Junji Takeshita

Depressive Symptoms in Medical Students and Residents: A Multischool Study

Background This multisite, anonymous study assessed depressive symptoms and suicidal ideation in medical trainees (medical students and residents). Method In 2003–2004, the authors surveyed medical trainees at six sites. Surveys included content from the Center for Epidemiologic Studies–Depression scale (CES-D) and the Primary Care Evaluation of Mental Disorders (PRIME-MD) (measures for depression), as well as demographic content. Rates of reported major and minor depression and of suicidal ideation were calculated. Responses were compared by level of training, gender, and ethnicity. Results More than 2,000 medical students and residents responded, for an overall response rate of 89%. Based on categorical levels from the CES-D, 12% had probable major depression and 9.2% had probable mild/moderate depression. There were significant differences in depression by trainee level, with a higher rate among medical students; and gender, with higher rates among women (&khgr;2 = 10.42, df = 2, and P = .005 and &khgr;2 = 22.1, df = 2, and P < .001, respectively). Nearly 6% reported suicidal ideation, with differences by trainee level, with a higher rate among medical students; and ethnicity, with the highest rate among black/African American respondents and the lowest among Caucasian respondents (&khgr;2 = 5.19, df = 1, and P = .023 and &khgr;2 = 10.42, df = 3, and P = .015, respectively). Conclusions Depression remains a significant issue for medical trainees. This study highlights the importance of ongoing mental health assessment, treatment, and education for medical trainees.

A program for reducing depressive symptoms and suicidal ideation in medical students.

Purpose Although depressive symptoms and suicidal ideation are common in medical students, few programs address this serious problem. The authors developed, and then tested the effectiveness of, an intervention meant to reduce reported depressive symptoms and suicidal ideation. Method To reduce the alarming reported rates of depression and suicidal ideation among medical students, the University of Hawaii John A. Burns School of Medicine implemented the following interventions: increased individual counseling for students, faculty education, and a specialized curriculum including lectures and a student handbook. Although counseling had always been available, a new emphasis was placed on facilitating an anonymous process and providing several options, including volunteer psychiatrists not involved in student education. In 2002 and 2003, the authors measured depressive symptoms and suicidal ideation in third-year medical students using, respectively, the Center for Epidemiologic Studies Depression Scale and a question about suicidal ideation from the Primary Care Evaluation of Mental Disorders Patient Health Questionnaire. Results Before the intervention, 26 medical students (59.1%) had reported depressive symptoms, and 13 (30.2%) reported suicidal ideation. After the intervention, 14 medical students (24.1%) reported depressive symptoms (&khgr;2 = 12.84, df = 2, P < .01), and 1 (3%) reported suicidal ideation (&khgr;2 = 13.05, df = 1, P < .001). Conclusions Programs that provide specific mental health support for medical students may significantly decrease the reported rates of depressive symptoms and suicidal ideation.

Sociodemographic Characterization of ECT Utilization in Hawaii

Objectives Minimal research has been done on sociodemographic differences in utilization of electroconvulsive therapy (ECT) for refractory depression, especially among Asian Americans and Pacific Islanders. Methods This study examined sociodemographic and diagnostic variables using retrospective data from Hawaii, an island state with predominantly Asian Americans and Pacific Islanders. Retrospective data were obtained from an inpatient and outpatient database of ECT patients from 2008 to 2010 at a tertiary care community hospital on O’ahu, Hawaii. Results There was a significant increase in overall ECT utilization from 2008 to 2009, with utilization remaining stable from 2009 to 2010. European Americans (41%) and Japanese Americans (29%) have relatively higher rates of receiving ECT, and Filipino Americans and Native Hawaiians have relatively lower rates in comparison with their population demographics. Japanese Americans received significantly more ECT procedures than European Americans. Conclusions Electroconvulsive therapy is underutilized by certain sociodemographic groups that may benefit most from the treatment. There are significant differences in ECT usage based on ethnicity. Such differences may be related to help-seeking behavior, economic differences, and/or attitudes regarding mental illness. Further research is needed to elucidate the reasons for differences in utilization.

