Efficacy of Esketamine among patients with treatment resistant depression in a 'real world' health-care setting in Israel

One in five people will likely suffer from major depressive disorder (MDD) during their life. Thirty percent of those with MDD will experience Treatment Resistant Depression (TRD), which is characterized by a failure to respond to two adequately administered trials of antidepressants. Esketamine is a rapidly acting intranasal antidepressant. Present-day Esketamine research has limited data in real-world populations. This study aimed to assess Esketamine treatment in a real-world community-based population. This naturalistic retrospective study included 94 individuals age 18 and above diagnosed with TRD, treated with Esketamine in an outpatient setting. The treatment was given in a single clinic, from January 2021 to January 2023, following approval of the Institutional Internal Review Board. The treatment included an acute phase (biweekly treatment, continuing 4-8 weeks), followed by a maintenance phase (once a week to once a month, for 6-12 months). Dosing ranged from 28 mg to 84 mg. Demographic and clinical data were retrospectively gathered. Depressive symptoms were assessed using the Quick Inventory of Depressive Symptomatology, at baseline and during each treatment phase. All patients completed the acute phase. About 60% completed the maintenance phase. Linear improvement of depressive symptoms was revealed in both phases. A sub-analysis of patients with comorbid personality disorder revealed a similar improvement pattern in the acute phase with milder improvement during the maintenance phase, compared to the other patients. This study supports the use of Esketamine for TRD, including patients with comorbid personality disorder and previous electroconvulsive therapy.

Short-term chloral hydrate as an add-on treatment may improve sleep and alleviate agitation in inpatients with treatment resistant schizophrenia: a retrospective case series study

Introduction

Chloral hydrate (CH), a medication dating back to 1832, is tranquilizer and sleep promoter still used today. It remains an option for short-term insomnia therapy and sedation before medical procedures, despite its controversial safety profile.

Methods

This study investigated the potential benefits of chloral hydrate addition for increasing sleep duration and reducing agitation and violence in inpatients with treatment-resistant schizophrenia (TRS). A retrospective, observational case series design was utilized, analyzing data from fourteen patients diagnosed with TRS disorders.

Results

CH addition increased the rate of full night sleep and decreased the rates of agitation and verbal and physical violence events. Notably, no adverse events including falls were reported during CH addition.

Discussion

CH shows some short-term benefits in improving sleep disorders and reducing violent and agitated behavior in patients with TRS. Our study has limitations due to its small sample size, retrospective design and lack of a control group. A large-scale, double-blind, randomized trial is needed to further explore the efficacy and safety of CH in psychiatric populations with TRS accompanied by agitation, violence and disturbed sleep.

Immune-related biomarkers and suicidal behaviors: A meta-analysis

Biomarkers that can differentiate between psychiatric disorders with and without suicidal behavior history from each other and from healthy volunteers may explain part of the pathogenesis of suicidal behavior. We conducted the hitherto largest meta-analysis comparing immune biomarkers between subjects with and without suicide attempt history or death by suicide. The study protocol was registered with PROSPERO, CRD42020212841. Standardized mean differences (SMD) were pooled with random-effects models. Heterogeneity between studies was assessed with the I2-statistic and publication bias was evaluated by the Egger test and funnel plots. Data were based on 36 studies including 2679 persons with suicidal behaviors and 6839 comparison subjects, and four immune-related biomarkers (CRP, IL-6, TNF-α and IL-1β). Suicidal behavior was associated with higher CRP blood levels compared with: healthy controls (SMD [95%CI] = 1.42[0.85-1.98]); patients with depression alone (SMD [95%CI] = 1.23[0.20-2.26]); and patients with any psychiatric disorders (SMD [95%CI] = 0.39[0.22-0.55]). IL-6 blood level was higher in patients with suicidal behaviors compared with healthy controls (SMD [95%CI] = 1.13[0.45-1.82]) and when compared with psychiatric patients without suicidal behaviors (SMD [95%CI] = 0.22 [0.11-0.33]). Meta-regression and subgroup analyses revealed that increased CRP in suicidal behavior is primarily driven by recent suicidal behavior. These results implicate the immune system and inflammatory response in suicidal behavior independent of a relationship to major psychiatric disorders, and that these biological measures are predominantly state-dependent markers. Future studies are needed to determine the cause-and-effect relationship of these immune system biomarkers with suicidal behavior, and their potential predictive properties.

