Treatment Of Severe Depression Research Articles

Intravenous Ketamine for Suicidal Behavior in Severe Depression with Psychotic Features

Abstract Depression is the leading cause of suicide, and antidepressants and modified electroconvulsive therapy (mECT) are the preferred treatment modalities. Ketamine is an established anesthetic agent and evidence for its use in depression is evolving. Here, we discuss the experience of treating severe depression with intravenous (IV) ketamine. A patient in his mid-forties presented with a 2-month history of pervasive low mood, altered biological functions, decreased interest, and suspiciousness and was diagnosed with severe depression with psychotic features and suicidal ideas. As per the guidelines, started on antidepressants and planned for mECT. As the patient and family members were not willing for mECT, based on evidence, IV ketamine was discussed and started. Over six sessions of IV ketamine, there was significant improvement in both objective rating scores and clinically. IV ketamine can be a good adjunctive in the treatment of severe depression with suicidal ideas but needs to be backed up by robust studies.

Ensuring the affordable becomes accessible-lessons from ketamine, a new treatment for severe depression.

In this paper, the case study of ketamine as a new treatment for severe depression is used to outline the challenges of repurposing established medicines and we suggest potential solutions. The antidepressant effects of generic racemic ketamine were identified over 20 years ago, but there were insufficient incentives for commercial entities to pursue its registration, or support for non-commercial entities to fill this gap. As a result, the evaluation of generic ketamine was delayed, piecemeal, uncoordinated, and insufficient to gain approval. Meanwhile, substantial commercial investment enabled the widespread registration of a patented, intranasal s-enantiomeric ketamine formulation (Spravato®) for depression. However, Spravato is priced at $600-$900/dose compared to ~$5/dose for generic ketamine, and the ~AUD$100 million annual government investment requested in Australia (to cover drug costs alone) has been rejected twice, leaving this treatment largely inaccessible for Australian patients 2 years after Therapeutic Goods Administration approval. Moreover, emerging evidence indicates that generic racemic ketamine is at least as effective as Spravato, but no comparative trials were required for regulatory approval and have not been conducted. Without action, this story will repeat regularly in the next decade with a new wave of psychedelic-assisted psychotherapy treatments, for which the original off-patent molecules could be available at low-cost and reduce the overall cost of treatment. Several systemic reforms are required to ensure that affordable, effective options become accessible; these include commercial incentives, public and public-private funding schemes, reduced regulatory barriers and more coordinated international public funding schemes to support translational research.

Potential advantages of ketamine over electroconvulsive therapy in the treatment of nonrefractory severe depression in older patients with multiple medical comorbidities.

Depression in older adults with multiple medical comorbidities can contribute to clinical deterioration, and increased mortality. Electroconvulsive therapy (ECT) is the first-line treatment for these patients. This study aimed to evaluate the effectiveness and safety of subcutaneous (SC) ketamine as an alternative to ECT. We reviewed the medical records of all consecutive older inpatients with severe depression and multiple medical comorbidities who were referred for ECT but treated with SC ketamine over 1 year in our institution. Demographic data, DSM-5 diagnosis, MÅDRS score, and CGI score were analyzed. Twelve patients aged 67-94 years were included. All patients were rated as severely ill, 83% were women, with a mean of 12.6 (SD, 1.4) medical comorbidities. Remission was achieved in 75% of the intention-to-treat population and 100% of treatment completers. The number of sessions ranged from 1 to 6, and days until remission from 1 to 16. Patients remained without relapse for 8-28 months. SC ketamine was safe and well tolerated, and most adverse events were mild and transient. Although limited by the retrospective open-label design of the study and small sample size, our findings provide a potential new indication for ketamine: treatment of severe depression, not necessarily resistant to antidepressants, in older patients with multiple medical comorbidities, at risk of clinical deterioration, and referral for ECT. SC ketamine was highly effective in this population, with no relapse and good tolerance. Randomized controlled trials are needed to adequately test the use of ketamine in this specific group.

