Adriana P. Hermida

Maintenance electroconvulsive therapy in autistic catatonia: A case series review

The usage of electroconvulsive therapy for the acute resolution of catatonia in autistic children and adults is a novel area that has received increased attention over the past few years. Reported length of the acute ECT course varies among these patients, and there is no current literature on maintenance ECT in autism. The maintenance ECT courses of three patients with autism who developed catatonia are presented. Clinical, research, legal, and administrative implications for ECT treatment in this special population are discussed.

The association between late-life depression, mild cognitive impairment and dementia: is inflammation the missing link?

Depression, mild cognitive impairment (MCI) and dementia are highly prevalent conditions that are increasing exponentially with similarly expanding social, medical and economic burdens. While there is a clear clinical connection between these three disorders, the mechanism of action that links them is less well understood. The lack of well-accepted biomarkers results in high levels of diagnostic subjectivity, which then greatly impacts research results when attempting to further explore their association. There is also a variety of clinical presentations of depressive syndromes, particularly in the elderly; each one may be associated with a different risk in the progression from MCI to different types of dementia. The diagnostic challenges, the importance of biomarkers and the discussion of inflammation as a possible link between depression, MCI and dementia are examined in this article.

A Case of Anti-NMDA Receptor Encephalitis Treated with ECT.

We describe the case of a 17-year-old male who presented with acute onset of seizures and malignant catatonia with psychosis, agitation, and hypermetabolism, who responded to electroconvulsive therapy (ECT). Soon after he began to respond, he was diagnosed with anti-N-methyl-D-aspartate (NMDA) receptor encephalitis and then given immunosuppressive therapy. Anti-NMDA receptor encephalitis is an increasingly recognized autoimmune disorder that often presents with neuropsychiatric symptoms. The mainstays for treatment have been early diagnosis, tumor work-up and removal if found, and initiation of immunosuppressive therapy. Treatment response is often slow and residual symptoms common. In this case, ECT produced clinical stabilization before the underlying diagnosis of anti-NMDA receptor encephalitis was made and standard treatment initiated. We suggest that ECT may be highly beneficial for stabilizing life-threatening neuropsychiatric symptoms in this syndrome and should be considered as a potentially additive treatment to immunotherapy when rapid relief is sought.

Use of Expert Consultation in a Complex Case of Neuroleptic Malignant Syndrome Requiring Electroconvulsive Therapy

Our team at Emory University Hospital contacted experts at the National Network of Depression Centers (NNDC) for clinical guidance concerning a patient with schizophrenia hospitalized in the intensive care unit with a complex case of prolonged delirium secondary to neuroleptic malignant syndrome (NMS). Through the NNDC, leading psychiatrists across the United States with expertise in electroconvulsive therapy (ECT) provided us with treatment strategies based on experience in our area of concern. This report describes our use of ECT to treat severe NMS in this patient with schizophrenia, utilizing the recommendations made by the NNDCs ECT experts concerning electrode position, number and frequency of treatments, and selection of anesthetic induction agents. This case report highlights the utility of expert consultation in the treatment of rare diseases and provides guidance on how to treat NMS in the intensive care unit setting.

A case of lithium-induced parkinsonism presenting with typical motor symptoms of Parkinson's disease in a bipolar patient.

Lithium is a mood stabilizer rarely associated with drug-induced parkinsonism (DIP). We present a case of an elderly woman with bipolar disorder who developed parkinsonian symptoms after chronic lithium administration despite therapeutic serum levels. Upon evaluation, classic parkinsonian signs of muscle rigidity, tremor, bradykinesia, freezing of gait, and cognitive decline were observed. Initially, she was diagnosed with Parkinsons disease (PD); however, DaTscan SPECT imaging clarified the diagnosis as DIP. As the daily lithium dosage was reduced, the patients motor symptoms improved. This report emphasizes close monitoring of lithium levels in geriatric populations and the need to consider lithium-induced parkinsonism when PD symptoms appear in chronic lithium users.

Electroconvulsive Therapy in Depression

The current practice of electroconvulsive therapy (ECT) has evolved over several decades with the implementation of safer equipment and advancement of techniques. In addition, modifications in the delivery of ECT, such as the utilization of brief and ultrabrief pulse widths and individualization of treatment parameters, have improved the safety of ECT without sacrificing efficacy. This article aims to provide psychiatrists with a balanced, in-depth look into the recent advances in ECT technique as well as the evidence of ECT for managing depression in special populations and patients with comorbid medical problems.

