Alpha-2 Agonists in Children and Adolescents With Post-traumatic Stress Disorder: A Systematic Review.

Exposure to traumatic stress is common among children. Post-traumatic stress disorder (PTSD) is a debilitating chronic mental disorder that can develop following exposure to a traumatic event. Psychopharmacological research in pediatric PTSD is limited. There is some evidence supporting the use of alpha-2 (α2) agonists for symptoms associated with PTSD. This systematic review identified published studies evaluating the effectiveness of α2 agonists in treating PTSD symptoms in children and adolescents. We conducted an extensive literature search on PubMed, MEDLINE, EMBASE, Cochrane Collaboration, and PsycINFO databases for published articles that evaluated the use of α2 agonists (clonidine and guanfacine) for treating symptoms of PTSD in children and adolescents. The study protocol was registered in Prospero (ID: CRD42021273692) and followed the PRISMA guidelines. A total of 10 published articles about clonidine or guanfacine use in PTSD in children and adolescents were identified. Studies found clonidine effective in reducing PTSD symptoms; however, the effects were variable. Clonidine and guanfacine showed effectiveness in treating nightmares, hyperarousal, aggression, and sleep disturbances and reducing re-experiencing, avoidant, and hyperarousal symptom clusters. No randomized, double-blind, placebo-controlled trials were found during the literature search. α2 agonists' effectiveness in treating symptoms associated with PTSD in children and adolescents is preliminary. Future placebo-controlled trials are needed to assess the efficacy and safety of α2 agonists.

Clozapine Withdrawal Catatonia: A Case Report.

Catatonia, which is associated with gamma-aminobutyric acid (GABA) hypoactivity, often responds robustly to benzodiazepines. It has been reported to be a consequence of abrupt discontinuation of clozapine, an antipsychotic used for treatment-resistant schizophrenia. Clozapine discontinuation, sometimes necessitated by medical concerns, can carry the risk of adverse outcomes, including catatonia. We present the case of a 66-year-old African-American male with schizoaffective disorder (depressive subtype) and a complex medical history. He discontinued clozapine abruptly due to medication unavailability, and, seven days later, presented with catatonic symptoms, initially unrecognized by emergency room clinicians. His symptoms included self-neglect, auditory hallucinations, isolation, psychomotor retardation, fixed gaze, and thought blocking. An attempt to reinstate clozapine led to orthostatic hypotension, prompting admission to an inpatient psychiatry unit. Attempt to initiate risperidone for psychosis worsened the catatonia, which then responded rapidly to intravenous lorazepam challenge. This facilitated the re-introduction of clozapine with slow re-titration.

Haloperidol Decanoate-Induced Pancytopenia: A Case Report.

Blood dyscrasias, including pancytopenia, can rarely occur as adverse effects of antipsychotic drug therapy. While neutropenia is more common, pancytopenia remains an infrequent but serious hematological complication. We present the case of an 85-year-old African-American female with a history of schizophrenia, stabilized on haloperidol decanoate, who developed pancytopenia during her outpatient care. Her blood counts progressively declined, leading to hospitalization. Hematology evaluation ruled out infectious or neoplastic causes, implicating haloperidol decanoate-induced pancytopenia. The pancytopenia improved gradually over three months after discontinuing haloperidol decanoate. Our case highlights the importance of monitoring and timely intervention in such cases. We discuss the rarity of pancytopenia with antipsychotics and the potential mechanisms and challenging management of this condition.

Ketamine Augmentation of Electroconvulsive Therapy: A Scoping Review of Dose-Dependent Effects in Major Depressive Disorder.

