in immune function reflect phenotypic changes that persist throughout the daily cycle, or merely reflect photoperiodic shifts in the circadian phase alignment of immunological rhythms. Diurnal rhythms in blood leukocyte trafficking, infection induced sickness responses, and delayed-type hypersensitivity skin inflammatory responses were examined at high-frequency sampling intervals (every 3 h) in Siberian hamsters (Phodopus sungorus) following immunological adaptation to summer or winter photoperiods. Photoperiod profoundly enhanced or suppressed immune function, in a trait-specific manner, and we were unable to identify a phase alignment of diurnal waveforms which eliminated these enhancing and suppressing effects of photoperiod. These results support the hypothesis that seasonal timescales affect immunity via mechanisms independent of circadian entrainment of the immunological circadian waveform.

Time of trauma prospectively affects PTSD symptom severity: The impact of circadian rhythms and cortisol.

A key feature of posttraumatic stress disorder (PTSD) is a disruption of hypothalamic-pituitary-adrenal (HPA) axis feedback sensitivity and cortisol levels. Despite known diurnal rhythmicity of cortisol, there has been little exploration of the circadian timing of the index trauma and consequent cortisol release. Stress-related glucocorticoid pulses have been shown to shift clocks in peripheral organs but not the suprachiasmatic nucleus, uncoupling the central and peripheral clocks. A sample of 425 participants was recruited in the Emergency Department following a DSM-IV-TR Criterion A trauma. The Zeitgeber time of the trauma was indexed in minutes since sunrise, which was hypothesized to covary with circadian blood cortisol levels (high around sunrise and decreasing over the day). Blood samples were collected M(SD)= 4.0(4.0) hours post-trauma. PTSD symptoms six months post-trauma were found to be negatively correlated with trauma time since sunrise (r(233) = -0.15, p = 0.02). The effect remained when adjusting for sex, age, race, clinician-rated severity, education, pre-trauma PTSD symptoms, and time of the blood draw (ß = -0.21, p = 0.00057). Cortisol levels did not correlate with blood draw time, consistent with a masking effect of the acute stress response obscuring the underlying circadian rhythm. Interactions between trauma time and expression of NPAS2 (punadjusted=0.042) and TIMELESS (punadjusted=0.029) predicted six-month PTSD symptoms. The interaction of trauma time and cortisol concentration was significantly correlated with the expression of PER1 (padjusted=0.029). The differential effect of time of day on future symptom severity suggests a role of circadian effects in PTSD development, potentially through peripheral clock disruption.