Inflammation Markers Among Schizophrenia Patients Who Use Cannabis

OBJECTIVES

The mechanism of inflammation of the immune system, for example, such circulatory markers as the neutrophil-to-lymphocyte ratio (NLR) and mean platelet volume (MPV), has been shown in many studies to be associated with schizophrenia. In addition, it has been shown that the cannabidiol component reduces the activation of the acquired immune system. This study examined the differences in the levels of NLR and MPV among schizophrenia patients with cannabis use versus those without.

METHODS

In 2019 to 2020, a retrospective cross-sectional study was conducted based on digital medical records. Demographic, clinical, and complete blood cell count data were collected from records of rehospitalization of active psychotic schizophrenia inpatients. Data on NLR, MPV values, and demographic and clinical characteristics were compared between the groups and according to the degree of prevalence of cannabis use.

RESULTS

No differences were found in the NLR and MPV values between the groups.

CONCLUSION

The results were contrary to our expectations. These results may be explained by the presentation of a "pseudo-balanced" picture created when multiple processes affect inflammatory indices.

Factors affecting the willingness of mental health staff to get vaccinated against COVID-19

RATIONALE AND OBJECTIVE

At the beginning of vaccination against coronavirus disease 2019 (COVID-19), information about the effects of the vaccine was not known and hesitancy was observed among the population. The mental health staff members in our center in Israel had to decide whether to get vaccinated or not. The objective of this study was to evaluate the differences in demographic characteristics of vaccinated and nonvaccinated mental health care workers (HCWs), and to identify their reasons for or against vaccination.

METHOD

Data on characteristics of 357 staff members at a mental health center (MHCS) in Israel and their attitudes regarding COVID-19 vaccination, those who were nonvaccinated, were collected via anonymous questionnaires, from 1 January to 10 January 2021. The groups were then compared using χ2 , Fisher's exact tests, t test or Mann-Whitney nonparametric test as appropriate. A logistic regression was then performed using the significant variables and odd ratios presented.

RESULTS

Eighty-one per cent of the sample received at least the first dose of the vaccine. Results indicated differences in seniority (p < 0.001), profession (p < 0.001), department (p < 0.001), risk groups (p < 0.05), religion (p < 0.001), religiosity (p < 0.001), previous care for COVID-19 patients (p < 0.05) and level of interaction with patients (p < 0.01), between the vaccinated and nonvaccinated staff. The factor that was found to be most influential regarding vaccination and which convinced those originally against the vaccine to become vaccinated was the level of scientific knowledge about the vaccine.

CONCLUSION

Efforts and resources should focus on the dissemination of reliable scientific data about the vaccine, to increase vaccination rates among mental HCWs.

Vitamin D as a Protective Factor in COVID-19 Infection in Elderly Schizophrenia and Dementia Inpatients: A Case Series

BACKGROUND

Risk factors for severe coronavirus disease-2019 (COVID-19) infection include old age, chronic illness, and neurological conditions. In contrast, high vitamin D levels are known to augment immune activity and to reduce the severity of viral infections. Recently, a possible association between the likelihood of COVID-19 infection, COVID-19 severity, and vitamin D blood levels was reported.

OBJECTIVES

To assess the possible association between vitamin D long-term supplementation and COVID-19 symptomatic severity and complications of COVID-19 infection in elderly psychiatric inpatients, a high at-risk group.

METHODS

We conducted a retrospective case series study. Data of 14 elderly COVID-19 positive inpatients, presenting with dementia or schizophrenia and other medical conditions were extracted from medical records. All patients maintained a 800 IU daily dose of vitamin D prior to the infection.

RESULTS

Most of the inpatients were asymptomatic or presented very few symptoms. No need for intensive care unit intervention or deaths were reported. Cognitive functioning of the patients remained unchanged.

CONCLUSIONS

Pre-existing vitamin D supplementation may reinforce immunity and reduce COVID-19 severity in elderly psychiatric inpatients.

