Oliver M. Glass

Use of Buprenorphine in treatment of refractory depression—A review of current literature

OBJECTIVE Current treatment strategies for depressive disorders have limited efficacy, leaving many patients unimproved or with significant residual symptoms. The development of additional treatments represent a significant unmet need for providers. Several lines of evidence suggest that the opioid system may be involved in regulation of mood and incentives salience. Intervention based on modifying central opioid receptors may represent a novel approach to treatment of depressive disorders among those unresponsive to accepted treatments. DATA SOURCES We searched the English language literature using keywords: Buprenorphine AND Major Depression; Buprenorphine AND Bipolar Depression; Buprenorphine AND Affective Disorders. RESULTS Use of low dose buprenorphine as augmentation of pharmacotherapy for depression has shown promise in several reported studies. Effect size of available randomized controlled studies is comparable if not greater than most accepted augmentation strategies. CONCLUSION Review of available literature on the use of buprenorphine in individuals with treatment resistant depression demonstrated efficacy in the treatment of depressive disorders. Further prospective randomized controlled trials should be undertaken to evaluate the efficacy of buprenorphine as an adjunct for depression refractory to current pharmacotherapies.

Training Residents in the Use of Telepsychiatry: Review of the Literature and a Proposed Elective

Many regions in the United States are deficient in mental health services, especially those in rural areas. As a result of these deficiencies, many patients in need of psychiatric services are often left untreated. Although it is clear that telepsychiatry has great potential in improving patient access to mental health care in areas where psychiatric services are deficient, the lack of familiarity with the technology and inadequate training are current barriers to expanding the use of telepsychiatry. A review of telepsychiatry, its clinical applications, and evidence-based literature regarding competencies in graduate medical education related to telepsychiatry are provided. An approach to implementing telepsychiatry into a curriculum is suggested. We also propose an elective clinical experience with resources for didactics or independent study that will enable residents to develop a knowledge base and competence in the practice of telepsychiatry.

Psychiatry Resident Training in Cultural Competence: An Educator’s Toolkit

Resident physicians training in psychiatry in the U.S. are required to master a body of knowledge related to cultural psychiatry; are expected to adopt attitudes that endorse the principles of cultural competence; and finally are expected to acquire specific cultural competence skills that facilitate working effectively with diverse patients. This article first provides an overview of the Accreditation Council for Graduate Medical Education (ACGME) competencies related to cultural competence, as well as the American Academy of Child and Adolescent Psychiatry’s (AACAP) recommendations for the cultural competence training of child/adolescent fellows. Next, numerous print and electronic resources that can be used in cultural competence education in psychiatry are reviewed and discussed. Finally, we conclude by providing recommendations for psychiatry residency programs that we culled from model cultural competence curricula.

A case of lithium-induced parkinsonism presenting with typical motor symptoms of Parkinson's disease in a bipolar patient.

Lithium is a mood stabilizer rarely associated with drug-induced parkinsonism (DIP). We present a case of an elderly woman with bipolar disorder who developed parkinsonian symptoms after chronic lithium administration despite therapeutic serum levels. Upon evaluation, classic parkinsonian signs of muscle rigidity, tremor, bradykinesia, freezing of gait, and cognitive decline were observed. Initially, she was diagnosed with Parkinsons disease (PD); however, DaTscan SPECT imaging clarified the diagnosis as DIP. As the daily lithium dosage was reduced, the patients motor symptoms improved. This report emphasizes close monitoring of lithium levels in geriatric populations and the need to consider lithium-induced parkinsonism when PD symptoms appear in chronic lithium users.

Electroconvulsive Therapy in Depression

The current practice of electroconvulsive therapy (ECT) has evolved over several decades with the implementation of safer equipment and advancement of techniques. In addition, modifications in the delivery of ECT, such as the utilization of brief and ultrabrief pulse widths and individualization of treatment parameters, have improved the safety of ECT without sacrificing efficacy. This article aims to provide psychiatrists with a balanced, in-depth look into the recent advances in ECT technique as well as the evidence of ECT for managing depression in special populations and patients with comorbid medical problems.

Exploring Ketamine Use in Geriatric Patients Suffering From Treatment-Resistant Depression

