Michael P. Wilson

Oxytocin and psychotherapy: A pilot study of its physiological, behavioral and subjective effects in males with depression

Individual psychotherapy is an important treatment for a number of psychiatric conditions and involves a unique form of human attachment. This raises the question of whether oxytocin (OT), the paradigmatic attachment hormone, may have benefits in this context. In this randomized, double-blind, crossover trial, we gave male psychiatric outpatients with major depressive disorder 40 IU intranasal OT or placebo before a videotaped session with a therapist and measured a number of subjective, physiological, and behavioral parameters. We report three main findings. Surprisingly - in contrast to prior reports of OTs anxiolytic properties - we found OT caused an increase in anxiety over the course of the therapy session. Secondly, though it had no main effect on cortisol, eye contact, or overall behavior, we did find that OT caused a decrease in nonverbal behaviors that cut off social contact, after controlling for level of depressive symptoms. Lastly, we replicated prior findings that OT improves social cognition (performance on the reading the mind in the eyes test (RMET)), albeit in a depressed patient group. These results inform future studies of oxytocin and psychotherapy and suggest that in certain clinical populations and contexts, OT has heterogeneous subjective effects which may include acute anxiogenesis. Moreover, the similarity of some of these acute effects to those of single-dose serotonergic antidepressants raises interesting questions about the potential antidepressant benefits of chronic OT administration.

A case of necrotizing fasciitis with a LRINEC score of zero: clinical suspicion should trump scoring systems.

BACKGROUNDnNecrotizing fasciitis (NF) is a potentially lethal infection involving the skin, subcutaneous tissue, and fascia. The Laboratory Risk Indicator for Necrotizing fasciitis (LRINEC) score has been proposed as a way of using abnormal laboratory values to distinguish between severe cellulitis and necrotizing fasciitis.nnnOBJECTIVESnThe utility of the LRINEC system, including a review of current literature on this scoring system, is discussed.nnnCASE REPORTnA case of a 37-year-old man is presented. As part of the diagnostic work-up, appropriate laboratory tests necessary to calculate a LRINEC score were obtained. Despite a LRINEC score of 0, NF was later confirmed at surgery.nnnCONCLUSIONSnAlthough the LRINEC score has been proposed as a robust way of identifying patients with early NF, it failed to detect NF in the patient reported here. NF should thus remain primarily a disease of clinical suspicion, and this suspicion should trump the LRINEC score.

INTRAMUSCULAR ZIPRASIDONE: INFLUENCE OF ALCOHOL AND BENZODIAZEPINES ON VITAL SIGNS IN THE EMERGENCY SETTING

BACKGROUNDnZiprasidone is a second-generation antipsychotic (SGA) approved for agitation. Few previous studies have examined ziprasidone in the emergency department (ED). For instance, it is unknown how often emergency physicians prescribe ziprasidone, whether it is typically prescribed in combination with a benzodiazepine, or whether use of intramuscular (i.m.) ziprasidone and benzodiazepines affects vital signs compared to i.m. ziprasidone alone.nnnOBJECTIVEnOur aims were to determine the demographics of patients receiving ziprasidone in an urban-suburban ED; the relative frequency with which ziprasidone is prescribed; and the effects on vital signs, repeat medication dosage, and lengths of stay.nnnMETHODSnThis is a multicentered structured chart review from 2003 to 2010 of ziprasidone use at two hospitals. If documented, vital signs were compared in patients who received concurrent benzodiazepines and in those who did not, and in patients who ingested alcohol and in those who did not.nnnRESULTSnPatients on 95 visits received ziprasidone during the study period, with one third of these receiving accompanying benzodiazepines. Forty-nine unique patients who were treated with i.m. ziprasidone had documented vital signs. In these patients, alcohol intoxication was associated with decreased oxygen saturations irrespective of benzodiazepines. Concurrent benzodiazepines had no other deleterious effect on vital signs but resulted in longer ED stays.nnnCONCLUSIONSnThis study suggests that many ED physicians, who commonly prescribe a benzodiazepine with a first-generation antipsychotic like haloperidol, have transferred this practice to SGAs like ziprasidone. In this sample, this pairing did not adversely affect vital signs but was associated with marginally longer ED stays. Caution should be exercised when treating alcohol-intoxicated patients with ziprasidone, as this can decrease oxygen saturations.

