The Utilization of a Rapid Agitation Scale and Treatment Protocol for Patient and Staff Safety in an Inpatient Psychiatric Setting.

Agitation is a common and potentially dangerous condition requiring rapid recognition and treatment in acute psychiatric units. Prompt intervention can prevent a patient with agitation from harming themselves, harming others, or needing restraints or seclusion. After the review of numerous guidelines, the Modified Agitation Severity Scale (MASS) agitation treatment protocol was developed to identify and manage agitation in an inpatient adult psychiatric setting. This protocol involved modifying an existing agitation scale and pairing scores with a treatment algorithm to indicate which behavioral and medication interventions would be most appropriate. All scoring and interventions were recorded in the electronic medical record (EMR). Three months of data were collected before and after the protocol was implemented. The new, modified scale had high reliability and correlated well with another validated agitation scale. Perceived patient safety was high during both study phases. Nurses' perceptions of safety trended upward after the protocol was implemented, though these differences were not significant, likely due to insufficient power. Although there was no decrease in seclusion events after implementation of the treatment protocol, there was a 44% decrease in restraint events and average restraint minutes per incident. Despite a potential increase in workload for nursing staff, implementation of the protocol did not increase burnout scores. Physicians continued to order the protocol for 55% of patients after the study period ended. These findings suggest that including a rapid agitation assessment and protocol within the EMR potentially improves nurses' perceptions of unit safety, helps assess treatment response, reduces time patients spend restrained, and supports decision making for nurses.

Treatment of bipolar depression with minocycline and/or aspirin: an adaptive, 2×2 double-blind, randomized, placebo-controlled, phase IIA clinical trial.

Given evidence of chronic inflammation in bipolar disorder (BD), we tested the efficacy of aspirin and minocycline as augmentation therapy for bipolar depression. Ninety-nine depressed outpatients with BD were enrolled in a 6 week, double-blind, placebo-controlled trial, and randomized to one of four groups: active minocycline (100 mg b.i.d.) + active aspirin (81 mg b.i.d.) (M + A); active minocycline + placebo aspirin (M + P); placebo-minocycline + active aspirin (A + P); and placebo-minocycline + placebo aspirin (P + P). A blinded interim analysis mid-way through the study led to the dropping of the M + P and A + P arms from further enrollment giving numbers per group who were included in the final analysis of: 30 (M + A), 18 (M + P), 19 (A + P), and 28 (P + P). When the study started, there were three primary outcome measures. Based on the results of the interim analysis, the primary outcome variable, response to treatment as defined by >50% decrease in Montgomery-Äsberg Depression Rating Scale (MADRS) score was maintained. The other two (i.e., the change in mean MADRS score from baseline to end of study and the remission rate, with remission being defined as a score of <11 on the MADRS) were reduced to exploratory outcome measures because the interim analysis indicated that the study was adequately powered to test differences in response rate but not the mean change in MADRS scores or remission rates. CRP and IL-6 were assayed to measure inflammation. Urinary thromboxane B2 (11-D-TXB2) concentrations, which were significantly increased at baseline in the combined BD sample (n = 90) vs. a healthy control group (n = 27), served as an indirect marker of cyclooxygenase (COX) activity. In a two-group analysis, the M + A group showed a greater response rate than the P + P group (p(one-tailed) = 0.034, OR = 2.93, NNT = 4.7). When all four arms were included in the analysis, there was a main effect of aspirin on treatment response that was driven by both the M + A and the A + P groups (p(two-tailed) = 0.019, OR = 3.67, NNT = 4.0). Additionally, there was a significant 3-way interaction between aspirin, minocycline, and IL-6, indicating that response to minocycline was significantly greater in participants in the M + P group with higher IL-6 concentrations. Further, participants in the M + P group who responded to treatment had significantly greater decreases in IL-6 levels between baseline and visit 7 vs. non-responders. Regarding the exploratory outcomes, there was a main effect for aspirin on the remission rate (χ12 = 4.14, p(2t) = 0.04, OR = 2.52, NNT = 8.0). There was no significant main effect of aspirin or minocycline on the mean change in MADRS score across visits. Aspirin and minocycline may be efficacious adjunctive treatments for bipolar depression. Given their potential import, additional studies to confirm and extend these findings are warranted.

The two-way relationship between medical illness and late-life depression.

This article reviews some common medical conditions and the interaction between those illnesses and depression in the geriatric population. The authors aim to help clarify the 2-way interaction between depression and these medical conditions, especially in older individuals, and impart some important diagnostic and treatment considerations to the practicing physician. The presence of multiple conditions further complicates treatment, as does associated medication use, substance abuse problems (often underappreciated in the elderly), age-related changes in sleep architecture, and an array of other psychosocial and environmental factors that can contribute to the development of depression.

Psychiatric care of the patient with hepatitis C: a review of the literature.

