Treating acute anxiety in patients with COVID-19

At present, there are no firm guidelines for the treatment of COVID-19-related emotional distress. The current approach is based on our knowledge of how to manage anxiety in medically ill patients, taking into consideration all associated medical comorbidities, drug-drug interactions, and the patient's specific needs and preexisting mental illness. Interventions should be implemented at the bedside to augment the patient's own resiliency in coping with these stressful events. A targeted combination of psychopharmacology (targeting acute anxiety and panic symptoms) and psychotherapy (relaxation techniques, breathing exercises, and encouragement) is recommended.

Medication Exposure in Highly Adherent Psychiatry Patients

Medication exposure is dependent upon many factors, the single most important being if the patient took the prescribed medication as indicated. To assess medication exposure for psychotropic and other medication classes, we enrolled 115 highly adherent psychiatry patients prescribed five or more medications. In these patients, we measured 21 psychotropic and 38 nonpsychotropic medications comprising a 59 medication multiplex assay panel. Strict enrollment criteria and reconciliation of the electronic health record medication list prior to study initiation produced a patient cohort that was adherent with 91% of their prescribed medications as determined by comparing medications detected empirically in blood to the electronic health record medication list. In addition, 13% of detected medications were not in the electronic health record medication list. We found that only 53% of detected medications were within the literature-derived reference range with 41% below and 6% above the reference range specific to each medication. When psychotropic medications were analyzed near trough-level, only sertraline was found to be within the literature-derived reference range for all patients tested. Concentrations of the remaining medications indicated extensive exposure below the reference range. This is the first study to empirically and comprehensively assess medication exposure obtained in comorbid polypharmacy patients, minimizing the important behavioral factor of adherence in the study of medication exposure. These data indicate that low medication exposure is extensive and must be considered when therapeutic issues arise, including the lack of response to medication therapy.

Association of SF-36 with coronary artery disease risk factors and mortality: a PreCIS study

This study examined the relationships among health-related quality of life and risk factors of coronary artery disease (CAD) and all-cause mortality in high-risk cardiac patients seen in a cardiology prevention clinic. At baseline, 1785 patients (age, 53.4+/-13.4 years; 58.8% men) had a medical history, physical examination, and laboratory tests. They completed the Medical Outcomes Study Short Form-36-Item Health Survey (SF-36). Analyses were conducted on associations of 2 SF-36 domain scores (overall physical health [OPH] and overall mental health [OMH]) with CAD biomarkers and all-cause mortality. Lower OPH scores were associated with CAD risk factors including smoking; history of hypertension, diabetes, and peripheral artery disease; the metabolic syndrome; and other novel CAD biomarkers. Lower OMH scores showed similar but weaker associations with CAD risk factors. OPH significantly predicted 5-year mortality in multivariable survival analysis. SF-36, especially OPH, was associated with many risk factors of CAD and significantly predicted mortality.

Depression and heart disease: what do we know, and where are we headed?

Depression and heart disease have an intricate association and perhaps a causal relationship. We review the current status of depression and heart disease and provide an algorithm for diagnosing and treating depression in cardiac patients that internists and cardiologists can use in their daily patient encounters.

Case study in heart-brain interplay: a 53-year-old woman recovering from mitral valve repair

This article presents the case of a 53-year-old female attorney who underwent successful mitral valve repair for mitral valve prolapse. The patient's postoperative course was marked by refractory pain, fatigue, shortness of breath, refusal to ambulate, frequent episodes of tearfulness, and a postsurgical decline in ejection fraction through postoperative week 4. Her slow recovery prompted a psychiatric consult, during which she reported panic and a fear of "losing it." After respective presentations of the case from the cardiology and psychiatry perspectives, the article concludes with a moderated discussion of the case to explore insights it provides into heart-brain interactions.

Management of symptoms associated with advanced cancer: olanzapine and mirtazapine. A World Health Organization project

Advanced cancer patients are polysymptomatic and often receive multiple medications for symptom relief. Common symptoms include anorexia, weight loss, delirium and depression. Olanzapine and mirtazapine may have several advantages over older agents despite increased acquisition costs. Both medications can treat several symptoms with a low risk for drug-drug interactions and with only once- or twice-daily dosing. Drug side effects are low, compared with more conventionally used agents. The pharmacokinetics and pharmacodynamics of both agents are unique and explain many of the benefits. More research and clinical experience will be necessary to define their role in the palliation of advanced cancer.

Agitated dementia: drug vs nondrug treatment

When an elderly patient with Alzheimer's disease or other form of dementia exhibits agitated behavior, the caregiver often wants the physician to "do something"--i.e., give a neuroleptic drug. Yet, an individualized, rational approach to identify and treat the cause of the agitation is more effective. We present an algorithm that emphasizes environmental and behavioral therapy.