Rachel B. Katz

A Survey of the Clinical, Off-Label Use of Ketamine as a Treatment for Psychiatric Disorders

TO THE EDITOR: Since 2000, several small randomized controlled trials have demonstrated that ketamine has potent and rapid-acting antidepressant effects in patients with treatment-resistant depression (1). Despite a lack of longterm data or Food and Drug Administration indication, many community providers and academic centers have begun offering ketamine treatment to patients with major depressive disorder and with other psychiatric disorders, determining the existing evidence justifies use for some individuals. Thepractice patterns of suchprovidershavenot been studied.

Lithium Toxicity Presenting as Transient Transcortical Motor Aphasia: A Case Report

Patients with chronic lithium toxicity typically present with symptoms of agitation, confusion, tremor, ataxia, and hyperreflexia. In rare cases, however, lithium toxicity can present with transient cognitive and language deficits. We report the case of a lithium-toxic patient who presented with transient transcortical motor aphasia, which resolved 2 days after discontinuation of lithium. This is the first report of focal transcortical motor aphasia in a patient with lithium toxicity. Given the narrow therapeutic range of lithium, clinicians should be aware of the possibility of focal aphasia as a rare manifestation of lithium toxicity.

Effective Research Mentorship for Residents: Meeting the Needs of Early Career Physicians

ObjectiveChallenges in pursuing research during residency may contribute to the shortage of clinician-scientists. Although the importance of mentorship in facilitating academic research careers has been described, little is understood about early career research mentorship for residents. The aim of this study was to better understand the mentorship process in the context of psychiatry residency.MethodSemi-structured interviews were conducted with experienced faculty mentors in a psychiatry department at a large academic medical center. Interviews were analyzed using inductive thematic analysis. Results from faculty interviews identified several key themes that were explored with an additional sample of resident mentees.ResultsFive themes emerged in our study: (1) being compatible: shared interests, methods, and working styles; (2) understanding level of development and research career goals in the context of residency training; (3) establishing a shared sense of expectations about time commitment, research skills, and autonomy; (4) residents’ identity as a researcher; and (5) the diverse needs of a resident mentee. There was considerable congruence between mentor and mentee responses.ConclusionsThere is an opportunity to improve research mentoring practice by providing guidance to both mentors and mentees that facilitates a more structured approach to the mentorship relationship.

Ketamine: A Promising Rapid-Acting Antidepressant

The monoaminergic deficiency hypothesis of depression has dominated the field of mood disorders research for several decades. This hypothesis has led to many advancements, including the theoretical underpinnings of the mechanism of action of all current oral antidepressants. However, the monoaminergic deficiency hypothesis does not fully explain the neurobiology of mood disorders, including the high rates of non-response and the delayed time between initiation of therapy and improvement in mood and related symptoms. Emerging evidence suggests a strong role for the glutamatergic system in the pathophysiology of mood disorders, which may provide more efficient therapeutic targets in the development of novel antidepressants. Ketamine, which acts directly on a glutamatergic receptor (N-methyl-d-aspartate receptor), has been shown to produce robust and rapid antidepressant effects after just a single dose. The effects of a single-dose have been replicated in several clinical trials of modest size. Less is known about multiple dosing protocols. While ketamine is approved by the Food and Drug Administration and similar agencies as an anesthetic, it is not approved in any country as an antidepressant. Concerns of the long-term effects on cognition and abuse from repeated ketamine exposure motivate the search for relapse prevention strategies that do not involve repeated administration of the drug. Given that a growing number of providers have begun offering ketamine off-label for the treatment of psychiatric disorders, future research is urgently needed to better understand long-term risks as well as evidence-based treatment regimens.

The Use of Electroconvulsive Therapy in Late-Life Psychiatric Disorders

PurposeTo review the current literature regarding the use and safety of electroconvulsive therapy (ECT) in the elderly population.Recent findingsElectroconvulsive therapy (ECT) is both a safe and effective treatment for geriatric patients with severe psychiatric illness. In an era of often inadequate or poorly tolerated pharmacologic treatments, ECT can provide life-saving treatment for depression, catatonia, movement disorders, and even mood and behavioral dysregulation in dementia syndromes. The Prolonging Remission in Depressed Elderly (PRIDE) study directed by Charles Kellner has provided clear and convincing empirical data for the use of ECT in this age group for the treatment of depression.SummaryThe data for the use of ECT for the treatment of depression in the elderly and in prolonging remission is convincing. The convergence of data for the treatment of late-life catatonia is also favorable. Data regarding the use as a treatment for the core movement disorder of Parkinson’s disease is intriguing and warrants further investigation. The data for its use in other areas, particularly dementia, is less clear and a possible clinical algorithm is presented.