Dr. Daniella Charles-Belzie, HAPA president
A Message from The President:
A time to reflect, to advocate, to heal and give hope!
Daniella Charles-Belzie, M.D.
The entire world has suddenly turned dark. So many people have died and continue to fall from this unexpected, invisible enemy: Covid-19. So many families are experiencing sadness, loneliness and sorrow at this time. Whether one has been physically sick or discouraged by the darkness brought by the coronavirus pandemic, there is a need for the HAPA group to help the vulnerable find their ways. HAPA has been, for 36 years, a positive force through dark days for Haitians living in the United States and in Haiti. The earthquake of 2010 was the worst natural disaster to hit Haiti. Many lives were lost, thousands of family members are still separated. A number of people have been afflicted with medical or and mental illnesses. Children, young and old adults are hungry, begging for food on the streets. In addition to being the poorest country in the Western hemisphere, Haiti is now also plagued by Covid-19. The impact that this dangerous virus will have on people living in this country will be heartbreaking. Immediate help is needed in Haiti to help cope with the devastating effects of the Coronavirus.
HAPA has foreseen the need for an advocacy program to support efforts to improve access to care at the individual and community level. This past March, the organization joined the SUNY Downstate/KCH Medical Center Fellowship program to engage the Caribbean community. Today, due to the various factors related to health disparities, this community which is largely comprised of African Americans and Hispanics has been disproportionately impacted by Covid-19. It calls to attention the dire need for more public health initiatives designed to combat health inequity. Yet, there is hope. There are many creative ways we can help and support one another. The rewards associated with compassion and humility are phenomenal. I hope you will join us in this battle against illness that threatens the lives of our brothers and sisters. Remember that we are better together: “l’union fait la force”.
May the world carry the lessons and experiences of the Coronavirus pandemic for a lifetime.
Information about cloth face covering from the CDC
Do
Make sure you can breathe through it
Wear it whenever going out in public
Make sure it covers your nose and mouth
Wash after using
Don’t
Use it on children under the age of 2
Use surgical masks or PPE intended for healthcare workers
Presentation by the President at the Beraca Church
HAPA members after a health fair at the Beraca Church.
COVID-19 Pandemic: Information provided by HAPA members
8 Coping Strategies To Stay Mentally Healthy during The Coronavirus Pandemic.
Dimitry Francois, MD, FAPA & Leila Jean-Baptiste, MD
- Too much news is bad news
Overexposure to the pandemic can be detrimental to your mental health. Find a couple of credible news sources that you trust and stick with them. The Centers for Disease Control and Prevention (CDC) or The World Health Organization (WHO) websites are excellent scientific resources for updates and precautions. Turn-off your news alert and consume only what you need to know, what is most relevant to you, your city, and your state.
- Practice physical distancing but stay socially connected.
Quarantine yourself and if you have to go out for essential excursions, maintain a distance of 6 feet or so between you and any other individuals on the street. However, do not become socially isolated. Stay connected with your friends and family by Skype, FaceTime, Zoom, email, messaging, and SMS.
- Control what you can control.
Establishing a routine for your days will help you maintain order amid the chaos and the collapse the coronavirus brought into your life. Go to bed and wake up according to your usual schedule. Take regular meals at regular intervals. If your children are at home, establish a routine for them also including schoolwork, meal and snack times, recreational activities.
- Fear vs. Reality
It is normal to feel frightened, stressed, and anxious in the current situation. Take time to notice your emotions and express how you feel. Write down your fears and address them one at a time. Talk to someone that you trust. Have a financial plan, and think about your emotional support.
- Help others
Helping others is a great way to feel better about yourself. During this pandemic, the best way to help others is to practice strict physical distancing. You can also support your community by checking on your neighbors, ordering takeout at local restaurants, calling the local hospital, firehouse, or police station, and asking if you can order pizza for the staff. You can also donate to local or national charities.
- Stay physically fit
It is essential to make your health a priority during this time. Avoid tobacco, alcohol, and drugs. Eat healthily and get enough sleep. Make eating together at home a positive experience. Gyms are closed, but you have to stay active. There are tons of equipment-free videos on YouTube. Meditate and practice mindfulness to relax your body, your mind, and reduce stress. If it is allowed in your community, take a walk outside and get some fresh air while maintaining appropriate physical distancing.