Intravenous ketamine infusions in subanesthetic doses have been shown to rapidly alleviate depressive symptoms. However, the efficacy of ketamine as an anesthetic during electroconvulsive therapy (ECT) for major depression has not yet been answered by a large randomized control trial (RCT). This scoping review aims to examine the available literature to determine whether the dose of ketamine used during ECT influences the response to treatment. A literature search was conducted on PubMed to identify all published RCTs within the last 10 years which compared ketamine anesthesia during ECT for major depression with another anesthetic. Studies using low (<0.8 mg/kg) versus high (≥0.8 mg/kg) doses of ketamine during ECT were evaluated for the differences in outcomes using depression rating scales. Studies that examined ketamine as a standalone treatment for depression or focused primarily on the anesthetic benefits of ketamine were excluded from our review. Fifteen studies were utilized for this literature review. Overall, the studies showed inconsistent results in terms of the speed and magnitude of response to ketamine-assisted ECT in patients with major depression. Limitations of the available literature are discussed, including the lack of head-to-head comparisons, differences in methodology, inclusion/exclusion criteria, and primary and secondary endpoints.

Comparison of efficacy of ketamine versus thiopentone-assisted modified electroconvulsive therapy in major depression.

BACKGROUND: It is well known that depression improves faster with electroconvulsive treatment (ECT) than with antidepressant medications. N-methyl-D-aspartate-receptor antagonists (ketamine) have been shown to have rapid antidepressant effects when given as an intravenous infusion. Faster recovery with ECT is likely when used with ketamine as anesthetic. AIM: The aim of the study is to compare the outcome of modified electroconvulsive therapy (MECT) in major depressive disorder patients undergoing MECT with ketamine versus thiopentone anesthesia. MATERIALS AND METHODS: Sixty hospitalized patients (age: 18-45 years) with major depressive disorder (Diagnostic and Statistical Manual of Mental Disorders-IV Text Revision) were randomly allocated to either of the two MECT groups (30 patients each) receiving ketamine or thiopentone as anesthetic agent. The participants were assessed on a weekly basis on Hamilton Rating Scale for Depression (HAM-D) and Beck Depression Inventory (BDI). RESULTS: Ketamine group required significantly lesser number of MECT sessions for achieving remission and had rapid improvement in HAM-D and BDI scores compared to the thiopentone group. Furthermore, the stimulus intensity required to elicit seizures was significantly less and seizure duration was longer in ketamine group compared to the thiopentone group. CONCLUSION: The use of ketamine for anesthesia led to rapid recovery from depressive symptoms and seems to be a better option for depressive patients, especially when a rapid response is desired.

Medical students' attitude toward suicide attempters.

BACKGROUND: Majority of health professionals have unfavorable attitudes toward the patients presenting with self-harm, which further compromises their therapeutic endeavors and outcomes. OBJECTIVES: This study was aimed to assess the medical students' attitudes toward suicide attempters. MATERIALS AND METHODS: A cross-sectional study was conducted in a tertiary care medical institute of Haryana, a Northern state of India. Two hundred and five final year medical students were recruited through total enumeration method. "Suicide Opinion Questionnaire" was administered to assess their attitudes toward suicide attempters. RESULTS: Only minority had previous exposure of managing any suicidal patient and attended suicide prevention programs. Majority agreed for suicide attempters being lonely and depressed. Nearly half of the students reported small family, disturbed interpersonal relationship, weak personality, self-punishment approach, cultural inhibitions in emotional expression, national instability, and disbelief in afterlife, as a major push to attempt suicide. Compared to boys, girls reported the greater contribution of weak personality and self-destructive behaviors and lesser contribution of family disturbances and religious convictions as suicide triggers. They held favorable attitude for only one-third of the attitudinal statement, and they were uncertain for two-third of the attitudinal statements. CONCLUSIONS: Such a high proportion of uncertain responses imply toward lack of awareness and clinical expertise for managing suicide attempters. It also signifies the urgent need for enhancing their educational and clinical exposure, to improve their attitudes toward patients presenting with self-harm.

Catatonia in mixed alcohol and benzodiazepine withdrawal.

Catatonia is mostly caused by different neuropsychiatric conditions. We report a case of a 30 year old man suffering from both alcohol and benzodiazepine dependence who exhibited catatonic features soon after stopping the intake of substances. This case will help clinicians to recognize catatonic features within the varied symptomatology of substance withdrawal and thereby helping in its early diagnosis and management.