White Matter Changes Following Electroconvulsive Therapy for Depression

Electroconvulsive therapy (ECT) is most effective as treatment for severe depression. ECT is proposed to exert an effect on white matter (WM) microstructure, but the limited power of previous studies made it difficult to highlight consistent patterns of change in diffusion metrics

Lipoic acid prevents mirtazapine-induced weight gain in mice without impairs its antidepressant-like action in a neuroendocrine model of depression

Mirtazapine (MIRT) is a multi-target antidepressant used in treatment of severe depression with promising efficacy, but also with important side effects, mainly sedation and weight gain. Thus, the present study aimed to test the effects of the neuroprotective antioxidant lipoic acid (ALA) in the reversal of weight and metabolic changes induced by MIRT in corticosterone-induced depression model in mice, as well as proposed mechanisms for their association antidepressant and pro-cognitive effects. To do these male Swiss mice received Tween 80 (control), corticosterone (CORT 20 mg / kg), MIRT (3 mg / kg) and ALA (100 or 200 mg / kg), alone or associated for 21 days. After this, the animals were subjected to behavioral tests for affective and cognitive domains. Daily weight changes, blood cholesterol fractions and corticosterone were measured. Also, hippocampus (HC) protein expression of the serotonin transporter (SERT), synaptophysin, protein kinase B-Akt (total and phosphorylated) and the cytokines IL-4 and IL-6 were investigated. CORT induced a marked depression-like behavior, memory deficits, metabolic changes (total cholesterol and LDL) and increased serum corticosterone. Also, CORT increased SERT expression in the HC. MIRT alone or combined with ALA sustained its antidepressant-like effect, as well as reversed CORT-induced impairment in spatial recognition memory. Additionally, the association MIRT+ALA200 reversed the weight gain induced by the former antidepressant, as well as reduced serum corticosterone levels and SERT expression in the HC. ALA alone induced significant weight loss and reduced total cholesterol and HDL fraction. Our findings provide promising evidence about the ALA potential to prevent metabolic and weight changes associated to MIRT, without impair its antidepressant and pro-cognition actions. Therefore, ALA+MIRT combination could represent a new therapeutic strategy for treating depression with less side effects.

Rheumatoid arthritis and depression.

Depression constitutes the most frequent comorbid condition associated with rheumatoid arthritis (RA), with prevalence rates ranging from 14% to 48%. This wide range can be explained by several factors including subtypes of depression considered, instrument of measure (i.e. self-questionnaires versus clinical interview), threshold applied but also the overlap of symptoms between the two conditions. Despite being a frequent comorbid condition in RA, depressive states are repeatedly underdiagnosed and thus, often remain untreated. Consequences are dramatic as conclusive evidence show that depression deleteriously impacts just about all outcomes of RA, including disease activity, arthritis-related complications, level of pain, chance of remission, quality of life and mortality. Importantly, links between depression and RA appear to be bidirectional as if RA patients show increased prevalence of depression. Conversely, patients with depression compared to the general population have higher risk to develop RA. Among the factors explaining this strong association between depression and RA, recent advances have underlined the putative role of models based on the inflammatory hypothesis. Pro-inflammatory cytokines such as tumor necrosis factor, interleukin (IL)-1, IL-6, and IL-18 are involved in RA pathogenesis, but also in depression. Furthermore, the connections between the central nervous system, the peripheral system and the immune system are now better understood. As a consequence of the strong comorbidity and the aggravate prognostic, the management of patient showing this dual diagnosis should be carefully monitor. The common physiopathology also opens the path to utilization of RA treatment in severe depression or treatment-resistant depression.

Ketamine: Safe and Effective Treatment for Severe Depression.

Depression resistant to standard treatment is devastating to an individual's quality of life. Ketamine offers a safe and effective alternative to standard depression treatment, but many patients and providers are often unaware of this option. The American Association of Nurse Anesthetists and the American Psychiatric Nurses Association partnered in developing a collaborative approach to providing ketamine infusion therapy for psychiatric disorders. The purpose of this project was to disseminate information through an educational video about the safety and efficacy of outpatient low-dose ketamine infusions as an alternative therapy for treatment-resistant depression. A thorough literature review was conducted in PubMed, PsychINFO, CINAHL, and Google Scholar for articles describing the safety and efficacy of ketamine use in treatment-resistant depression. Based on the current research, an educational video reporting the benefits and safety of ketamine was developed and launched on two social media platforms-YouTube and Facebook-for individuals to view. The effectiveness of the video was evaluated through the number of views, likes, shares, and comments recorded. At 9 months, 156 views, 60 likes, 8 shares, and 4 comments were recorded in both platforms. Comments indicated that viewers found the video informative and encouraging. A short evidence-based educational video provides individuals with information regarding the safety and efficacy of low-dose ketamine infusions as an option for depression treatment. Ketamine outpatient clinics support and treat depressed patients who do not benefit from conventional pharmacologic medications.