Olanzapine intramuscular shows better efficacy than zuclopenthixol acetate intramuscular in reducing the need for restraint, but not in comparison to haloperidol intramuscular

Many psychotic patients are treated with antipsychotic medications during acute agitation and aggressive behavior episodes in an attempt to achieve a rapid calming effect. Those medications include olanzapine, zuclopenthixol acetate, and haloperidol intramuscular administration. This study compared the effectiveness of these injections in reducing the need for restraint during agitated-psychotic episodes that include aggression. Sociodemographical and clinical data were retrieved from the electronic medical records of 179 patients who needed rapid calming while hospitalized in a mental health center with acute psychosis. The treatments administered were olanzapine intramuscular, zuclopenthixol acetate intramuscular, and haloperidol intramuscular. The assessed outcomes were rate of restraint and violent behavior. Olanzapine was found significantly more effective in reducing the need for restraint compared to zuclopenthixol acetate. No significant differences were found between haloperidol and the other two with regard to restraint. Neither were other significant differences found between the groups with regard to violent or self-harming behaviors. No significant differences were found in the rate of violent behavior and antipsychotic dosage at discharge. In conclusion, in inpatients with acute agitated psychosis, olanzapine intramuscular shows better efficacy in reducing the need for restraint, at least as compared to zuclopenthixol acetate intramuscular.

A Pilot Study of Cognitive Impairment in Longstanding Electroconvulsive Therapy-treated Schizophrenia Patients Versus Controls

BACKGROUND

Electroconvulsive therapy (ECT), though reliable and effective, is controversial due to its media portrayal as a treatment with severe side effects. Electroconvulsive therapy is mainly given to patients suffering from affective disorders and treatment-resistant schizophrenia. Although past research assessed the amount and duration of memory loss due to ECT, little is known about its influence on cognition for patients suffering from schizophrenia, whose cognitive decline is an inherent part of their illness. We aimed to test whether maintenance ECT causes cognitive decline among elderly schizophrenia patients.

METHODS

Twenty elderly (age >65 years) patients suffering from schizophrenia and schizoaffective disorder who received maintenance ECT were matched with 20 controls suffering from the same illnesses that have never been treated with ECT. The match was based on age, sex, and illness duration. The participants were evaluated using the Montreal Cognitive Assessment for cognitive decline and a Positive and Negative Syndrome Scale (PANSS) for illness severity.

RESULTS

A lower score in the abstraction subscale was found in the maintenance ECT population (P = 0.002), without significant differences in the total Montreal Cognitive Assessment and the delayed-recall subscale scores. In the treatment group, a correlation was found between an impairment in naming and positive symptoms in the PANSS score (r = -0.45) and between abstraction impairment and negative symptoms (r = -0.56) and total PANSS score (r = -0.497).

CONCLUSIONS

Maintenance ECT does not worsen existing global cognitive deficits or delayed recall in elderly schizophrenia patients. The abstraction impairment was possibly due to the higher disease burden of the patients referred to ECT.

Equine Assisted Therapy for Patients with Post Traumatic Stress Disorder: A Case Series Study

INTRODUCTION

Equine assisted therapy (EAT) which includes therapeutic horseback riding (THR), grooming, horsemanship and ground level work with horses, has been studied as treatment for children with special needs and/or autistic spectrum disorder. Preliminary evidence indicates that EAT is also effective for improving self-efficacy and self-esteem in adults with psychiatric disorders. Empowerment, bonding and building trust with the horses, may promote functioning of patients struggling with post traumatic stress disorder (PTSD).The authors performed a prospective, pilot open case series study to assess the effect of EAT on patients with PTSD in terms of symptoms and functioning in work, family and social interaction.

METHODS

Patients with PTSD received EAT once a week for 3 consecutive hours for 6 months. The Short Post Traumatic Stress Disorder Rating Interview (SPRINT) and the Sheehan Disability Scale (SDS) were assessed at baseline, the SDS after 1 and 6 months, and the SPRINT after 6 months.

