Ketamine for major depressive disorder during an inpatient psychiatric admission: Effectiveness, adverse events, and lessons learned

OBJECTIVE

Most studies examining the efficacy of ketamine for Major Depressive Disorder (MDD) have been conducted in outpatient or mixed inpatient/outpatient settings. Less is known about effectiveness and tolerability of ketamine for psychiatrically hospitalized patients. Efficacy and tolerability data from a naturalistic sample of acute inpatients may help inform institutions considering ketamine therapy for inpatient services.

METHODS

We performed a retrospective chart review of inpatients with non-psychotic MDD treated during the initial 3 years of a ketamine infusion program. Treatment effectiveness was defined using change in Montgomery Asberg Depression Rating Scale (MADRS) scores over five infusions. MDD treatment response was defined by a 50 % reduction of MADRS score, and remission was defined as MADRS score ≤ 10 at any point during the treatment. We also report the frequency of adverse events.

RESULTS

41 patients with MDD were treated and had outcome data. 19 patients (46.5 %) met criteria for response and 15 patients (26.5 %) met criteria for remission during treatment. Four patients (10 %) had adverse psychological or behavioral outcomes.

LIMITATIONS

MADRS scales were administered by psychiatrists, psychologists, and trainees in each discipline who did not undergo standardized training in scale administration. Consistent data regarding the race/ethnicity of the patients was not available.

CONCLUSION

Twice weekly racemic ketamine infusion is an effective treatment option for patients hospitalized with MDD. Unmonitored or at home ketamine therapy may pose substantial risks.

Low COVID-19 Vaccination Rates Among Psychiatric Inpatients: Implications for Institutional Settings and Outreach Efforts

OBJECTIVE

This study sought to determine COVID-19 vaccination rates for individuals with serious mental illness admitted to a large health system in New York State.

METHODS

Vaccination rates among 12,714 patients admitted to psychiatric units and to medical and surgical units were compared between April 6, 2021, and September 30, 2021.

RESULTS

Only 40% (N=416 of 1,029) of patients admitted to psychiatric services had at least one COVID-19 vaccination, whereas 64.4% (7,523 of 11,685) of patients admitted to medical and surgical services had at least one vaccination. After adjustment for differences in key demographic and clinical characteristics, patients admitted to psychiatric services had a significantly lower likelihood of vaccination during the study period (risk ratio=0.78, 95% confidence interval=0.73-0.85, p<0.001). Black psychiatric patients had the lowest vaccination rate (28%).

CONCLUSIONS

Psychiatric patients with acute illness had low COVID-19 vaccination rates. Targeted outreach for COVID-19 vaccination is necessary to reach this population.

Inpatient psychiatry response to the SARS-CoV-2 Omicron variant surge

The increased transmissibility of the omicron variant of the SARS-CoV-2 virus resulted in a rapid increase in infection among many psychiatric inpatients in our hospital between December 2021 and February 2022. This required our institution to close affected units to new admissions. In response, we implemented a model utilizing universal SARS-CoV-2 polymerase chain reaction (PCR) testing at the time of admission, the development of "admitting units" where all patients were quarantined for four days followed by repeat PCR testing, and subsequent transition to COVID-19 negative and COVID-19 positive "receiving units" based on the results of the second test. No unit closures occurred following full implementation of the model.

Universal COVID-19 testing and a three-space triage protocol is associated with a nine-fold decrease in possible nosocomial infections in an inpatient psychiatric facility

In May of 2020, the Substance Abuse and Mental Health Service Administration (SAMSA) issued guidelines for state psychiatric hospitals, recommending that these facilities adopt universal testing for COVID-19 and "three-space" triage protocols for dedicated COVID-19 positive, negative, and quarantine spaces to mitigate the risk of nosocomial infection. The Westchester Behavioral Health Center of New York Presbyterian Hospital (WBHC-NYP) adopted a comprehensive infection control protocol consistent with these recommendations in April, 2020. We reviewed the records of 1,139 patients treated on the inpatient service at WBHC-NYP between March 14th and June 10^th, 2020, dates corresponding to the first COVID-19 surge in the New York City metropolitan region. The incidence of detected nosocomial or possible nosocomial infections before and during the implementation of the protocol was 0.096 (16/167), or 0.96 infections per 10 at-risk patients. The incidence of nosocomial or possible nosocomial infections after complete implementation was 0.0110 (2/182), or 1.1 infections per 100 at-risk patients. The difference in incidence between the two time points was statistically significant (p<.0003) and represents a 9-fold decrease.  Our findings support the institutional use of a combined testing and space allocation protocol to mitigate risk of outbreaks in confined settings.