Exploring Ketamine Use in Geriatric Patients Suffering From Treatment-Resistant Depression

with Major Depressive Disorder. Anhedonia likely reflects altered functioning of key brain circuits involved in the reward process but it is unclear whether increased anhedonia is associated with distinct clinical and cognitive symptoms. The purpose of this study is to examine demographic, clinical and cognitive characteristics associated with increased levels of anhedonia in older depressed adults. Methods: We examined 65 currently depressed older adults aged 60 years or older. Participants completed a standardized diagnostic interview and clinical assessments, including self-report of depressive symptoms. These assessments included the Snaith-Hamilton Pleasure Scale (SHAPS) to quantify severity of anhedonia. Participants additionally completed a neuropsychological battery, including tests focused on processing speed and executive function. We examined participant characteristics associated with SHAPS score in a staged approach, first examining demographics, then clinical measures, followed by cognitive profile. Analyses controlled for overall depression severity using a modified MADRS score with the anhedonia item removed. In secondary analyses, we dichotomized sample into those with high or low SHAPS scores determined by a median split and re-analyzed the clinical and cognitive variables. Results: Total SHAPS score was not associated with demographic variables, but did exhibit a positive association with modified MADRS score (Pearson correlation coefficient = 0.32, p 0.0094). After controlling for modified MADRS score, SHAPS score was not associated with clinical measures of perceived stress, apathy, rumination, fatigue, worry, or insomnia. However, after controlling for age and medical morbidity, it was positively associated with disability (F = 5.03, p=00334). After controlling for modified MADRS, age, and education, higher SHAPS scores were also positively associated with better performance on the Stroop test measures of processing speed (color naming; F=9.51, p=0.0034) and executive functioning (color-word interference; F=9.43, p = 0.0035). When we dichotomized the sample into high and low anhedonia groups based on the median, we replicated the above findings. We additionally observed that the high anhedonia sample was younger (t=2.76, p = 0.0083) with an earlier age of initial onset of depression (t=2.18, p=0.0332). Conclusions: Greater anhedonia is associated with greater overall depression severity and with greater disability. However, it is also associated with better processing speed and executive function performance as measured by the Stroop test. This apparent discrepancy may be explained by analyses of high versus low anhedonic subjects, where individuals with higher anhedonia were more likely to be younger patients and report an earlier age of first episode. We propose greater anhedonia occurs in younger, earlier onset depressed elders with perhaps a greater lifetime duration of depression or higher number of recurrent depressive episodes. This may contribute to the greater reported disability, but their age may be related to the superior cognitive test performance.

Complementary and Integrative Therapies for Older Age Bipolar Disorder

There is a growing interest in complementary and alternative medicine (CAM) in psychiatric disorders, including bipolar disorder. Individuals may continue to experience symptoms and impairment from their illness despite appropriate pharmacologic treatment. Moreover, psychotropic medications can be especially problematic for many older adults with regard to adverse effects, tolerability, and drug interactions. Complementary and alternative therapies may fill the gaps where traditional treatment modalities fall short. Treatment goals may range from alleviating residual symptoms to improving quality of life and general well-being. There is a dearth of research on CAM in older age bipolar disorder but there is growing research in adult psychiatric populations more generally. CAM studies often have methodological limitations, and so findings should be interpreted with caution. This chapter aims to give a general overview of CAM therapies to consider as adjuncts to standard treatment, including several nutraceutical supplements and meditation. CAM offers the opportunity to take a truly integrative approach to psychiatric care. Psychiatrists have the ability not only to treat troubling symptoms, but also to improve patients’ quality of life. Incorporating dietary supplements when indicated, promoting exercise and nutrient rich diets, and teaching mindfulness and acceptance can be key ingredients in achieving wellness for bipolar patients.

Neuromodulation Therapies and Ketamine in Older Age Bipolar Disorder

Neuromodulation therapies are important alternatives for the management of treatment-resistant mood disorders in the elderly. Some of these therapies are relatively modern strategies such as the recently FDA-approved transcranial magnetic stimulation (TMS), vagal nerve stimulation (VNS), and deep brain stimulation (DBS), which is still undergoing extensive research. The use of electroconvulsive therapy (ECT) has evolved in its practice since the 1940s with a recent significant shift toward the use of right unilateral, ultra-brief-pulse width. Additionally, ECT is increasingly delivered in outpatient settings. The roles of the newer therapies have not been systematically studied in the geriatric population, and despite the fact that ECT has been widely used in the older population, there is limited evidence-based data about the use of ECT in the older adults. Older individuals are particularly vulnerable to polypharmacy given increasing medical comorbidity with advancing age. Neuromodulation techniques are not pharmacotherapies and, therefore, have the potential of limiting polypharmacy in older adults with psychiatric disorders. While the vast majority of neuromodulation therapy research focuses on unipolar depression, there is an increase in research examining the safety and efficacy of ECT for individuals with bipolar disorder. In this chapter, we will review the evidence-based data for electroconvulsive therapy (ECT), transcranial magnetic stimulation (TMS), deep brain stimulation (DBS), transcranial direct current stimulation (tDCS), magnetic seizure therapy (MST), and focal electrically administered seizure therapy (FEAST) in older adults with psychiatric disorders. Relevant evidence for the use of ketamine during ECT and independent of ECT treatment will also be reviewed.

A Comprehensive Approach to Care in Parkinson's Disease Adds Quality to the Current Gold Standard

Providing high‐quality care for patients with Parkinsons disease (PD) involves addressing both motor and nonmotor features. We describe the implementation and evaluation of a 2‐day, interdisciplinary Comprehensive Care Clinic (CCC) for patients with PD.