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Park S, Forester BP, Lapid MI, Harper DG, Hermida AP, Inouye SK, McClintock SM, Nykamp L, Petrides G, Schmitt EM, Seiner SJ, Mueller M, Patrick RE. A Novel Approach to Monitoring Cognitive Adverse Events for Interventional Studies Involving Advanced Dementia Patients: Insights From the Electroconvulsive Therapy for Agitation in Dementia Study. J Geriatr Psychiatry Neurol 2024; 37:234-241. [PMID: 37848185 DOI: 10.1177/08919887231207641] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2023]
Abstract
OBJECTIVE To develop an individualized method for detecting cognitive adverse events (CAEs) in the context of an ongoing trial of electroconvulsive therapy for refractory agitation and aggression for advanced dementia (ECT-AD study). METHODS Literature search aimed at identifying (a) cognitive measures appropriate for patients with advanced dementia, (b) functional scales to use as a proxy for cognitive status in patients with floor effects on baseline cognitive testing, and (c) statistical approaches for defining a CAE, to develop CAEs monitoring plan specifically for the ECT-AD study. RESULTS Using the Severe Impairment Battery-8 (SIB-8), baseline floor effects are defined as a score of ≤5/16. For patients without floor effects, a decline of ≥6 points is considered a CAE. For patients with floor effects, a decline of ≥30 points from baseline on the Barthel Index is considered a CAE. These values were derived using the standard deviation index (SDI) approach to measuring reliable change. CONCLUSIONS The proposed plan accounts for practical and statistical challenges in detecting CAEs in patients with advanced dementia. While this protocol was developed in the context of the ECT-AD study, the general approach can potentially be applied to other interventional neuropsychiatric studies that carry the risk of CAEs in patients with advanced dementia.
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Affiliation(s)
- Soohyun Park
- Department of Psychiatry, Tufts Medical Center, Boston, MA, USA
- Department of Psychiatry, Tufts University School of Medicine, Boston, MA, USA
| | - Brent P Forester
- Department of Psychiatry, Tufts Medical Center, Boston, MA, USA
- Department of Psychiatry, Tufts University School of Medicine, Boston, MA, USA
| | - Maria I Lapid
- Department of Psychiatry & Psychology, Mayo Clinic, Rochester, MN, USA
| | - David G Harper
- Geriatric Psychiatry Research Program, McLean Hospital, Belmont, MA, USA
- Department of Psychiatry, Harvard Medical School, Boston, MA, USA
| | - Adriana P Hermida
- Department of Psychiatry and Behavioral Science, Emory University School of Medicine, Atlanta, GA, USA
| | - Sharon K Inouye
- Aging Brain Center, Hebrew Senior Life, Hinda and Arthur Marcus Institute for Aging Research, Boston, MA, USA
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Shawn M McClintock
- Division of Psychology, Department of Psychiatry, UT Southwestern Medical Center, Dallas, TX, USA
| | - Louis Nykamp
- Pine Rest Christian Mental Health Services, Grand Rapids, MI, USA
| | - Georgios Petrides
- Zucker Hillside Hospital, Northwell Health, Glen Oaks, NY, USA
- Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Eva M Schmitt
- Aging Brain Center, Hebrew Senior Life, Hinda and Arthur Marcus Institute for Aging Research, Boston, MA, USA
| | - Stephen J Seiner
- Psychiatric Neurotherapeutics Program, McLean Hospital, Belmont, MA, USA
| | - Martina Mueller
- College of Nursing and Department of Public Health Sciences, Medical University of South Carolina (MUSC), Charleston, SC, USA
| | - Regan E Patrick
- Geriatric Psychiatry Research Program, McLean Hospital, Belmont, MA, USA
- Department of Psychiatry, Harvard Medical School, Boston, MA, USA
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Ketcham E, Glass OM, Hermida AP. Electroconvulsive Therapy in Heart Transplant Patients: To Avoid or Embrace? J ECT 2024; 40:6-9. [PMID: 37561916 DOI: 10.1097/yct.0000000000000954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/12/2023]
Abstract
ABSTRACT Patients with heart disease are at an increased risk of depression. Electroconvulsive therapy (ECT) is a highly effective treatment for severe depressive episodes. However, ECT may increase the risk for adverse outcomes in certain patients because of changes in blood pressure and heart rate secondary to an initial parasympathetic surge followed by a sympathetic surge and peripheral catecholamine release. In post-cardiac transplant patients, these acute hemodynamic changes on a denervated heart may bring clinical challenges. The available data on ECT in heart transplant patients are limited. The authors of this article present a summary of the available literature relating to ECT in heart transplant patients.The authors performed a literature search of 6 online databases yielding 6 English-language case reports of ECT in cardiac transplant patients. All patients experienced changes in hemodynamic variables during and immediately after ECT, ranging from moderate decrease in blood pressure to extreme hypertension. The cases did not report any serious cardiac complications during the course of ECT. In the 5 patients whose psychiatric responses to treatment were detailed, all had improvement in their depressive symptoms. Electroconvulsive therapy may be considered for severe cases of depression in patients with a history of cardiac transplant, but the potential benefit of ECT needs to be weighed against risks. In the limited number of cases reported in the literature, ECT seems to have been relatively safe and effective.
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Affiliation(s)
- Evan Ketcham
- From the Department of Psychiatry, Dartmouth Hitchcock Medical Center, Lebanon, NH
| | | | - Adriana P Hermida
- Department of Psychiatry and Behavioral Sciences, Emory University, Augusta, GA
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Rakofsky JJ, Stoddard HA, Haroon E, Hermida AP, Debrey SM, Crowell AL, Dunlop BW. A Chart-Stimulated Recall Activity to Assess Psychiatry Residents' Treatment-Based, Clinical Reasoning Skills. Acad Psychiatry 2023; 47:663-666. [PMID: 37173552 DOI: 10.1007/s40596-023-01789-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Accepted: 05/02/2023] [Indexed: 05/15/2023]
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Liu X, Liang S, Liu J, Sha S, Zhang L, Jiang W, Jiang C, Hermida AP, Tang Y, McDonald WM, Ren Y, Wang G. Psychometric Properties of the Chinese Version of the ElectroConvulsive Therapy Cognitive Assessment: An Electroconvulsive Therapy-Specific Cognitive Screening Tool. J ECT 2023:00124509-990000000-00120. [PMID: 38009975 DOI: 10.1097/yct.0000000000000977] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2023]
Abstract
OBJECTIVES Electroconvulsive therapy (ECT) is an effective somatic treatment, but it may be limited by cognitive adverse effects. The existing cognitive screening instruments often lack specificity to ECT-associated cognitive deficits. The ElectroConvulsive Therapy Cognitive Assessment was developed and validated in a clinical setting, but the reliability and validity of the Chinese version of ElectroConvulsive Therapy Cognitive Assessment (ECCA-C) have not been studied in a large clinical sample. METHODS The ECCA-C and the Montreal Cognitive Assessment (MoCA) were administered to patients with major depressive disorder (MDD) undergoing ECT at 3 time points: pretreatment (baseline), before the fifth treatment, and 1 week posttreatment. The instruments were also administered to a sample of healthy subjects. RESULTS Sixty-five patients with MDD and 50 age- and sex-matched healthy controls were recruited in this study. Overall, the patient group had statistically significantly lower MoCA and ECCA-C scores than the control group (both P values <0.001). The Cronbach α of the ECCA-C was 0.88 at baseline. Statistically significant decreases over time were observed in ECCA-C: pre-ECT (23.9 ± 4.0) > mid-ECT (21.3 ± 3.4) > post-ECT (18.7 ± 4.8) (all P values <0.001), whereas no statistically significant changes in MoCA scores were found at these 3 time points (F = 1.86, P = 0.165). A cutoff score of 26.5 on the ECCA-C was found to best differentiate between MDD patients and healthy controls. CONCLUSIONS The ECCA-C showed satisfactory psychometric properties and may be a more sensitive instrument than the MoCA to assess cognitive impairment associated with ECT.