Antipsychotic-Induced Dysphagia: A Case Report

To the Editor: Dysphagia is a serious condition in which swallowing problems interfere with a patient’s ability to eat, resulting in aspiration pneumonia, malnutrition, choking, and asphyxia. Antipsychotic medications have been classically associated with parkinsonian symptoms such as bradykinesia or dystonia. Dysphagia, on the other hand, is seen in the late stages of Parkinson’s disease but typically is not associated with medication-induced parkinsonism.1 Here, we report on a patient with antipsychotic-induced dysphagia from haloperidol. Case report. Mr A, a 55-year-old man with a history of traumatic brain injury, was initially brought to the hospital emergency department in August 2012 for altered mental status and bizarre behavior, including walking around outside naked. He was reportedly nonadherent with medications and food for 3 days. Emergency evaluation revealed renal failure due to dehydration. The hospital course was significant for bacteremia and subsequent acute endocarditis with viridans streptococcus bacteremia, which was treated with a 4-week course of ceftriaxone 2 gm intravenous (IV) daily. Mr A remained intermittently agitated during his hospital stay. Prazosin 1 mg orally twice a day, risperidone 0.25 mg orally at bedtime, haloperidol 5 mg orally every hour as needed, and haloperidol 2 mg IV every 12 hours as needed were started for treatment of agitation. He received as-needed haloperidol 5 mg orally daily for 3 days. On day 5 after starting haloperidol, Mr A developed acute dysphagia, and he was unable to ingest oral medications. He also developed mild rigidity and cogwheeling of his extremities. Subsequent medical workup revealed no etiology of the new-onset dysphagia or rigidity. Computed tomography of the head without contrast was negative for any acute intracranial abnormalities, and abdominal series X-ray showed no acute abnormalities. He was treated for presumed extrapyramidal symptoms secondary to multiple doses of haloperidol. Risperidone and haloperidol were discontinued, and diphenhydramine 25 mg IV twice daily was started for extrapyramidal symptoms. Within a few days of stopping haloperidol, Mr A’s rigidity and dysphagia improved. Extrapyramidal symptoms are common with antipsychotics, particularly with typical antipsychotics. Clinicians rarely think about medications causing acute dysphagia and typically consider obstructive causes or a new neurologic finding such as stroke. This case illustrates an example of dysphagia induced by use of the antipsychotic medications haloperidol and risperidone. In this case, Mr A received 2 different types of antipsychotics, but his parkinsonian symptoms developed acutely after he received multiple doses of haloperidol. Therefore, haloperidol was the most likely cause of his dysphagia, though the concurrent use of risperidone was most likely a contributing factor. The rapid improvement of Mr A’s symptoms once antipsychotic medications were discontinued also suggests that the parkinsonian symptoms including dysphagia resulted from antipsychotic use. Most clinicians are aware of extrapyramidal symptoms with antipsychotics, but dysphagia due to antipsychotics is a less commonly known adverse effect. There have been other reported cases in which dysphagia was associated with both first-generation and second-generation antipsychotic use. Previous studies have found haloperidol, loxapine, trifluoperazine, olanzapine, risperidone, quetiapine, clozapine, and aripiprazole to be associated with dysphagia.1–4 Dysphagia is a rare adverse effect, but it is potentially dangerous to the patient. Fortunately, in most cases, this condition is reversible. Clinicians should be aware of this potential adverse effect so that they may quickly intervene. Strategies to treat antipsychotic-induced dysphagia include discontinuing the antipsychotic medication, lowering the dose, and changing to another medication. All of these strategies have been found to be effective in improving dysphagia.

A DESCRIPTIVE STUDY OF A UNIQUE MULTI-ETHNIC CONSULTATION-LIAISON PSYCHIATRY SERVICE IN HONOLULU, HAWAII

Objective: To provide a descriptive characterization of the CL Psychiatry service at a major medical center in Honolulu, Hawaii. We hypothesized differing demographic trends than seen nationally and internationally, an increasing prevalence of elderly and substance abusing patients, and increasing consultation requests related to these issues. Methods: Retrospective data was gathered from 180 randomly selected patient records, identified as having a request for inpatient psychiatric consultation on the medical-surgical floors during identical 3-month periods in 2000 and 2005. Descriptive statistics were calculated. Chi-square and ANOVA were used to compare differences across time. Results: There were no significant differences by age, reason for referral, or diagnoses between the 2 years. Patients age 65 years and older accounted for only 16.6% of the consults. Caucasians accounted for 45.6% of consultations despite low prevalence rates in the population. Hawaiian/Pacific Islander (15%), Japanese (12.5%), Filipino (5.6%), and other Asians (10.6%) accounted for the majority of remaining patients. Depression/anxiety (27.4%), alcohol/drugs (21.8%), and agitation/ psychosis (20.5%) were the most frequent reasons for consultation. Substance use (32.5%), mood (16%), and cognitive (14.1%) disorders were the top diagnoses. Conclusions: As expected, the patient demographic data reflects a unique patient population served by the QMC CL service. Much of the consultation process, diagnoses, and treatment, however, are in line with our Mainland counterparts. There were no major differences in trends over time.