- Distract yourself
Between laundry and dusting, plus vacuuming and taking out the garbage, household chores should keep you busy for hours. Enroll for a free online university course; this is a great way to boost your skillset and gain valuable knowledge. Watch movies, documentaries, and funny videos. Puzzles, handcrafts, and coloring can decrease feelings of anxiety. Keep your faith alive by participating in virtual parishes.
- Stay hopeful and positive
Focus on the positive things in your life. You are quarantined at home, but you never had this much one on one time with your family. Begin your day by having an uplifting conversation or by reading something inspirational. End your day by jotting down the day’s two or three positive events. This exercise will force you to take notice of positive events when they happen. Allow yourself to feel and truly appreciate individual moments in your life, the smell of a dish you are cooking, the beauty of a flower, and the smile of your child. Finally, it is essential to remember that the vast majority of those infected with the virus have recovered from the illness.
References
Centers for Disease Control and Prevention. Stress and Coping
https://www.cdc.gov/coronavirus/2019-ncov/daily-life-coping/managing-stress-anxiety.html
World Health Organization. Mental health and psychosocial considerations during the
COVID-19 outbreak
Dr. Francois is Assistant Professor of Psychiatry, Associate Director, Psychiatry Clerkship and Site Director, Psychiatry Clerkship (Westchester) at Weill Cornell Medicine, NewYork-Presbyterian Westchester Behavioral Health Center.
Dr. Jean-Baptiste is a Fourth-Year Psychiatry Resident at Westchester Medical Center.
The authors report no conflict of interest.
Patients with serious mental illness in the Age of COVID-19: What Psychiatrists need to know.
Pierre Francois, M.D.
Symptoms
The world’s response to COVID-19 needs to be understood in the context of patients’ symptoms as the symptoms can significantly alter what has been the general population’s response.
Paranoia: Remote form of communication can increase patients’ paranoia as they are required to communicate through electronic tools- seeing their psychiatrist on a screen for example. The fear experienced by staff is felt by patients whose paranoid thinking can be magnified.
Delusions: Besides beliefs about an evil government or an evil world, some patients have incorporated COVID-19 into their long-held beliefs such as the illuminati being in control of the world pandemic or the world’s population deserving to be punished. Another example is a patient who believes she is a physician but is giving misinformed medical advice on COVID-19 to other patients on the unit.
Hallucination: People with serious mental illness may attribute information they receive to their “voices” or hear the viruses making noises. Most important is the need for the psychiatrist to be sensitive to the fact that auditory hallucinations can interfere with patient’s ability to communicate by telephone. The patient mixes up all the voices. The loss of visual clues may seriously compromise communication between doctor and patient that has previously been effective.
Cognitive Deficits: Individuals with cognitive deficits may not understand what this is all about, leading to their ability to appreciate the seriousness of the situation. They may not remember what they have been taught about the virus and may require reminders multiple times a day to get them to adopt new habits such as washing their hands more often and practicing social distancing. Individuals with cognitive deficits may be incontinent, leading caretakers to have physical contact with the individual multiple times a day. And some patients with cognitive deficits can be agitated, aggressive and assaultive, again requiring caretakers to have physical contact with the individual multiple times a day.
Disorganization: Like those with cognitive deficits, disorganized patients may struggle with following procedures about hand hygiene and social distancing. They may be confused about their stay in the hospital or why they cannot have visitors.
Anxiety: Patient with previous trauma symptoms or posttraumatic stress disorder, especially complex PTSD, can be triggered by COVID-19 fears: The hospital is no longer a place of safety. Symptoms of COVID-19 especially shortness of breath, may compound anxiety and panic attacks that patients experience. This can lead to difficulties of breathing, confusing two origins for poor oxygenation. Anxiety also can lead to ignoring early symptoms of the virus or to confabulating symptoms, with or without secondary gain.
Incidence of Serious Mental Illness
During this pandemic, it is reasonable to expect that new cases of serious mental illness will arise and need to be addressed by the current psychiatric workforce. But there is reason to believe there will be additional cases that mimic or may in fact become serious mental illness. It comes as no surprise that anxiety is at high levels during the pandemic in the United States.
In health care workers exposed to COVID-19 in China, depression showed a rate of reported symptoms in a sample of 1257, higher than any symptoms other than distress, exceeding anxiety and insomnia. As with PTSD, some who develop depressive symptoms will achieve resolution of those symptoms through brief intervention, but others will progress to major depressive disorder and need longer-term treatment.