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Affiliation(s)
| | | | | | | | | | | | | | - Adriana P Hermida
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine
| | | | - William M McDonald
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine
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5
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Sterina E, Gregory N, Hermida AP. Acute and Prophylactic Management of Postictal Agitation in Electroconvulsive Therapy. J ECT 2023; 39:136-140. [PMID: 36215425 DOI: 10.1097/yct.0000000000000886] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/08/2023]
Abstract
ABSTRACT Postictal agitation (PIA) is a common adverse effect of electroconvulsive therapy (ECT), a treatment used for a variety of psychiatric disorders. Because of risk of harm to patients and health providers when patients develop PIA, its acute management and prophylaxis are of vital importance for ECT practitioners. This article describes PIA risk factors, as well as practical steps to manage this ECT complication. Nonpharmacologic patient safety interventions are critical components of PIA management. Benzodiazepines, antipsychotics, and additional anesthetic doses are discussed as acute treatment interventions. Prophylactic pharmacologic choices described include antipsychotics, postseizure anesthetics, and dexmedetomidine. Exploratory choices such as melatonin and intranasal formulations of sedatives are also discussed. This review suggests that common medication like olanzapine and propofol are cost-effective considerations to decrease PIA incidence and/or severity after ECT. In addition, dexmedetomidine presents a management alternative for treatment-resistant PIA. This literature review outlines treatment choices while suggesting future directions for considering effective treatments of postictal agitation in clinical settings.
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Affiliation(s)
| | | | - Adriana P Hermida
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA
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Benjamin I, Hershenberg R, Dorrell KD, Tan AC, Riva-Posse P, McDonald WM, Hermida AP, Crowell A, Feinstein BA. Differences in clinical presentations of patients seeking care for treatment-resistant depression across sexual orientations and gender identities. Ann Clin Psychiatry 2023; 35:199-208. [PMID: 37459501 DOI: 10.12788/acp.0112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/20/2023]
Abstract
BACKGROUND Sexual and/or gender minority (SGM) individuals experience higher rates and greater severity of depressive disorders than non-SGM persons. SGM individuals are more likely than non-SGM individuals to seek mental health treatment and to present to treatment with unique characteristics that should be accounted for when considering treatment recommendations. Patients seeking care for treatment-resistant depression (TRD) are offered a variety of evidence-based interventions ranging in modality and invasiveness (eg, psychotherapy and neuromodulation). METHODS The current study used data from a TRD clinical research program to examine whether SGM (N = 52) and non-SGM (N = 202) patients differed in their clinical presentations and the treatment recommendations offered to them. RESULTS We found that SGM patients were younger, had a more severe history of childhood trauma, and reported greater current suicidality than non-SGM patients. There were no significant differences in treatment recommendations between groups. CONCLUSIONS This study adds to nascent literature investigating clinical characteristics of SGM populations seeking mental health care and provides foundational evidence for the unique treatment considerations necessary for SGM individuals seeking treatment for TRD. Research into whether treatment outcomes differ for SGM and non-SGM individuals with TRD is encouraged, given clinical differences in trauma history and suicidality.
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Affiliation(s)
- Isabel Benjamin
- Department of Psychology, Rosalind Franklin University of Medicine and Science, North Chicago, Illinois, USA
| | - Rachel Hershenberg
- Department of Psychiatry and Behavioral Sciences, Emory University, Atlanta, Georgia, USA
| | - Kate D Dorrell
- Department of Psychology, Rosalind Franklin University of Medicine and Science, North Chicago, Illinois, USA
| | - Amanda C Tan
- Department of Psychiatry and Behavioral Sciences, Emory University, Atlanta, Georgia, USA
| | - Patricio Riva-Posse
- Department of Psychiatry and Behavioral Sciences, Emory University, Atlanta, Georgia, USA
| | - William M McDonald
- Department of Psychiatry and Behavioral Sciences, Emory University, Atlanta, Georgia, USA
| | - Adriana P Hermida
- Department of Psychiatry and Behavioral Sciences, Emory University, Atlanta, Georgia, USA
| | - Andrea Crowell
- Department of Psychiatry and Behavioral Sciences, Emory University, Atlanta, Georgia, USA
| | - Brian A Feinstein
- Department of Psychology, Rosalind Franklin University of Medicine and Science, North Chicago, Illinois, USA
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Giampetruzzi E, Tan AC, LoPilato A, Kitay B, Posse PR, McDonald WM, Hermida AP, Crowell A, Hershenberg R. The impact of adverse childhood experiences on adult depression severity and treatment outcomes. J Affect Disord 2023; 333:233-239. [PMID: 37086798 DOI: 10.1016/j.jad.2023.04.071] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Revised: 04/06/2023] [Accepted: 04/16/2023] [Indexed: 04/24/2023]
Abstract
BACKGROUND Past research has established that adverse childhood experiences (ACE) are correlated with depression severity. The purpose of the present study was to examine how the number and nature of ACE exposure is associated with symptomatology and treatment outcomes in adult patients with treatment resistant depression (TRD). METHODS Participants include 454 patients with a diagnosis of major depression or persistent depressive disorder. A one-way analysis of variance (ANOVA) was used to assess whether number of ACEs was associated with certain outcomes. Linear regression analyses were performed to model the associations between the five ACE subtypes (e.g., sexual abuse, physical violence, injury/illness, childhood grief, and parental upheaval) and symptom severity. Logistic regression analyses were then used to model the association between ACE subtypes and history of lifetime suicide attempt(s) and inpatient admission(s). RESULTS Greater ACE exposure was associated with more severe symptomatology and treatment outcomes, but these differences were only seen between patients reporting no ACEs versus 3+ ACEs. Only the subtypes of violence and illness/injury were significant predictors of more severe symptomatology. The ACE subtypes of sexual trauma and violence uniquely predicted a lifetime suicide attempt(s), and only the subtype of sexual trauma predicted lifetime inpatient admission(s). LIMITATIONS Limitations of the present study include retrospective adult assessments of childhood trauma, lack of data on ACE severity and timing, and the cross-sectional reporting of multiple study measures. CONCLUSIONS Exposure to multiple ACE subtypes, particularly sexual and physical trauma, is associated with depression symptom severity, and history of suicidality, and inpatient admission(s).
