Magdalena Romanowicz

Changes in heart rate variability associated with acute alcohol consumption: Current knowledge and implications for practice and research

Alcohol consumption is associated with a broad array of physiologic and behavioral effects including changes in heart rate. However, the physiologic mechanisms of alcohol effects and the reasons for individual differences in the cardiac response remain unknown. Measuring changes in resting heart rate (measured as beats/min) has not been found to be as sensitive to alcohols effects as changes in heart rate variability (HRV). HRV is defined as fluctuations in interbeat interval length which reflect the hearts response to extracardiac factors that affect heart rate. HRV allows simultaneous assessment of both sympathetic and parasympathetic activity and the interplay between them. Increased HRV has been associated with exercise and aerobic fitness, while decreased HRV has been associated with aging, chronic stress, and a wide variety of medical and psychiatric disorders. Decreased HRV has predictive value for mortality in general population samples and patients with myocardial infarction and used as an indicator of altered autonomic function. A significant inverse correlation was found between HRV and both the severity of depression and the duration of the depressive episode. HRV analysis provides insights into mechanisms of autonomic regulation and is extensively used to clarify relationships between depression and cardiovascular disease. This article will review the methodology of HRV measurements and contemporary knowledge about effects of acute alcohol consumption on HRV. Potential implications of this research include HRV response to alcohol that could serve as a marker for susceptibility to alcoholism. At present however there is almost no research data supporting this hypothesis.

HTR2A gene–child abuse interaction and association with a history of suicide attempt among Caucasian depressed psychiatric inpatients

BACKGROUND The serotonin transporter gene polymorphism (5HTTLPR) has been associated with vulnerability for depression after exposure to stressful life event as well as with difference in treatment response to SSRI. Although the A/A genotype of the serotonin receptor SNP (rs7997012) was associated with better citalopram response than the G/G in the STAR⁎D sample, the effects of this SNP in the moderation of child abuse history on the characteristics of mental illnesses are not well understood. We examined if there are similar gene-environment interaction with the SNP. METHODS Retrospective chart review of 250 Caucasian depressed psychiatric inpatients, who had genotype for rs7997012. Subjects with each genotype were subcategorized into 2 groups with/without history of child abuse. The history of suicide attempts of each group was compared. RESULTS A trend for an interaction was found between the HTR2A genotype and child abuse history influencing the prevalence of suicide attempts. Although each genotype did not show significant difference in the risk of suicide attempt when there was no abuse history, the A carriers (A/A+A/G) showed significantly higher rate of suicide attempt compared to the G/G when there is a history of child abuse (48.4% versus 22.7% respectively, p=0.0050). The likelihood ratio test from the logistic model showed a trend for an interaction between the A/A genotype and abuse history (Odds Ratio 2.10, χ(2)=2.49, p=0.11). LIMITATIONS Retrospective study design and small sample size with borderline significance. CONCLUSIONS Our findings showed a potential interaction between the HTR2A gene and stressful life events.

A new interaction between SLC6A4 variation and child abuse is associated with resting heart rate

Background: The short form of the indel promoter polymorphism (5HTTLPR) of the serotonin transporter gene (SLC6A4) and a history of child abuse have been reported to be associated with an increased risk for the development of depression. A child abuse history has also been associated with more rapid heart rate reactions. Methods: A retrospective chart review identified 282 patients with major depression who had been hospitalized and genotyped for the 5HTTLPR polymorphism. A subgroup of 185 females of European ancestry was also identified and analyzed. While hospitalized, heart rate was measured. Child abuse history was documented during the diagnostic evaluation. Analyses of the relationship between 5HTTLPR genotype, history of child abuse, and admission heart rate were conducted. Results: No main effect on heart rate from the 5HTTLPR genotype or a child abuse history was demonstrated for the entire sample or the subgroup of female patients. However, a genotype‐by‐abuse interaction was associated with resting heart rate on admission to the hospital (P<.05). Depressed patients, who were homozygous for the long allele and who had been abused, had a heart rate on hospital admission, which was statistically higher than patients with the same genotype but who had not been abused. These findings were consistent both for the 282 patients (7.2 bpm higher) as well as for the subgroup of 185 female patients of European ancestry (9.6 bpm higher). Conclusions: A 5HTTLPR genotype interaction of elevated heart rate with a history of child abuse was demonstrated in depressed psychiatric inpatients. Depression and Anxiety 28:227‐233, 2011.  © 2010 Wiley‐Liss, Inc.

Investigation of serotonin transporter gene (SLC6A4) by child abuse history interaction with body mass index and diabetes mellitus of White female depressed psychiatric inpatients.