In addition, beyond fear of, exposure to, or actual infection by coronavirus producing psychiatric symptoms, the act of quarantine and isolation itself induces psychiatric symptoms
Settings
Inpatient hospitals: Psychiatric hospitals have followed general hospitals in restricting who is going into the building and in setting up screening of those who enter. Psychiatric hospitals have to enact additional restrictions that limit the movement of patients within the building: In hospitals with multiple units, patients are being restricted to their own unit.
With the outpatient community not able to accommodate discharges as it could before, patients’ hospital stays are lengthened. Psychiatrists are making uncharted risk-benefit analyses: Is the patient at more or less risk if the patient stays in the hospitals or if the patient is discharged with a less than optimal discharge plan.
Community: With agencies providing community services operating on skeleton crews and/or with no face to face contact, how do individuals who have been dependent on these services for decades survive?
What about patient without phones or who know nothing about their phone other than it is an instrument with which to make calls?
Residential settings for individuals with severe mental illness are doing preventive interventions, such as having residents spend very little time in common areas of the house, staggering mealtimes, and excluding all visitors. Residents who visit their family must remain with the family until the crisis is over.
Shelters need to adjust business as usual. It has long been their practice to put people out during daytime hours; yet they too may be facing problems with overcrowding and the inability to accommodate the same numbers of individuals.
Social isolation: For many persons with mental illness, being alone is a terrible burden, far beyond that experienced by many others. Loneliness precipitates psychiatric symptoms in those without serious mental illness, let alone those with these disorders.
People in abusive households can be in danger from sources other than the coronavirus. They can be isolated with their abusers; tempers may flare and violence could ensure. Their abuser may threaten them with eviction if they show symptoms.
Prejudice(stigma): We can anticipate an increased shunning of many people with serious mental illness due to their looking like someone more likely to be infected and their appearance in general. It comes as no surprise that people quickly move away from someone who does not keep usual distance from them even when there is no pandemic.
Office of Civil rights of the Department of health and Human Services has released guidelines saying that states, hospitals, and physicians cannot put people with disabilities at the back of the line for care.
Benefits
Amid all these concerns during the COVID19 pandemic, the symptoms and functioning of some psychiatric patients have actually improved when interventions are knowingly framed by their psychiatrist.
Mental health support: As indicated by and APA poll released In March, anxiety about COVID-19 runs high among Americans, as does the sense that coronavirus is having a serious impact on their lives. Health care workers are proving to be especially vulnerable to showing elevated psychiatric symptoms. But while some services have become less available, others have been newly developed: The Texas health and Human Services created a free, statewide 24/7 mental health hotline to support Texans struggling with mental health repercussions of the COVID-19 pandemic. Will states that have not done so follow suit? Will individuals who were previously reluctant to seek psychiatric help find this pandemic a good reason to do so?
Conclusion
In this article, we have attempted to provide an overview of what is happening to people with serious mental illness in this pandemic to better equip us all to more effectively deliver care and treatment to this vulnerable population. Like so many others in health care, we now find ourselves in rough waters with one broken oar in a craft that require two paddles. In this health care crisis, Psychiatry, like every other medical discipline, finds itself venturing forth in practice patterns with which we have no experience. We might do well to heed the words of Mahatma Gandhi: You may never know what results come of your actions, but if you do nothing, there will be no results.
HAPA eNewsletter: Articles submitted by members
Opioid Use Disorder: Diagnosis and Updated Treatment Options
Pierre Francois, M.D.
Abstract: The United States is in the midst of an opioid crisis that has led to an immense number of overdose deaths. It is urgent to provider to recognize signs of opioid use disorder through clinical interview, review of laboratory results, use of the prescription drug monitoring program and other signs. After a patient is safely detoxicated from opioids, a decision must be made together with the patient about whether to engage in abstinence based treatment, or medication- assisted treatment. With medication assisted treatment, the options are to use mu receptor agonists and antagonist. Each of these options has its own specific benefits. Additional psychosocial interventions are also recommended during treatment of opioid use disorder.
Opioid misuse has led to a staggering amount of lost lives and economic costs. In 2015, a total of 20101 overdose deaths were related to prescription of pain relievers. There is a concern that addiction to prescription opioids may lead to use of additional dangerous substances. In a survey conducted in 2014, it was found that 94% of people in treatment for opioid addiction stated that they chose to use heroin because prescription of were even more expensive and harder to obtain.
Challenges in Diagnosis
In cases where a patient may minimize use, diagnosing opioid use disorder may be more complex and require analysis of a patient’s behavioral patterns, and using multiple sources of information to confirm clinical suspicion. Laboratory testing may be helpful. Although opioid use itself is not associated with liver injury; chronic use of Tylenol-containing formulations may present with elevated liver enzymes.
