Electroconvulsive Therapy for Trauma-Related Nightmares: A Case Report and Commentary.

Trauma-related nightmares (TRN), one of the most reported symptoms of posttraumatic stress disorder (PTSD), may not always respond to current pharmacologic and therapeutic treatments. Validity of electroconvulsive therapy (ECT), which is used worldwide in clinical treatment for a broad range of neuropsychiatric conditions, is investigated as a potential therapeutic option for TRN in this report. A case of a 39-year-old male with a history of severe combat-related PTSD, major depressive disorder, history of traumatic brain injury, suicidal ideations, and persistent TRN is discussed here. Successful treatment outcome of this case with six sessions of right unilateral ECT is presented. On initial presentation, the patient had a Patient Health Questionnaire-9 (PHQ-9) score of 27 and a Posttraumatic Stress Disorder Checklist for DSM-5 (PCL-5) score of 77. After six sessions of ECT, the patient had a PHQ-9 score of 3 and a PCL-5 score of 45. Furthermore, the rationale and potential mechanisms of action underlying the ECT treatment for treatment-resistant PTSD and TRN are also reviewed in this report.

Therapeutic Horticulture as a Therapeutic Intervention in Patients Receiving Electroconvulsive Therapy (ECT) Treatment for Major Depressive Disorder.

This study explored the effect of a structured therapeutic horticulture (TH) program on depression symptoms and quality of life indicators for individuals receiving inpatient electroconvulsive therapy (ECT) for major depressive disorders (MDD). Self-reported measures of depressive symptomatology (PHQ9, BDI-II) and quality of life (SF-36) were employed to compare intervention (n = 25) and control groups (n = 27), with the intervention group attending TH sessions for one-hour periods, twice per week, in addition to standard inpatient care associated with ECT received by both groups. All patients were assessed at admission, and after two weeks' time or prior to discharge, during which the intervention group participated in a minimum of four TH sessions. Sessions were led by a horticultural therapist in an accessible on-campus greenhouse. Both groups improved significantly between assessment times one and two on both measures of depression, with a statistically significant difference in change scores for the BDI-II only, favoring the control over the intervention group (16.5, s.d. 12.78 versus 9.6, s.d. 10.15; p = 0.36). Both groups improved significantly on four of eight SF-36 subscales during the same period. A statistically significant difference in change scores was found for the Role Limitations-Physical Health (RLPH) subscale, where the intervention group improved between assessment periods, whereas the control group worsened (16.0, s.d.48.8 versus -9.3, s.d. 33.4; p = .033). Although quantifying group changes or improvement for individuals receiving intensive treatment for major depressive disorders (ECT) by the addition of an adjunct therapy is difficult, this study provides a basic premise for the consideration of various therapeutic horticulture settings to achieve therapeutic benefits through TH.

Diagnosing Urothelial Carcinoma from Delirium: A Near Miss.

Urinary tract infection (UTI) is a common cause of delirium in the elderly. Although diagnosis of delirium secondary to UTI is relatively straightforward, a lack of thorough investigation could result in missing underlying factors and medical conditions that may require immediate clinical/surgical intervention. Case of a 77-year-old male with delirium diagnosis and multiple psychiatric hospital admissions is reported here. This patient with multiple medical disorders and anxiety was admitted to psychiatric facilities on three different occasions with multiple psychiatric diagnoses including delirium. After a month of hospital stay and thorough medical and radiological examinations, the cause of refractory delirium was identified as multifactorial including urothelial carcinoma. Although UTI and urinary retention are common in the elderly, this case shows the importance of multifactorial diagnoses in cases of prolonged or refractory delirium to avoid delays in appropriate treatment.

Mania Induced by Epidural Steroid Injection in an Elderly Female With No Psychiatric History.

The psychiatric risks of epidural steroid injections for chronic pain in a geriatric patient with no prior psychiatric history are presented here. A 76-year old Caucasian female presented to the emergency department with her family for an inability to sleep, confusion, and behavioral outbursts. The mood instability and psychosis were reported as having started a week after her third epidural steroid injection for low-back pain associated with a prior fall. After 12 days of mixed treatment outcomes and increasing paranoia without any localized neurological findings, the patient was transferred to the geriatric psychiatry unit. Upon admission to the inpatient unit, she was loud, grandiose, verbally aggressive, unable to sleep, hyper-religious, paranoid, and identified her husband and daughter as demons. The patient was started on risperidone and valproic acid for the management of psychosis and manic symptoms. Hyper-religiosity and paranoia greatly improved within a week, though the patient remained very talkative and tangential, with a disorganized thought process. Valproic acid was titrated to 500 mg twice a day, yielding a level of 56.2 ug/ml, accompanied by improvement to mild talkativeness and circumstantiality. She was able to interact appropriately, with minimal lorazepam requirement, and discharged with a linear thought process and absence of psychosis. On outpatient follow up, there were minimal residual mania and no recurrence of psychosis, allowing her to be weaned off valproic acid and to discontinue risperidone. Two months later, symptoms resolved completely. The persistence of this patient's psychosis for nearly one month, and mania for about three months, underscores the importance of careful risk-benefit analysis before initiating epidural steroids. This is particularly important in elderly patients who may be more susceptible to psychiatric adverse effects that can outlast any analgesic benefits.

Attempted Suicides in the Elderly With Existing DNRs: An Emerging Geriatric Ethical Dilemma.

Several critical clinical and ethical issues, including immediate treatment decisions, emerged in a case of a double suicide attempt by an elderly couple with a suicide pact and existing do-not-resuscitate (DNR) documentation. This case was complicated by the advanced age of both patients and their family's expectations and perception of mental illness in the geriatric population. In addition to the myriad of legal and ethical challenges that frequent the end-of-life care, the emerging trend of suicide pacts among the elderly, particularly with existing DNR documentation, warrants further exploration.

Efficacy of electroconvulsive therapy for comorbid frontotemporal dementia with bipolar disorder.

Challenges encountered in the diagnosis and treatment of frontotemporal dementia (FTD) are further confounded when presented with comorbid psychiatric disorder. Here we report a case of progressive FTD in a patient with a long history of bipolar affective disorder (BAD) 1, depressed type. We also report beneficial effects of electroconvulsive therapy and its potential application in similar comorbid disorders.