with Major Depressive Disorder. Anhedonia likely reflects altered functioning of key brain circuits involved in the reward process but it is unclear whether increased anhedonia is associated with distinct clinical and cognitive symptoms. The purpose of this study is to examine demographic, clinical and cognitive characteristics associated with increased levels of anhedonia in older depressed adults. Methods: We examined 65 currently depressed older adults aged 60 years or older. Participants completed a standardized diagnostic interview and clinical assessments, including self-report of depressive symptoms. These assessments included the Snaith-Hamilton Pleasure Scale (SHAPS) to quantify severity of anhedonia. Participants additionally completed a neuropsychological battery, including tests focused on processing speed and executive function. We examined participant characteristics associated with SHAPS score in a staged approach, first examining demographics, then clinical measures, followed by cognitive profile. Analyses controlled for overall depression severity using a modified MADRS score with the anhedonia item removed. In secondary analyses, we dichotomized sample into those with high or low SHAPS scores determined by a median split and re-analyzed the clinical and cognitive variables. Results: Total SHAPS score was not associated with demographic variables, but did exhibit a positive association with modified MADRS score (Pearson correlation coefficient = 0.32, p 0.0094). After controlling for modified MADRS score, SHAPS score was not associated with clinical measures of perceived stress, apathy, rumination, fatigue, worry, or insomnia. However, after controlling for age and medical morbidity, it was positively associated with disability (F = 5.03, p=00334). After controlling for modified MADRS, age, and education, higher SHAPS scores were also positively associated with better performance on the Stroop test measures of processing speed (color naming; F=9.51, p=0.0034) and executive functioning (color-word interference; F=9.43, p = 0.0035). When we dichotomized the sample into high and low anhedonia groups based on the median, we replicated the above findings. We additionally observed that the high anhedonia sample was younger (t=2.76, p = 0.0083) with an earlier age of initial onset of depression (t=2.18, p=0.0332). Conclusions: Greater anhedonia is associated with greater overall depression severity and with greater disability. However, it is also associated with better processing speed and executive function performance as measured by the Stroop test. This apparent discrepancy may be explained by analyses of high versus low anhedonic subjects, where individuals with higher anhedonia were more likely to be younger patients and report an earlier age of first episode. We propose greater anhedonia occurs in younger, earlier onset depressed elders with perhaps a greater lifetime duration of depression or higher number of recurrent depressive episodes. This may contribute to the greater reported disability, but their age may be related to the superior cognitive test performance.

Neuromodulation Therapies and Ketamine in Older Age Bipolar Disorder

Neuromodulation therapies are important alternatives for the management of treatment-resistant mood disorders in the elderly. Some of these therapies are relatively modern strategies such as the recently FDA-approved transcranial magnetic stimulation (TMS), vagal nerve stimulation (VNS), and deep brain stimulation (DBS), which is still undergoing extensive research. The use of electroconvulsive therapy (ECT) has evolved in its practice since the 1940s with a recent significant shift toward the use of right unilateral, ultra-brief-pulse width. Additionally, ECT is increasingly delivered in outpatient settings. The roles of the newer therapies have not been systematically studied in the geriatric population, and despite the fact that ECT has been widely used in the older population, there is limited evidence-based data about the use of ECT in the older adults. Older individuals are particularly vulnerable to polypharmacy given increasing medical comorbidity with advancing age. Neuromodulation techniques are not pharmacotherapies and, therefore, have the potential of limiting polypharmacy in older adults with psychiatric disorders. While the vast majority of neuromodulation therapy research focuses on unipolar depression, there is an increase in research examining the safety and efficacy of ECT for individuals with bipolar disorder. In this chapter, we will review the evidence-based data for electroconvulsive therapy (ECT), transcranial magnetic stimulation (TMS), deep brain stimulation (DBS), transcranial direct current stimulation (tDCS), magnetic seizure therapy (MST), and focal electrically administered seizure therapy (FEAST) in older adults with psychiatric disorders. Relevant evidence for the use of ketamine during ECT and independent of ECT treatment will also be reviewed.

Oral Health in Electroconvulsive Therapy: A Neglected Topic.

Abstract Psychiatric medications may have serious and untoward adverse effects such as blurred vision, restlessness, agranulocytosis, muscle rigidity, and tremors. When compared to medications, electroconvulsive therapy (ECT) is becoming a more acceptable treatment due to its efficacy, tolerability, and minimal adverse effect profile. Oral trauma can be an ECT-related adverse effect. We reviewed the published literature on oral health and dental protection in patients undergoing ECT, and found that there are deficits in all guidelines on dental protection during ECT. Dental assessment and treatment before and after ECT is warranted. Given the increased risk of poor oral health in psychiatric patients, and the continued evolution of ECT as a mainstay treatment, it is important that studies be conducted to determine the optimal method of oral protection. If adequate care can be ensured, the risks of ECT-induced oral trauma will be minimized.

“Meth Mouth”: An Interdisciplinary Review of a Dental and Psychiatric Condition

Objective: Chronic methamphetamine (MA) users experience many dental problems, a condition characterized as “meth mouth.” These devastating effects on dentition is the main reason why many seek professional help. Here, we discuss the effects of MA on oral health and advocate for improved collaboration between dentists and mental health providers. We also introduce a dental evaluation tool with the goal of improving the quality of care for this often-marginalized patient population. Methods: A Medline literature search (1985–2016) was conducted with keywords “meth mouth,” “methamphetamine AND oral health”; “methamphetamine AND dental”; “methamphetamine AND dentist.” Results were supplemented by references gleaned from recent reviews, credible online sources, and citations of search returns. Results: MA predisposes users to tooth decay. They are also more likely to have missing dentition with a linear relationship correlating the number of years of use. A constellation of dental symptoms resulting from chronic MA use has been described in literature: gingival inflammation, excessive tooth wear, decreased salivary output, and severe dental caries. With continued use, mucosal lesions may appear on the lips and the gingival tissue may recede. MA can trigger bruxism, resulting in severe wear patterns and even cracked teeth. Conclusions: Users of MA have many unmet medical and mental health needs. An interdisciplinary approach between dentists and mental health providers can improve outcomes. The dental evaluation tool described here can improve the bidirectional collaboration between mental health and dentistry. Dental professionals are in a unique position to identify users and can facilitate referral to substance abuse treatment. Likewise, mental health providers can identify, assess severity, and prompt users for medical and dental attention.