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Affiliation(s)
- Eugenia Giampetruzzi
- Department of Psychiatry and Behavioral Sciences, Emory School of Medicine, United States of America.
| | - Amanda C Tan
- Department of Psychiatry and Behavioral Sciences, Emory School of Medicine, United States of America
| | - Allison LoPilato
- Department of Psychiatry and Behavioral Sciences, Emory School of Medicine, United States of America
| | - Brandon Kitay
- Department of Psychiatry and Behavioral Sciences, Emory School of Medicine, United States of America
| | - Patricio Riva Posse
- Department of Psychiatry and Behavioral Sciences, Emory School of Medicine, United States of America
| | - William M McDonald
- Department of Psychiatry and Behavioral Sciences, Emory School of Medicine, United States of America
| | - Adriana P Hermida
- Department of Psychiatry and Behavioral Sciences, Emory School of Medicine, United States of America
| | - Andrea Crowell
- Department of Psychiatry and Behavioral Sciences, Emory School of Medicine, United States of America
| | - Rachel Hershenberg
- Department of Psychiatry and Behavioral Sciences, Emory School of Medicine, United States of America
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Tan AC, Giampetruzzi E, Tsygankova V, Hershenberg R, Job GP, Crowell A, Posse PR, McDonald WM, Kitay BM, Hermida AP, Li M. Tolerability and effectiveness of rTMS for geriatric patients with treatment-resistant depression in a naturalistic clinic setting. The American Journal of Geriatric Psychiatry 2023. [DOI: 10.1016/j.jagp.2022.12.167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/18/2023]
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9
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Kim J, Rice H, Bonsu N, Tan AC, Posse PR, Kitay BM, Hershenberg R, McDonald WM, Crowell A, Hermida AP. Ketamine infusion therapy for the management of treatment resistant depression in an outpatient geriatric population. The American Journal of Geriatric Psychiatry 2023. [DOI: 10.1016/j.jagp.2022.12.175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/18/2023]
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Tsygankova V, Pritchett C, Forester B, Petrides G, Lapid M, Mueller M, Nykamp L, Harper D, Tan AC, Hermida AP. ECT-AD Trial: Rationale for ECT lead placement and dosing in the treatment of refractory agitation and aggression in dementia. The American Journal of Geriatric Psychiatry 2023. [DOI: 10.1016/j.jagp.2022.12.222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/18/2023]
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Lapid MI, Forester BP, Patrick RE, Fong TG, Green ME, Harper DG, Heintz HL, Hermida AP, McManus KR, Mueller M, Nykamp LJ, Petrides G, Inouye SK. Identifying delirium in advanced dementia in the ECT‐AD clinical trial. Alzheimers Dement 2022. [DOI: 10.1002/alz.066388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
| | | | - Regan E. Patrick
- Harvard Medical School Boston MA USA
- McLean Hospital Belmont MA USA
| | - Tamara G. Fong
- Harvard Medical School Boston MA USA
- Marcus Institute for Aging Research, Hebrew SeniorLife Boston MA USA
- Beth Israel Deaconess Medical Center Boston MA USA
| | | | - David G. Harper
- Harvard Medical School Boston MA USA
- McLean Hospital Belmont MA USA
| | | | | | | | | | - Louis J. Nykamp
- Pine Rest Christian Mental Health Center Grand Rapids MI USA
| | | | - Sharon K. Inouye
- Harvard Medical School Boston MA USA
- Marcus Institute for Aging Research, Hebrew SeniorLife Boston MA USA
- Beth Israel Deaconess Medical Center Boston MA USA
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12
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McManus KR, Lapid MI, Forester BP, Mueller M, Hermida AP, Nykamp L, Harper DG, Seiner SJ, Sanghani S, Patrick R, Gentry MT, Kung S, Leal JC, Johnson EK, Petrides G. Simulated Electroconvulsive Therapy: A Novel Approach to a Control Group in Clinical Trials. J ECT 2022; 38:165-170. [PMID: 35220356 PMCID: PMC9420159 DOI: 10.1097/yct.0000000000000832] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Agitation is the most common behavioral symptom of Alzheimer disease (AD) affecting approximately 40% to 60% of the AD population, yet there are no Food and Drug Administration-approved therapies for the myriad of behavioral or psychological symptoms of dementia. There is growing evidence from naturalistic studies that electroconvulsive therapy (ECT) is a safe and effective treatment for agitation in AD patients who are refractory to pharmacotherapy and behavioral interventions. Despite the existing evidence, ECT remains underused because of stigma, lack of education, and concerns regarding adverse cognitive effects. Randomized controlled clinical trials of ECT are an opportunity to provide high-quality evidence of ECT as a safe and efficacious treatment for agitation in the AD population. We describe the methods for the Electroconvulsive Therapy in Alzheimer's Dementia study, which uses a novel, simulated ECT (S-ECT) control group to conduct a single-blind efficacy study of ECT for the treatment of agitation and aggression in individuals with moderate to severe AD. METHODS We discuss the rationale, study design, methodology, ethical and practical challenges, and management strategies in using an S-ECT group as the comparator arm in this randomized controlled trial of ECT in AD-related treatment refractory agitation and aggression. CONCLUSIONS Validation of the safety and efficacy of ECT in patients with advanced AD with refractory agitation and aggression is necessary. This can be accomplished through creative formulation of S-ECT groups that effectively maintain the blind while providing scientific integrity.
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Affiliation(s)
| | | | - Brent P. Forester
- Division of Geriatric Psychiatry, McLean Hospital, Belmont, MA
- Harvard Medical School, Boston, MA
| | | | | | - Louis Nykamp
- Pine Rest Christian Mental Health Services, Grand Rapids, MI
| | - David G. Harper
- Division of Geriatric Psychiatry, McLean Hospital, Belmont, MA
- Harvard Medical School, Boston, MA
| | - Stephen J. Seiner
- Division of Geriatric Psychiatry, McLean Hospital, Belmont, MA
- Harvard Medical School, Boston, MA
| | - Sohag Sanghani
- The Zucker Hillside Hospital, Northwell Health, Glen Oaks, NY
- Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY
| | - Regan Patrick
- Division of Geriatric Psychiatry, McLean Hospital, Belmont, MA
- Harvard Medical School, Boston, MA
| | | | | | | | | | - Georgios Petrides
- The Zucker Hillside Hospital, Northwell Health, Glen Oaks, NY
- Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY
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Abstract
PURPOSE OF REVIEW We reviewed recent evidence on the use of electroconvulsive therapy (ECT) in the geriatric population. This review looked at the literature on depression, for which there is a breadth of data, as well as other conditions that have historically not been as well studied, as well as attempting to provide practical recommendations for ECT practitioners. This review also examined the impact of the COVID-19 pandemic on ECT in the elderly. RECENT FINDINGS ECT shows robust efficacy across many psychiatric diseases, from depression and bipolar disorder to psychosis and catatonia. It has also shown positive results at improving behavioral symptoms of dementia, as well as improving motor symptoms seen in Parkinson's disease. It is routinely found to be a safe treatment as well, generally with only minimal transient side effects. ECT should not be considered a "last-resort" treatment for geriatric patients suffering from psychiatric disorders. It has historical and recent literature supporting its use in many psychiatric disorders and has been shown to be safe with minimal side effects when appropriate considerations are taken for the elderly population.
