Felicia A. Smith

Pre-Existing Major Depression Predicts In-Hospital Cardiac Complications After Acute Myocardial Infarction

BACKGROUND Depression (MDD) and anxiety have been associated with negative long-term outcomes among patients with acute myocardial infarction (MI). OBJECTIVE The objective of the study was to determine whether MDD and anxiety preceding MI were associated with in-hospital post-MI cardiac complications. METHOD Subjects (N=129) underwent psychiatric interviews within 72 hours of MI and were evaluated for five in-hospital cardiac complications (recurrent ischemia, ventricular arrhythmia, ventricular arrhythmia requiring intervention, congestive heart failure, and reinfarction). RESULTS Current (pre-MI) MDD was a significant and independent predictor of all complications except recurrent ischemia on multivariate regression analysis. In contrast, pre-MI anxiety was not associated with complications. CONCLUSION These findings underscore the importance of identifying and treating MDD in post-MI patients and those at risk for MI.

Rapid screening for major depression in post-myocardial infarction patients: an investigation using Beck Depression Inventory II items

Objective: To determine the ability of three questions from the Beck Depression Inventory II (BDI-II) to detect major depressive disorder (MDD) in a cohort of patients hospitalised for acute myocardial infarction (MI). Design: Prospective observational study. Setting: Coronary care unit and cardiac step-down unit of an urban academic medical centre. Patients: 131 post-MI patients within 72 h of symptom onset. Interventions: Patients were administered the BDI-II and participated in a structured diagnostic interview for MDD. Three individual BDI-II items (regarding sadness, loss of interest and loss of pleasure) were examined individually and in two-question combinations to determine their ability to screen for MDD. Main outcome measures: Sensitivity, specificity, negative and positive predictive values and proportion of patients with MDD correctly identified. Results: The individual items and two-question combinations had good sensitivity (76–94%), specificity (70–88%) and negative predictive values (97–99%). Item 1 (sadness) performed the best of the individual items (48% with a positive response to the item had MDD; 3% with a negative response had MDD; over 80% of patients with MDD were correctly identified). A combination of questions about sadness and loss of interest performed best among the two-question combinations (37% with positive response had MDD v 1% with a negative response; 94% of patients with MDD were identified). Conclusions: One to two questions regarding sadness and loss of interest serve as simple and effective screening tools for post-MI depression.

Screening for Major Depression in Post-Myocardial Infarction Patients: Operating Characteristics of the Beck Depression Inventory-II

Objective: To assess the operating characteristics of the Beck-Depression Inventory-II (BDI-II) and the BDI-II cognitive subscale (BDI-II-cog) in screening for major depression (MDD) in post-myocardial infarction (MI) patients. Methods: Between October 2003 and July 2005, 131 post-MI patients admitted to an urban academic medical center completed the BDI-II and a semi-structured interview for depression within 72 hours of symptom onset. Sensitivity, specificity, positive and negative predictive values, overall correct classification, and likelihood ratios for various cutoff values on both scales were evaluated by comparing scores to interview diagnosis of MDD. Receiver-operator curves (ROC) were also calculated and area under the curve (AUC) measured. Results: The optimal cutoff value for the BDI-II was > 16, with a sensitivity of 88.2% and a specificity of 92.1%. Cutoff values of > 3 or > 4 were both acceptable for the BDI-II-cog (sensitivity = 88.2% and 82.4%, respectively; specificity = 81.6% and 88.6%, respectively). AUC was 0.96 for the BDI-II and 0.89 for the cognitive subscale. Conclusions: Effective depression screening is important in post-MI patients because of depressions independent association with morbidity and mortality following MI. Our results suggest that the BDI-II and its cognitive subscale are effective tools for screening for MDD in post-MI patients.

Post-MI Psychiatric Syndromes: Six Unanswered Questions

&NA; Depression, anxiety, and other psychological variables following acute myocardial infarction (MI) have been the subject of intense study over the last two decades. Through selective literature review and editorial commentary, we address six vital, unanswered questions concerning these psychological variables and their impact on coronary outcome. The picture that emerges is complex. Despite all that has been learned about the nature, consequences, and management of post‐MI depression and related disorders, there remain many open issues. First, the prevalence, phenomenology, medical impact, and method of diagnosis of post‐MI depression and other psychiatric syndromes remain unclear. In addition, at least four pathophysiologic mechanisms have been proposed to explain the link between depression and cardiac disease, but evidence of causation remains elusive. There have been increasingly well‐designed treatment studies of post‐MI depression, but the optimal agents and timing of treatment have yet to be defined. Finally, few recent studies of post‐MI anxiety have been conducted. To make further progress, large, multicenter trials that use optimized screening tools, obtain data at several time points, consider multiple psychosocial variables, and correct carefully for medical/cardiac severity are required.