Urine toxicology screens that are positive for opioid help to confirm suspicion of use in those who deny taking narcotics. However, the caveat is that urine toxicology screens have limitation, as they only detect compounds metabolized to morphine (heroin, codeine, poppy seeds). Standard urine drugs screens may nor detect synthetic opioids (fentanyl, oxymorphone, meperidine, propoxyphene, buprenorphine, methadone) and have variable cross-reactivity with hydrocodone, hydromorphone and oxycodone.
On mental status examination, it is also important to recognize signs of opioid withdrawal. A common cold may mimic withdrawal, but mydriasis, frequent yawning, elevated vital signs, tremor and piloerection are more withdrawal-specific signs.
The presence of Opioid Use Disorder is characterized by three C of Addiction: Loss of control, Compulsion to use or Craving and continued use despite adverse consequencesLoss of control may be demonstrated by the inability to ration supply of medication and the patient may frequently run out early. This may be evidence by requesting early refills or replacement of lost refills of prescriptions.
The primary purpose of the prescription drug monitoring program is to reduce the overprescribing of controlled substances by health practitioners, and to curtail the diversion and misuse of opioid analgesic. It can also be challenging to distinguish an actual use disorder from pseudoaddiction. Pseudoaddiction describes a phenomenon in which patients who are treated with opioids for pain may exhibit seemingly aberrant behaviors when analgesia is inadequate. They may display preoccupation with seeking opioid medication, switch providers, run out of medication from other sources early or use medication from other sources. When adequate pain control is achieved, the aberrant behavior ceases.
The National Institue on Drug Abuse (NIDA) suggested using their quick screen and NIDA-modified ASSIST (The Alcohol Smoking and Substance Involvement Screen test) questionnaires for identifying Opiate use disorder in a general medical setting.
Treatment of Opioid Use Disorder
Understanding the pharmacology of opioids is important for eventual treatment planning of OUD. There are three classic opioid receptors: mu, delta, and kappa. A new receptor nociceptin also belongs to a nonopioid branch of the opioid receptor family. Most the opioid used in clinical practice today have their primary action on the mu receptor. These receptors belong to ag protein couple family of receptors and are found widely in the body. Inhibition of neurotransmitter release via hyperpolarization is considered the primary mechanism responsible for the clinical effects. This may include analgesia, but may also lead to overdose death, via respiratory depression. On the other hand, receptor antagonists naloxone and naltrexone can be used to reverse the effects of agonists at all three of the classical opioid receptors.
After a patient is diagnosed with Opioid Use Disorder, several important decisions must be made. If the patient is actively in withdrawal from opioids detoxification using buprenorphine or methadone taper may be extremely helpful as they are mu receptor partial agonist and full agonist respectively. If dose options are not available, supportive care with antiemetics, antidiarrhea and sedatives may be helpful to ameliorate symptoms. To reduce noradrenergic excess during withdrawal, the alpha 2 adrenergic receptor agonist clonidine and lofexidine may have less risk of hypotension and sedation compared to clonidine
Once Detoxification is initiated the next step in treatment planning involves deciding between long term treatment that is abstinence-based or medication-assisted. Use of abstinence-based treatment does not involve medications specifically targeting Opioid use disorder. For some it may be more helpful to transition to medication-assisted treatment with a full mu receptor antagonist (naltrexone), agonist(methadone) or partial agonist (buprenorphine). Predictors of relapse after inpatient detoxification may include history, greater amount of use, longer duration of use, positive family history and past attempt of opioid detoxification
If the patient is enrolled in a Medication Assisted Treatment (MAT), a provider should keep in mind that medication alone may not be sufficient enough for recovery. A large role of the medication is to relieve withdrawal, reduce cravings substantially, reduce overdose risk, improve treatment retention, and allow for improved engagement in psychosocial interventions and lifestyles changes.
Buprenorphine is becoming available in a variety of forms to help improve treatment compliance. Although sublingual films and tablets have been available, newer formulations now exist including 6-month subdermal implants and monthly intramuscular injections. Naltrexone comes in two formulations: oral and intramuscular monthly extended-release(NTX-XR). Patient on MAT are recommended to be involved in psychosocial interventions which may include 12 steps groups, Self Management and Recovery Training recovery, and individual and group therapies.