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Affiliation(s)
- Anthony N Chatham
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA, USA.
- Emory Brain Health Center, 12 Executive Park Drive, Atlanta, GA, 30329, USA.
| | - Hadia Shafi
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA, USA
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Ochije S, Hershenberg R, Hermida AP. MAINTAINING ROBUST SERVICE UTILIZATION IN GERIATRIC PSYCHIATRY DURING THE PANDEMIC: SUPPORT FOR THE FEASIBILITY OF TELEMEDICINE. The American Journal of Geriatric Psychiatry 2022. [DOI: 10.1016/j.jagp.2022.01.236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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15
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Hermida AP, Sterina E, Schwab PP, Browning CM, Chapman HM, Marques Pinheiro AP, Mori N. Ultrabrief Right Unilateral Electroconvulsive Therapy for the Treatment of the Neuropsychiatric Symptoms of Dementia with Lewy Bodies. J ECT 2022; 38:39-44. [PMID: 34739421 DOI: 10.1097/yct.0000000000000809] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Dementia with Lewy bodies (DLB) is a debilitating disorder associated with a number of distressing neuropsychiatric symptoms. There is currently limited guidance regarding the most effective strategies of managing these symptoms, and both pharmacologic and nonpharmacologic strategies are often used. Electroconvulsive therapy (ECT) has been reported as a potential nonpharmacologic method to alleviate some of these debilitating neuropsychiatric symptoms. However, there remains a paucity of evidence in current literature. This report aims to add to existing literature regarding ECT in DLB by highlighting successful treatment in seven cases. METHODS Our study is a retrospective case series of 7 patients with DLB who received treatment with ultrabrief (UB) right unilateral (RUL) ECT for the treatment of agitation and depressive symptoms. Participants included patients with a diagnosis of DLB who were admitted to Emory University Hospital at Wesley Woods from 2011 to 2020 presenting with agitation and/or depressive symptoms after failing pharmacologic intervention. Patients underwent UB RUL ECT administered by a board-certified psychiatrist. After treatment, Pittsburg Agitation Scale and Clinical Global Impression-Improvement scales were recorded as measures of agitation and clinical improvement, respectively. RESULTS All 7 patients responded to UB RUL ECT with marked improvement in their presenting symptoms of agitation and/or depression without significant adverse effects from treatment. CONCLUSIONS Ultrabrief RUL ECT seems to be a safe and effective treatment of the agitative and depressive features of DLB.
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Affiliation(s)
| | | | | | - Cody Michael Browning
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA
| | - Hannah M Chapman
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA
| | | | - Neil Mori
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA
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Abstract
ABSTRACT Electroconvulsive therapy (ECT) remains stigmatized in the broader medical community because of misunderstandings about treatment procedures, mortality rates, and cardiovascular complications. Electroconvulsive therapy causes periprocedural hemodynamic variability because of the surges in parasympathetic and sympathetic nervous systems after the administration of the electrical charge. Patients experience an increase in cardiac workload, which is potentially dangerous for patients with preexisting heart disease. Several findings suggest that cardiac complications occur most frequently in patients with underlying cardiovascular disease. We describe the cardiovascular complications that may result from ECT treatment and offer insight on how to mitigate these concerns if they occur. PubMed was queried using terms "electroconvulsive therapy" and "cardiovascular adverse effects." A table is provided with the common cardiovascular side effects of ECT and the most recent evidence-based treatment strategies to manage them. Generally, ECT is a safe procedure in which complications are minor and manageable. Most major complications caused by ECT are related to the cardiovascular system; however, with an appropriate pre-ECT evaluation and a comprehensive multidisciplinary team approach, the cardiovascular complications can be well managed and minimized. Providing proper cardiac clearance can prevent cardiac complications and provide timely care to treatment-resistant populations who are at risk for excessive morbidity and suicide.
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Affiliation(s)
- Adriana P Hermida
- From the Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA
| | - Mamoona Mohsin
- Department of Psychiatry and Behavioral Medicine, Charleston Area Medical Center/West Virginia University, Charleston, West Virginia
| | - Ana P Marques Pinheiro
- From the Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA
| | - Elizabeth McCord
- From the Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA
| | - John C Lisko
- Division of Cardiology, Department of Internal Medicine, Emory University School of Medicine, Atlanta, GA
| | - Lyndsay W Head
- Department of Anesthesiology, Emory University School of Medicine, Atlanta, GA
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Abstract
OBJECTIVES To examine post-traumatic stress, depression, anxiety, and well-being in older adults under quarantine. METHODS A systematic review of CINAHL, Ovid EBM Reviews, Ovid Embase, Ovid Medline, Ovid PsycINFO, Scopus, and Web of Science from 2000 to 2020 was conducted. Keywords included coronavirus, epidemic, quarantine, stress, mental health, and similar terms. Included studies enrolled participants under quarantine, quantitatively measured mental health or well-being, and characterized outcomes by age. RESULTS Of 894 initial results, 20 studies met the criteria and were included. Studies comprise 106,553 participants from eight countries, ages 6-100, two epidemics (COVID-19, SARS), and 27 assessment tools. One study found greater distress in older adults relative to younger adults, one found no significant differences, and 18 found lower negative outcomes in older participants in at least one metric. CONCLUSIONS Older adults in this review generally have lower stress and less negative emotions under quarantine than younger adults. It is unknown how this compares to pre-pandemic measures. More representative and longitudinal studies are needed to measure the impact of quarantine on the mental health of older adults. CLINICAL IMPLICATIONS As existing scales may not capture the full extent of pandemic psychological effects on older adults, clinicians must vigilantly monitor older adults' mental health.
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Affiliation(s)
| | - Adriana P Hermida
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, Georgia, USA
| | | | - Maria I Lapid
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, Minnesota, USA
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18
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Schreiber Z, Wang C, Tan A, Riva-Posse P, McDonald WM, Crowell A, Hermida AP, Hershenberg R. Do baseline anxiety symptoms impact response to IV Ketamine in treatment resistant depression? Journal of Affective Disorders Reports 2021. [DOI: 10.1016/j.jadr.2021.100253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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19
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Hermida AP. Keeping Health Care Professionals Current on Geriatric Knowledge. Focus (Am Psychiatr Publ) 2021; 19:269-270. [PMID: 34690592 PMCID: PMC8475941 DOI: 10.1176/appi.focus.20210014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Accepted: 05/05/2021] [Indexed: 06/13/2023]
Affiliation(s)
- Adriana P Hermida
- Department of Psychiatry and Behavioral Science, Emory University School of Medicine, Atlanta
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20
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Nagar A, Boazak M, Hermida AP. Dementia Syndrome of Depression: Diagnostic Challenges and Clinical Relevance. Focus (Am Psychiatr Publ) 2021; 19:308-310. [PMID: 34690597 PMCID: PMC8475928 DOI: 10.1176/appi.focus.20210009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
Late-life depression is frequently associated with cognitive impairment. Because of the overlap of symptoms, however, it can be challenging to discern a neurocognitive disorder (NCD) from a late-life depressive disorder. Although neuropsychological testing provides evidence, there are limited neurochemical or neuroimaging biomarkers for the etiological classification of NCD versus late-life depression. Without formal DSM-5 criteria for a dementia syndrome of depression (DSD), patients may be incorrectly diagnosed as having an NCD. Without recognition and appropriate aggressive treatment, patients may develop severe depression with cognitive impairment leading to significant morbidity. It is crucial that clinicians become aware of and assess for elements that differentiate DSD from neurocognitive disorders. In so doing, this syndrome can be identified and treated early in its course, allowing for the best patient outcomes. In this article, the authors demonstrate, through a case presentation, the diagnostic challenges and clinical value of accurately identifying and treating DSD.