CONTEXT: Approximately 1.8% of the US population is chronically infected with the hepatitis C virus (HCV). The prevalence rates of psychiatric illness in patients with HCV infection are higher than those rates in the general US population, and the prevalence of HCV infection in patients with severe mental illness may be as high as 9 times that of the general US population. Primary care physicians and psychiatrists are on the forefront of identifying patients with psychiatric illness who are at risk for HCV infection and can screen for HCV infection. This review summarizes the psychiatric implications of HCV infection and strategies for the management of interferon alfa-induced neuropsychiatric adverse effects. EVIDENCE ACQUISITION: English-language studies were identified by computerized searches using the term hepatitis C psychiatric between 1972 and 2009, and further references were obtained from bibliographies of the reviewed articles. Relevant references were reviewed by the authors and included the basis of significance and applicability to practicing psychiatrists and internists. RESULTS: Since primary care physicians and psychiatrists are sometimes the only medical link for patients with psychiatric illness, they are expected to provide posttest counseling for their patients with HCV and psychiatric illness. The task of conducting a psychiatric and psychosocial pretreatment risk-benefit assessment to determine whether or not to treat HCV infection is increasingly delegated to primary care providers as well as psychiatrists. The use of interferon alfa-based therapies to eradicate HCV has been associated with frequent neuropsychiatric adverse effects (eg, affective, anxiety, cognitive, and psychotic symptoms) that compromise the management of HCV patients with and without a preexisting history of psychiatric illness. Primary care physicians and psychiatrists are frequently asked to assist in the management of these neuropsychiatric adverse effects and evaluate the risks and benefits of using prophylactic psychotropics. CONCLUSIONS: Despite the clinical challenge that interferon alfa treatment for patients with comorbid HCV and psychiatric illness presents, recent research indicates that interferon alfa can be safely administered to HCV-infected patients with psychiatric disorders provided there is a comprehensive pretreatment assessment, a risk-benefit analysis, and intensive ongoing medical and psychiatric follow-up.

Gastroenterologists' perceptions of need and availability of psychiatric services for patients with hepatitis C.

The authors examined gastroenterologists' perceptions of psychiatric comorbidity in hepatitis C, access to, and use of psychiatric services. An eight-item survey was mailed to gastroenterologists, with a total of 75 participating. Fifty-eight (77.3%) agreed with the statement "My patients with hepatitis C have significant rates of psychiatric and substance-abuse comorbidity." Less than half (41%) agreed or strongly agreed that "My patients with hepatitis C have adequate access to psychiatric consultation." However, only eight (11%) referred to a mental health provider. Gastroenterologists are aware of the need for psychiatric services for their hepatitis C patients, but few refer for it, and access may be limited.

Preventing relapse of major depression during interferon-alpha therapy for hepatitis C--A pilot study.

Depression is common in hepatitis C, exacerbated by interferon, and is a major reason for discontinuing interferon therapy. We aimed to determine (1) whether patients with a history of major depression could complete a course of peginterferon alpha-2a and ribavirin if pretreated with escitalopram and (2) the relapse rate of depression during the course of therapy in these subjects. Ten patients were enrolled in the study and treated with escitalopram. The Hamilton Depression Rating Scale (Ham-D) and other psychiatric scales were administered throughout the study. There were no statistically significant increases in mean Ham-D scores. No subjects were discontinued from the study due to depression relapse. Nine of 10 subjects maintained remission of depression throughout the study. We conclude that pretreatment with escitalopram in subjects with major depressive disorder in remission may prevent recurrence of major depression during a course of interferon and ribavirin therapy for hepatitis C.

Major depressive disorder in hepatitis C: an open-label trial of escitalopram.

BACKGROUND: Depression is a common condition associated with hepatitis C and may be induced by interferon alfa, the primary treatment for hepatitis C. Depression is also a major barrier to the initiation of such treatment. This study examined the effect of escitalopram on measures of depression, quality of life, and tests of liver function in subjects with comorbid hepatitis C and depression. METHOD: Subjects with DSM-IV major depressive disorder and hepatitis C were included in this open-label study. The recruitment period was from October 2002 through February 2004. Treatment status with regard to interferon therapy was neither an inclusion nor an exclusion criterion. Subjects received escitalopram for 8 weeks starting at 10 mg/day. Dosage adjustments up to 20 mg/day were made after week 4, as deemed clinically necessary. Scores on the 17-item Hamilton Rating Scale for Depression (HAM-D-17) and the Clinical Global Impressions-Severity of Illness scale (CGI-S) and results of liver function tests (AST, ALT, GGT) were obtained at baseline, 2 weeks, 4 weeks, and 8 weeks. Medical Outcomes Study Short Form Health Survey (SF-36) ratings and Hopkins Symptom Checklist-90-Revised (SCL-90-R) scores were obtained at baseline and week 8. RESULTS: Eighteen subjects (12 female, 6 male) participated in this study. The mean daily dose of escitalopram at endpoint was 12.78 mg. Mean HAM-D-17 scores decreased significantly with treatment (t = 8.535, df = 17, p < .0001). Statistically significant improvement was also demonstrated on many subscales of the SF-36, the SCL-90-R, and the CGI-S. Tests of liver function showed no significant changes. CONCLUSION: These results suggest that depression in patients with hepatitis C may be effectively and safely treated with escitalopram.