Additional Interventions
Additional psychiatric intervention and collaboration with primary care providers and specialists can help to address chronic pain that can increase a patient’s relapse risk. The relationship between pain and depression can be complex to manage. It is well known that dysregulation of the neurotransmitters serotonin and norepinephrine is linked to both depression and pain. Thus, antidepressant that inhibit the reuptake of both serotonin and norepinephrine such as venlafaxine and duloxetine are the first line treatments in patient who are depressed with physical symptoms.
The other antidepressants that are efficacious include the TCA amitriptyline and norepinephrine in management of neuropathic pain.Other psychotropic medications used to treat pain include gabapentin, pregabalin. Topamax and depakote are used as adjunct to treat migraine.The most widely used psychological treatment for persistent pain is CBT which targets belief about pain. This include education about pain, learning skills such as relaxation or problem solving and finally practicing the skills at home
Attention-Deficit Hyperactivity Disorder Across The Lifespan
Pierre Francois, M.D.
ADHD is a neurodevelopmental disorder in which the ability to attend and/or control impulses is a) significantly less than that of a typically developing individual of a given age, b) causes impairment in the individual’s academic, employment or social functioning and c) is not better accounted for by some other medical or psychiatric condition. The only major change in he criteria from DSM-4 is the change in the age of onset, which now requires some symptoms to be present before age 12 years, rather than age 7 years. The individual symptoms descriptions have been broadened to also include behaviors typical of an adolescent or adult rather than just a young child.
Epidemiology
A recent data suggests that the rate of diagnosis is increasing. Epidemiology suggests a prevalence of 4.4% for ADHD among adults.
Comorbidity
Both oppositional defiant and conduct disorders, as well as anxiety disorder affect 25%-33% of children with ADHD. Learning and language disorder affect another one quarter of children with ADHD. Many children with ADHD will have two or more comorbid disorders, complicating clinical management. Compared with children with ADHD alone, those with oppositional defiant/conduct disorder show more severe symptoms of impulsivity, higher rates of aggression, a greater prevalence of learning disorders and a greater propensity to develop both antisocial personality and substance abuse during their adolescent years. Compared with those with ADHD alone, individuals with comorbid anxiety show lower levels of impulsivity on laboratory measures of attention as well as a greater tendency to respond to psychosocial interventions. How depression affects the clinical expression of ADHD has not been explored; family study suggest that ADHD and major depression disorder might share genetic factors. Because treatment of depression rarely leads to remission of ADHD symptoms, it seems unlikely that major depressive disorder masquerades as ADHD to any significant degree
Etiology and Risk Factors
Approximately 71%-90% of the variance in ADHD traits is found to be attributable to genetics. Heritability estimates include the effects of gene-environment interactions. Maternal smoking during pregnancy and prenatal/perinatal adversity have been established as risk factor for ADHD. Children with ADHD exposed to smoking during pregnancy have more severe behavioral problems, lower IQ and poorer neuropsychological test performance than nonexposed children with ADHD. even when controlling for income level, ethnicity, maternal age and maternal alcohol use. Severe head injury can result in ADHD even when preinjury ADHD diagnosis is controlled for.
Patholophysiology
A) Cognitive Deficit
Recent research has suggested multiple cognitive deficits of children with ADHD. Working memory deficit robustly delineate individuals with ADHD from those in a control group, particularly central executive working memory deficits such as updating of working memory, manipulating information in working memory and mental manipulation of temporal order. That is, children with ADHD either cannot tolerate a delay to wait for an anticipated reward or are hypo responsive to the reward, making their behavior difficult to shape by the normal reinforcements and punishments in the environment. Despite these findings, many children with ADHD show no deficits on either neuropsychological or laboratory testing of cognition.
B) Neuroanatomical Findings
A meta-analysis of anatomical MRI studies showed reduced volume of multiple brain regions in persons with ADHD versus control. Studies have shown a global cortical maturational delay in the development of both cortical surface area and cortical thickness relative to control participants. Individuals with ADHD have a thinner cortex at baseline than controls and prune later.
C) Functional neuroimaging
Functional studies in ADHD have been performed principally using tasks assessing response inhibition as well as tasks measuring attention. In a meta- analysis, patients with ADHD showed reduced activation during response inhibition in the right inferior frontal cortex, supplementary motor area and anterior cingular cortex as well as in striatothalamic areas. For attention tasks, patients with ADHD showed reduced activation relative to the control group for attention in the right dorsal lateral prefrontal cortex, posterior basal ganglia, and thalamic and parietal regions. As noted earlier, patients with ADHD have difficulty delaying gratification and often seem unresponsive to reward.