The Tooth, the Whole Tooth, and Nothing But the Tooth: Can Dental Pain Ever Be the Sole Presenting Symptom of a Myocardial Infarction? A Systematic Review

BACKGROUNDnPain symptoms related to cardiac ischemia can vary greatly from patient to patient. However, should emergency physicians consider the possibility of myocardial infarction in patients who present solely with dental pain?nnnOBJECTIVEnThis is a systematic review of the literature investigating the incidence of jaw, tooth, or facial pain as the sole symptom of cardiac ischemia.nnnMETHODSnStudies investigating jaw, tooth, or facial pain of cardiac origin were identified using the PubMed database. All English studies in which cardiac pain originated in the face, teeth, or jaw were screened for inclusion. Data were abstracted from each study utilizing a structured review process, and rated for methodological quality.nnnRESULTSnEighteen studies met study criteria: 16 were case reports, and the remaining 2 were prospective cohort studies. After quality assessment and categorization, nine reports were categorized as weak, eight moderate, and one strong methodological quality.nnnCONCLUSIONnCardiac ischemia may present in no anatomic location other than face or jaw. However, despite frequent claims in the literature to the contrary, the lack of methodological quality of the studies investigated impedes a firm conclusion of face, jaw, or tooth pain as the only symptom of cardiac insufficiency.

Suicide screening scales may not adequately predict disposition of suicidal patients from the emergency department

Background Suicide screening scales have been advocated for use in the ED setting. However, it is currently unknown whether patients classified as low‐risk on these scales can be safely discharged from the emergency department. This study evaluated the utility of three commonly‐used suicide screening tools in the emergency department to predict ED disposition, with special interest in discharge among low‐risk patients. Methods This prospective observational study enrolled a convenience sample of patients who answered “yes” to a triage suicidal ideation question in an urban academic emergency department. Patients were administered the weighted modified SADPERSONS Scale, Suicide Assessment Five‐step Evaluation and Triage, and Columbia‐Suicide Severity Rating Scale. Patients who subsequently received a psychiatric evaluation were included, and the utility of these screening tools to predict disposition was evaluated. Results 276 subjects completed all three suicide screening tools and were included in data analyses. Eighty‐two patients (30%) were admitted or transferred. Three patients (1%) died by suicide within one year of enrollment; one was hospitalized at the end of his or her enrollment visit, dying by suicide seven months later and the other two were discharged, dying by suicide nine and ten months later, respectively. The screening tools exhibited modest negative predictive values (range: 0.66–0.73). Conclusion Three suicide screening tools displayed modest ability to predict the disposition of patients who presented to an emergency department with suicidal ideation. This study supports the current ACEP clinical policy on psychiatric patients which states that screening tools should not be used in isolation to guide disposition decisions of suicidal patients from the ED.

Health Care Usage and Suicide Risk Screening within 1 Year of Suicide Death

BACKGROUNDnResearch indicates patients often seek medical care within 1xa0year of suicide. Health care encounters are a crucial opportunity for health professionals to identify patients at highest risk and provide preventative services.nnnOBJECTIVEnStudy aims were to determine the characteristics of persons seeking health care within 12xa0months of suicide death and evaluate suicide risk screening (SRS) frequency in the emergency department (ED) vs. clinic settings.nnnMETHODSnMedical examiner and hospital data of patients who died by suicide from 2007 to 2013 were evaluated. Descriptive analyses included demographics and frequency of ED vs. clinic visits. We also compared SRS before and after implementation of The Joint Commissions recommendation to assess suicide risk.nnnRESULTSnThe 224 deceased patients were primarily single white males (mean age 67xa0years). Mental health issues, substance abuse, and prior suicide attempts were present alone or in combination in 74%. Visits were primarily behavioral health or substance abuse problems in the ED, and medical issues in the clinic. After implementation of universal SRS in the ED, screening increased from 39% to 92%. Among patients screened in the ED, 73% (37 of 51) screened negative for suicide risk.nnnCONCLUSIONSnUniversal SRS increased the number of people screened in the ED. However, negative SRS may not equate to reduced risk for future suicide within 1xa0year. Future studies might investigate targeted screening of individuals with known suicide risk factors, as well as alternatives to patient self-report of intent to self-harm for patients with mental health or substance abuse problems.