Plasma levels of citalopram in depressed patients with hepatitis C.

Hepatitis C affects an estimated 4 million Americans and 100 million people worldwide. Rates of depression are higher than that seen in the general population. Antidepressant therapy is often initiated at lower doses in patients with liver disease because of concerns about impaired metabolism and clearance. This study assessed plasma levels of citalopram in 15 subjects with hepatitis C and major depression during an 8-week trial. The mean citalopram dose at study completion was 26.67 mg/day. Mean plasma levels of citalopram, compared with levels previously reported, were lower than expected (at 10 mg/day [N = 1]: 21 ng/ml [N = 1]; at 20 mg/day [N = 8]: mean = 42.25 ng/ml, SD = 18.38; at 30 mg/day [N = 1]: 54 ng/ml; at 40 mg/day [N = 5]: mean = 76.2 ng/ml, SD = 35.86). There was a tendency for lower plasma levels to be found in those subjects receiving interferon, although a statistically significant difference was not observed. Citalopram was well tolerated. The results of this study suggest that patients with major depression and hepatitis C, but without evidence of severe liver disease, may be able to tolerate usual recommended doses of citalopram, thus avoiding the potential for undertreatment of the depression.

Delirium.

Delirium is characterized by an acute change in cognition and a disturbance of consciousness, usually resulting from an underlying medical condition or from medication or drug withdrawal. Delirium affects 10 to 30 percent of hospitalized patients with medical illness; more than 50 percent of persons in certain high-risk populations are affected. The associated morbidity and mortality make diagnosis of this condition extremely important. Patients with delirium can present with agitation, somnolence, withdrawal, and psychosis. This variation in presentation can lead to diagnostic confusion and, in some cases, incorrect attribution of symptoms to a primary psychiatric disorder. To make the distinction, it is important to obtain the history of the onset and course of the condition from family members or caregivers. Primary care physicians must be able to recognize delirium so that the underlying etiology can be ascertained and addressed. The management of delirium involves identifying and correcting the underlying problem, and symptomatically managing any behavioral or psychiatric symptoms. Low doses of antipsychotic drugs can help to control agitation. The use of benzodiazepines should be avoided except in cases of alcohol or sedative-hypnotic withdrawal. Environmental interventions, including frequent reorientation of patients by nursing staff and education of patients and families, should be employed in all cases.

An open-label trial of citalopram for major depression in patients with hepatitis C.

BACKGROUND: Hepatitis C affects nearly 4 million Americans. Depression is a common comorbid condition in this population and may be induced by interferon alfa, an approved treatment for hepatitis C. Depression is a major indicator for discontinuation of interferon therapy. This open-label study examines the effect of citalopram on measures of depression and quality of life and tests of liver function in subjects with hepatitis C and major depressive disorder. METHOD: Subjects were recruited by advertisement; those with DSM-IV major depressive disorder were included in the study. Subjects received citalopram for 8 weeks starting at 20 mg/day. Dosage adjustments were made as the physicians deemed clinically necessary. No dosages were increased prior to week 4 of the study. Hamilton Rating Scale for Depression (HAM-D) scores, Clinical Global Impressions-Severity of Illness scale (CGI-S) scores, Medical Outcomes Study Short Form Health Survey (SF-36) ratings, Symptom Checklist-90-Revised (SCL-90-R) scores, and liver function tests were obtained at baseline, 4 weeks, and 8 weeks. RESULTS: A total of 15 patients (10 men, 5 women) participated in this study. The mean daily dose of citalopram at endpoint was 26.67 mg. Mean HAM-D scores decreased significantly with treatment (F = 36.3, df = 2,42; p = .0001). Thirteen of the 15 subjects demonstrated a clinical response, defined as a 50% or greater reduction in HAM-D scores. CGI-Severity of Illness scores also improved significantly (p = .0001). Subjects demonstrated statistically significant improvement (p < .05) on all of the SF-36 subscales. Statistically significant improvements (p < .05) were also demonstrated on all subscales of the SCL-90-R. Tests of liver function showed no significant worsening of aspartate aminotransferase, alanine aminotransferase, or gamma-glutamyltransferase levels. CONCLUSION: These results suggest that depression in patients with hepatitis C may be effectively and safely treated with citalopram.