The Interface of COVID-19 and Inpatient Psychiatry: Our Experience and Lessons Learned

The coronavirus disease 2019 (COVID-19) pandemic presented unprecedented challenges to the provision of inpatient psychiatric care. The nature of the physical plant, programmatic constraints, and the patient population required a rapid and agile approach to problem-solving under conditions of uncertainty and stress. Flexibility in decision-making, excellent communication, an effective working relationship with infection prevention and control experts, and attention to staff morale and support were important elements of successful provision of care to our inpatients. We present our experience, lessons learned, and recommendations should a resurgence of the pandemic or a similar crisis occur.

The Psychiatric Inpatient Multidisciplinary Team Meeting: A Model for Current Practice

The multidisciplinary treatment team meeting (MTTM) has been the central forum for treatment planning and clinical decision-making on many psychiatric inpatient units for decades. While the principles underlying MTTMs were described in the distant past, a detailed model for how these meetings are structured and how they function has not been well presented. In an era of very brief hospital lengths of stay, collaborative, thoughtful, comprehensive, and efficient team meetings have become increasingly important. The goal of this article is to describe a highly structured, successful MTTM model that borrows heavily from an invaluable knowledge base and tradition and is well suited for the modern era.

When patients refuse COVID-19 testing, quarantine, and social distancing in inpatient psychiatry: clinical and ethical challenges

The COVID-19 pandemic has introduced new ethical challenges in the care of patients with serious psychiatric illness who require inpatient treatment and who may have beeen exposed to COVID-19 or have mild to moderate COVID-19 but refuse testing and adherence to infection prevention protocols. Such situations increase the risk of infection to other patients and staff on psychiatric inpatient units. We discuss medical and ethical considerations for navigating this dilemma and offer a set of policy recommendations.

A COVID-19 testing and triage algorithm for psychiatric units: One hospital's response to the New York region's pandemic

Psychiatric patients are at high risk for contracting COVID-19, and inpatient psychiatric units face substantial risks of institutional outbreaks. Here, the authors describe an algorithm for testing and triage in a large psychiatric facility designed to prevent local COVID-19 transmission. The algorithm is based on expert opinion and clinical experience between March and April of 2020, during which the institution cared for 47 COVID-19 positive psychiatric inpatients. The implementation of the algorithm is designed to mitigate COVID-19 transmission, preserve the safest and least restrictive treatment environment for psychiatric inpatients, and provide a model adaptable to other institutional settings.

Correlates of the Third Victim Phenomenon

The third victim phenomenon refers to a system-wide organizational response to a serious untoward event in health care settings. The objective of this report is to describe possible measurable correlates of this phenomenon. A serious incident on one unit in the hospital is described. Utilization of constant observation and rate of discharge in the aftermath throughout the hospital were assessed. There was a hospital-wide uptick in conservative decision making following the serious incident, exemplified by an increase in the utilization of constant observation and decreased rate of discharges. These findings lend support to the validity of the concept of the third victim phenomenon and underscore the imperative for a coherent leadership response to prevent damage to institutional core values, morale, and reputation. Systematic investigation of this phenomenon and its potential effects on clinical practice in the aftermath of serious incidents is warranted.

Discontinuing the Use of PRN Intramuscular Medication for Agitation in an Acute Psychiatric Hospital

This study examined the impact of eliminating intramuscular PRN medication for agitation on patient and staff safety in an acute psychiatric inpatient setting. The current retrospective chart review investigated the use of PRN medications (oral and intramuscular) to treat acute agitation, including aggression, and related outcomes before and after a mandated change in PRN practice that required real time physician input before administration of intramuscular medications. The use of both oral and intramuscular PRN medications dramatically decreased following implementation of the mandated change in practice. In particular, the use of intramuscular PRNs for agitation decreased by about half. Despite this decrease, the assault rate in the hospital was unchanged, and the utilization of restraint and seclusion continued to decrease. It is possible to reduce the utilization of PRN medications for agitation without broadly compromising safety on acute care psychiatric inpatient units.

Body mass index identified as an independent predictor of psychiatric readmission

BACKGROUND

Psychiatric hospital readmissions correlate with illness severity, drug selection, and compliance with treatment in the outpatient setting. The risk factors for psychiatric rehospitalization have been mainly assessed in databases lacking information regarding somatic comorbidity and anthropometric variables, such as body mass index (BMI), which are known to predict readmissions in nonpsychiatric settings.