RESULTS

Thirteen of 23 participants completed the study. Ten participants withdrew from the study for various reasons including discomfort from horses. Total SPRINT scores showed a statistically significant improvement in PTSD symptoms (baseline vs. 6 months: 24.38 ± 6.4 vs. 21.54 ± 7.94 points; p < 0.05). SPRINT scores indicated improvement in the ability to work and perform daily tasks (p < 0.05). A statistically significant improvement in the total SDS score was revealed following 1 month (p < 0.03) and after 6 months (p < 0.02) of EAT. There was also a significant decline in the days of inefficiency (baseline vs. 6 months: 4.15 ± 2.73 vs, 1.88 ± 2.18 days per week, p < 0.02).

CONCLUSION

This preliminary pilot open case series study suggests that EAT may be a beneficial treatment for patients suffering from PTSD. The study demonstrated improved ability to work and perform daily tasks and reduction in the number of days of inefficiency. Further large-scale long-term studies are warranted to substantiate our observation.

Reducing Stigma Toward Psychiatry Among Medical Students: A Multicenter Controlled Trial

Objective

To examine the effect of a novel antistigma intervention curriculum (ASIC) in reducing stigma toward psychiatry among medical students.

Methods

Medical students from 8 hospitals in central Israel were divided into intervention (n = 57) and control (n = 163) arms. The students completed the 30-item Attitudes Toward Psychiatry (ATP-30) and the Attitudes Toward Mental Illness (AMI) scales at psychiatry rotation onset and conclusion. The ASIC was designed to target prejudices and stigma through direct informal encounters with people with serious mental illness (SMI) during periods of remission and recovery. Supervised small-group discussions followed those encounters to facilitate processing of thoughts and emotions that ensued and to discuss salient topics in psychiatry. The study was conducted between November 2017 and July 2018.

Results

Significant between-group differences were found at endpoint for attitudes toward psychiatry and psychiatric patients (P < .001). Although changing attitudes toward psychiatry as a career choice was not part of the ASIC, a significant between-group difference emerged by endpoint (P < .001).

Conclusions

Implementation of an ASIC that includes contact with individuals with lived SMI experience followed by supervised small-group discussions is effective in reducing stigma in medical students' perceptions of people with mental illness and psychiatry. Further evaluation is warranted with regard to the long-term destigmatizing effects of an ASIC.

Trial Registration

ClinicalTrials.gov identifier: NCT03907696.

Deliberate Self-Harm in Older Adults: A General Hospital Emergency Department Survey

BACKGROUND

Deliberate self-harm (DSH) increases the danger of future suicide death and the risk increases with age. Self-harm in older adults is often associated with greater suicidal intent and lethality.

OBJECTIVES

To investigate clinical and psychosocial variables of older patients (age ≥ 65 years) assessed due to DSH, compared with younger adults.

METHODS

Patients admitted to the Emergency Department following DSH during an 8 year period were included.

RESULTS

Of 1149 participants, 187 (16.6%) were older adults (age ≥ 65) and 962 (83.4%) were younger adults (< 65). The older adults reported DSH closer to mid-day (P < 0.01) and suffered more frequently from adjustment disorder and depression. Personality disorders and schizophrenia were less commonly diagnosed (P < 0.001). Prescription medication (sedatives and hypnotics) were a more frequent means (88% vs. 71%) of DSH among older patients. Younger patients with DSH used over-the-counter medications (21.9% vs. 6.4%) three times more than did the older patients (P < 0.01). Past DSH was significantly more frequent in younger adults. Following DSH the older patients were frequently admitted for further general hospitalization (P < 0.001).

CONCLUSIONS

Older adults with DSH are a unique group with different clinical characteristics. There is a need for targeted prevention strategies and education of caregivers regarding DSH in older adults.

Happiness amongst Israel Defense Force (IDF) Mental Health Officers (MHO's)

BACKGROUND

Positive psychology is the scientific study of positive experiences and positive individual traits. Happy people have a better quality of life and other benefits, including better health. The Mental Health Department of the IDF employs a large cadre of Mental Health Officers (MHO's). The rate of burnout among MHO's is considered to be high. Career satisfaction has received attention recently with publications dealing with the growing discontent of healthcare system workers. High MHO's satisfaction is likely to result in good outcomes with patients. Continued state of dissatisfaction, may result in health problems. In this study we tried to assess levels of happiness and its correlates among MHO's.