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Affiliation(s)
- Anusuiya Nagar
- Department of Psychiatry, University of South Carolina, Greenville (Nagar); Department of Psychiatry, Duke University, Durham, North Carolina (Boazak); Department of Psychiatry, Emory University, Atlanta (Hermida)
| | - Mina Boazak
- Department of Psychiatry, University of South Carolina, Greenville (Nagar); Department of Psychiatry, Duke University, Durham, North Carolina (Boazak); Department of Psychiatry, Emory University, Atlanta (Hermida)
| | - Adriana P Hermida
- Department of Psychiatry, University of South Carolina, Greenville (Nagar); Department of Psychiatry, Duke University, Durham, North Carolina (Boazak); Department of Psychiatry, Emory University, Atlanta (Hermida)
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21
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Dhingra A, Janjua AU, Hack L, Waserstein G, Palanci J, Hermida AP. Exploring Nonmotor Neuropsychiatric Manifestations of Parkinson Disease in a Comprehensive Care Setting. J Geriatr Psychiatry Neurol 2021; 34:181-195. [PMID: 32242493 DOI: 10.1177/0891988720915525] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Parkinson disease (PD) is a debilitating neurological condition that includes both motor symptoms and nonmotor symptoms (NMS). Psychiatric complaints comprise NMS and are collectively referred to as neuropsychiatric manifestations. Common findings include atypical depressive symptoms, anxiety, psychosis, impulse control disorder, deterioration of cognition, and sleep disturbances. Quality of life (QoL) of patients suffering from NMS is greatly impacted and many times can be more debilitating than motor symptoms of PD. We expand on knowledge gained from treatment models within a comprehensive care model that incorporates multidisciplinary specialists working alongside psychiatrists to treat PD. Insight into background, clinical presentations, and treatment options for patients suffering from neuropsychiatric manifestations of PD are discussed. Identifying symptoms early can help improve QoL, provide early symptom relief, and can assist tailoring treatment plans that limit neuropsychiatric manifestations.
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Affiliation(s)
- Amitha Dhingra
- Department of Psychiatry and Behavioral Sciences, 12239Emory University School of Medicine, Atlanta, GA, USA
| | - A Umair Janjua
- Department of Psychiatry and Behavioral Sciences, 12239Emory University School of Medicine, Atlanta, GA, USA
| | - Laura Hack
- Department of Psychiatry and Behavioral Sciences, 12239Emory University School of Medicine, Atlanta, GA, USA
| | - Gabriella Waserstein
- Department of Psychiatry and Behavioral Sciences, 12239Emory University School of Medicine, Atlanta, GA, USA
| | - Justin Palanci
- Department of Psychiatry and Behavioral Sciences, 12239Emory University School of Medicine, Atlanta, GA, USA
| | - Adriana P Hermida
- Department of Psychiatry and Behavioral Sciences, 12239Emory University School of Medicine, Atlanta, GA, USA
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22
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Affiliation(s)
- Daniel F Maixner
- Department of Psychiatry, University of Michigan, Ann Arbor (Maixner); Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, N.C. (Weiner); Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore (Reti); Department of Psychiatry and Behavioral Sciences, Emory School of Medicine, Atlanta (Hermida, McDonald); Department of Psychiatry, University of Texas Southwestern Medical Center, Dallas (Husain); National Network of Depression Centers, Ann Arbor, Mich. (Larsen)
| | - Richard Weiner
- Department of Psychiatry, University of Michigan, Ann Arbor (Maixner); Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, N.C. (Weiner); Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore (Reti); Department of Psychiatry and Behavioral Sciences, Emory School of Medicine, Atlanta (Hermida, McDonald); Department of Psychiatry, University of Texas Southwestern Medical Center, Dallas (Husain); National Network of Depression Centers, Ann Arbor, Mich. (Larsen)
| | - Irving M Reti
- Department of Psychiatry, University of Michigan, Ann Arbor (Maixner); Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, N.C. (Weiner); Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore (Reti); Department of Psychiatry and Behavioral Sciences, Emory School of Medicine, Atlanta (Hermida, McDonald); Department of Psychiatry, University of Texas Southwestern Medical Center, Dallas (Husain); National Network of Depression Centers, Ann Arbor, Mich. (Larsen)
| | - Adriana P Hermida
- Department of Psychiatry, University of Michigan, Ann Arbor (Maixner); Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, N.C. (Weiner); Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore (Reti); Department of Psychiatry and Behavioral Sciences, Emory School of Medicine, Atlanta (Hermida, McDonald); Department of Psychiatry, University of Texas Southwestern Medical Center, Dallas (Husain); National Network of Depression Centers, Ann Arbor, Mich. (Larsen)
| | - Mustafa M Husain
- Department of Psychiatry, University of Michigan, Ann Arbor (Maixner); Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, N.C. (Weiner); Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore (Reti); Department of Psychiatry and Behavioral Sciences, Emory School of Medicine, Atlanta (Hermida, McDonald); Department of Psychiatry, University of Texas Southwestern Medical Center, Dallas (Husain); National Network of Depression Centers, Ann Arbor, Mich. (Larsen)
| | - Dane Larsen
- Department of Psychiatry, University of Michigan, Ann Arbor (Maixner); Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, N.C. (Weiner); Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore (Reti); Department of Psychiatry and Behavioral Sciences, Emory School of Medicine, Atlanta (Hermida, McDonald); Department of Psychiatry, University of Texas Southwestern Medical Center, Dallas (Husain); National Network of Depression Centers, Ann Arbor, Mich. (Larsen)
| | - William M McDonald
- Department of Psychiatry, University of Michigan, Ann Arbor (Maixner); Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, N.C. (Weiner); Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore (Reti); Department of Psychiatry and Behavioral Sciences, Emory School of Medicine, Atlanta (Hermida, McDonald); Department of Psychiatry, University of Texas Southwestern Medical Center, Dallas (Husain); National Network of Depression Centers, Ann Arbor, Mich. (Larsen)
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23
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Lapid MI, Seiner S, Heintz H, Hermida AP, Nykamp L, Sanghani SN, Mueller M, Petrides G, Forester BP. Electroconvulsive Therapy Practice Changes in Older Individuals Due to COVID-19: Expert Consensus Statement. Am J Geriatr Psychiatry 2020; 28:1133-1145. [PMID: 32863137 PMCID: PMC7413089 DOI: 10.1016/j.jagp.2020.08.001] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 07/21/2020] [Accepted: 08/01/2020] [Indexed: 12/18/2022]
Abstract
The ubiquitous coronavirus 2019 (COVID-19) pandemic has required healthcare providers across all disciplines to rapidly adapt to public health guidelines to reduce risk while maintaining quality of care. Electroconvulsive therapy (ECT), which involves an aerosol-generating procedure from manual ventilation with a bag mask valve while under anesthesia, has undergone drastic practice changes in order to minimize disruption of treatment in the midst of COVID-19. In this paper, we provide a consensus statement on the clinical practice changes in ECT specific to older adults based on expert group discussions of ECT practitioners across the country and a systematic review of the literature. There is a universal consensus that ECT is an essential treatment of severe mental illness. In addition, there is a clear consensus on what modifications are imperative to ensure continued delivery of ECT in a manner that is safe for patients and staff, while maintaining the viability of ECT services. Approaches to modifications in ECT to address infection control, altered ECT procedures, and adjusting ECT operations are almost uniform across the globe. With modified ECT procedures, it is possible to continue to meet the needs of older patients while mitigating risk of transmission to this vulnerable population.
