Journal of the Academy of Consultation-Liaison Psychiatry最新文献

Background: Neuroleptic malignant syndrome (NMS) is a rare yet potentially fatal iatrogenic syndrome that can manifest with life-threatening symptoms. Theorized to be caused by the dopamine-blocking effects of certain medications, such as antipsychotics, or the withdrawal of dopaminergic agents, NMS is characterized by hyperthermia, autonomic instability, altered mental status, and muscular rigidity. Most treated cases resolve within weeks; however, in some cases, residual catatonic symptoms can persist for months after the resolution of acute hyperthermic and hypermetabolic symptoms. The utilization of dopaminergic agents, such as bromocriptine, to alleviate the catatonic symptoms of NMS has been described in the literature but has not been explored systematically.

Objective: The objective of this study is to present a case where high-dose bromocriptine was used to successfully treat significant, residual catatonia following NMS and to further delineate the role of bromocriptine in the management of residual catatonia secondary to NMS through a systematic review.

Methods and results: This study presents an illustrative case report, and a systematic review of bromocriptine use in managing residual NMS catatonia. The databases of PubMed, Cochrane, PsycINFO, EBSCO, and OVID Medline were queried, identifying 338 studies. Utilizing COVIDENCE, 137 duplicate articles and 76 irrelevant studies were excluded. Ultimately, 125 studies were assessed for eligibility, yielding seven manuscripts and nine total cases of bromocriptine use in residual NMS catatonia. Including our case, bromocriptine use led to an improvement in catatonic symptoms in 80.0% of patients (8 out of 10) and resolved catatonic symptoms in 50.0% of patients (5 out of 10).

Conclusions: Based on this case and the accompanying systematic review, bromocriptine may serve as an effective treatment for residual catatonia following NMS, particularly when first-line strategies such as benzodiazepine and/or ECT treatment have failed or are infeasible. This highlighted efficacy of bromocriptine may be attributed to relieving persistent dopaminergic blockade in susceptible patients, necessitating further research into the etiological heterogeneity of catatonia.

Introduction: Traumatic brain injury (TBI) is associated with greater risk and earlier onset of dementia. This study investigated whether later-life changes in subjective cognition and behavior - potential markers of AD - could be observed in cognitively unimpaired older persons with a history of suspected mild TBI (smTBI) earlier in life and whether changes in cognition and behavior mediated the link between smTBI and daily function.

Methods: Data for 1392 participants from the Canadian Platform for Research Online to Investigate Health, Quality of Life, Cognition, Behaviour, Function, and Caregiving in Aging (CAN-PROTECT) were analyzed. A validated self-reported brain injury screening questionnaire was used to determine history of smTBI. Outcomes were measured using the Everyday Cognition (ECog-II) scale (for subjective cognitive decline - SCD), MBI Checklist (MBI-C, for mild behavioural impairment - MBI), and Standard Assessment of Global Everyday Activities (SAGEA, for function). Inverse probability of treatment weighted logistic and negative binomial regressions were used to model smTBI (exposure) associations with SCD+ and MBI+ statuses, and ECog-II and MBI-C total scores, respectively. Mediation analyses were conducted using bootstrapping.

Results: History of smTBI was linked to higher odds of SCD+ (OR=1.45, 95%CI: [1.14-1.84]) or MBI+ (OR=1.75, 95%CI: [1.54-1.98]), as well as 24% (95%CI: [18%-31%]) higher ECog-II and 52% (95%CI: [41%-63%]) higher MBI-C total scores. Finally, SCD+ and MBI+ statuses mediated approximately 45% and 56%, respectively, of the association between smTBI history and poorer function, as indicated by higher SAGEA total scores.

Discussion: smTBI at any point in the life course is linked to poorer cognition and behavior even in community-dwelling older persons without MCI or dementia. Older persons with smTBI may benefit from early dementia risk assessment using tools that measure changes in cognition and behavior. Interventions for declining cognition and behavior may also be beneficial in this population to address functional impairment.

Background: Palliative care (PC) is the standard of care for patients with serious medical illnesses, or those conditions associated with high risk of mortality and negative impact on quality of life (QOL). Electroconvulsive therapy (ECT) is the gold standard treatment for certain psychiatric conditions, which may co-occur with serious medical illnesses. However, the use of "palliative ECT" (PECT) in this context is understudied.

Methods: We conducted a descriptive retrospective cohort study reviewing the indications, outcomes, and regimens of PECT. We included patients who had an ECT consultation, in addition to either a PC consultation or a do-not-attempt-resuscitation code status between 2018 and 2023.

