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Suicide in Older Adults: Intervention Required

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Research Paper Title

Suicide in Older Adults.

Abstract

Suicide in older adults is a critical problem that nurses and other health professionals need to address.

Evidence-based interventions for prevention of late-life suicide are urgently needed, as well as increased availability of health care professionals with knowledge and skills to recognise suicide risks and intervene to provide effective care for this vulnerable population.

Reference

Sorrell, J.M. (2020) Suicide in Older Adults. Journal of Psychosocial Nursing and Mental Health Services. 58(1), pp.17-20. doi: 10.3928/02793695-20191218-04.

Benzodiazepines & Older Adults

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Research Paper Title

Little Helpers No More: A Framework for Collaborative Deprescribing of Benzodiazepines in Older Adults.

Abstract

Benzodiazepines are a class of medications that tend to fly “under the radar” within the general population but nonetheless post a significant risk to older adults when not used appropriately.

The current article aims to shine a spotlight on this medication class along with a framework for a team-based approach to successfully de-escalate use when clinically appropriate.

Reference

Suss, T. & Oldani, M. (2020) Little Helpers No More: A Framework for Collaborative Deprescribing of Benzodiazepines in Older Adults. Journal of Pyschosocial Nursing and Mental Health Services. 58(1), pp.23-28. doi: 10.3928/02793695-20191218-05.

A Provider’s Experience of Making Alliances With Patients Dependent on Benzodiazepines

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Research Paper Title

Making Alliances With Patients Dependent on Benzodiazepines: A Provider’s Experience.

Background

Tens of millions of benzodiazepine (BZD) prescriptions are written annually for the outpatient management of anxiety disorders and insomnia.

Many prescribers do not follow published treatment guidelines for these disorders. Psychiatric-mental health nurse practitioners (PMHNPs) regularly meet patients who have been treated with BZDs for years.

The dangers posed by outpatient BZD use are recognised, especially among older adults, and their use should be minimised or eliminated.

There are multiple manualised approaches to outpatient down-titration of BZDs, but little evidence about which methods really work.

To effect change, it is essential that PMHNPs establish a sound therapeutic alliance with these patients, especially by using their skills in therapeutic communication.

One major conflict that may occur early in the relationship is the patient’s expectation that the BZD medication regimen will continue indefinitely and their unwillingness to risk discontinuing the drug.

This conflict commonly raises non-adherence to a down-titration plan or patient termination of the relationship.

It is essential that PMHNPs take the time and patience to build strong therapeutic alliances with patients to design and implement a successful BZD discontinuation regimen.

Reference

Amberg, A. (2020) Making Alliances With Patients Dependent on Benzodiazepines: A Provider’s Experience. Journal of Pyschosocial Nursing and Mental Health Services. 58(1), pp.29-32. doi: 10.3928/02793695-20191218-06.

Benzodiazepine Use during Hospitalisation

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Research Paper Title

Let’s Talk About Benzodiazepine Use: Inpatient Psychiatric Nurses Initiating the Conversation.

Abstract

Inpatient psychiatric nurses regularly dispense pro re nata (PRN) medication to individuals during their psychiatric hospitalisation.

International studies indicate that 66% to 90% of patients receive PRN medications during hospitalisation, a large percentage of which are benzodiazepines (BZDs).

Although clear opportunities exist for nursing intervention to reduce BZD use, there is little recent US literature on inpatient psychiatric nurses’ proactive approach to the issue.

The current article examines the factors that support BZD use during inpatient hospitalisation, including nurses’ attitudes around BZD use, the perceived effectiveness of the medication to address difficult situations, and the barriers to using alternative nonpharmacological methods.

Suggestions are presented for how nurses might begin dialogues with patients around BZD use and alternative strategies to manage distress.

It is recommended that the specialty initiate a research agenda for reducing BZD use during inpatient psychiatric treatment and champion the issue as a focus for systematic improvement efforts.

Reference

Delaney, K.R. (2020) Let’s Talk About Benzodiazepine Use: Inpatient Psychiatric Nurses Initiating the Conversation. Journal of Psychosocial Nursing and Mental Health Services. 58(1), pp.33-38. doi: 10.3928/02793695-20191218-07.

A Study into an Intervention to Decrease Benzodiazepine Prescribing by Providers in an Urban Clinic

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Research Paper Title

An Intervention to Decrease Benzodiazepine Prescribing by Providers in an Urban Clinic.

Background

The objective of this quality improvement project was to decrease the amount of benzodiazepines (BZDs) prescribed by providers at a Midwestern university outpatient clinic.

Methods

Clinic providers participated in a brief, live educational intervention combining academic detailing (i.e., the provision of current evidence about BZD) and pharmaceutical detailing (i.e., a sales technique borrowed from pharmaceutical companies).

A 1% decrease in BZD prescribing was set as the measure of success.

Using data from the electronic medical record, the monthly average of BZD prescriptions written within calendar year 2017 (before project launch) was compared to the number written 30 days after the intervention.