Risperidone in the Emergency Setting is Associated with More Hypotension in Elderly Patients

BACKGROUNDnExpert consensus panels have recommended risperidone as first-line treatment for agitation of psychiatric origin. However, there are few if any studies on this medication in the emergency setting.nnnOBJECTIVESnTo assess the hemodynamic effects of risperidone in an emergency department (ED) setting, stratified by age.nnnMETHODSnThis is a structured chart review of all patients who received oral risperidone over a 6-year period in an ED setting, excluding patients who received this medication as a prescription refill. Vital signs were analyzed for this subset prior to and after medication administration, and changes in vital signs were stratified by age.nnnRESULTSnThe median dose of risperidone was less in patients aged > 65xa0years. However, the median drop in systolic blood pressure was larger in this age group compared with younger patients.nnnCONCLUSIONSnClinicians tend to be more cautious with dosing of risperidone to geriatric patients in the ED. Despite this, decreases in systolic blood pressure are larger and more frequent in this age group. When possible, clinicians should consider or attempt nonpharmacologic methods of agitation treatment prior to administering medications such as risperidone to elderly patients.

Oral Medication for Agitation of Psychiatric Origin: A Scoping Review of Randomized Controlled Trials

BACKGROUNDnUnderstanding more about the efficacy and safety of oral second-generation antipsychotic medications in reducing the symptoms of acute agitation could improve the treatment of psychiatric emergencies.nnnOBJECTIVEnThe objective of this scoping review was to examine the evidence base underlying expert consensus panel recommendations forxa0the use of oral second-generation antipsychotics to treat acute agitation in mentally ill patients.nnnMETHODSnThe Cochrane Schizophrenia Groups Study-Based Register was searched for randomized controlled trials comparing oral second-generation antipsychotics, benzodiazepines, or first-generation antipsychotics with or without adjunctive benzodiazepines, irrespective of route of administration of the drug being compared. Six articles were included in the final review.nnnRESULTSnTwo oral second-generation antipsychotic medications were studied across the six included trials. While the studies had relatively small sample sizes, oral second-generation antipsychoticsxa0were similarly effective to intramuscular first-generationxa0antipsychotics in treating symptoms of acute agitation and had similar side-effect profiles.nnnCONCLUSIONSnThis scoping review identified six randomized trials investigating the use of oral second-generation antipsychotic medications in the reduction of acute agitation among patients experiencing psychiatric emergencies. Further research will be necessary to make clinical recommendations due to the overall dearth of randomized trials, as well as the small sample sizes of the included studies.

Neuropsychiatric Complications of Steroids

Steroids are ubiquitous medications used to treat myriad disease processes.They are not without complications or side effects, however.In addition to weight gain, hyperglycemia, and immunosuppression, neuropsychiatric complications may also be present.Often referred to as “steroid psychosis” the neuropsychiatric complications of steroid use are much more diverse and not necessarily so obvious as the moniker implies.Manifestations range from an increased sense of well-being to hypomania, mania, depression, and frank psychosis.In addition, cognitive symptoms may be present such as difficulty with attention, concentration, and memory impairment.Symptoms generally start within days to weeks of starting steroids.Cases have occurred hours after starting therapy as well as after discontinuation of steroids, however.The true incidence is unclear and various studies report a broad range of 2–60%.Higher doses of steroids do convey an increased risk for developing neuropsychiatric symptoms, however, doses as low as 2.5 mg of prednisone daily have resulted in symptoms.In addition, essentially all routes of administration have been associated with the development of symptoms including inhaled, intra-articular, epidural, topical, and of course oral.Outcomes are generally good with resolution of neuropsychiatric symptoms within 6 weeks for 90% of individuals.Cognitive insults may take months to fully resolve.Treatment details are discussed below.

Neuroleptic Malignant Syndrome

Neuroleptic Malignant Syndrome (NMS) is the result of dopamine receptor blockade in the CNS.Classically it is characterized by the tetrad of altered mental status, rigidity, hyperthermia, and autonomic dysfunction.In practice, however, NMS exists on a spectrum and not all four features need be present for the diagnosis.It is also important to understand that less severe dopamine receptor blockade may present only with dystonia or akathisia.While not classified as NMS, these manifestations are the result of the same pathophysiologic mechanism.