Course and Prognosis
Results of the Montreal Children hospital studies a longitudinal study of hyperactive children into adulthood revealed that 50% still showed symptoms of inattention, impulsivity, low self-esteem, and social skills deficits. Biederman compared boys with ADHD with matched controls 16 years later after initial diagnosis. Individuals with ADHD had significantly higher rates of mood, antisocial, anxiety and addictive disorders, moreover, they had more psychosocial impairments than did the boys in the control group.
Adult with a childhood history of ADHD have a higher than expected rates of antisocial behavior, injuries and accidents, employment and marital difficulties, health problem, teen pregnancies, and children out of wedlock. Risky sexual behavior, traffic tickets and accidents were more prevalent in the ADHD groups with comorbid conduct disorder predicting poor outcome.
Clinical Evaluation
Achievement and IQ testing to rule out learning disability is not mandatory before making a diagnosis of ADHD. If a child’s academic performance does not improve with control of ADHD symptoms or if the development history of mental status examination yields evidence of language or motor delays, then IQ and achievement testing should be performed because the child most likely has a comorbid language learning disorder. The patient’s medical history should be obtained as well as a physical examination within the last year
Pharmacotherapy
A) Stimulants
Response rate to stimulants can be as high as 90% when both methylphenidate and amphetamines are fully titrated. Although preschoolers may have a slightly decreased rate of response relative to school age children, adults show a response equally robust to that of school-age children and adolescents. Short term side effects of stimulants include decreased appetite, insomnia and headache whereas mood changes and tics are much rarer and may be idiosyncratic. Long term effect on height, up to 2 cm have been found in long term studies.
B) Atomoxetine
This nonstimulant agent is a noradrenergic reuptake blocker that has some indirect agonism on dopamine. Numerous studies show that atomoxetine is superior to placebo in the treatment of ADHD for children and adolescents.
C) Alpha-Agonists
The alpha- 2 receptor agonists clonidine and guanfacine have varied effect on noradrenergic functions. Long acting versions of both agents have been the focus of studies either as a monotherapy or as an add-on to stimulant treatment.
Psychosocial Intervention
Behavior therapy is the only psychosocial intervention validated in the treatment of ADHD. General principles of behavioral therapy in the treatment of ADHD are as follow: information about the nature of ADHD, learning to attend more carefully to the Child’s misbehavior and to when the child complies, establishing a home token economy, using time out effectively, managing noncompliant behaviors in public setting, using a daily school report card, and anticipating future misconduct. Occasional booster sessions often are recommended.
Conclusions
The clinical presentation, epidemiology, and acute pharmacotherapy of ADHD are now well established. Behavior therapy is an important adjunct treatment, particularly for partial responders or those with comorbid condition. At least one third continue to meet criteria for the disorder as adult with many more suffering some degree of impairment. Although genetics plays a major role in the disorder, specific genes for ADHD have not been discovered.
Suicide Prevention
Marie Daniella Charles-Belzie, MD
Objectives of presentation:
1. Understand the range of factors that can contribute to suicide
2. Recognize the need for early and accurate diagnosis
3. Review general principles in treating suicidal patients
Suicide and suicide attempts are important public health concerns, currently accounting for 40,000 deaths. Of all deaths, eight (8) to twenty-five (25) attempted suicides. Factors include mental illness, substance abuse, previous suicide attempts, family history of suicide, (history of being sexually abused and impulsive or aggressive tendencies.
Suicide and suicide attempts are important public health concerns, currently accounting for 40,000 deaths per year in the United States. It is the tenth (10th) leading cause of death for Americans and has been among the top twelve (12th) leading causes of death since 1975 in the United States. With respect to youth, the incidence of suicide noticeably increases in the late teens and continues to ascend until the early twenties. Suicide is the second (2nd) leading cause of death among older adolescents and young adults under 25 years of age. People of all gender and ethnicities can be at risk.
According to a 2017 CDC’s report (Center for Disease Control and Prevention): “Many more people survive suicide attempts than actually die. In 2015, more than half a million people (505,507) received medical care for self-inflicted injuries at emergency departments across the United States. Almost 1.4 million adults self-reported a suicide attempt and 9.7 million adults self-reported serious thoughts of suicide.
Suicide is usually the result of multiple risk factors. Having these risk factors, however, does not mean that suicide does not occur.”