Results

Following the intervention, an 80% reduction in BZD prescribing was calculated.

Conclusions

Combined academic and pharmaceutical detailing could be an effective way to change prescribing behaviour in this provider population.

Further investigation is needed to ascertain whether the change in prescribing behaviour can be sustained, and that no harm is being done to patients who are currently dependent on BZD medications.

Reference

Platt, L., Savage, T.A. & Rajagopal, N. (2020) An Intervention to Decrease Benzodiazepine Prescribing by Providers in an Urban Clinic. Journal of Psychosocial Nursing and Mental Health Services. 58(1):39-45. doi: 10.3928/02793695-20191218-08.

What are the Side Effects Associated with a Single Dose of Ketamine in Treatment-Resistant Depression?

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Research Paper Title

Comprehensive assessment of side effects associated with a single dose of ketamine in treatment-resistant depression.

Background

Concerns about ketamine for treating depression include abuse potential and the occurrence of psychotomimetic effects.

This study sought to comprehensively assess side effects (SEs) associated with a single subanesthetic-dose intravenous ketamine infusion.

A secondary aim was to examine the relationship between Clinician-Administered Dissociative States Scale (CADSS) scores and dissociative symptoms reported on a comprehensive, clinician-administered SE questionnaire.

Methods

Data from 188 participants were pooled from four placebo-controlled, crossover ketamine trials and one open-label study (n = 163 with either treatment-resistant major depressive disorder or bipolar disorder and 25 healthy controls).

SEs were actively solicited in a standardized fashion and monitored over the time-course of each study.

Statistical analyses assessed the effect of drug (ketamine, placebo) on SEs and measured the relationship between CADSS total score and SEs contemporaneously endorsed during structured interviews.

Results

Forty-four of 120 SEs occurred in at least 5% of participants over all trials.

Thirty-three of these 44 SEs were significantly associated with active drug administration (versus placebo).

The most common SE was feeling strange/weird/loopy.

Most SEs peaked within an hour of ketamine administration and resolved completely by two hours post-infusion.

No serious drug-related adverse events or increased ketamine craving/abuse post-administration were observed.

A positive correlation was found between dissociative SEs and total CADSS score.

The post-hoc nature of the analysis; the limited generalisability of a single subanesthetic-dose ketamine infusion; and the lack of formal measures to assess ketamine’s cognitive, urological, or addictive potential.

Conclusions

No long-lasting significant SEs occurred over the approximately three-month follow-up period.

Reference

Acevedo-Diaz, E.E., Cavanaugh, G.W., Greenstein, D., Kraus, C., Kadriu, B., Zarate, C.A. & Park, L.T. (2019) Comprehensive assessment of side effects associated with a single dose of ketamine in treatment-resistant depression. Journal of Affective Disorders. pii: S0165-0327(19)31983-4. doi: 10.1016/j.jad.2019.11.028. [Epub ahead of print].

Linking Collaborative Care & Relapse Prevention for Depression

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Research Paper Title

The role of relapse prevention for depression in collaborative care: A systematic review.

Background

Relapse (the re-emergence of depression symptoms before full recovery) is common in depression and relapse prevention strategies are not well researched in primary care settings.

Collaborative care is effective for treating acute phase depression but little is known about the use of relapse prevention strategies in collaborative care.

The researchers undertook a systematic review to identify and characterise relapse prevention strategies in the context of collaborative care.

Methods

The researchers searched for Randomised Controlled Trials (RCTs) of collaborative care for depression.

In addition to published material, they obtained provider and patient manuals from authors to provide more detail on intervention content.

They reported the extent to which collaborative care interventions addressed four relapse prevention components.

Results

93 RCTs were identified.

31 included a formal relapse prevention plan; 42 had proactive monitoring and follow-up after the acute phase; 39 reported strategies for optimising sustained medication adherence; and 20 of the trials reported psychological or psycho-educational treatments persisting beyond the acute phase or focussing on long-term health/relapse prevention.

30 (32.3%) did not report relapse prevention approaches.

The researchers did not receive trial materials for approximately half of the trials, which limited their ability to identify relevant features of intervention content.

Conclusions

Relapse is a significant risk amongst people treated for depression and interventions are needed that specifically address and minimise this risk.

Given the advantages of collaborative care as a delivery system for depression care, there is scope for more consistency and increased effort to implement and evaluate relapse prevention strategies.

Reference

Moriarty, A.S., Coventry, P.A., Hudson, J.L., Cook, N., Fenton, O.J., Bower, P., Lovell, K., Archer, J., Clarke, R., Richards, D.A., Dickens, C., Gask, L., Waheed, W., Huijbregts, K.M., van der Feltz-Cornelis, C., Ali, S., Gilbody, S. & McMillan, D. (2019) The role of relapse prevention for depression in collaborative care: A systematic review. Journal of Affective Disorders. pii: S0165-0327(19)30734-7. doi: 10.1016/j.jad.2019.11.105. [Epub ahead of print].