Background The serotonin transporter gene promoter polymorphism (5HTTLPR) and child abuse have been associated with an increased risk for depression. We previously reported the long/long (l/l) genotype of 5HTTLPR being associated with higher heart rate among patients with a history of child abuse compared with those without a history of child abuse, whereas the short allele carriers did not have heart rate differences dependent on child abuse history. This time, we extended our investigation to other outcomes with body mass index (BMI), and diabetes mellitus (DM) diagnosis. Methods A retrospective chart review identified 185 White female depressed inpatients who were genotyped for 5HTTLPR. Child abuse history, BMI, and DM diagnosis were recorded. The relationship between 5HTTLPR, child abuse, and BMI, as well as a prevalence of DM were analyzed. Results Among the l/l genotype group, patients with a history of child abuse had a higher prevalence of DM (14.3 vs. 0%, P=0.06), and higher BMI (32.3 vs. 27.3 kg/m2, P=0.03) compared with those without. Patients with the short allele (s/s or s/l) had fewer differences on the basis of abuse history. Conclusion A potential interaction between 5HTTLPR and child abuse influenced metabolic profiles of White female depressed inpatients. In contrast with the widely recognized ‘reactivity’ associated with the short allele of 5HTTLPR, our White female depressed psychiatric inpatients with the l/l genotype showed relatively greater clinical pathology in metabolic profiles if they have a history of child abuse than inpatients with at least one short allele who had a history of child abuse.

Testing a Diathesis-Stress Model: Potential Genetic Risk Factors for Development of Distress in Context of Acute Leukemia Diagnosis and Transplant

OBJECTIVE Brain-derived neurotrophic factor (BDNF) is a nerve growth factor that has antidepressant-like effects in animals and may be implicated in the etiology of mood-related phenotypes, specifically in the context of stressful life events. We hypothesized that this single-nucleotide polymorphism will predict the development of psychological distress among patients diagnosed with acute leukemia and preparing for hematopoietic stem cell transplant (HSCT). We also explored the relationship of other genetic factors to psychological distress, including 5HTTLPR and STin2, FKBP5, and the CRHR1 TAT haplotype. METHOD In a retrospective cohort design, 107 adult acute leukemia survivors preparing for HSCT at a major medical center completed a pre-HSCT psychological evaluation and volunteered to donate blood to the HSCT Cell and Serum Research Repository for future research studies. RESULTS There was evidence of a potential association between BDNF (Val66Met) and psychological distress. More specifically, rs6265 was related to both personal mental health history (P = 0.09, 0.06 adjusted) and diagnosis of depression/adjustment disorder at time of pre-transplant evaluation (P = 0.11, 0.09 adjusted). Other genetic factors were unrelated to distress. CONCLUSION The BDNF Val66Met polymorphism may contribute to development of depressive symptomatology in patients undergoing stressful life events, such as diagnosis of acute leukemia and preparation for HSCT. The SNPs in BDNF might be applicable in identifying patients at risk for developing psychological distress and depression in the context of coping with stressful medical conditions. Polymorphism in other genes (FKBP5, CRHR1, and 5HTT) did not show any significant relationships. Replication studies are needed with larger samples of people undergoing similar significant life stressors.

Use of the Suicide Status Form-II to investigate correlates of suicide risk factors in psychiatrically hospitalized children and adolescents

BACKGROUND Suicide is the third leading cause of death in the United States for youth 12-17 years or age. Acute psychiatric hospitalization represents a clear worst point clinically and acute suicide risk is the most common reason for psychiatric admission. We sought to determine factors associated with differences in individual suicide risk assessment for children and adolescents during acute psychiatric admission. METHODS Study participants were 1153 youth consecutively admitted to an inpatient psychiatry unit who completed a self-administered Suicide Status Form (SSF) within 24h of admission. Additional information on suicide risk factors was obtained through medical chart abstraction. RESULTS Females reported significantly greater psychological pain, stress, hopelessness, and self-hate on the SSF and were significantly more likely to have made a suicide attempt just prior to the index hospital admission (OR=1.59, SE=0.29; CI=1.12-2.26), report a family history of suicide (OR=2.02, SE=0.33; CI=1.47-2.78), and had experienced a greater number of inpatient psychiatry admissions related to suicidal ideation (RR=1.33, SE=0.13; CI=1.10-1.61). High school aged youth and those with a primary diagnosis of depression displayed consistently elevated SSF scores and risk factors for suicide compared to comparison groups. LIMITATIONS Diagnosis was determined through chart abstraction. Responses to access to firearm question had missing data for 46% of the total sample. CONCLUSIONS Systematic administration of a suicide-specific measure at admission may help clinicians improve identification of suicide risk factors in youth in inpatient psychiatry settings.