METHODS

Survey among MHO's. Participants answered a questionnaire including the Satisfaction with Life Scale (SLS);personal details: sex, age, marital status, number of children, family income, state of healthand military details:seniority as MHO, rank, administrative executive or clinical position, unit type, army service placement.

RESULTS

In the period of the survey100 MHO's completed the questionnaire. Amongst them were 14 psychiatrists, 25 psychologists and 60 social workers. Mean age 37.37 ± 7.12 years, mean years in army service 7.83 ± 6.47. 44% of the MHO's were Captains, 44% Majors, 3% Lieutenant Colonels and 8% citizens working for the I.D.F. The SLS score was analyzed in order to identify correlations to demographic and clinical variables and Pearson coefficient correlations were calculated. The mean total SLS score was 24.29 ± 5.22. The only statistically significant association with SLS score was family income (p = 0.0109).

CONCLUSIONS

MHO's reported similar levels of happiness as the mean score found in an Israeli national survey and slightly higher level of happiness compared to Israeli physicians. Family income was found to be associated to the level of happiness. Army rank and unit type were not associated with higher satisfaction with life.

Psychosocial and medical aspects of older suicide completers in Israel: a 10-year survey

OBJECTIVES

The rate of completed suicide among the elderly continues to be the highest of any age group worldwide. The aim of the present study was to investigate the sociodemographic data, mental and physical health characteristics, and suicide methods of the elderly population who completed suicide in Israel.

METHODS

A national retrospective record-based case series study of consecutive elder (50 years or older) suicide completers who had undergone autopsy over a 10-year period was conducted.

RESULTS

Three hundred and fourteen consecutive records of suicide completers, 69.6% males, and mean age 64.7 were analyzed. The largest group (38%) emigrated from the Former Soviet Union and 19% emigrated from East Europe. Immigrants from East Europe committed suicide at an older age. Hanging was the predominant suicide method. Jumping from height increased more than threefold in the ‘old-old’(older than 75 years) group. Hanging and firearms were more frequently used by males. Females were more likely to employ poisoning and suffocation. A significant minority (30%) had been diagnosed as suffering from psychiatric morbidity. Most common diagnoses were depression and alcohol abuse or dependence. Physical disorders (mainly cardiovascular disease and malignancy) were present in 27% of cases. Subjects with psychiatric illness were more likely to complete suicide at a younger age compared with subjects with physical illness.

CONCLUSIONS

Findings of male predominance, psychiatric morbidity, and physical illness are consistent with previously published studies. Immigrants from East Europe completed suicide at an older age and the older victims had used more lethal methods of suicide.

[Medical grade cannabis (MGC): regulation mechanisms, the present situation around the world and in Israel]

Over the past several years, there is an increased demand and use of medical grade cannabis (MGC) in Israel and around the world. Regulation of cannabis growth, use and distribution has been a subject for many discussions in the Israeli medical system, parliament and the media. The increased demand for this kind of treatment, which is considered to be safe and effective in various indications, caused increased interest in the MGC approval mechanisms. Some countries have created regulation and control mechanisms for MGC. The United Nation convention of 1961 defines the medical legal use of narcotic substances. The convention demands full governmental control of the stock of narcotic substances, including cannabis and a governmental mechanism which will license, supervise, control, document and report the yield and consumption. In the Netherlands there is full accordance with the United Nations requirements and there is a special office for MGC which approves growth, production and marketing. MGC is prescribed in the Netherlands and supplied by a pharmacist as a regular drug. In Canada, after a long legal struggle, patients pressured the government to begin a federal program of MGC. In the U.S.A there are differences in cannabis authorization policy between some of the states and the federal government, which opposes MGC use and therefore, places numerous obstacles. Currently in Israel, the Director General of the Ministry of Health, appoints a representative to certify MGC and approve marijuana growers. MGC is directly supplied by the marijuana growers. This is a problematic model which lacks separation between the growers and the patients. Another problem is that the United Nations requirements are not fulfilled. In this review we present the advantages and drawbacks of the current model and propositions for future models for control and regulation of MGC.

Therapist-patient sexual relations: results of a national survey in Israel

BACKGROUND

Studies focusing on Patient-Therapist sexual relations have been carried out mainly in the U.S. This study comes to broadly explore this phenomenon in Israel.