Mental Health Nurse experiences of delivering care to severely depressed adults receiving electroconvulsive therapy.

WHAT IS KNOWN ON THE SUBJECT?: ECT is a fast-working and potentially life-saving treatment, but it is still considered a controversial treatment choice. Due to lack of knowledge and public stigma, ECT can be an anxiety-inducing treatment for people experiencing severe depression. The nurse's role is to alleviate this anxiety, aid recovery and minimize the risk of relapse. They manage this onerous task ideally through the therapeutic relationship, and use the skills of assessment and risk identification in order to maximize patient outcomes. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: The views of mental health nurses who provide care for adults receiving treatment of ECT for severe depressive illness are in the main positive. The knowledge of and attitude towards ECT among nurses may reflect on patients and influence treatment choice. If stigma is not addressed, then patients will not be appropriately informed regarding their treatment options. Mental health nurses need to engage in reflective practice to ensure that the dignity of the patient is maintained throughout this treatment. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Mental Health nurses should engage with additional training, formalized clinical supervision and avail of peer support in order to improve confidence, skills and quality of care in the delivery of ECT. Education modules should include a presentation of evidence of effectiveness of ECT as a treatment option. Dialogue among mental healthcare colleagues is important about caring for people presenting for ECT treatment. This will ensure that the mental health nurse can remain cognizant of the potential for patient distress throughout this treatment. ABSTRACT: Background There is a considerable dearth of literature on attitudes towards Electroconvulsive Therapy (ECT) as a treatment for severe depression. Despite being a highly effective treatment, it is still stigmatized even among professionals. Understanding perceptions and knowledge related to ECT treatment among healthcare providers is important for ensuring that treatment can be safely explored as a treatment option with patients. Aim The overall aim of this study is to explore the views of mental health nurses who provide nursing care to people receiving ECT for severe depressive illness in a mental health setting. Methods This is a qualitative study using focus groups (n=2) with 14 mental health nurses who had a minimum of 3months experience caring for older adults receiving ECT. Transcripts were subjected to a thematic analysis. Full ethical approval was granted for this study. Results In total, four themes were identified exploring attitudinal changes, managing patient dignity, reflecting changes in practice and managing the unknown. In general, participants experienced ECT as a positive treatment option for adults with severe depressive illness contributing to an enhanced quality of life. Conclusion Findings indicate a desire to improve person-centred care for patients undergoing ECT. Educational support for nurses who work in this area would improve confidence on work practices and lead to improved patient experience. Mental health personnel without direct experience of the treatment should be exposed to educational modules to decrease stigma and to best facilitate informed decision-making among the patient cohort.

COMPARISON OF THE SPEED OF REMISSION BETWEEN BILATERAL AND RIGHT UNILATERAL ECT IN A COHORT OF GERIATRIC PSYCHIATRY PATIENTS