Increased Elderly Utilization of Psychiatric Emergency Resources as a Reflection of the Growing Mental Health Crisis Facing Our Aging Population

The elderly population continues to soar in the United States, with the number of those older than 65 years expected to double from 2010 to 2050. Many are predicting an imminent mental health crisis for our seniors, as available resources lag further behind the demand. One contributing factor is the evergrowing number of individuals with dementia-related behavioral symptoms. In Hawaii, a top retirement destination known for longevity of life, we have experienced greater use by elderly patients of the psychiatric emergency department (ED) at the largest general hospital in the state. As evidence of this trend, we present age-specific psychiatric ED utilization patterns from 2007 to 2011, a period during which local resources for geriatric mental health had remained static. We collected data (age, mode of arrival, main diagnosis, length of stay [LOS], and disposition) for all psychiatric ED visits (N = 22,124) in the 5-year period. Patients were grouped as younger (aged <65 years) or older (aged ≥65 years, N = 1,370). Within this period, there was a general trend of more access by elderly patients, with yearly numbers and proportions at 234 (5.7%) in 2007, 220 (5.5%) in 2008, 301 (7.2%) in 2009, 298 (6.2%) in 2010, and 319 (6.5%) in 2011. A more pronounced and alarming progression was seen in law enforcement being increasingly relied upon, usually because of violent behavior, to bring older patients to the ED (12.5% in 2007, 11.0% in 2008, 16.9% in 2009, 18.4% in 2010, and 24.5% in 2011; χ(8) = 41.56, p < 0.01), whereas the numbers of those who arrived by ambulance (64.7%, 50.7%, 59.5%, 59.2%, 54.5%, respectively) or with caregivers/self (22.8%, 38.4%, 23.6%, 22.4%, 21.0%, respectively) trended downward. Behavior due to dementia of all types was recorded as the main presenting diagnosis among 14% of older patients. This number is likely much higher as we were unable to capture secondary diagnoses reliably. Using LOS to estimate ED utilization, older patients had longer LOS (median: 400 minutes) than younger patients (median = 351 minutes, U = 12,362,765, p < 0.01). Among older patients, those receiving medical admission (11% of all elderly visits) had the highest LOS (median: 519 minutes), followed by psychiatric admission (31%, median = 431 minutes) and discharge (58%, median = 352 minutes, KruskalWallis (df 2) = 76.43, p < 0.01; post-hoc medical > psychiatric > discharge). Further, highly advanced age (≥80 years defined as “older old”), compared with “younger old” (aged 65–79 years), was associated with an even greater LOS, but only among those who were psychiatrically admitted (F(2, 1364) = 5.36, p = 0.01, using log-transformed LOS because of positive skew), with the significant interaction term characterized by a median LOS of 457 minutes in “older old” and 409 minutes in “younger old”. Such findings were not surprising. Because of a shortage of geriatric mental health services, exhausted caregivers were often unwilling accept patients back from the ED (usually cases involving the oldest old), where they had to endure lengthy (often multi-day) searches for a limited number of appropriate psychiatric beds. Our observations reflect worrisome outcomes of a fairly stagnant geriatric mental health system, during a period in which growth of the elderly population outpaced other age groups. As a result, symptom acuity and potential for harm rose steadily, as indicated by more law enforcement being invoked by caregivers for transfer to the ED. Lack of acute placement options further worsened crowding in the ED, straining finite acute resources further. Our study period (2007–2011) ushers the very beginning of the baby boomer cohort becoming 65 years or older. Thus, the degree of reliance on ED behavioral services by seniors, especially those with dementia, and their caregivers is likely to increase. Long-term solutions to shore up widening gaps in geriatric mental health are becoming even more urgent.

