Jeremy Hirst

Ketamine for the Treatment of Depression in Patients Receiving Hospice Care: A Retrospective Medical Record Review of Thirty-One Cases

BACKGROUND Depression is prevalent in patients receiving hospice care. Standard antidepressant medications do not work rapidly enough in this setting. Evidence suggests that ketamine rapidly treats treatment refractory depression in the general population. Ketamine׳s role for treating depression in the hospice population warrants further study. METHODS A retrospective medical record review of 31 inpatients receiving hospice care who received ketamine for depression on a clinical basis was conducted. The primary outcome measure was the Clinical Global Impression Scale, which was used retrospectively to rate subjects׳ therapeutic improvement, global improvement, and side effects from ketamine over 21 days. Additionally, time to onset of therapeutic effect was analyzed. RESULTS Using the Clinical Global Impression Scale, ketamine was found to be significantly therapeutically effective through the first week after ketamine dosing (p < 0.05), with 93% of patients showing positive results for days 0-3 and 80% for days 4-7 following ketamine dosing. Patients experienced global improvement during all 4 studied time periods following ketamine dosing (p < 0.05). Significantly more patients had either no side effects or side effects that did not significantly impair functioning at each of the 4 assessed time periods following ketamine dosing (p < 0.05). Additionally, significantly more patients experienced their first therapeutic response during days 0-1 following ketamine dosing (p < 0.001) than during any other time period. CONCLUSIONS These data suggest that ketamine may be a safe, effective, and rapid treatment for clinical depression in patients receiving hospice care. Blinded, randomized, and controlled trials are required to substantiate these findings and support further clinical use of this medication in hospice settings.

Complex Clinical Intersection: Palliative Care in Patients with Dementia

Because of the rapidly growing older population and increases in longevity, rates of dementia have been rising. Clinical challenges of treating dementia include limited resources and lack of curative therapies. Palliative care approaches improve quality of life and alleviate suffering for dementia patients at the end of life, although implementation may be limited by societal acceptance and feasibility. This review examines the published literature on pain assessments, pain and behavior interventions, tools for advanced care planning, and clinical concerns in dementia patients. Ultimately, modification of the traditional palliative care model may improve outcomes and functioning for dementia patients at all stages of their illness.

Olanzapine for chemotherapy-induced nausea: Lessons learned from child and adolescent psychiatry

1Department of PsychosocialOncology andPalliativeCare, Dana–FarberCancer Institute, Boston,Massachusetts 2Department of Psychiatry, BostonChildrensHospital, Boston,Massachusetts 3HarvardMedical School, Boston,Massachusetts 4Department of Psychiatry andBehavioral Sciences,Memorial SloanKetteringCancerCenter, NewYorkCity, NewYork 5Department of Psychiatry andPediatrics, University of KentuckyCollege ofMedicine, Lexington, Kentucky 6KentuckyChildrensHospital, Lexington, Kentucky 7Department of Pediatric Psychosocial Oncology,MassachusettsGeneral Hospital, Boston,Massachusetts 8Department of Psychiatry andPalliativeCare, University of California SanDiego School ofMedicine, SanDiego, California Correspondence ChaseSamsel,DepartmentofPsychosocialOncologyandPalliativeCare,Dana–FarberCancer Institute, SW360A,450BrooklineAvenue,Boston,MA,02115. Email: chase_samsel@dfci.harvard.edu

Reply to: Comment on: Olanzapine for chemotherapy-induced nausea: Lessons learned from child and adolescent psychiatry

To the Editor: We thankDrsDupuis et al for their letter and for enhancing the discussion regarding the use of Olanzapine for refractory chemotherapyinduced nausea and vomiting (CINV).1 The intent of our commentary was to foster collaboration among pediatric oncology, pharmacy, and psychiatry in the novel use of this medication.2 We applaud the development of guidelines to provide effective relief of CINV in children and adolescents and are encouraged by the role that olanzapine can play. There are important distinctions between the long-term use of antipsychotic medications in the treatment of acute and chronic psychiatric illness and the short-term targeted use of olanzapine for refractory CINV. Our commentary is meant to contribute additional information to concurrently reduce risk and allay concerns, and we do not intend to create barriers to the use of potentially effective antiemetic therapy. We are especially enthusiastic about the use of olanzapine for children and adolescents with comorbid CINV and psychiatric symptoms such as severe anxiety, mood instability, or delirium. We agree the existing pediatric and psychiatric consensus guidelines regarding metabolic and waist circumference monitoring in long-term use of atypical antipsychotics may not be applicable for short-term use in pediatric oncology.3,4 It is important background information to have should prolonged treatment be considered or become necessary, as olanzapine has the strongest metabolic effects of its class.5,6 We agree that severe QTc prolongation is not an acute risk with olanzapine monotherapy in children without other cardiac risk factors or QTc prolonging polypharmacy. However, in clinical oncology practice, many children are on concomitant QTc prolonging medications and may need a reference electrocardiogram, often available from their baseline medical work-up.7 In terms of dosing, we agree that 0.1 mg/kg/dose (max: 10 mg/dose) is a reasonable rule of thumb, though dosage forms of oral and disintegrating tablets may limit the increments for dosing. Doses of greater than 5 mg may be too sedating and should only be considered for older children or adolescents who do not respond to lower doses. Intramuscular administration is only used for acute psychiatric emergencies. We are hopeful that prospective research can be done regarding the efficacy and side effects of olanzapine for refractory CINV in children and adolescents.8 Some of our own institutions are rolling out evidence-based guidelines based on those developed by Pediatric Oncology Group of Ontario and endorsed by The Childrens Oncology Group,9,10 with olanzapine as a treatment for refractory CINV. We appreciate the multidisciplinary efforts that can contribute to supportive care and symptom relief for our young patients with cancer,

