Impact of COVID-19 on ECT Practice in Qatar.

There is paucity of Electroconvulsive therapy (ECT) utilization surveys from the Arabian Gulf region and none available from Qatar. There is no literature available on impact of Coronavirus Disease 2019 (COVID-19) pandemic on ECT provision. ECT is a lifesaving treatment in psychiatric practice requiring anesthetic support and there were concerns that redeployment of anesthetists due to COVID-19 pandemic might have comparatively bigger impact on the provision of ECT. These concerns stem from the fact that psychiatric patients often get discriminated against in health care systems; largely due to stigma and the belief among healthcare providers that psychiatric illness is somehow not as serious as other types of medical or surgical illness. In this brief report we present pre-COVID ECT utilization from Qatar. We also report findings on ECT utilization during COVID-19 and compare changes with other elective and non-elective surgeries. ECT provision was down by 40% during March to August 2020 in our setting. The decline in ECT provision was comparable to other elective and non-elective surgeries.

Abnormal corneal nerve morphology and brain volume in patients with schizophrenia.

Neurodevelopmental and neurodegenerative pathology occur in Schizophrenia. This study compared the utility of corneal confocal microscopy (CCM), an ophthalmic imaging technique with MRI brain volumetry in quantifying neuronal pathology and its relationship to cognitive dysfunction and symptom severity in schizophrenia. Thirty-six subjects with schizophrenia and 26 controls underwent assessment of cognitive function, symptom severity, CCM and MRI brain volumetry. Subjects with schizophrenia had lower cognitive function (P ≤ 0.01), corneal nerve fiber density (CNFD), length (CNFL), branch density (CNBD), CNBD:CNFD ratio (P < 0.0001) and cingulate gyrus volume (P < 0.05) but comparable volume of whole brain (P = 0.61), cortical gray matter (P = 0.99), ventricle (P = 0.47), hippocampus (P = 0.10) and amygdala (P = 0.68). Corneal nerve measures and cingulate gyrus volume showed no association with symptom severity (P = 0.35-0.86 and P = 0.50) or cognitive function (P = 0.35-0.86 and P = 0.49). Corneal nerve measures were not associated with metabolic syndrome (P = 0.61-0.64) or diabetes (P = 0.057-0.54). The area under the ROC curve distinguishing subjects with schizophrenia from controls was 88% for CNFL, 84% for CNBD and CNBD:CNFD ratio, 79% for CNFD and 73% for the cingulate gyrus volume. This study has identified a reduction in corneal nerve fibers and cingulate gyrus volume in schizophrenia, but no association with symptom severity or cognitive dysfunction. Corneal nerve loss identified using CCM may act as a rapid non-invasive surrogate marker of neurodegeneration in patients with schizophrenia.

Cardiovascular risk assessment for patients with serious mental illnesses: An internal review.