Successful use of ECT in post-stroke depression.

Post-stroke depression is a potentially persistent complication of stroke. Electroconvulsive therapy (ECT) is an effective treatment for depression, but with limited data regarding safety in stroke patients. We report the case of a 30-year-old woman with a history of stroke and antiphospholipid syndrome, who became depressed and suicidal. Neurologic and Internal Medicine consults did not reveal any contraindications to ECT, but stroke risk factor management was identified as an important measure for patient safety. The patient tolerated ECT well, reporting improvement of mood and abatement of hopelessness. This case suggests that ECT may be a safe and well-tolerated treatment for post-stroke depression.

The Need for Infant Mental Health Training for All Child and Adolescent Psychiatrists

Social-emotional development is understood as “the developing capacity of the child from birth through five years of age to form relationships and regulate emotions” [1]. Children who experience delays in social-emotional development are at risk for psychiatric disorders, poor school performance, and difficulties in relationships. The American Academy of Pediatrics directs pediatricians to assess psychosocial and behavioral issues during well-child visits [2]. Unfortunately, even if pediatricians diagnose specific behavioral issues, there is a significant shortage in the number of child psychiatrists trained to help them [3]. Training in child psychiatry should contain a well-defined curriculum that addresses normal development and the emerging emotional world of infants and preschoolers. It also should help trainees understand and manage most common disorders and parental concerns in this patient population. The excellent commentary by Osofsky et al. [4] is a call to action for incorporating principles and practices from the field of infant mental health into all training programs for child and adolescent psychiatrists. Further, the article references materials from the authors’ program at Louisiana State University that other programs can utilize, from lectures to reading lists [4, 5]. Manymore resources for teaching are available, including Geri Fox’s tapes of the first 10 years of life [6, 7], the Practice Parameter for the Assessment of Young Children [8], and textbooks on infants ages 0–3 years [9] and preschoolers [10]. Martin Drell has been writing eloquently since 1988 about the need to incorporate infant mental health information into training [11]. We assert that this training has not been incorporated into many programs because of the following factors:

Electroconvulsive Therapy-Responsive Catatonia in a Medically Complicated Patient

Background: Profoundly depressed states of awareness classified as either catatonia or akinetic mutism have been reported in patients with various general medical conditions including encephalitis, frontal lobe tumors, or paraneoplastic limbic encephalitis. Catatonic features are often difficult to apprise in this context. This can result in electroconvulsive therapy (ECT) discontinuation, although it remains the most effective treatment of catatonia. Case Report: We describe the case of a patient with a history of unresectable right retroorbital squamous cell carcinoma, status poststereotactic radiation and cisplatin, and subsequent pneumococcal meningitis of the temporal lobe with abscess formation who became catatonic after receiving 3 bitemporal treatments with ECT for severe depression and whose catatonia improved with continued ECT. Furthermore, she demonstrated progressive improvement in mood, interactivity, and overall neurologic function after ECT treatment was completed. Conclusions: The search for an etiology of a profound catatonic state should include the probability of underlying medical disorder. Although lorazepam may be helpful in some cases, ECT deserves early consideration in catatonia, especially in cases where the underlying cause seems to be uncertain, even if the catatonia begins in the midst of treatment.

Safety and efficacy of electroconvulsive therapy for depression following cerebrovascular accident

Introduction: Depressive syndromes are common following cerebrovascular accident (CVA) and many patients do not respond to pharmacotherapy. Electroconvulsive therapy (ECT) is a safe and effective treatment for mood disorders arising with many comorbid medical conditions. In this paper, we describe the successful treatment of post-CVA depression with ECT. Methods: Retrospective chart review of 24 patients hospitalised for depression on an in-patient Medical Psychiatry unit between 2000 and 2010. Medical, neurologic and psychiatric histories, physical examination findings, results of laboratory, imaging and neurophysiologic investigations and treatment response with medications and ECT were recorded. Results: Twenty patients (83%) showed a positive response to treatment with ECT. None had worsening of depression after the ECT or experienced exacerbation of post-stroke neurological deficits. Three patients suffered from minor complications of ECT (prolonged confusion or short-term memory problems). Conclusions: This review supports the use of ECT after a stroke with appropriate clinical observation. The treatment was well tolerated and the majority obtained clinical benefit.