Introduction • Electroconvulsive therapy (ECT) has been clinically proven to be an effective form of treatment for severe depression. It is also a safe treatment option when a quick response is needed. ECT is especially useful in the geriatric population where the complications of severe depression like not eating or drinking, self-neglect, deteriorating medical co morbidities lead to increased morbidity and mortality. •Several studies have compared efficacy of the different electrode placements as well as any resulting cognitive side effects from ECT. • A randomized trial comparing bifrontal, bitemporal and right unilateral electrode placement in ECT (commonly referred to as CORE) showed clinical and statistically significant antidepressant outcomes with all three electrode placements. Bitemporal electrode placement in this study however resulted in a more rapid decline in symptoms over the early course of treatment leading to the recommendation that bitemporal leads be considered the preferred placement for urgent clinical situations. Of note the mean age characteristics of these patients was 53.1 and all carrying a diagnosis of Unipolar/bipolar depression with/without psychosis, receiving acute ECT treatment. • In Phase I of the PRIDE study, a sample of geriatric patients with severe depression were given RUL ECT 3?times a week. One of the secondary outcomes they looked at was the speed of remission which was determined by the number of RUL ECT treatments required to achieve remission. In this study, the mean number of RUL ECT treatments to achieve remission was 7.3. • In this retrospective chart review we hypothesized that using bitemporal electrode placement would lead to remission of symptoms with fewer ECT treatments than right unilateral placement among a strictly geriatric population. • Potentially fewer treatments could lead to lower treatment costs, reduce the risk of cognitive impairment and illness burden by achieving quicker response. Methods •Retrospective chart review of 20 inpatient psychiatry patients all over age 65. Diagnoses included Major depressive disorder with psychosis (6), without psychosis (11), Bipolar disorder, depressed (2) and schizoaffective disorder (1). •All 20 patients received and responded positively to acute ECT treatment at Mount Sinai Hospital administered 3 times a week. •10 patients received bitemporal treatment and 10 received right unilateral treatment. •Treatment outcome was measured by the Quick Inventory of Depressive Symptomatology (QIDS) before each ECT treatment. The QIDS-SR is a self-report inventory that measures depressive symptom severity in the following domains: sleep, psychomotor activity, appetite/weight, sad mood, concentration, energy, interest, guilt and suicidal ideations/intent. • We looked at QIDS scores at baseline and over the course determined how many ECT treatments each group received before their QIDS scores were reduced by 50%. Results Of the 20 patient ECT records reviewed, 11 were male and 9 females. 6 patients were between ages 66-70 and the remaining 14 patients were all above age 70. . At the start of ECT the average QIDS score for patients receiving bitemporal ECT was 19.8 and for RUL was 17. This indicates a moderate to severe depression from the QIDS inventory. . The average number of ECT treatments to achieve 50% QIDS score reduction in bitemporal ECT was 4.5 and that for RUL ECT was 4.1. Conclusions The average number of bitemporal ECT treatments to achieve a QIDS score reduction of 50% was 4.5 whilst that for right unilateral ECT was 4.1. • Patients that received bilateral ECT had higher average QIDS scores of 19.8 suggesting that sicker patients are treated with BL ECT. This could potentially have been because of a perceived need for a quicker response compared to RUL ECT which was not consistent with our findings. •We observed that there was little difference in the number of treatments needed to achieve fifty percent reduction in symptoms. From our findings it appears that in the geriatric population both bitemporal and right unilateral electrode placements have rapid onset of action with only a marginal difference. •Our study was limited by it being a retrospective medical chart review with only 20 patients. This research was funded by: Not Applicable

Homoeopathic treatment forsevere depression with psychotic features: a case report

Homoeopathic treatment forsevere depression with psychotic features: a case report

Efficacy of Ketamine in the Treatment of Substance Use Disorders: A Systematic Review.

Background: Despite advances in behavioral and pharmacotherapy interventions, substance use disorders (SUDs) are frequently refractory to treatment. Glutamatergic dysregulation has received increasing attention as one common neuropathology across multiple substances of abuse. Ketamine is a potent N-methyl-D-aspartate (NMDA) glutamatergic receptor antagonist which has been found to be effective in the treatment of severe depression. Here we review the literature on the efficacy of ketamine in the treatment of SUDs.Methods: A systematic review of the PubMed, Scopus, and ClinicalTrials.gov databases was undertaken to identify completed and ongoing human studies of the effectiveness of ketamine in the treatment of SUDs between January 1997 and January 2018.Results and conclusion: Seven completed studies were identified. Two studies focused on alcohol use disorder, two focused on cocaine use disorder, and three focused on opioid use disorder. Both cocaine studies found improvements in craving, motivation, and decreased cocaine use rates, although studies were limited by small sample sizes, a homogeneous population and short follow-up. Studies of alcohol and opioid use disorders found improvement in abstinence rates in the ketamine group, with significant between-group effects noted for up to two years following a single infusion, although these were not placebo-controlled trials. These results suggest that ketamine may facilitate abstinence across multiple substances of abuse and warrants broader investigation in addiction treatment. We conclude with an overview of the six ongoing studies of ketamine in the treatment of alcohol, cocaine, cannabis, and opioid use disorders and discuss future directions in this emerging area of research.