METHOD

An indirect questionnaire was sent to all 1,817 psychiatrists, psychologists and social workers who are members of the Israeli Psychiatric Association, Psychologists Association and Psychotherapy Association, respectively.

RESULTS

29% of the responding therapists reported that at least one of their patients had experienced sexual relations with the most recent, former therapist.

LIMITATION

The design of our survey made it impossible for us to conduct a follow-up after termination of therapy and to differentiate intercourse from nonintercourse sexual exploitation.

CONCLUSIONS

Similar numbers of the gender of the exploiting therapist and exploited patients were obtained for both the indirect current Israeli study and previous U.S. studies. This may suggest that such parameters are influenced by common norms regarding the relationships between men and women of both societies, and from the psychotherapeutic dyadic situation.

An open-label trial of sildenafil addition in risperidone-treated male schizophrenia patients with erectile dysfunction

BACKGROUND

Sexual dysfunction frequently occurs in treated and untreated patients with schizophrenia. Sildenafil is used for treatment of erectile dysfunction caused by diverse factors. The aim of our study was to evaluate its potential value, safety, and effect on compliance with anti-psychotic medications in risperidone-treated male schizophrenia patients suffering from erectile dysfunction.

METHOD

In a 6-week open-label trial, sildenafil was administered to 12 male schizophrenia (DSM-IV) patients, treated with risperidone and reporting erectile dysfunction. The starting dose was 25 mg with the possibility to increase the dose to 75 mg. Three patients who did not respond stopped sildenafil treatment after 3 weeks. The effect on sexual function was assessed by the International Index of Erectile Function and the Valevski-Weizman Male Sexual Function scale.

RESULTS

Nine (75%) of the 12 patients completed the 6-week trial, and 3 patients (25%) stopped taking sildenafil after 3 weeks due to lack of response. We observed statistically significant improvements in all sexual function domains (desire, erectile function, orgasmic function, intercourse satisfaction, and overall satisfaction) in the 9 patients who completed the trial and in most of the domains for all 12 study participants. More than half (8/12; 67%) of the patients exhibited partial or much improvement.

CONCLUSION

Sildenafil is a useful agent for the treatment of erectile dysfunction in risperidone-treated male schizophrenia patients.

Elevated platelet vesicular monoamine transporter density in untreated patients diagnosed with major depression

The intraneuronal uptake of monoamines into brain synaptic vesicles is mediated by the vesicular monoamine transporter (VMAT2). This transporter plays a major role in monoamine storage and quantal release. Recently we demonstrated a high degree of similarity between the pharmacodynamic characteristics of platelet and brain VMAT2. In the present study we measured the VMAT2 density, using [3H]dihydrotetrabenazine ([3H]TBZOH) as a ligand, in platelets of untreated patients diagnosed with major depressive disorder (MDD) (n=10; three with recurrent depression and seven with first episode depression) compared to sex- and age-matched healthy control subjects (n=23). A significant elevation in the VMAT2 density (B(max)) was observed in the platelets of untreated MDD patients (+24%) compared to healthy control subjects. No significant change was found in the affinity constant (K(d)). The increased platelet VMAT2 density may reflect depression-related enhancement of the capacity to accumulate monoamines in the vesicles in the presence of lower monoamine turnover.

Bone marrow involvement, in intensively treated patients with intermediate grade non-Hodgkin's lymphoma, is a risk factor for granulocytopenia and fever

Intensive combination chemotherapy administered to patients with non-Hodgkin's lymphoma (NHL) is inevitably associated with neutropenia and fever. However, the subset of patients who are at increased risk for myelotoxicity has not been clearly identified as yet. We evaluated 58 patients with NHL in order to verify whether bone marrow involvement (BMI) at diagnosis is a risk factor for neutropenia and infection following intensive chemotherapy. Patients with bone marrow involvement had significantly lower neutrophil counts both at diagnosis and following chemotherapy. An higher percentage of patients with BMI developed neutropenia (< 1000/mm3) following chemotherapy. Furthermore events of febrile neutropenia were more frequently encountered in patients with BMI. We conclude that BMI in patients with NHL is a risk factor for chemotherapy induced neutropenia and fever. The role of colony stimulating factors, administered in an attempt to prevent this complication, should be explored.