Clinical features and predictors of non-response in severe catatonic patients treated with Electroconvulsive Therapy

Catatonia is a severe neuropsychiatric syndrome frequently associated with mood disorder. Treatment approach is based on i.v. benzodiazepines and electroconvulsive therapy (ECT). The identification of predictors of non-response to ECT has relevant clinical implications. The study sample comprised 59 catatonic in-patients Treated with ECT and evaluated with Bush-Francis Catatonia Rating Scale, Brief Psychiatric Rating Scale, Hamilton Rating Scale for Depression, Young Mania Rating Scale and Clinical Global Improvement (CGI). The patients had a diagnosis of mood disorder with or without mixed or psychotic features. Response was defined as a CGI-Improvement subscale rating 1 “very much improved” or 2 “much improved”. Response rate resulted of 83.1%. Comparing responders (n=49) and non-responders (n=10), the latter presented more frequently a neurological comorbidity and treatments with dopamine agonist and anticholinergic drugs, suggesting an association of extrapyramidal symptoms with the ECT non response. Non-responders also presented waxy flexibility and echophenomena. The last one was a significant predictor of non-response also after multivariate analysis. The major limitation of the present study is the low number of non-responders. In line with previous reports we confirm the efficacy of ECT in the vast majority of severe catatonic patients. The association of neurological comorbidity and use of dopamine-agonist and anticholinergic medications with ECT resistant catatonia is consistent with the hypothesis that ECT is more effective in “top-down” than in “bottom-up” variant of catatonia. Our results should be considered preliminary and further research is necessary

A critical review of the psychomotor agitation treatment in youth.

(1) Background: To systematically review evidence on the safety and efficacy of psychopharmacological treatments available for psychomotor agitation (PA) in children and adolescents. (2) Methods: Studies assessing the safety and efficacy of psychopharmacological treatments for acute PA in children and adolescents that were published between January 1984 and June 2022 on PubMed were systematically reviewed. We included: (i) papers that presented a combination of the search terms specified in the "" sub-paragraph; (ii) manuscripts in English; (iii) original papers; (iv) prospective or retrospective/observational studies and experimental or quasi-experimental reports. The exclusion criteria were: (i) review papers; (ii) non-original studies including editorials and book reviews; (iii) studies not specifically designed and focused on the selected topic. (3) Results: We selected 42 papers: 11 case series (11/42, 26.19%), 8 chart reviews (8/42, 19.05%), 8 case reports (8/42, 19.05%), 6 double-blind placebo-controlled randomized studies (6/42, 14.29%), 4 double-blind controlled randomized studies (4/42, 9.52%), 4 open-label trials (4/42, 9.52%) and 1 case control (1/42, 2.38%). (4) Conclusions: The drugs most frequently used to treat agitation in children and adolescents were ziprasidone, risperidone, aripiprazole, olanzapine and valproic acid. Further studies are needed to evaluate the efficacy/safety ratio, considering the limited number of observations in this field

Electroconvulsive therapy and age: Age-related clinical features and effectiveness in treatment resistant major depressive episode

Objective This study was aimed to compare clinical features, treatments outcomes and tolerability between young (18â\u80\u9345 years), middle age (46â\u80\u9364 years) and old (â\u89¥ 65 years) patients treated with bilateral ECT for treatment resistant major depressive episode. Method 402 patients were evaluated 1 day prior to ECT and a week after the treatment termination using the Clinical Global Impression Scale (CGI), the Hamilton Rating Scale for Depression-17 items (HAM-D-17), the Brief Psychiatric Rating Scale (BPRS), the Young Mania Rating Scale (YMRS) and the Mini Mental State Examination (MMSE). Response was defined as a reduction of at least 50% from baseline on the HAM-D-17 score. Remission was defined as a score â\u89¤ 7 on the HAM-D-17 at the final evaluation. Results Rates of response were not statistically different in the three groups (69.6% in old versus 63.5% in young and 55.5% in middle age groups). No significant differences were also observed in the proportions of remitters between the age groups (31.4% in young group, 27.7% in middle age group and 29.3% in old group). One week after the end of the ECT course the middle and old age groups showed a statistically significant increase in the MMSE score compared to baseline. We did not find significant differences between the three age groups in rates of premature drops-out due to ECT-related side effects. Conclusion Our data support the use of ECT in elderly patients with treatment-resistant major depressive episode, with rates of response around 70% and effectiveness being independent from age. In the old age group the baseline cognitive impairment improved after ECT and no life-threatening adverse event was detected