The Longitudinal Effects of Electroconvulsive Therapy on Ictal Interhemispheric Coherence and Its Associations With Treatment Outcome: A Naturalistic Cohort Study.

Electroconvulsive therapy (ECT) is an effective treatment for severe depression. Electroencephalogram (EEG) measures between ECT sessions seem to be related to the antidepressant efficacy of ECT. In this naturalistic cohort study, we examine longitudinal effects of ECT on interhemispheric EEG coherence measures during seizure activity and its relation to the antidepressant efficacy. This study included 65 patients diagnosed with severe depressive disorder. Depressive symptoms were rated according to the Montgomery-Åsberg Depression Rating Scale before and after the course of ECT. Frequency-specific ictal interhemispheric (fp1-fp2) EEG coherence measures were established during the first and each consecutive sixth treatment session. Linear mixed-effect models were used to determine longitudinal changes in ictal coherence measures during the course of ECT and its relation to treatment efficacy. Ictal interhemispheric coherence in the theta and alpha frequency bands increased over the course of treatment, whereas no significant change was found for the delta and beta frequency bands. A main effect of treatment efficacy on the interhemispheric coherence in the delta and theta band was revealed. However, the longitudinal effects of ECT were not associated with treatment efficacy. The current study suggests that interhemispheric coherence during ECT-induced seizures increases over the course of treatment. Furthermore, these longitudinal effects seem to be unrelated to the antidepressant efficacy of ECT. These findings contribute to the understanding of the mechanism of action of ECT.

Erythropoietin as an add-on treatment for cognitive side effects of electroconvulsive therapy: a study protocol for a randomized controlled trial

BackgroundElectroconvulsive therapy (ECT) is the most effective treatment for severe depression, but its use is impeded by its cognitive side effects. Novel treatments that can counteract these side effects may therefore improve current treatment strategies for depression. The present randomized trial investigates (1) whether short-term add-on treatment with erythropoietin (EPO) can reduce the cognitive side -effects of ECT and (2) whether such effects are long-lasting. Further, structural and functional magnetic resonance imaging (MRI) will be used to explore the neural underpinnings of such beneficial effects of EPO. Finally, the trial examines whether potential protective effects of EPO on cognition are accompanied by changes in markers of oxidative stress, inflammation, and neuroplasticity.Methods/designThe trial has a double-blind, randomized, placebo-controlled, parallel group design. Patients with unipolar or bipolar disorder with current moderate to severe depression referred to ECT (N = 52) are randomized to receive four high-dose infusions of EPO (40,000 IU/ml) or placebo (saline). The first EPO/saline infusion is administered within 24 h before the first ECT. The following three infusions are administered at weekly intervals immediately after ECT sessions 1, 4, and 7. Cognition assessments are conducted at baseline, after the final EPO/saline infusion (3 days after eight ECT sessions), and at a 3 months follow-up after ECT treatment completion. The neuronal substrates for potential cognitive benefits of EPO are investigated with structural and functional MRI after the final EPO/saline infusion. The primary outcome is change from baseline to after EPO treatment (3 days after eight ECT sessions) in a cognitive composite score spanning attention, psychomotor speed, and executive functions. With a sample size of N = 52 (n = 26 per group), we have ≥ 80% power to detect a clinically relevant between-group difference in the primary outcome measure at an alpha level of 5% (two-sided test). Behavioral, mood, and blood-biomarker data will be analyzed using repeated measures analysis of covariance. Functional MRI data will be preprocessed and analyzed using the FMRIB Software Library.DiscussionIf EPO is found to reduce the cognitive side effects of ECT, this could have important implications for future treatment strategies for depression and for the scientific understanding of the neurobiological etiology of cognitive dysfunction in patients treated with ECT.Trial registrationClinicalTrials.gov, NCT03339596. Registered on 10 November 2017.