Medical Complications of Psychiatric Treatment

Psychiatric medications are frequently an essential component of care for critically ill patients. Their use may lead to medical complications, however, as a result of (1) direct toxicity from psychotropic medications, (2) drug-drug interactions, or (3) intoxication or withdrawal states. These complications may be a nuisance (eg, dry mouth and nausea) or serious and life-threatening (eg, neuroleptic malignant syndrome and cardiac arrhythmias). This article addresses the most important medical complications (organized by organ systems) of psychiatric treatment.

Prior discharges against medical advice and withdrawal of consent: what they can teach us about patient management.

Have you ever had a patient who bolted from the operating room or a procedure suite, despite the fact that the planned procedure was of vital importance? Have you wondered if there was a relationship between a prior discharge against medical advice and a patients current behavior? Have you ever considered how you might manage a patients fear of procedures or loss of control? If you have, then the following case vignette should serve as a stimulus for the tactical evaluation and management of patients who have precipitously refused interventions or left the hospital prematurely. Every clinician who performs procedures has encountered a patient who withdraws consent at the eleventh hour. For some of these patients, their treatment refusal has been presaged by prior discharges against medical advice or by last-minute cancellations of procedures. Although few clinicians routinely inquire about a history of against medical advice discharges or abrupt refusals of procedures, this knowledge of why a patient has left the hospital or has refused procedures in the past may guide future care and management of patients. Discharges against medical advice, defined as patient discharges from the hospital or health care facility before the treating physician recommends discharge, have emerged as a pervasive problem in general hospitals. Such encounters often lead to frustration and resentment on the part of clinicians and poor outcomes and worsening health for patients. In this article, we present a case vignette to illustrate an example of a discharge against medical advice, discuss the known characteristics and prevalence of such discharges, and highlight our management of the presented case as a guide to help clinicians with similar encounters.

Depression and failure of cholesterol lowering after acute myocardial infarction.

OBJECTIVE Depression after acute myocardial infarction (MI) is independently associated with cardiac mortality, but the mechanism explaining this association remains unclear. To our knowledge, there has been no prior study exploring the impact of post-MI depression on lipid lowering, a key secondary prevention measure in post-MI patients. In this prospective observational cohort pilot study, we hypothesized that patients with early post-MI depression would have inferior cholesterol reduction 6 months post-MI compared to nondepressed patients. METHOD Patients admitted to a cardiac intensive care unit or a cardiac step-down unit between October 2003 and July 2005 were enrolled in the study within 72 hours of MI. Two weeks post-MI, subjects were assessed for depression using the module for current major depressive disorder (MDD) from the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID) and the Beck Depression Inventory-II (BDI-II). Information regarding cholesterol levels was collected 6 months after MI. RESULTS Initial and 6-month cholesterol levels were available for 70 subjects who had 2-week post-MI depression assessments. Post-MI depression, measured both using an interview for MDD and the BDI-II, was associated with inferior cholesterol reduction, with depressed subjects improving their cholesterol levels by approximately 8 mg/dL compared to a cholesterol reduction of 37 mg/dL in nondepressed subjects. Furthermore, depression diagnosed by formal MDD interview (beta=-.301; P<.001) and the BDI-II (beta=-.269; P=.001) continued to be associated with significantly smaller reductions in cholesterol levels on linear regression analyses that accounted for demographic and medical variables. CONCLUSIONS In this exploratory pilot study, early post-MI depression was independently associated with impaired lipid lowering 6 months after MI.

Case records of the Massachusetts General Hospital. Case 39-2012. A 55-year-old man with alcoholism, recurrent seizures, and agitation