Chronobiological dis-rhythmicity is related to emotion dysregulation and suicidality in depressive bipolar II disorder with mixed features

In Bipolar Disorder, chronobiological rhythm alterations play a key role by negatively influencing its entire trajectory. Our aim was to assess their potential association with emotion dysregulation and suicidality in subjects with Bipolar Disorder. Eighty-five patients with Bipolar Disorder - II depressive episode with mixed features were recruited and 35 as healthy controls. Subjects were evaluated with SCID-DSM-5, the Biological Rhythms Interview of Assessment in Neuropsychiatry (BRIAN), the DERS: Difficulties in Emotion Regulation Scale, the Beck Depression Inventory-II (BDI-II), the Young Mania Rating Scale (YMRS) and the Scale for Suicide Ideation (SSI). When compared to healthy controls, subjects with bipolar disorder showed significantly higher scores in the BRIAN, the DERS, the BDI-II, the YMRS and the SSI total scores. Chronobiological dis-rhythmicity was significantly related to the severity of depressive symptoms, emotion dysregulation, and suicidality in bipolar individuals. In particular, the dis-rythmicity of the sleep/wake pattern showed a significant correlation with manic symptoms, the dis-rythmicity of daily activities with depressive symptoms and emotion dysregulation and that of social life with suicidality. Emotion dysregulation played as a mediator for the association between chronobiological dis-rhythmicity and depressive symptoms (mediated effect = 3.25, p = 0.001) and for social life dis-rhythmicity and suicidality (mediated effect = 2.52, p = 0.011) as well. Therefore, our findings showed that chronobiological dis-rhythmicity in bipolar individuals was related to the severity of mood swings, emotion dysregulation and suicidality. The assessment of potential alteration in chronobiological rhythms should be investigated in the clinical setting in subjects with bipolar disorder to identify those who may benefit from early chronobiological intervention

Pharmacological Hypotension as a Cause of Delirious Mania in a Patient with Bipolar Disorder

Delirious mania is a severe but often underrecognized syndrome characterized by rapid onset of delirium, mania, and psychosis, not associated with a prior toxicity, physical illness, or mental disorder. We discuss the case of a delirious mania potentially triggered and maintained by a systemic hypotension induced by antihypertensive drugs. Symptoms recovered completely after the discontinuation of antihypertensive medications and the normalization of blood pressure levels

Protracted Hiccups Induced by Aripiprazole and Regressed after Administration of Gabapentin

Hiccups are sudden, repeated, and involuntary contractions of the diaphragm muscle (myoclonic contraction). It involves a reflex arc that, once activated, causes a strong contraction of the diaphragm immediately followed by the closure of the glottis translating into the classic “hic” sound. Hiccups can be short, persistent, and intractable depending on the duration. The most disabling hiccups often represent the epiphenomenon of a medical condition such as gastrointestinal and cardiovascular disorders; central nervous system (CNS) abnormalities; ear, nose, and throat (ENT) conditions or pneumological problems; metabolic/endocrine disorders; infections; and psychogenic disorders. Some drugs, such as aripiprazole, a second-generation antipsychotic, can induce the onset of variable hiccups. We describe herein the cases of three hospitalized patients who developed insistent hiccups after taking aripiprazole and who positively responded to low doses of gabapentin. It is probable that aripiprazole, prescribed at a low dosage (<7.5 mg/day), would act as a dopamine agonist by stimulating D2 and D3 receptors at the “hiccup center” level—located in the brain stem—thus triggering the hiccup. On the other hand, gabapentin led to a complete regression of the hiccup probably by reducing the nerve impulse transmission and modulating the diaphragmatic activity. The present case series suggests the use of low doses of gabapentin as an effective treatment for aripiprazole-induced hiccups. However, our knowledge of the neurotransmitter functioning of the hiccup reflex arc is still limited, and further research is needed to characterize the neurotransmitters involved in hiccups for potential novel therapeutic targets