Researchers identified some of these risk factors:
· Depression, other mental disorders, or substance abuse disorder
· Certain medical conditions
· Chronic pain
· A prior suicide attempt
· Family history of mental disorder or substance abuse
· Family violence, including physical or sexual abuse
· Having guns or other firearms in the home
· Having recently been released from prison or jail
· Being exposed to others’ suicide behavior, such as that of family members, peers, or celebrities
Despite significant precursors and risk markers for suicide attempts and completed suicides, the management of suicide risks is a formidable challenge. Treatment and carefully designed prevention remain powerful tools for reducing suicide.
The alarming numbers of suicide deaths and attempts emphasize the need for public awareness and clinical attention.
1. Suicide Prevention Outreach and Response, NYSOMH / NIMH Suicide Prevention (CDC)
2. Suicide Risk Factors (AACAP 2005) in Adolescents
3. “Suicide and Attempted Suicide,” author: Keith Hawton and Kees vas Heeringen
Treatment of Sleep Disturbances in Nursing Home Patients. Practical management strategies.
Pierre Francois, M.D.
Sleep disorders are a significant issue in the nursing home population, with prevalence rates from 6% to 65%. They can lead to several deleterious effects, such as increased malaise, falls and cognitive decline. There are a variety of treatment options with nonpharmacological interventions being first line treatment. If nonpharmacologic measures fail, pharmacotherapy can be considered. Melatonin agonist, select antidepressants, suvorexant, and magnesium supplement have data to support their use in the elderly patient with minimal side effects. Medication with safety profiles that indicate the risks may outweigh the benefits should be avoided. These include benzodiazepines, non benzodiazepines, hypnotics, antihistamines, and most TCA. Additionally, the lowest effective dose of any medication is recommended to minimize adverse effects.
As people age, they experience increasing difficulty with sleep for a variety of reasons, including decreased slow wave sleep, more sleep fragmentation, earlier awakening and changes in the circadian rhythm. Sleep quality affects memory, concentration, and performance of psychomotor tests
Nonpharmacologic
Before initiating medication for insomnia, it is important to ensure that nonpharmacologic approaches have been explored and implemented. If the individual has an underlying issue causing insomnia, address those issues first. Ensure proper sleep hygiene is being practiced. Increased activity level, minimizing light and noise exposure and maintaining a comfortable temperature are recommended.
Sedative Hypnotics
Benzodiazepines
Benzodiazepines improve insomnia by shortening sleep onset latency and decreasing nocturnal awakenings. Triazolam and temazepam are used for short term treatment of insomnia. Benzodiazepines are associated with confusion, memory impairment, daytime drowsiness and impaired balance that can lead to fall.
Nonbenzodiazepine Hynoptics
Zolpidem, zaleplon and eszopiclone
They were to reduce polysomnographic and subjective sleep latency. They are associated with adverse effects such as cognitive or psychomotor effects, daytime fatigue, tolerance, addiction and excess mortality
Melatonin Agonist
Melatonin is thought to decline as a person ages and this leads to sleep disturbance. Ramelteon is more selective and has a longer half life than melatonin. Patient has a significant reduction on sleep latency.
Antidepressants:
Trazodone
Trazodone is often prescribed for insomnia at dose subtherapeutic. Trazodone side effects include dizziness, sedation, blurred vision. Cardiac effects include hypotension and syncope.
Mirtazapine
Mirtazapine has been found to promote sleep, improve sleep continuity and increased low delta activity. Side effects include dry mouth, constipation, increased appetite, dizziness and confusion.
Doxepin
Doxepin has a high affinity for H1 receptor which promotes and maintain sleep. Side effects include blurred vision, dizziness and sedation.
Orexin Receptor
Suvorexant is an orexin receptor antagonist that is thought to improve sleep through dampening the orexin-mediated wakefulness system of the brain. Suvorexant at doses of 30 mg and 15 mg were both found to statistically improve subjective and polysomnographic measures of sleep. The most common adverse effect was somnolence with excessive daytime sleepiness.
Antihistamines
There are few studies evaluating the effectiveness of antihistamines in nursing home residents due to the risk of cognitive impairment and anticholinergic effects.
Antipsychotics
Antipsychotic particularly those with sedating properties are used off label for insomnia.
Quetiapine is the most frequently prescribed antipsychotic for sleep and sedation.
Antipsychotics in the elderly are associated with an increased risk of adverse effects, including, EPS, metabolic disease and sudden cardiac death. A recent warning linked the use of antipsychotic and sleep apnea.