Fronto-Temporal Connectivity Predicts ECT Outcome in Major Depression

Electroconvulsive therapy (ECT) is arguably the most effective available treatment for severe depression. Recent studies have used MRI data to predict clinical outcome to ECT and other antidepressant therapies. One challenge facing such studies is selecting from among the many available metrics, which characterize complementary and sometimes non-overlapping aspects of brain function and connectomics. Here, we assessed the ability of aggregated, functional MRI metrics of basal brain activity and connectivity to predict antidepressant response to ECT using machine learning. A radial support vector machine was trained using arterial spin labeling (ASL) and blood-oxygen-level-dependent (BOLD) functional magnetic resonance imaging (fMRI) metrics from n = 46 (26 female, mean age 42) depressed patients prior to ECT (majority right-unilateral stimulation). Image preprocessing was applied using standard procedures, and metrics included cerebral blood flow in ASL, and regional homogeneity, fractional amplitude of low-frequency modulations, and graph theory metrics (strength, local efficiency, and clustering) in BOLD data. A 5-repeated 5-fold cross-validation procedure with nested feature-selection validated model performance. Linear regressions were applied post hoc to aid interpretation of discriminative features. The range of balanced accuracy in models performing statistically above chance was 58-68%. Here, prediction of non-responders was slightly higher than for responders (maximum performance 74 and 64%, respectively). Several features were consistently selected across cross-validation folds, mostly within frontal and temporal regions. Among these were connectivity strength among: a fronto-parietal network [including left dorsolateral prefrontal cortex (DLPFC)], motor and temporal networks (near ECT electrodes), and/or subgenual anterior cingulate cortex (sgACC). Our data indicate that pattern classification of multimodal fMRI metrics can successfully predict ECT outcome, particularly for individuals who will not respond to treatment. Notably, connectivity with networks highly relevant to ECT and depression were consistently selected as important predictive features. These included the left DLPFC and the sgACC, which are both targets of other neurostimulation therapies for depression, as well as connectivity between motor and right temporal cortices near electrode sites. Future studies that probe additional functional and structural MRI metrics and other patient characteristics may further improve the predictive power of these and similar models.

Intravenous chlorimipramine in the treatment of severe depression.

Intravenous chlorimipramine in the treatment of severe depression.

Botulinum Toxin as a Treatment for Depression in a Real-world Setting.

A series of randomized controlled trials have shown the efficacy of glabellar botulinum toxin (BTX) injection as a treatment for depression in women. We wanted to extend these findings and assess how they may be translated to a real-world setting. For that purpose, 42 patients with severe, in most cases chronic and treatment-resistant depression received adjunctive treatment with BTX in private practice. Depression severity was rated before and 3 weeks after the treatment using the Hamilton Depression Rating Scale, the Montgomery Åsberg Depression Rating Scale, and the Beck Depression Inventory. Almost all of the patients improved clinically, with depression scores dropping by 27% on all 3 scales in the sample as a whole. These changes were highly significant (P<0.001, paired t test or Wilcoxon test) and the absolute prepost score differences were similar to those observed in previous randomized controlled trials. Importantly, treatment effects did not differ between male (n=23) and female (n=19) patients. These findings suggest that glabellar BTX injection may also be effective in the treatment of severe depression and in the treatment of depression in men, when treatment is carried out not just in clinical trials but in real-world settings.

Knowledge and attitudes on electroconvulsive therapy in Germany: A web based survey

ObjectiveThe aim of this article is to examine knowledge and attitudes on electroconvulsive therapy (ECT) among the German population. MethodA web-based population survey based on a standardized questionnaire was used to examine knowledge and attitudes towards ECT as a treatment of severe depression among the general public (sample of 1000; representative in terms of age, gender and federal states of the German population). ResultsECT is not well known and negatively connoted among the German population. A higher level of awareness and knowledge about ECT correlates with higher agreement to treatment with it. The analysis of feedback from the open question underlines the complexity of ECT: on the one hand, negative attitudes, stereotypes, and associations, and on the other hand interest, willingness, and acceptance to deal with the method were shown. ConclusionThe results suggest an urgent need for more information about the basic facts, psychiatric applications, and effectiveness of ECT in order to increase the level of awareness and knowledge, and thus the method's acceptance. An increase in acceptance would expand the therapeutic spectrum for the mentally ill. Correspondingly, persons affected and their relatives as well as physicians and healthcare professionals should be involved in awareness-raising measures.