OBJECTIVE

To determine independent predictors of 1-year readmission occurring among unselected adults consecutively admitted for treatment of severe mental illness to an academic, freestanding psychiatric hospital in New York City from August 2010 through January 2011.

METHOD

After identifying univariate correlates of readmission, we used logistic regression with backward elimination to identify independent predictors of readmissions within 1 year after the index psychiatric hospitalization.

RESULTS

Among 224 (23.7%) of 945 readmitted patients, psychiatric readmission was significantly associated with age (P = .0029), length of stay (P = .036), schizophrenia/schizoaffective disorder (P < . 0001), dementia (P = .027), major depressive disorder (P = .0006), treatment with atypical antipsychotic drugs (P = .0054), electroconvulsive therapy (P < .0001), and BMI (P = .0079), but not with physical comorbidities and routine laboratory data.The independent predictors of readmission were higher BMI (median = 28.5 kg/ m2; odds ratio [OR] = 3.6; Cl, 1.2-10.6), a diagnosis of schizophrenia/schizoaffective disorder (OR = 2.2; Cl, 1.5-3.4), clozapine treatment (OR = 2.8; CI, 1.1-6.9), no electroconvulsive therapy (OR = 0.13; Cl, 0.02-0.45), and shorter length of stay (median = 18 days; OR = 0.08; Cl, 0.01-0.42).

CONCLUSIONS

Body mass index was identified, for the first time, as an independent predictor of psychiatric rehospitalization. Enhanced outpatient treatment programs for overweight and obese psychiatric patients might influence readmission rates and should be explored in prospective studies.

Outcomes associated with court-ordered treatment over objection in an acute psychiatric hospital

The postdischarge outcomes of court-ordered treatment of acute psychiatric inpatients have not been adequately investigated. We reviewed the medical records of all patients who refused medication for whom a court order was sought during a recent three-year period, and compared this group to control patients who agreed to treatment and a group of patients who transiently refused medication. The principal outcome measures were successful linkage after discharge, readmission within six months of discharge, and transfer to a state hospital. The study group was less likely to link to an aftercare provider, and more likely to be transferred to a state hospital, had poorer insight on admission, had a longer average stay, and was more likely to utilize mandatory outpatient treatment and long-acting injectable medications after discharge. Patients who require court-ordered medication over objection constitute a group that is high risk for nonadherence after discharge and being refractive to treatment.

Plasma free polyunsaturated fatty acid levels are associated with symptom severity in acute mania

OBJECTIVES

Nutritionally essential polyunsaturated fatty acids (PUFAs) have been implicated as potentially important factors in mood disorders. For instance, n-3 PUFA supplementation is reported to improve outcomes in major depressive disorder and bipolar disorder. However, the role of PUFAs in acute mania has been minimally investigated. We performed a pilot study to compare plasma levels of free (non-esterified) and esterified PUFAs between patients in an acute manic episode and healthy volunteers, and to explore associations between symptom severity and levels of fatty acids and of the arachidonic acid metabolite, prostaglandin E2 (PGE2).

METHODS

Patients (n=10) who were medication-free for at least two weeks and seeking inpatient admission for an acute manic episode were compared with healthy volunteers (n=10). Symptom severity was assessed at admission and after six weeks of naturalistic treatment. Fasting baseline free and esterified plasma levels of docosahexaneoic acid (DHA, 22:6n-3), eicosapentaenoic acid (EPA, 20:5n-3), arachidonic acid (AA,20:4n-6) and the AA metabolite PGE2 were determined, and PGE2 levels were tested again at six weeks.

RESULTS

No between-group differences were found in levels of individual or total fatty acids, or of PGE2. Among subjects, manic symptom severity correlated negatively with levels of free AA and free EPA, and positively with the free AA:EPA ratio. PGE2 levels did not differ between groups or in subjects pre- and post-treatment.

CONCLUSIONS

Our preliminary results suggest that, in susceptible persons, low plasma levels of free EPA compared with AA are related to the severity of mania.

Evidence for a role of the arachidonic acid cascade in affective disorders: a review

The treatment of affective disorders continues to present significant clinical challenges, notwithstanding the existence of available mood stabilizers and antidepressants. These difficulties include incomplete response, relapse, and intolerable medication side effects. Fundamental to the therapeutic impasse is incomplete knowledge concerning the neurobiology of mood disorders. Although some relevant biochemical pathways have been identified, including abnormalities of monoamine neurotransmission and of immunological functioning, a fuller understanding is likely to embrace other interrelated pathways. Arachidonic acid (AA) and prostaglandins (PGs) are important second messengers in the central nervous system that participate in signal transduction, inflammation and other vital processes. Their release, turnover, and metabolism represent the 'arachidonic acid cascade'. A significant body of diverse clinical and preclinical research suggests that the AA cascade may be important in affective states. This paper reviews the literature describing the association of affective illness with AA and its metabolites. Possible links between this and other prevailing hypotheses are considered, and implications for further research and for treatment are discussed.