Cardiovascular diseases (CVD) are the leading cause of excess premature mortality among patients with serious mental illness (SMI), mainly because of higher cardiovascular risk and metabolic syndrome compared to the general population.1,2 A pertinent contributing factor is second-generation antipsychotics, which further negatively impact the cardiovascular risk burden, amounting to a significant clinical and public health challenge among patients with SMI.3 Qatar has a high metabolic syndrome prevalence of 26%, and the blood pressure of patients with SMI receiving antipsychotics is significantly higher.4 In 2019, the Pharmacy Department of Mental Health Services at Hamad Medical Corporation (HMC) in Doha, Qatar flagged four moderately and one mildly severe cases of adverse drug reaction secondary to antipsychotics. In response to above mentioned incidents, this quality improvement (QI) project was conducted in an acute inpatient male ward from November 2019 to June 2020 in the Psychiatry Hospital of Hamad Medical Corporation to implement a cardiovascular risk assessment for inpatients with SMI. The atherosclerotic cardiovascular disease (ASCVD) risk estimator was used to estimate the 10-year risk of CVD, and inpatients were categorized into low-risk ( < 5%), borderline risk (5%-7.4%), intermediate-risk (7.5%-19.9%), and high risk ( ≥ 20%).5 Patients with SMI above 40 years of age were included. Within 72 hours of admission, the admitting inpatient nurse filled a cardiovascular risk assessment (CVRA) questionnaire, including basic demographics, past and present cardiology and smoking history, laboratory test results such as lipid panel, and renal function tests. This study used an in-depth, semi-structured face-to-face interview as a primary data collection technique. An interview guide was developed to address the purpose. At the end of each assessment, the QI nurse approached the participants again to educate them about the cardiovascular risk result accordingly and explained the required referrals (Cardiology and/or Smoking Cessation). The QI team member calculated the cardiovascular risk by utilizing the ASCVD plus application to determine inpatient cardiovascular risk. Out of 26 inpatients with SMI who underwent CVRA, nine (35%) scored moderate to high risk, and were referred to Cardiology for further intervention. Among these nine patients, two (22%) were started on statin therapy, three (33%) started on aspirin, and the remaining four (44%) received lifestyle modifications advice and counseling. Ten (38%) were referred to a smoking cessation clinic for nicotine replacement therapy and counseling. Table 1 shows the clinical characteristics of patients included in this study. Three inpatient consultations to cardiology were rejected, which shows how health professionals underestimate and stigmatize effective interventions for patient with SMI. In case of comorbidities of two diseases, one of them is known overlooked and this is particularly true for mental illness.6 A cohort study on medical comorbidities in patients with SMIs in Qatar concluded that an evidence of individuals with SMI is less likely to receive standard levels of care for their medical comorbidities.7 Mental health training could help medical health professionals from other specialties improve their understanding on the impact of both psychotropic medications and mental illness in the physical health of people with SMI and address the fear and stigma. Communication improvement between professionals by meaningful discussion of objectives of referral with the patient and contacting the consultant referred to might improve coordination among the referring psychiatrist, physician referred to, and patient.8 Patients who scored high on (ASCVD) assessment and are asymptomatic might benefit from referral to primary health care centers for further assessment by a generalist from whom a referral to other specialty like cardiology might be more easily accepted. From the patients' perspective, physical health education, and most importantly, cardiovascular risk assessment are now significantly invested. All patients above 40 years old with SMI will undergo a CVRA. Besides, their assigned nurse will work jointly with allied health professionals to educate them about the importance of healthy lifestyle, including healthy diet and staying fit. Tailor-made recommendations will be established, taking into consideration the cardiovascular risk status and antipsychotic medications. Close participation with the clinical pharmacist and dietician will ensure constant psychoeducation about the metabolic side effects of antipsychotic medications. Physiotherapists will identify barriers, if any, for patients to participate in physical activities offered by the ward. Simultaneously, facilitators will include one-to-one contact with staff and work on increasing awareness of the positive impact of physical activity at the departmental level. Leadership involvement is crucial to ensure joint agreement with different specialties, particularly those based in other HMC facilities, such as cardiology and smoking cessation clinics, to accept referrals when required.

Anti-N-methyl-D-aspartate receptor encephalitis in a young female with subclinical hypothyroidism associated with anti-thyroid peroxidase and anti-thyroglobulin antibodies: A case report.

Anti-N-methyl-D-aspartate receptor encephalitis is a life-threatening medical emergency that can be clinically misperceived as Hashimoto's encephalopathy. We present a case of anti-N-methyl-D-aspartate receptor encephalitis in an otherwise healthy young female with subclinical hypothyroidism without an associated ovarian teratoma. She was first misdiagnosed as Hashimoto's encephalopathy due to delirium and behavioral changes, seizures, psychosis, and increased amount of thyroid peroxidase and thyroglobulin antibodies in serum. Final diagnosis was established by third week following presentation with the detection of anti-N-methyl-D-aspartate receptor antibodies in her cerebrospinal fluid. After treatment with intravenous immunoglobulin, methylprednisolone, and amisulpride, she recovered significantly with minimal sequelae at 3-week follow-up.