Results: Thirty-one patients met our inclusion criteria, and 21 received ECT. The cohort was predominantly female (70%) with a mean age of 67.6 (range 25-90). Catatonia (64.5%) and treatment-resistant depressive disorder (35.5%) were the most common indications for ECT. At the time of ECT consultation, 16 patients (51.6%) had a serious medical illness, including cancer (19.4%) or end-organ disease (22.6%). Fourteen patients had major neurocognitive disorder (MNCD) (45.2%). Surrogate decision-makers consented for ECT in 64.5% of cases. All 21 patients who received ECT experienced psychiatric symptom improvement. ECT was associated with reduced mortality risk in 5 (23.8%) cases. Five patients initially misdiagnosed with MNCD experienced recovery in cognitive function after ECT, and the diagnosis was revised to depression-related cognitive dysfunction. Eight patients retained a comorbid MNCD diagnosis but experienced a mean Montreal Cognitive Assessment (MoCA) improvement of 5 points (range 0 to 17) with ECT.

Discussion: This work highlights the use of ECT among patients with serious medical illnesses, identifying cases when ECT was beneficial or deemed unsuitable. Patients with serious medical illnesses who also had an indication for ECT experienced improved QOL with ECT. Misdiagnoses, such as confusing depression-related cognitive dysfunction and catatonia for MNCD, were effectively addressed through ECT. The findings underscore the importance of cross-specialty collaboration between C-L psychiatry and PC.

Conclusions: Patients who receive PECT experience reduced suffering and improved QOL. PECT may be helpful in scenarios of life-threatening psychiatric illnesses, terminal medical illnesses with comorbid treatment-refractory psychiatric illnesses, and diagnostic uncertainty with MNCD.

Background: The End of Life Option Act (EOLOA) legalized medical aid in dying (MAID) in California in 2015. University of California, San Francisco Health initially implemented a policy requiring a mandatory mental health assessment of all patients seeking MAID, though this was not required by the EOLOA. State-level statistics on EOLOA are available, but less is known about outcomes at individual institutions and how institutional policy affects outcomes for patients seeking MAID.

Objectives: Investigators examined the factors contributing to patients' decisions to request MAID and how the mandatory mental health assessment impacted determinations of decisional capacity and access to MAID.

Methods: Retrospective chart review was conducted on a sample of patients who had pursued MAID or been prescribed MAID medications between June 2016 and May 2020 obtained by a combination of purposive sampling (n = 78) and systematic electronic health record sampling (n = 22). Descriptive statistics were used to examine demographic factors, neuropsychiatric diagnoses and rating scales, factors contributing to patients' decision to request MAID, and outcomes of the psychiatric evaluation process.

Results: Of the 78 patients in the purposive sample who had initiated EOLOA requests, 67% had MAID medications prescribed. Zero patients were found to lack decisional capacity due to a current psychiatric condition. Many patient records were missing relevant data including neuropsychiatric rating scale scores and factors contributing to patients' decision to request MAID. The neuropsychiatric rating scale scores and diagnoses that were present did not suggest a high prevalence of severe psychiatric illness in the sample.

Conclusions: The findings from this study suggest that mandatory mental health assessments for all patients requesting MAID at a single academic medical center did not identify patients who lacked decisional capacity to pursue MAID, and potentially created access barriers to seriously ill patients seeking this intervention. Generalizability of findings may be limited by the fact that mental illness burden was low in the studied sample. Results from this study contributed to changes in EOLOA institutional policy at University of California, San Francisco, including elimination of the mandatory mental health assessment for EOLOA candidates in favor of a conditional mental health assessment based on certain clinical criteria.

Background: Catatonia is a frequently missed diagnosis on medical wards, delaying effective treatment or permitting accidental use of neuroleptics that can exacerbate the condition. Thyroid storm has rarely been associated with catatonia in case reports, with no prior reviews synthesizing this research.

Objective: We present a case of catatonia during thyroid storm following administration of low-dose haloperidol, followed by a review of previously published cases and discussion of their common factors and potential mechanisms.

Methods: We first describe a case of a 37-year-old woman with untreated hyperthyroidism and bipolar disorder admitted for mania in the context of thyroid storm. She developed catatonic symptoms after receiving each of two doses of haloperidol. We then present a systematic review of the literature, drawn from the OVID Medline, PsycINFO, and Embase databases, using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to identify case reports of catatonia presenting in association with hyperthyroidism.

Results: Seventeen cases were identified-10 in published reports and seven in poster abstracts. The degree of evidence for catatonia varied, with few cases using formal scales. Several cases, including ours, reported recent administration of neuroleptics with dopamine antagonism (29%), usually at relatively low doses or with subsequent tolerance of neuroleptics when euthyroid. Other common factors included a history of psychiatric symptoms (41%) or presence of thyroid autoantibodies (41%).

Conclusions: These results are consistent with clinical and preclinical evidence that hyperthyroidism might potentiate dopamine blockade, and they encourage clinicians to minimize neuroleptic use in this population. Other theories have also been proposed for catatonia's association with hyperthyroidism, including direct thyrotoxic effect, autoimmune reaction, and mediation via another secondary psychiatric syndrome (e.g., mania). Clinicians should be aware of the potential for catatonia in thyroid storm, with or without neuroleptic use.