Dr. Benjamin C. Silverman (Psychiatry): A 55-year-old man with a history of alcoholism was admitted to the medical intensive care unit (ICU) at this hospital because of seizures and agitation. One day before admission, the patient discontinued his daily consumption of alcohol in preparation for a family event. On the day of admission, generalized tonic–clonic movements developed and resolved spontaneously after 1 minute. During the episode, he was caught while falling; he had no head trauma. On examination by emergency medical services personnel, he was oriented to person, place, and time. The blood pressure was 160/110 mm Hg, the pulse 88 beats per minute and regular, and the respiratory rate 16 breaths per minute. The patient had dilated pupils, slurred speech, and diaphoresis. There was no evidence of incontinence. Oxygen was administered through a nonrebreather face mask at a rate of 15 liters per minute. A capillary glucose level was 135 mg per deciliter. He was brought to the emergency department at this hospital. The patient reportedly drank one case of beer daily. Nine years earlier, he had had a seizure related to alcohol withdrawal. Approximately 3.5 years earlier, he was found on the street intoxicated, with a fractured mandible; he was admitted to another hospital, and delirium and agitation associated with alcohol withdrawal developed during admission. He had asthma, hypertension, atrial fibrillation, congestive heart failure, and coronary artery disease; in the past, he had undergone coronary-artery bypass grafting and aortic-valve replacement with a porcine valve and had had Klebsiella pneumoniae infection. A skin test was positive for tuberculosis 4 years earlier. The patient had taken cardiac and antihypertensive medications in the past; current medications were unknown. He had no known allergies. He lived with his girlfriend and had previously been homeless. He had been smoking cigarettes for many years; it was not known whether there was a history of illicit drug use. His father had died of heart disease, and there was a family history of diabetes mellitus.

Case 39-2012

Dr. Benjamin C. Silverman (Psychiatry): A 55-year-old man with a history of alcoholism was admitted to the medical intensive care unit (ICU) at this hospital because of seizures and agitation. One day before admission, the patient discontinued his daily consumption of alcohol in preparation for a family event. On the day of admission, generalized tonic–clonic movements developed and resolved spontaneously after 1 minute. During the episode, he was caught while falling; he had no head trauma. On examination by emergency medical services personnel, he was oriented to person, place, and time. The blood pressure was 160/110 mm Hg, the pulse 88 beats per minute and regular, and the respiratory rate 16 breaths per minute. The patient had dilated pupils, slurred speech, and diaphoresis. There was no evidence of incontinence. Oxygen was administered through a nonrebreather face mask at a rate of 15 liters per minute. A capillary glucose level was 135 mg per deciliter. He was brought to the emergency department at this hospital. The patient reportedly drank one case of beer daily. Nine years earlier, he had had a seizure related to alcohol withdrawal. Approximately 3.5 years earlier, he was found on the street intoxicated, with a fractured mandible; he was admitted to another hospital, and delirium and agitation associated with alcohol withdrawal developed during admission. He had asthma, hypertension, atrial fibrillation, congestive heart failure, and coronary artery disease; in the past, he had undergone coronary-artery bypass grafting and aortic-valve replacement with a porcine valve and had had Klebsiella pneumoniae infection. A skin test was positive for tuberculosis 4 years earlier. The patient had taken cardiac and antihypertensive medications in the past; current medications were unknown. He had no known allergies. He lived with his girlfriend and had previously been homeless. He had been smoking cigarettes for many years; it was not known whether there was a history of illicit drug use. His father had died of heart disease, and there was a family history of diabetes mellitus.

Curriculum Overhaul in Psychiatric Residency: An Innovative Approach to Revising the Didactic Lecture Series.

Creating a comprehensive, longitudinal didactic curriculum is a challenge for any psychiatry residency program. With the advent of the Accreditation Council for Graduate Medical Education (ACGME) milestones, residents must show progression throughout the 4 years in specific competencies within defined topics. Many milestones dictate didactic content areas to which residents require exposure, but do not provide detailed guidelines for an overarching curriculum [1, 2].Many content areas in psychiatry are rapidly evolving, and it is daunting for program leadership to stay apprised of changes in each area to guide curricular development. Residents in the Massachusetts General Hospital (MGH)/ McLean Adult Psychiatry Residency, a midsize to large program with two primary teaching campuses, have a protected half-day during which the bulk of didactic material is taught. Additional didactics are typically organized by rotation directors on individual rotations, and these talks pertain more specifically to the clinical content of each rotation. In our program and in this article, we use the term “didactics” to refer to any formal, scheduled teaching, which might include traditional lecture format, discussion-based lessons, or experiential-learning-based seminars. Prior to the project described here, the entire didactic curriculum had not been systematically evaluated and revised for many years. In addition to growing concerns about didactic content aligning with impending milestones, program directors noted decreased attendance at didactics, mixed informal feedback regarding the value of specific talks, and apparent gaps in knowledge on Psychiatry Resident-In-Training Exam (PRITE) scores and in clinical practice. In speaking with faculty, it became apparent that many who taught in the program did not have an understanding of how their content fit into the overall curriculum or an awareness of potential overlaps with other talks. In 2012, program leadership invested resources to inventory, organize, and obtain trainee input to revise the didactic curriculum. In this Educational Case Report, we describe the initial phase of a longitudinal didactic curriculum reform in a general psychiatry residency. We elucidate the challenges and strengths of our approach and provide a framework for continued evolution of the curriculum going forward.