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Affiliation(s)
- Maria I. Lapid
- Department of Psychiatry and Psychology, (MIL) Mayo Clinic, Rochester, MN,Send correspondence and reprint requests to Maria I. Lapid, M.D., Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN
| | - Stephen Seiner
- Neurotherapeutics Program (SS), McLean Hospital, Boston, MA,Harvard Medical School (SS, BPF), Boston, MA
| | - Hannah Heintz
- Division of Geriatric Psychiatry (HH, BPF), McLean Hospital, Boston, MA
| | - Adriana P. Hermida
- Department of Psychiatry and Behavioral Sciences (APH), Emory University, Atlanta, GA
| | - Louis Nykamp
- Pine Rest Christian Mental Health Center (LN), Grand Rapids, MI
| | - Sohag N. Sanghani
- Zucker Hillside Hospital, Northwell Health System (SNS, GP), Glen Oaks, NY,Zucker School of Medicine at Hofstra/Northwell (SNS, GP), Hempstead, NY
| | - Martina Mueller
- College of Nursing & Department of Public Health Sciences (MM), Medical University of South Carolina, Charleston, SC
| | - Georgios Petrides
- Zucker Hillside Hospital, Northwell Health System (SNS, GP), Glen Oaks, NY,Zucker School of Medicine at Hofstra/Northwell (SNS, GP), Hempstead, NY
| | - Brent P. Forester
- Harvard Medical School (SS, BPF), Boston, MA,Division of Geriatric Psychiatry (HH, BPF), McLean Hospital, Boston, MA
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24
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Hermida AP, Goldstein FC, Loring DW, McClintock SM, Weiner RD, Reti IM, Janjua AU, Ye Z, Peng L, Tang YL, Galendez GC, Husain MM, Maixner DF, Riva-Posse P, McDonald WM. ElectroConvulsive therapy Cognitive Assessment (ECCA) tool: A new instrument to monitor cognitive function in patients undergoing ECT. J Affect Disord 2020; 269:36-42. [PMID: 32217341 DOI: 10.1016/j.jad.2020.03.010] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Revised: 02/23/2020] [Accepted: 03/03/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Electroconvulsive therapy (ECT) is a well-established treatment for severe depression but may result in adverse cognitive effects. Available cognitive screening instruments are nonspecific to the cognitive deficits associated with ECT. An ECT-cognitive assessment tool which can be easily administered was developed and validated in a clinical setting. METHODS One hundred and thirty-six participants were enrolled. The ElectroConvulsive therapy Cognitive Assessment (ECCA) and the Montreal Cognitive Assessment (MoCA) were administered prospectively to 55 participants with major depressive disorder (MDD) undergoing ECT at three time points: pre-treatment, before the sixth treatment and one-week post-treatment. The psychometric properties of the total and domain scores were evaluated at all three time points. Forty demographically comparable participants with MDD who did not receive ECT, and 41 healthy, age-matched controls were evaluated at a single time point. RESULTS ECCA and MoCA scores were not statistically different at baseline. Prior to the sixth and final ECT session, total ECCA scores were significantly lower than the MoCA total scores. The ECCA domains of subjective memory, informant-assessed memory, attention, autobiographical memory and delayed verbal recall were significantly lower post-ECT compared to pre-ECT. LIMITATIONS The ECCA was compared only to the MoCA rather than to a more comprehensive neuropsychological testing. This limitation reflected the real-life clinical burden of performing full neuropsychological testing at three time points during the treatment course. CONCLUSIONS The ECCA is a brief, reliable, bedside cognitive screening assessment tool that may be useful to monitor cognitive function in patients treated with ECT. The test can be downloaded from fuquacenter.org/ecca.
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Affiliation(s)
- Adriana P Hermida
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, 12 Executive Park Drive, Atlanta, GA, USA.