Hydromorphone-induced chorea as an atypical presentation of opioid neurotoxicity: A case report and review of the literature:

Background: While opioid-induced myoclonus is well described, there are limited reports of opioid-induced chorea. Here we present the first case of chorea as a manifestation of opioid neurotoxicity due to hydromorphone. Case presentation: A 20-year-old woman presenting with fevers and cutaneous lesions was diagnosed with hemophagocytic lymphohistiocytosis secondary to primary cutaneous lymphoma. Surgical resection of a cutaneous lesion was complicated by severe postoperative pain requiring rapid opioid dose escalation. Seven days after hydromorphone was initiated, she developed positive myoclonus, hallucinations, delirium, and involuntary, flowing movements consistent with chorea. She had no personal or family history of nervous system disorders and was not taking any medications associated with drug-induced chorea. Case management: The remainder of her neurologic examination was unremarkable. Her renal function was normal and no etiology was found on neuroimaging or laboratory workup. Hydromorphone was discontinued and pain control was achieved with fentanyl. Case outcome: The patient’s neurotoxic symptoms including chorea resolved within 72 h of hydromorphone discontinuation. Conclusion: Further studies are needed to determine which patients have a unique sensitivity to opioids predisposing them to chorea. Clinicians should be aware that chorea may be a sign of such toxicity so that rapid corrective action can be taken.

Ketamine and Depression: Is It Ready for Primetime? (SA515)

Objectives Describe the pathophysiology, clinical manifestations, and prevention of mucositis, pruritus, and insomnia. Identify pharmacologic and non-pharmacologic interventions for mucositis, pruritus, and insomnia. Summarize the scientific evidence underlying the successful management of mucositis, pruritus, and insomnia. Symptom assessment tools are designed for the clinician to quickly and effectively determine the presence and severity of the most common symptoms encountered in palliative care or hospice patients. Mucositis, pruritus, and insomnia are all assessed in the Memorial Symptom Assessment Scale but could be missed by using a tool such as the Edmonton Symptom Assessment Scale (ESAS). The purpose of this session is to raise the awareness of these less common but equally distressing symptoms that can pose a challenge to successful management in many patients. Mucositis refers to mucosal damage within the gastrointestinal tract. It occurs in 20e40% of patients receiving conventional chemotherapy and up to 80% of patients receiving high-dose chemotherapy preparation for stem cell transplantation and nearly all patients receiving chemotherapy and radiation therapy for head and neck cancer. Additionally, certain oraltargeted therapies for cancer produce a significant amount of morbidity from this adverse effect. Pruritus is a nuisance symptom, but many patients suffer from protracted episodes of suffering as a result of poorly executed therapy by clinicians. Opioid therapy for an underlying pain condition often produces pruritus. However, it may be an adverse effect of other medications as well as experienced by patients with end-stage hepatic or renal disease. Insomnia is often overlooked in the overall symptom burden of many patients in hospice and palliative care. Clinicians must exercise great care when using sleep aids in combination with opioids due to the enhanced risk of opioid-induced respiratory depression. Insomnia is the most common risk factor for the subsequent development of delirium, especially in the hospitalized patient. Restoration of sleep hygiene is essential to the overall care of the palliative care and hospice patient. At the completion of this concurrent session, participants will be prepared to utilize the latest evidencebased information to palliate the symptoms discussed. Ketamine and Depression: Is It Ready for Primetime? (SA515) Eric Prommer, MD HMDC FAAHPM, University of California, Los Angeles and VA HPM Program, Los Angeles, CA. Scott Irwin, MD PhD, Cedars-Sinai, Los Angeles, CA. Jeremy Hirst, MD, UC San Diego Health, San Diego, CA.

Depression and Anxiety: Assessment and Management in Hospitalized Patients with Serious Illness

The journal publishes original research and synthetic review articles covering molecular, genetic, biopsychosocial, neurochemical, neuropsychological, physiological, behavioral, sociological, psychodynamic, psychotherapeutic, cognitive and pharmacotherapeutic aspects of mood and anxiety disorders and related phenomena in humans and animals. The journal publishes full-length research papers, topical reviews, brief reports, book reports, clinical case studies, and letters. Contributions are grouped and published by topic.

Depression and Anxiety

The journal publishes original research and synthetic review articles covering molecular, genetic, biopsychosocial, neurochemical, neuropsychological, physiological, behavioral, sociological, psychodynamic, psychotherapeutic, cognitive and pharmacotherapeutic aspects of mood and anxiety disorders and related phenomena in humans and animals. The journal publishes full-length research papers, topical reviews, brief reports, book reports, clinical case studies, and letters. Contributions are grouped and published by topic.

6. Depression and Anxiety

The journal publishes original research and synthetic review articles covering molecular, genetic, biopsychosocial, neurochemical, neuropsychological, physiological, behavioral, sociological, psychodynamic, psychotherapeutic, cognitive and pharmacotherapeutic aspects of mood and anxiety disorders and related phenomena in humans and animals. The journal publishes full-length research papers, topical reviews, brief reports, book reports, clinical case studies, and letters. Contributions are grouped and published by topic.

A Whirlwind Tour: Psychopharmacologic Management of Depression, Anxiety, Delirium, and Insomnia in Children—A Palliative Care Perspective (308) (Advanced): Pediatric

1. Discuss a major palliative and end-of-life care research initiative in Canada, funded through the Canadian Institutes of Health Research (