A Pilot Study of Ketamine Infusion after Suicide Attempt: New Frontiers in Treating Acute Suicidality in a Real-World Medical Setting.

Ketamine, in research settings, rapidly reduces suicidal thoughts 2-24 h after a single infusion in patients with high suicidal ideation. In this study, the authors investigate ketamine's effects on suicidality in a real-world sample of recent suicide attempters on a tertiary-care Consultation-Liaison (CL) psychiatry service. Using an open-label design, 16 transdiagnostic CL patients were recruited, 18-65 years old, to receive a single dose of intravenous ketamine (0.5 mg/kg) in the acute medical setting. All were psychiatrically hospitalized post-infusion. Baseline suicidality and depression measures were compared to ratings taken at 24 h, 5 days, 12 days, and 1, 3 and 6 months post-infusion using paired t-tests. Across all measures, rapid, statistically significant decreases (p's < 0.001) were observed with large to very large effect sizes (Cohen's d's: 1.7-8.8) at acute timepoints (24 h; 5 days). These gains were uniformly maintained to 6 months post-infusion. Open-label ketamine appeared to rapidly and robustly reduced suicidal symptoms in an ultra-high-risk, heterogeneous, real-world sample. Ketamine infusion may therefore be a safe, feasible, viable method to rapidly reduce suicidality among medically hospitalized patients after a suicide attempt, with potentially enduring benefits. The current pilot findings suggest ketamine could be readily integrated into the settings where high-risk CL patients already receive healthcare, with the potential to become an important and novel tool in the treatment of suicidality.

A systematic review of community pharmacy initiatives to improve treatment of depression and pain: Focus on types of programs and patient-reported outcomes.

INTRODUCTION: Depression and pain are common, disabling, mutually exacerbating conditions. Many patients living with these conditions present to community pharmacies on a regular schedule to purchase both prescribed and over-the-counter medications. Community-pharmacy based programs have been developed to improve depression and pain outcomes. METHODS: The PRISMA guidelines were utilized to answer the following question: In patients with depression and/or pain, what is the effect of the existing community pharmacy programs on depression and/or pain outcomes. Queried databases included Pubmed, EMBASE, and PsychINFO. DistillerSR was used to organize the screening, abstraction, and review of data. All potential articles were evaluated by two authors, and conflicts were discussed to achieve resolution. In addition to primary outcomes, sources of potential bias and quality indicators were abstracted for every article. RESULTS: Three thousand nine hundred and twenty articles were reviewed, and 13 studies met eligibility criteria (n = 7 for depression; n = 6 for pain). Most studies demonstrated improvement in measures of depression or pain. However, compared to usual care or other control conditions, most of the depression and pain-specific interventions did not provide additional symptomatic benefit. The community pharmacy-based interventions were superior for other outcomes including medication adherence, reducing stigma, improvement in self-efficacy, and improvement in general management of disease. CONCLUSION: Community pharmacies may be uniquely positioned to deliver interventions that improve outcomes associated with successful depression and pain treatment outcomes. However, the benefits of published community pharmacy-based treatments for actually improving depression and pain severity has not yet been established. Innovative interventions and additional research may be needed to achieve clinical success for pharmacy interventions for depression and pain.

Improving Effective Mental Health Consultation for Rural Older Adults Living With Depression and Pain: Learning From the Experiences of Rural Primary Care Physicians.

OBJECTIVE: Novel approaches are needed to assist rural primary care physicians (PCPs) in caring for older patients living with depression and pain who are at an elevated suicide risk. To refine and improve a model of care (PREDICTOR: Pharmacy Identification and Primary Care Intervention of Older Adults at Risk for Suicide), we conducted qualitative interviews with rural PCPs about (1) caring for seniors with depression, pain, and suicidality and (2) their favored procedures for working with psychiatric consultants and the professional characteristics desired in an effective consultant. METHODS: The study utilized a best-practice approach (including double coding) for qualitative interviews with 10 PCPs practicing in rural Pennsylvania. PCPs were interviewed about 3 themes related to caring for older adults with depression, pain, and suicidal ideation and working with psychiatric consultants. The study was conducted from January 2019 to May 2019. RESULTS: Four primary themes emerged from the interviews. (1) Rural PCPs become comfortable managing depression in older adults out of necessity, but desire collaboration on more complex mental health care. (2) Comorbid depression and pain are universally described as related through a vicious cycle in older adults. (3) Rural PCPs experience varying comfort with prescribing opioids for pain management in older patients, but most prefer not to prescribe opioids, and some refuse to do so. (4) PCPs endorsed the PREDICTOR remote consultation model as potentially beneficial to themselves and their older patients, but strongly desired that the consultant work with them as collaborators and for a collegial professional relationship with the mental health specialist. CONCLUSIONS: Rural PCPs are comfortable with remote consultation for older patients living with depression but desire collegial relationships with these consultants, supporting a collaborative approach. We describe explicit plans for implementing these findings as we refine PREDICTOR, in efforts to promote PCP practice change.

Clinical features and functioning of patients with minor depression.

BACKGROUND: The two essential features of minor depression are that it has fewer symptoms than major depression and that it is less chronic than dysthymia. This study describes the clinical features and functioning of outpatients with minor depression. METHODS: Subjects with minor depression (with and without a prior history of major depression) were recruited through clinical referrals and community advertising. Assessments included the Structured Clinical Interview for DSM-IV (SCID), the 17-item Hamilton Rating Scale for Depression (HAM-D), the Inventory of Depressive Symptomatology-Self Report (IDS-SR) and Clinician Rated (IDS-C) scales, the Global Assessment of Functioning (GAF) scale, the Medical Outcomes Study 36-item Short-Form scale (MOS), and the Clinical Global Impressions Severity Scale (CGI). Data from previously published studies of major depression, minor depression, and normal controls were compared to our data set. RESULTS: Minor depression is characterized primarily by mood and cognitive symptoms rather than vegetative symptoms; the functional impairment associated with minor depression is as severe as for major depression in several areas; minor depression occurs either independently of major depression or as a stage of illness during the long-term course of major depression, and minor depression patients with and without a history of major depression have similar levels of depressive severity and functional impairment. CONCLUSIONS: These findings support the notion that minor depression is an important clinical entity that fits within the larger spectrum of depressive disorders.