Clinicians should limit the use of antipsychotics to cases where nonpharmacologic measures have failed and the patients’ symptoms may create a threat to themselves or others.
Supplements
There are very few studies evaluating supplements for sleep in the elderly.
Magnesium supplementation has been found to increase slow wave sleep, delta power and sigma power.
Conclusion
For treatment of sleep disturbances in nursing home residents, nonpharmacologic treatment should be first line. If pharmacologic treatment is necessary, melatonin agonist, especially ramelteon can be considered or low dose antidepressant such as trazodone or doxepin. If a patient has a comorbid depression, mirtazapine is a good choice. Medication that should be minimized due to their unfavorable safety profile include sedatives, hypnoptics, antipsychotics, antihistamine, and TCA.
10 Myths about ECT
Dimitry Francois, MD, FAPA and Elaina DellaCava, MD
As evidence supporting the use of electroconvulsive therapy (ECT) to treat patients with depression and other psychiatric illnesses continues to grow, myths about this treatment persist. In light of these myths, patients might be reluctant to receive ECT. As clinicians, we need to educate patients about the safety and effectiveness of this treatment. Here are 10 of the most commonly held myths about ECT, and why each is a misconception.
1. It is a barbaric treatment. ECT is conducted in a controlled medical environment, either during a hospitalization or as an outpatient procedure, by a team consisting of a psychiatrist, anesthesiologist, and nurse. Patients receive a short-acting intravenous anesthetic to ensure that they are unaware of the procedure, and a muscle relaxant to help prevent physical injury. Vital signs and brain waves are monitored throughout the procedure, which typically lasts 15 to 20 minutes. Patients remain relaxed, are unaware that they are having a seizure, and experience no pain. Following ECT, the patient is taken to a recovery area, where he or she is closely monitored as the medications wear off.
2. It causes brain damage. Studies using MRI to look at the brain before and after ECT have found no evidence that ECT causes negative changes in the brain’s structural anatomy. To the contrary, there is evidence that there is neuroplasticity in the brain in response to ECT, and the neurotrophin brain-derived neurotrophic factor also may be increased.
3. It causes permanent memory loss. ECT can result in both anterograde and retrograde memory impairment; however, anterograde amnesia typically lasts only days to weeks. Retrograde amnesia is much less common, but when it occurs, it tends to be loss of memory of events that took place in the weeks leading up to and during treatment. Using an ultrabrief (as opposed to standard brief) pulse, as well as right unilateral (as opposed to bilateral) electrode placement, substantially reduces the risk of cognitive and memory adverse effects.
4. It is a treatment of last resort. Typically, ECT is used for patients who have not responded to other interventions. However, ECT can be used as a first-line treatment for patients if a rapid or higher likelihood of response is necessary, such as when a patient is suicidal, catatonic, or malnourished as a result of severe depression.
5. It only works for depression. Evidence shows ECT is efficacious for several psychiatric conditions, not just unipolar depressive disorder. It can effectively treat bipolar depression, mania, catatonia
and schizoaffective disorders. ECT also has been demonstrated to be effective in acute and maintenance treatment of Parkinson’s disease.
6. It is not safe. Death associated with ECT is extremely rare. A recent analysis estimated that the rate of ECT-related mortality is 2.1 deaths per 100,000 treatments. In comparison, the mortality rate of general anesthesia used during surgery has been reported as 3.4 deaths per 100,000 procedures. Evidence also suggests ECT can be safely administered to patients who are pregnant.
7. It cannot be given to patients with epilepsy. There are no absolute contraindications to using ECT for these patients. Most patients with epilepsy can be successfully treated with ECT without requiring an adjustment to the dose of their antiepileptic medications.
8. It will change one’s personality. ECT has not been found to cause any alterations in personality. Patients who are treated with ECT may describe feeling more like themselves once their chronic symptoms of depression have improved. However, ECT has not been shown to effectively treat the symptoms or underlying illness of personality disorders, and it may not be an effective treatment for depression associated with borderline personality disorder.
9. Its success rate is low. ECT has the highest response and remission rates of any form of treatment used for depression. An estimated 70% to 90% of patients with depression who are treated with ECT show improvement.
10. It is a permanent cure. ECT is not likely a permanent solution for severe depression. The likelihood of relapse in patients with severe depression who are helped by ECT can be reduced by receiving ongoing antidepressant treatment, and some patients may require continuation or maintenance ECT.