Mirtazapine induced steatosis

Introduction Mirtazapine is a commonly used drug indicated for the treatment of severe depression. It works as a presynaptic alpha2-adrenoreceptor antagonist which increases central noradrenergic and serotonergic neurotransmission. Although steatosis is not a noted side effect or risk in the British National Formulary, we present a case of mirtazapine induced steatosis in a 48-year-old office worker in the absence of any other risk factors, discuss management options and review the literature associated with drug induced steatosis. Case description A 48-year-old woman with a past medical history of pernicious anaemia, hypertension and depression was admitted with a two day history of painless jaundice and a three week history of peripheral oedema and lethargy. No other stigmata of liver disease were present. Medications included once daily Ramipril 2.5mg and Mirtazapine 15mg (recently started). She denied any alcohol use/unprotected sex/recent travel. On admission, her bilirubin level was 199umol/L (normal Results and conclusions Liver ultrasound and CT imaging of the abdomen/pelvis did not yield a cause for her acute jaundice. An ERCP with sphincterotomy and balloon trawl was also negative. Subsequent liver biopsy indicated marked steatosis with active steatohepatitis and early fibrosis which were not consistent with large bile duct obstruction. Experimentally, and with no other identifiable cause for her worsening jaundice, her mirtazapine was stopped. Her liver function results improved immediately with notable improvements in her bilirubin and ALP levels. She subsequently made a full recovery. Take-home message We demonstrate a case where no autoimmune/anatomical infectious or alcohol pathology accounted for the significant steato-hepatitis. Furthermore, with withdrawal of Mirtazipine, the patients' liver function rapidly improved, giving a Naranjo score of 7, thus suggesting a highly probable adverse drug reaction induced by Mirtazipine. Mirtazipine induced hepato-toxicity is rare, probably owing to toxic intermediates following cytochrome p450 metabolism. Acute steatosis is even rarer, and may reflect weight gain caused by the offending drug. We conclude that drug causes should always be sought following exclusion of all other causes.

New buzz on brain stimulation for depression [News

Here are three things we know for sure about deep brain stimulation (DBS) as a treatment for severe depression: 1. When the pacemaker-like brain implants do help depressed people, those people get dramatically better. "I have patients who got their implants 10 years ago now," says Helen Mayberg, a professor of psychiatry and neurology at Emory University, in Atlanta. "These people get well and they stay well," she says. 2. Unfortunately, DBS doesn't help everybody. Experimental trials by Mayberg and others have consistently had a subset of people who simply don't respond to the treatment. And two big industry-sponsored trials were counted as failures by the companies involved, squashing hopes that the treatment would soon be available for mainstream clinical use. 3. Researchers must figure out why some depressed patients respond to DBS while others don't; otherwise their experiments will never lead to a truly practical treatment that can gain regulators' approval. Two new academic studies show that researchers are progressing toward that understanding.

An evaluation of the use of electroconvulsive therapy in a United Kingdom high secure psychiatric hospital

IntroductionElectroconvulsive therapy (ECT) is an effective NICE-approved treatment for severe depression, treatment-resistant mania and catatonia; the Royal College of Psychiatrists’ (RCPsych) guidelines also support its use fourth line for treatment-resistant schizophrenia.ObjectivesEvaluate the use of ECT at Broadmoor High Secure psychiatric hospital, focusing on the indications for its prescription and patients’ capacity to consent.MethodAnalyse case records of all patients who received ECT, and of all patients referred for Second Opinion Appointed Doctor (SOAD) certified ECT treatment under Section 58 of the Mental Health Act 1983 (MHA) due to incapacity, between 01.09.11 and 30.07.15.ResultsAll patients lacked capacity to consent to treatment during this time. Thirty-three referrals were made to the SOAD service for 15 patients, and of these 30 resulted in certification (T6) of which 10 were not subsequently used. Improvements in mental state and agreement to take clozapine were common reasons for T6s either not being certified or used. Urgent treatment under Section 62 of the MHA was employed 7 times for 4 patients during this period. Of the referrals to the SOAD service, 25 were for treatment-resistant schizophrenia, 5 for mania, 3 for catatonia and none for depression.ConclusionsThose patients requiring ECT within this population tended to be the most unwell and all lacked the capacity to consent to it. The majority (76%) of patients receiving ECT at Broadmoor do so outside of NICE (but within RCPsych) guidelines. ECT may be an effective strategy for promoting compliance with clozapine.Disclosure of interestThe authors have not supplied their declaration of competing interest.