| | - Felicia C Goldstein
- Department of Neurology, Emory University School of Medicine, Atlanta, Georgia, USA
| | - David W Loring
- Department of Neurology, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Shawn M McClintock
- Department of Psychiatry, UT Southwestern Medical Center, Dallas, Texas, USA; Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, North Carolina, USA
| | - Richard D Weiner
- Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, North Carolina, USA
| | - Irving M Reti
- Department of Psychiatry and Behavioral Science, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - A Umair Janjua
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, 12 Executive Park Drive, Atlanta, GA, USA
| | - Zixun Ye
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Limin Peng
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Yi-Lang Tang
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, 12 Executive Park Drive, Atlanta, GA, USA
| | - Gail C Galendez
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, 12 Executive Park Drive, Atlanta, GA, USA
| | - Mustafa M Husain
- Department of Psychiatry, UT Southwestern Medical Center, Dallas, Texas, USA; Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, North Carolina, USA
| | - Daniel F Maixner
- Department of Psychiatry, University of Michigan, Ann Arbor, Michigan, USA
| | - Patricio Riva-Posse
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, 12 Executive Park Drive, Atlanta, GA, USA
| | - William M McDonald
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, 12 Executive Park Drive, Atlanta, GA, USA
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- National Network of Depression Centers, Ann Arbor, Michigan, USA
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25
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Abstract
PURPOSE OF REVIEW To provide consultation-liaison psychiatrists with an updated resource that can assist in the treatment and management of geriatric patients. RECENT FINDINGS The current available literature has not shown any differences in efficacy between haloperidol and second-generation antipsychotics in patients with delirium. When considering relative advantages of forms of antipsychotic administration, there is no support for a superior safety profile of oral compared to intramuscular or intravenous administration. A recent meta-analysis of four randomized controlled trials concluded that when melatonin was administered to older age patients on medical wards, it significantly prevented the incidence of delirium when compared with the control group. While suvorexant administered nightly to elderly patients in acute care settings may lower the incidence of delirium, larger studies are needed to confirm this finding. Despite the black box warning of increased mortality risk in older patients with dementia, antipsychotics may be used with caution by the consultation-liaison (CL) psychiatrist to treat the neuropsychologic symptoms of dementia including hallucinations and psychosis in the hospital setting. While antidepressant studies have focused primarily on citalopram and escitalopram in the treatment of agitation in the setting of dementia, these two medications have not been adequately compared directly to other SSRIs for this condition. It is therefore not clear whether citalopram and escitalopram are more efficacious in treating agitation in the setting of dementia when compared to other SSRIs. While the evidence supporting trazodone's use is limited, it is generally well tolerated and is an option as a PRN for irritability and agitation in patients with Alzheimer's and mixed dementia. While there is some evidence to support the use of acetylcholinesterase inhibitors for treating cognitive impairments and hallucinations in Lewy body dementia, the usefulness of these agents in other forms of dementia is not well studied, and those studies did not show any benefit in the management of acute agitation. It is important to note that memantine can cause or exacerbate agitation and may be the cause of behavioral dysregulation. There is no evidence to support the routine use of benzodiazepines for behavioral improvement in patients with dementia. Escitalopram and citalopram do have a unique pharmacokinetic properties in the sense that they have been found to have 50-56% plasma protein binding, compared to sertraline, fluoxetine, and paroxetine (95% or more). Pooled analyses suggest that antidepressants are more effective than placebo in reducing the symptoms of post-stroke depression. SSRIs are considered first-line antidepressants in stroke patients, who are often elderly with underlying cardiovascular problems. Although treatment with SSRIs is recommended for post-stroke depression, there are no studies providing conclusive data on the superiority of a specific drug. Older age is associated with a better outcome from ECT, with remission rates of approximately 73% to 90% in patients over 65 years. ECT is the treatment of choice for patients with psychotic depression, and elderly patients with psychotic depression have been shown to have a higher remission rate and faster time to response than depressed patients without psychotic symptoms. With the average life expectancy increase, it is projected that 19 million people will reach the age of 85 or higher, an increase from 5.5 million in 2010. With an increasing older population, psychiatric consultation in the management of geriatric patients is becoming more necessary. Psychiatrists must be aware of the unique considerations in elderly patients. In this article, we provide evidence-based guidance to the CL psychiatrist on major issues relating to the older age patient, highlighting recent trends in treatment. First, we provide background on the evaluation of the medically hospitalized geriatric patient. As rates of medical and psychiatric illnesses increase with advancing age, elderly patients are more likely to be taking a higher number of medications as compared to younger patients, and physicians must pay special attention to polypharmacy, including side effects and drug interactions in this group. Next, we focus on the diagnosis, management, and unique needs of the geriatric patient presenting with common clinical syndromes of delirium, dementia, and depression. Delirium and dementia are among the most common causes of cognitive impairment in clinical settings yet are often either unrecognized or misdiagnosed as they may have similar signs and symptoms. In addition, depression is prevalent in older adults, especially in those with comorbid medical illness. Depression can be fatal as the rates of suicide are higher in later life than in any other age group. Consultation can improve the management of elderly patients and prevent unnecessary nursing home placement.
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Affiliation(s)
| | | | - Rachel Hershenberg
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA, USA
- Treatment Resistant Depression Program, Emory University, Atlanta, GA, USA
| | - Ann C Schwartz
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA, USA.
- Psychiatry Consultation-Liaison Service, Grady Memorial Hospital, 80 Jesse Hill Jr. Dr., Atlanta, GA, USA.
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Hermida AP, Tang YL, Glass O, Janjua AU, McDonald WM. Efficacy and Safety of ECT for Behavioral and Psychological Symptoms of Dementia (BPSD): A Retrospective Chart Review. Am J Geriatr Psychiatry 2020; 28:157-163. [PMID: 31668364 DOI: 10.1016/j.jagp.2019.09.008] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Revised: 09/21/2019] [Accepted: 09/23/2019] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Much of the functional disturbance in patients with dementia reflects the presence of noncognitive behavioral and psychological symptoms of dementia (BPSD). Agitation is among the most distressing symptoms for patients, clinicians, and caregivers. Currently no pharmacotherapy has clearly been shown to be of value for this condition. This study used a chart review method to examine the safety and efficacy of electroconvulsive therapy (ECT) for patients with dementia receiving ECT for agitation. METHODS A retrospective chart review was conducted of patients with dementia presenting with symptoms of aggression or agitation and who received ECT treatments. Aggression and agitation were measured by pre- and post-ECT Pittsburg Agitation Scale (PAS) scores. Detailed history of the use of psychotropic medications as well as other clinically relevant variables was analyzed. FINDINGS Sixty elderly patients (45 women and 15 men, 75% female, mean age 77.5 ± 8.0 years) were included in the analysis. Most patients were treatment resistant to multiple psychotropic medications prior to ECT (mean number 6.1±1.5). The baseline PAS total was 9.3 ± 3.7 and it decreased significantly after three (2.5±2.8) and six (1.5±2.3) ECT treatments. No significant ECT-related medical complications were observed except transient confusion. A decrease in the number of psychotropics prescribed along with an increase in the GAF score was observed after the ECT treatment course. CONCLUSION ECT was safe in this sample of patients who had co-morbid medical conditions. ECT was associated with the following observations: 1) a reduction in agitation; 2) a reduction in psychotropic polypharmacy; and 3) an improvement in global functioning level. Further research evaluating the effects of ECT in the setting of dementia is warranted.
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Affiliation(s)
- Adriana P Hermida
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA.
| | - Yi-Lang Tang
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA
| | - Oliver Glass
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA
| | - A Umair Janjua
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA
| | - William M McDonald
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA
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Abstract
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.
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Affiliation(s)
- Adriana P Hermida
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, 12 Executive Park Drive Northeast, Atlanta, GA 30329, USA.
| | - Oliver M Glass
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, 12 Executive Park Drive Northeast, Atlanta, GA 30329, USA
| | - Hadia Shafi
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, 12 Executive Park Drive Northeast, Atlanta, GA 30329, USA
| | - William M McDonald
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, 12 Executive Park Drive Northeast, Atlanta, GA 30329, USA
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28
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Vaughan CP, Prizer LP, Vandenberg AE, Goldstein FC, Trotti LM, Hermida AP, Factor SA. A Comprehensive Approach to Care in Parkinson's Disease Adds Quality to the Current Gold Standard. Mov Disord Clin Pract 2017; 4:743-749. [PMID: 30363392 PMCID: PMC6174369 DOI: 10.1002/mdc3.12508] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2016] [Revised: 04/28/2017] [Accepted: 04/28/2017] [Indexed: 11/07/2022] Open
Abstract
BACKGROUND Providing high-quality care for patients with Parkinson's disease (PD) involves addressing both motor and nonmotor features. We describe the implementation and evaluation of a 2-day, interdisciplinary Comprehensive Care Clinic (CCC) for patients with PD. METHODS Patients who attended the CCC between January 2010 and July 2013 were matched by sex and age with patients who were evaluated in specialist care during the same time frame. Provider documentation of the American Academy of Neurology (AAN) quality measures for PD and Unified Parkinson's Disease Rating Scale (UPDRS) motor scores were compared between specialist and CCC visits at baseline and at 12 months. RESULTS Ninety-five patients participated in the CCC (60% men; 75% white; mean age, 68 years; age range, 38-97 years). Of these, 29 patients were matched to specialist care patients based on the availability of 12-month follow-up data. Both groups were similar with respect to race, marital status, years with PD, and baseline UPDRS motor scores. On average, patients who received CCC care met 10 of 10 AAN quality measures, whereas those who received specialist care met only 5 of 10 quality measures (P < 0.001) over 12 months. At 12-months, there were no significant differences in UPDRS motor scores between the groups (P = 0.5). CONCLUSIONS According to the AAN quality measures, the CCC provided higher quality care than the gold standard of specialty care. A randomized controlled trial of the CCC model is warranted to determine its impact on patient-centered outcomes and to assess whether the standard model of care should be altered.