LSD-Like Flashbacks Associated with ECT

We report the occurrence of spontaneous LSD (lysergic acid diethylamide)-like flashbacks after seven nondominant unilateral electroconvulsive therapy (ECT) treatments in a depressed patient with a history of hallucinogen abuse and flashbacks in the distant past. The similarity of the patient's reported experiences following ECT to the characteristic descriptions of LSD flashbacks is discussed. The differential diagnosis of LSD flashbacks in this case, and speculations regarding their origin, are also considered.

Analysis of catechol-O-methyltransferase and 5-hydroxytryptamine transporter polymorphisms in patients at risk for suicide

Genotype frequencies of functional polymorphisms in the genes encoding the serotonin transporter (5-HTT) and the enzyme catechol-O-methyltransferase (COMT) were not different in 51 suicidal inpatients compared to 51 control subjects. Within the patient group, increased hopelessness and suicide ideation were associated with homozygosity of the 5-HTT high promotor activity allele.

EEG theta activity and pain insensitivity in self-injurious borderline patients

The principal aim of this study was to investigate possible neurophysiological underpinnings of self-injurious behavior in women with borderline personality disorder (BPD). Pain report and EEG power spectrum density during a laboratory pain procedure, a 4-min 10 degrees C cold pressor test (CPT), were compared among four groups; female inpatients with BPD who do (BPD-P group, n = 22) and do not (BPD-NP group, n = 19) report pain during self-injury, female inpatients with major depression (n = 15), and normal women (n = 20). The BPD-NP group reported less pain intensity during the CPT compared to the other groups. Total absolute theta power was significantly higher in the BPD-NP group compared to the Depressed (P = 0.0074) and Normal (P = 0.0001) groups, with a trend toward being significantly higher compared to the BPD-P group (P = 0.0936). Dissociative Experience Scale scores were significantly higher in the BPD-NP group compared to the Depressed and Normal groups (maximum P = 0.0004), and significantly higher in the BPD-P group compared to the Normal group (P = 0.0016). Beck Depression Inventory and Sheehan Patient Rated Anxiety Scale scores were significantly lower in the Normal group compared to all patient groups. Theta activity was significantly correlated with pain rating (Pearson partial r = -0.43, P = 0.0001) and Dissociative Experiences Scale score (Pearson partial r = 0.32, P = 0.01).

Assessment of suicide risk 24 hours after psychiatric hospital admission

Of 69 patients admitted to a hospital because of suicide risk, 30 (44 percent) were completely free of suicidal ideation 24 hours after admission. Scores on the Scale for Suicide Ideation at the time of admission distinguished patients who continued to have suicidal ideation 24 hours later (the sustained-ideation group) from those who did not (the transient-ideation group). Patients in the transient group were more likely than those in the sustained group to have made a suicide attempt during the week before admission. At admission patients in the sustained group were more likely to have psychotic symptoms and to report a family history of psychiatric illness.

Self-injurious behavior and mood regulation in borderline patients

This article explores the hypothesis that self-injurious behavior (SIB) of the type associated with borderline personality disorder (BPD) has an important mood regulatory function. Thirty-eight female inpatients with an Axis II diagnosis of BPD and a history of SIB rated a variety of mood and affective states, using visual analog scales recalled over the course of usual SIB experiences. Subjects were additionally divided into two groups according to whether they typically experience pain during SIB (BPD-P group) or did not (BPD-NP group). For both groups, the visual analog scale ratings revealed significant mood elevation and decreased dissociation following self injury, with a peak in dissociative symptoms during self injury. The ratings of dissociative symptoms were found to be higher in the BPD-NP group when compared to the BPD-P group across all stages of SIB. The ratings of sexual arousal did not change over the course of SIB for either group. These findings are discussed in light of current knowledge of the relationship between SIB and mood.

Pain assessment in self-injurious patients with borderline personality disorder using signal detection theory

Signal detection theory measures of thermal responsivity were examined to determine whether differences in reported pain experienced during self-injurious behavior in female patients with borderline personality disorder (BPD) are explained by neurosensory factors and/or attitudinal factors (response bias). Female patients with BPD who do not experience pain during self-injury (BPD-NP group) were found to discriminate more poorly between noxious thermal stimuli of similar intensity, low P(A), than female patients with BPD who experience pain during self-injury (BPD-P group), female patients with BPD who do not have a history of self-injury (BPD-C group), and age-matched normal women. The BPD-NP group also had a higher response criterion, B (more stoical) than the BPD-C group. These findings suggest that 'analgesia' during self-injury in patients with BPD is related to both neurosensory and attitudinal/psychological abnormalities.