A Case of Hyponatremia Due to Self-Treatment of Anxiety With a Beverage Containing Valerian Root

To the Editor: Hyponatremia in psychiatric patients is often due to psychogenic polydipsia (PPD) and/or syndrome of inappropriate secretion of antidiuretic hormone (SIADH) from antidepressant medications. Regardless of etiology, severe hyponatremia can result in confusion, delirium, seizures, and, ultimately, death.1 Assessment is complicated by overlap of symptoms such as confusion with psychiatric illness. We report a case of an anxious man whose self-treatment of anxiety with an herbal beverage containing valerian root worsened hyponatremia. Valerian root has been used historically for anxiety/insomnia, as valerian affects the gamma-aminobutyric acid (GABA) receptor involved in anxiety.2 However, controlled studies have not shown efficacy.3 Case report. Mr A, a 48-year-old man, was found unresponsive and brought to the emergency department, where he developed generalized tonic-clonic seizures. He was intubated and treated with lorazepam 2 mg intravenously every hour. Workup revealed a serum sodium level of 114 mmol/L, and the medication list included escitalopram 20 mg/d (started 2 months previously) for generalized anxiety disorder (DSM-IV) along with inhaled fluticasone and albuterol. The patient was admitted to the intensive care unit, all outpatient medications including escitalopram were discontinued, and the patient was given hypertonic sodium chloride (3%). Conivaptan was also started at 20 mg/d. Toxicology screen was positive only for benzodiazepines, presumably the lorazepam given for seizures. Findings of brain magnetic resonance imaging were unremarkable. SIADH resulting from escitalopram was initially of concern, but urinalysis revealed urine sodium level of less than 10 mmol/L. After Mr A was extubated, he admitted to drinking approximately 5 cans (473 cc each) of Purple Stuff (http://mypurplestuff.com/) and 2 bottles of Marley’s Mellow Mood (473 cc each) (http://www.marleysmellowmood.com/) to help with chronic anxiety on the day prior to admission. Purple Stuff contains valerian root; Marley’s Mellow Mood contains valerian root, lemon balm, passion flower, hops, and chamomile. The recommended serving size is one half can or 236.5 cc. There were no further seizures or flu-like symptoms suggesting a selective serotonin reuptake inhibitor (SSRI) discontinuation syndrome. He did not consume excessive fluids. He was discharged in a stable condition with a serum sodium level of 139 mmol/L. Anxiety disorders are common, and patients frequently self-treat with herbal supplements. A recent trend includes addition of supplements to beverages and foods. This patient drank close to 3.5 L of excess fluid in 1 day, resulting in hyponatremia. Since the patient could not initially provide history, hyponatremia was attributed to an SSRI-induced SIADH, although urinalysis did not show the characteristic sodium wasting. The amount of valerian root in beverages is typically low, and a case report of a valerian overdose showed only brief abdominal discomfort.4 Hyponatremia is more likely related to excess water consumed with the beverage rather than an adverse pharmacologic consequence of valerian. This case illustrates the novel problem of hyponatremia from self-treatment of anxiety with an herbal beverage.

A case of paraneoplastic limbic encephalitis associated with ovarian teratoma and N-Methyl-d-Aspartate receptor antibodies.