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Affiliation(s)
- Camille P. Vaughan
- Merrie Boone Comprehensive Care Clinic for Parkinson DiseaseEmory HealthcareAtlantaGeorgia
- Department of Veterans AffairsBirmingham/Atlanta Geriatric Research Education and Clinical CenterDecaturGeorgia
- Department of MedicineEmory University School of MedicineAtlantaGeorgia
| | - Lindsay P. Prizer
- Merrie Boone Comprehensive Care Clinic for Parkinson DiseaseEmory HealthcareAtlantaGeorgia
- Department of Veterans AffairsBirmingham/Atlanta Geriatric Research Education and Clinical CenterDecaturGeorgia
- Department of MedicineEmory University School of MedicineAtlantaGeorgia
| | - Ann E. Vandenberg
- Department of MedicineEmory University School of MedicineAtlantaGeorgia
| | - Felicia C. Goldstein
- Merrie Boone Comprehensive Care Clinic for Parkinson DiseaseEmory HealthcareAtlantaGeorgia
- Department of NeurologyEmory University School of MedicineAtlantaGeorgia
| | - Lynn Marie Trotti
- Merrie Boone Comprehensive Care Clinic for Parkinson DiseaseEmory HealthcareAtlantaGeorgia
- Department of NeurologyEmory University School of MedicineAtlantaGeorgia
- Emory Sleep CenterEmory University School of MedicineAtlantaGeorgia
| | - Adriana P. Hermida
- Merrie Boone Comprehensive Care Clinic for Parkinson DiseaseEmory HealthcareAtlantaGeorgia
- Department of Psychiatry and Behavioral SciencesEmory University School of MedicineAtlantaGeorgia
| | - Stewart A. Factor
- Merrie Boone Comprehensive Care Clinic for Parkinson DiseaseEmory HealthcareAtlantaGeorgia
- Department of NeurologyEmory University School of MedicineAtlantaGeorgia
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Rakofsky JJ, Garlow SJ, Haroon E, Hermida AP, Young JQ, Dunlop BW. Assessing Residents' Confidence in the Context of Pharmacotherapy Competence. Acad Psychiatry 2017; 41:350-353. [PMID: 27757927 DOI: 10.1007/s40596-016-0613-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/25/2016] [Accepted: 08/29/2016] [Indexed: 06/06/2023]
Abstract
OBJECTIVE We aimed to determine whether residents' confidence initiating medications increased with the number of times they prescribed individual medications and to quantify the relationship between prescription frequency and gains in confidence. METHODS From July 2011 to June 2014, PGY-3 residents completed a survey of confidence levels at their psychopharmacology clinic orientation and then again 12 months later. The Emory Healthcare electronic medical record was used to identify all medications prescribed by each resident during their 12-month rotation and the frequency of these prescriptions. RESULTS Confidence in initiating treatment with all medicines/medication classes increased over the 12-month period. For three of the medication classes for which residents indicated they were least confident at orientation, the number of prescriptions written during the year was significantly associated with an increase in confidence. CONCLUSIONS Measuring resident confidence is a relevant and achievable outcome and provides data for educators regarding the amount of experience needed to increase confidence.
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Affiliation(s)
| | | | | | | | - John Q Young
- Hofstra Northshore-LIJ School of Medicine, Hempstead, NY, USA
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Bryson EO, Hermida AP, Kellner CH. Should the laryngeal mask airway play a role in electroconvulsive therapy? Rev Psiquiatr Salud Ment 2017; 10:126-127. [PMID: 26897253 DOI: 10.1016/j.rpsm.2016.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/24/2015] [Accepted: 01/08/2016] [Indexed: 06/05/2023]
Affiliation(s)
- Ethan O Bryson
- Departamentos de Anestesiología y Psiquiatría,The Icahn School of Medicine at Mount Sinai, New York, NY.
| | - Adriana P Hermida
- Departamento de Psiquiatría, Emory University School of Medicine, New York, NY
| | - Charles H Kellner
- Departamento de Psiquiatría, The Icahn School of Medicine at Mount Sinai, New York, NY
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Abstract
Geriatric depression is associated with increased mortality because of suicide and decreases in functional and physical health. Many elders' depression is resistant to psychotherapy and medication and can become chronic. Electroconvulsive therapy (ECT) is increasingly used in the treatment of medication-resistant or life-threatening geriatric depression. Neuromodulation therapies (subconvulsive, focal, or subconvulsive and focal) are alternatives for the management of treatment-resistant depression in the elderly. Therapies that combine both strategies could be safer but may not be as effective as ECT. This review covers the evidence on the safety and efficacy of ECT and the neuromodulation therapies in geriatric depression.
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Affiliation(s)
- Patricio Riva-Posse
- Department of Psychiatry and Behavioral Sciences, Emory University, 101 Woodruff Cir NE, Suite 4000, Atlanta, GA 30322, USA
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Hermida AP, McDonald WM, Steenland K, Levey A. The association between late-life depression, mild cognitive impairment and dementia: is inflammation the missing link? Expert Rev Neurother 2012; 12:1339-50. [PMID: 23234395 PMCID: PMC4404497 DOI: 10.1586/ern.12.127] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Depression, mild cognitive impairment (MCI) and dementia are highly prevalent conditions that are increasing exponentially with similarly expanding social, medical and economic burdens. While there is a clear clinical connection between these three disorders, the mechanism of action that links them is less well understood. The lack of well-accepted biomarkers results in high levels of diagnostic subjectivity, which then greatly impacts research results when attempting to further explore their association. There is also a variety of clinical presentations of depressive syndromes, particularly in the elderly; each one may be associated with a different risk in the progression from MCI to different types of dementia. The diagnostic challenges, the importance of biomarkers and the discussion of inflammation as a possible link between depression, MCI and dementia are examined in this article.
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Affiliation(s)
- Adriana P Hermida
- Department of Psychiatry and Behavioral Science, Emory University School of Medicine, Wesley Woods Health Center, 4th Floor, 1841 Clifton Road, NE, Atlanta, GA 30329, USA.
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