Electroconvulsive therapy in geriatric patients: A literature review and program report from Virginia Commonwealth University, Richmond, Virginia, USA

Electroconvulsive therapy (ECT) is an effective therapeutic intervention in the elderly patients with major depression, especially those with psychosis, suicidality, catatonia, nutritional compromise, and resistance to medications. Response rates can be as high as 80%. We present an extensive review of the relevant literature, provide a description of the ECT program at Virginia Commonwealth University in Richmond, Virginia, USA, and present results of our experience with ECT in fifty elderly patients. The treatments were safe, well tolerated, and produced high response rates, variably between 68% and 84%. Patients in the long‑term maintenance ECT program continue to show sustained benefits from ECT

Delayed Onset and Prolonged ECT-Related Delirium

Electroconvulsive therapy (ECT) is effective in the treatment of depression. Delayed post-ECT delirium is rare but can occur in a small subset of patients with risk factors and in most cases resolves with the use of psychotropic medications. We report a unique presentation of a patient who developed a delayed post-ECT delirium with fecal incontinence that commenced 24 hours after the administration of ECT. The condition resolved spontaneously after 48 hours without the use of psychotropic medications

QTc Prolongation in Veterans With Heroin Dependence on Methadone Maintenance Treatment

Background: QTc prolongation and Torsade de Ppointes have been reported in patients on methadone maintenance. Objectives: In this study, QTc was compared before and after the veteran (n = 49) was on a stable dosage of methadone for 8.72 ± 4.50 years to treat heroin dependence. Risk factors were correlated with the QTc once the veteran was on a stable dose of methadone. Differences in the clinical risk factors in subgroups of veterans with below and above mean QTc change was compared. Patients and Methods: ECG data was obtained from a 12-lead electrocardiogram (pre-methadone and on methadone) on 49 veterans. Data and risk factors were retrospectively collected from the medical records. Results: The mean QTc at baseline (pre-methadone) was 426 ± 34 msec and after being on methadone for an average of 8.72 ± 4.50 years was significantly higher at 450 ± 35 msec. No significant relationships were found between QTc prolongation and risk factors except for calcium. The methadone dosage was significantly higher in veterans with a QTc change above the mean change of ≥ 24 msec (88.48 ± 27.20 mg v.s 68.96 ± 19.84 mg). None of the veterans experienced cardiac arrhythmias. Conclusions: The low complexity of medical co-morbidities may explain the lack of a significant correlation between any risk factor with the QTc except calcium and methadone dosage. The absence of TdP may be explained by the low prevalence of QTc values \u3e 500 msec as well as the retrospective design of the study. During long-term methadone treatment, there was a slight increase in the QTc interval but we did not find evidence of increased cardiac toxicity as a reason for treatment termination

Case Report Delayed Onset and Prolonged ECT-Related Delirium

Electroconvulsive therapy (ECT) is effective in the treatment of depression. Delayed post-ECT delirium is rare but can occur in a small subset of patients with risk factors and in most cases resolves with the use of psychotropic medications. We report a unique presentation of a patient who developed a delayed post-ECT delirium with fecal incontinence that commenced 24 hours after the administration of ECT. The condition resolved spontaneously after 48 hours without the use of psychotropic medications

A Brief Analysis of Suicide Methods and Trends in Virginia from 2003 to 2012

Background. The objective is to analyze and compare Virginia suicide data from 2003 to 2012 to US suicide data. Methods. Suicide trends by method, age, gender, and race were obtained from Virginia’s Office of the Chief Medical Examiner’s annual reports. Results. Similar to US suicide rates, suicide rates in Virginia increased between 2003 and 2012 from 10.9/100,000 people to 12.9/100,000 people. The most common methods were firearm, asphyxia, and intentional drug overdose, respectively. The increase in asphyxia (r=0.77, P≤0.01) and decrease in CO poisoning (r=-0.89, P≤0.01) were significant. Unlike national trends, intentional drug overdoses decreased (r=-0.55, P=0.10). Handgun suicides increased (r=0.61, P=0.06) and are the most common method of firearm suicide. Hanging was the most common method of asphyxia. Helium suicides also increased (r=0.75, P=0.05). Middle age females and males comprise the largest percentage of suicide. Unlike national data, the increase in middle age male suicides occurred only in the 55–64-year-old age group (r=0.79, P≤0.01) and decreased in the 35–44-year-old age group (r=-0.60, P=0.07) and 10–14-year-old age group (r=-0.73, P=0.02). Suicide in all female age ranges remained stable. Caucasians represent the highest percentage of suicide. Conclusion. There has been a rise in suicide in Virginia and suicide rates and trends have closely resembled the national average albeit some differences. Suicide prevention needs to be enhanced

Medical events in SARS-Cov-2 infected psychiatric inpatients with and without pre-existing co-morbid medical conditions

SARS-CoV-2 (COVID-19) infection can be associated with significant medical complications. This risk could be even higher in psychiatric patients due to an increased risk of medical co-morbidity. In addition, psychiatric patients are also vulnerable to acquiring SARS-CoV2 infection due to homelessness, living in crowded areas, and poor adherence to recommended preventive measures. This retrospective study aims to compare two groups of patients, namely COVID-19 positive inpatient psychiatric patients with and without preexisting medical comorbidity on specific clinical and socio-demographic features and more importantly how many patients in the two groups subsequently developed medical complications. All COVID-19 positive psychiatric patients who were admitted to acute psychiatric inpatient units over a one-year period during the peri-pandemic phase were included for this study. Data was collected from the electronic medical records of 174 patients admitted to the inpatient psychiatric facility between January and December 2020.Among the COVID-19 positive patients, twenty individuals out of eighty-nine in the WC (with pre-existing medical comorbidity) group and two individuals out of eighty-five in the WOC (without pre-existing medical comorbidity) group developed COVID-related pneumonia. Ten WC patients and two WOC patients required supplemental oxygen, while only one patient in the WC group developed critical illness and required ventilatory support. The WC group had longer stay in both psychiatric and medical units compared to the WOC group. Consistent with existing literature that patients with comorbid medical condition are higher risk of COVID-19 complications, this study replicates the finding that in psychiatric inpatients pre-existing comorbid medical conditions create a higher risk of experiencing COVID-19 related medical complications. More interestingly, however that increased risk of developing new medical complications was not significantly different from the published rates observed in the general population which is surprising given how vulnerable psychiatric patients are, both medical, psychiatrically and psychosocially. In fact, in some ways and for reasons as yet unclear, the medical complication rate was slightly better in the WC compared to published data in the general population groups

Methadone, QTc interval prolongation and torsade de pointes:Case reports offer the best understanding of this problem

We reviewed the literature and found 31 adult cases and 1 newborn case of methadone-associated QTc interval prolongation and/or torsade de pointes (TdP). Parametric statistics may not be useful in studying this issue because methadone-associated TdP is a very rare event and, hence, “an extreme outlier” consistent with scalable randomness. We may have to rely upon narrative medicine in the form of case reports with all its limitations and hazards to provide our best understanding. We report risk factors for methadone-associated QTc interval prolongation and TdP based on review of published case reports. We believe both drug manufacturers and the FDA would better serve our patients and inform clinicians if they more readily reported drug-induced outliers such as methadone-associated TdP using a case report format