To the Editor: Paraneoplastic limbic encephalitis (PLE) is a disorder of the nervous system, often the result of malignancy such as lung, ovarian, or testicular tumors.1 Neuropsychiatric symptoms such as mood disturbance, psychosis, cognitive impairment, sleep changes, and irritability are common.2 Psychiatric treatment primarily involves medications to target symptoms such as agitation and hallucinations.3 Despite symptoms such as severe hypoventilation requiring ventilator support, individuals often make a full recovery. The majority of PLE cases have been reported in neurologic or subspecialty psychiatric journals (per a MEDLINE review March 9, 2011, using the keywords paraneoplastic limbic encephalitis for the years 1998 to 2011). We describe the psychiatric and neurologic presentation and management of a patient with PLE associated with mature ovarian teratoma and N-methyl-D-aspartate (NMDA) receptor antibodies. Case report. Ms A, a 25-year-old woman without past medical or psychiatric history, initially presented in 2009 to the emergency department with complaints of near syncope and the following day returned with left temporal headaches, episodic confusion, and memory disturbance. Medical workup including computed tomography (CT) of the head and drug toxicology was unremarkable. She returned to the emergency department on the third day and was admitted to the hospital after complaining of a seizure that was unwitnessed. She was started on treatment with acyclovir 10 mg/kg (for a total dose of 905 mg) for presumed herpes encephalitis and fosphenytoin 18 mg/kg (for a total dose of 1,633 mg) for seizures, but these medications were ultimately discontinued due to negative tests for herpes simplex virus and no further seizures. Electroencephalogram revealed mild-to-moderate disorganized activity with occasional increase in β activity and slow waves, but no epileptiform activity. Magnetic resonance imaging (MRI) of the head showed cerebrospinal fluid (CSF) collection and mass effect on the left hippocampus. Lumbar puncture revealed the following values: 75% lymphocytes, white blood cells (WBCs) 8/mm3, 16% neutrophils, 9% monocytes, red blood cells 2/mm3, protein 42 mg/dL, and glucose 72 mg/dL. A second lumbar puncture 10 days later revealed 92% lymphocytes and WBCs 15/mm3. Three days after discharge (the discharge occurred 3 days after hospitalization), the patient presented to the emergency department with paranoia, hallucinations, and acute agitation. She was admitted to the psychiatric unit for new-onset psychotic disorder not otherwise specified (DSM-IV), although notes indicate the suggestion of “pseudoseizures.” Urine toxicology findings were again unremarkable. The patient was started on risperidone 0.5 mg twice daily, but her condition rapidly deteriorated with drooling, dyskinesias (slapping thighs), poor intake, and decrease in responsiveness despite discontinuation of risperidone after 4 days. She was then transferred to the medical intensive care unit 6 days after admission to the psychiatric unit. In the medical intensive care unit, Ms A had respiratory failure due to aspiration pneumonia and thus was intubated and started on treatment with vancomycin 1 g every 8 hours and piperacillin/tazobactam 3.375 g every 6 hours. Propofol 5 μg/kg/min and dexmedetomidine 0.2–0.7 μg/kg/h were used to manage agitation. She was seen by psychiatric, neurologic, and infectious disease specialists and underwent a battery of tests including ceruloplasmin, cytomegalovirus, cryptococcus, antinuclear antibodies, Epstein-Barr virus, enterovirus polymerase chain reaction, IgM and IgG, mycoplasma, chlamydia, bartonella, rickettsia, influenza, measles, mumps, rubeola, West Nile virus, leptospira, herpes simplex virus types 1 and 2, ova and parasites (stool tests), botulism, microfilaria, and malaria. Findings of a second MRI, magnetic resonance angiography, and single photon emission computed tomography of the head were unremarkable. Negative autoimmune studies included tests for antinuclear antibodies, antineutrophil cytoplastic antibody and antithyroid peroxidase, anti-dsDNA, anticardiolipin, anti-SSA/Ro, anti-SSB/La, and anti-Sm and anti-ribonucleoprotein antibodies. Paraneoplastic workup included CSF studies for anti-CV2, anti-Hu, anti-Ma, and anti-Ta antibodies; voltage-gated potassium channel, NMDA antibodies; collapsin response mediator protein; and acetylcholine receptor, with all tests negative other than that for NMDA receptor antibodies. Subsequent CT and MRI of the pelvis showed a mature teratoma of the left ovary measuring 4.7 cm × 2.7 cm. The patient had recovery with return to baseline shortly after undergoing a left salpingo-oophorectomy. This case illustrates the sudden presentation yet difficult diagnosis of PLE. Treatment resulting in full recovery is not uncommon, particularly with ovarian teratoma. The confusing neuropsychiatric and medical symptoms result in diagnostic confusion with the differential including drug abuse, malingering, and seizure disorders.4 Paraneoplastic limbic encephalitis has also been confused with bipolar disorder.5 False attribution of symptoms to a psychiatric disorder may result in inadequate treatment or delay in seeking medical attention. Patients with PLE may present to the primary care practitioner or general psychiatrist. Therefore, PLE and ovarian teratoma should be considered in young women with encephalitis who present with acute onset of psychiatric symptoms, seizures, autonomic instability, hypoventilation, and dyskinesias.