Is Protein Intake Associated with Cognitive Functioning in Individuals with Psychiatric Disorders?

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Research Paper Title

Protein intake is associated with cognitive functioning in individuals with psychiatric disorders.

Background

Schizophrenia and bipolar disorder are associated with reduced cognitive functioning which contributes to problems in day-to-day functioning and social outcomes.

A paucity of research exists relating dietary factors to cognitive functioning in serious mental illnesses, and results are inconsistent.

The study aims to describe the nutritional intake of persons with schizophrenia and those with a recent episode of acute mania and to determine relationships between the intake of protein and other nutrients on cognitive functioning in the psychiatric sample.

Methods

Persons with schizophrenia and those with acute mania were assessed using a 24-h dietary recall tool to determine their intakes of protein and other nutrients.

They were also assessed with a test battery measuring different domains of cognitive functioning. Results indicate that lower amounts of dietary protein intake were associated with reduced cognitive functioning independent of demographic and clinical factors.

Results

The association was particularly evident in measures of immediate memory and language.

There were not associations between cognitive functioning and other nutritional variables, including total energy, gluten, casein, saturated fat, or sugar intakes.

Conclusions

The impact of dietary interventions, including protein intake, on improving cognitive functioning in individuals with psychiatric disorders warrants further investigation.

Reference

Dickerson, F., Gennusa, J.V. 3rd, Stallings, C., Origoni, A., Katsafanas, E., Sweeney, K., Campbell, W.W. & Yolken, R. (2019) Protein intake is associated with cognitive functioning in individuals with psychiatric disorders. Psychiatry Research. doi: 10.1016/j.psychres.2019.112700. [Epub ahead of print].

Utility of Add-on Mirtazapine to Clozapine-Responsive Early-Onset Schizophrenia

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Research Paper Title

Add-on mirtazapine to clozapine-responsive early-onset schizophrenia.

Abstract

Early-onset schizophrenia is notorious for poor prognostication and treatment-refractoriness.

Clozapine remains a viable option, albeit off-label, but is clearly underutilised in this population.

Use is typically fraught with panoply of drastic side effects.

Here, the authors report on an adolescent case with schizophrenia that responded ultimately to clozapine.

Add-on mirtazapine was advantageous spanning negative and cognitive symptom domains whilst addressing clozapine-related sialorrhea and urinary incontinence.

This might open new venues for such complicated clinical scenarios.

Reference

Moodliar, S., Naguy, A. & Elsori, D.H. (2019) Add-on mirtazapine to clozapine-responsive early-onset schizophrenia. Psychiatry Research. https://doi.org/10.1016/j.psychres.2019.112701.

Do Lipid Alterations Predate Antipsychotic Treatment in Adolescents with Early-Onset Pyschosis?

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Research Paper Title

Lipid alterations in adolescents with early-onset psychosis may be independent of antipsychotic medication.

Background

Dyslipidemia and insulin resistance (HOMA-IR) are cardiovascular risk factors prevalent in patients with psychosis.

Whether these factors are intrinsic or affected by lifestyle or antipsychotic medication (AP) is unclear.

Therefore, the researchers investigated lipid profiles, HOMA-IR, and psychotic phenotypes in patients aged 12-18 years with early-onset psychosis (EOP) with and without AP exposure.

Methods

The researchers measured fasting total cholesterol (TC), high-density lipoprotein cholesterol (HDLC), triglycerides (TG), insulin, and glucose in patients with EOP (n = 39) and healthy controls (HC) (n = 66).

Diet information was not available. Negative symptoms were assessed using the Positive and Negative Syndrome Scale (PANSS).

They used univariate analysis of variance to compare TC/HDL-C ratios and TG and HOMA-IR values, controlling for body mass index (BMI) and AP exposure.

They also assessed the explained variance of having EOP using multiple regression analysis.

Results

Patients with and without AP exposure had significantly higher TC/HDL-C (p = 0.003, p = 0.029) and TG values (p < 0.001, p = 0.021) than HC.

Significantly increased HOMA-IR scores were found only in AP-exposed patients (p = 0.037). EOP significantly increased the explained variance for TC/HDL-C and TG, but not for HOMA-IR.

Patients with a PANSS negative score > 21 had significantly higher levels of TG than those with low scores (p = 0.032).

Conclusions

The results suggest that lipid alterations predate AP treatment in adolescents with EOP.

Higher levels of negative symptoms and AP further increase metabolic risk.

The preliminary findings propose that subclinical dyslipidemia may be intrinsic to EOP.

Reference

Wedervang-Resell, K., Friis, S., Lonning, V., Smelror, R.E., Johannessen, C., Agartz, I., Ulven, S.M., Holven, K.B., Andreassen, O.A. & Myhre, A.M. (2019) Lipid alterations in adolescents with early-onset psychosis may be independent of antipsychotic medication. Schizophrenia Research. pii: S0920-9964(19)30546-8. doi: 10.1016/j.schres.2019.11.039. [Epub ahead of print].