Pain and self-injury in borderline patients: sensory decision theory, coping strategies, and locus of control

Fifteen women with borderline personality disorder who do not experience pain during self-injury were found to discriminate more poorly between imaginary painful and mildly painful situations, to reinterpret painful sensations (a pain-coping strategy related to dissociation), and to have higher scores on the Dissociative Experiences Scale than 24 similar female patients who experience pain during self-injury and 22 age-matched normal women. "Analgesia' during self-injury in borderline patients may be related to a cognitive impairment in the ability to distinguish between painful and mildly painful situations, as well as to dissociative mechanisms.

Construct validity of the Three-Factor Eating Questionnaire: flexible and rigid control subscales

This study investigated the construct validity of two dietary restraint subscales, flexible control (FC) and rigid control (RC), identified by Westenhoefer (1991; Appetite, 16, 45-55) as a subset of the restraint scale items from the Three-Factor Eating Questionnaire (TFEQ, Stunkard & Messick. [1985]. Journal of Psychosomatic Research, 29, 71-83). The subjects were 31 women on long-term personality disorder units. Based on the Structured Clinical Interview for DSM-III-R (SCID), 68% has past anorexia and/or bulimia diagnoses and 94% were borderline. The subjects completed the TFEQ and supplied weight and height data for body mass index (BMI) calculations. The results supported the validity of the two restraint constructs by showing that FC was inversely related to BMI and predicted an anorexia diagnosis. In contrast, RC directly predicted BMI when tested concurrently with FC. RC was also more associated with a history of bulimia and problems with weight fluctuations than FC was. Thus, the FC-RC distinction was valid and useful in this population of women.

Subtypes of self-injurious patients with borderline personality disorder

Twenty-seven female inpatients with borderline personality disorder were assigned to two groups on the basis of whether they did (N = 14) or did not (N = 13) report experiencing pain during self-injurious episodes. Ratings of depression, anxiety, impulsiveness, dissociation, and trauma symptoms were higher in the women who did not experience pain while injuring themselves, as were the number of suicide attempts and the prevalence of childhood sexual abuse.

Pain perception in self-injurious patients with borderline personality disorder

Pain ratings during the cold pressor test were significantly lower in female inpatients with borderline personality disorder who report that they do not experience pain during self-injury (BPD-NP group, n = 11), compared with similar patients who report that they do experience pain during self-injury (BPD-P group, n = 11), and normal female subjects (n = 6). Pain ratings were not significantly different in the BPD-P and normal control groups. Self-report ratings of depression, anger, anxiety, and confusion were significantly lower, and ratings of vigor significantly higher following the cold pressor test in the BPD-NP group, but not in the BPD-P group. Only anxiety was significantly lower in the normal control group following the cold pressor test. The implications and limitations of these preliminary findings are discussed.

Plasma tryptophan to large neutral amino acid ratios in depressed and normal subjects

The ratios of total and free plasma tryptophan to the sum of five large neutral amino acids (LNAAs) were found to be significantly lower in a group of 16 depressed inpatients compared to nine normal subjects after oral loading with L-tryptophan. The group differences in these ratios were significant before, and 2 weeks after starting treatment with a tricyclic antidepressant. Plasma tryptophan ratios and severity of depression were not significantly correlated.

Antidepressants and weight gain

Weight gain is an often reported, but incompletely understood, side effect of many antidepressant medications. We will discuss the literature with respect to the following issues: weight gain as a pharmacological effect of antidepressants or as an effect of recovery from depression; the incidence of antidepressant-induced weight gain and possible reasons for individual variability in its occurrence; possible mechanisms of antidepressant-induced weight gain; and options for clinical management. Further elucidation of these issues may contribute to our understanding of the neurobiology of affective disorders and appetitive mechanisms.

Salivation and depression: a role for appetitive factors

A decrease in salivary flow rate (SFR) is associated with depressive illness although the mechanisms underlying this association are unknown. Appetitive factors are known to influence SFR, but are not adequately considered in the studies of salivation and depression. Diminished SFR in depressive illness may be more closely related to the appetite disturbances commonly associated with depressive illness than to mood disorder or depressive illness per se. The implications for considering SFR as a physiological correlate of depressive illness are discussed in light of this possibility.