Jain, A., Saslo, C. J., Brown, G. A. Identifying and Managing the Severity of Lactic Acidosis in a Case of Serotonin Syndrome, QTc Prolongation, & Psychosis. American Psychiatric Association Annual Meeting, 2020.
Serotonin Syndrome (SS) is a potentially life-threatening condition due to amplified serotonergic agonism in the central and peripheral nervous systems, characterized by a myriad of symptoms involving mental status changes, autonomic instability, and neuromuscular hyperactivity, commonly due to complex interactions between two or more mechanistically-different serotonergic drugs. The Hunter Serotonin Toxicity Criteria validates the presence of SS by assessing any serotonergic agent use and either spontaneous clonus, inducible clonus plus agitation or diaphoresis, ocular clonus plus agitation or diaphoresis, tremor and hyperreflexia, or hypertonia and a temperature above 38 C plus ocular or inducible clonus. In this case presentation, we highlight the importance of identifying lactic acidosis as a prominent feature of SS and understanding appropriate management in concomitant psychosis and QTc prolongation.
A 27-year-old South Asian female with a past medical history of bipolar disorder with psychotic features presented to the ED with altered mental status, fever, hypertension, hyperthermia, tachycardia, and bilateral lower extremity hyperreflexia. Per collateral, the patient was erratic and having visual and auditory hallucinations, while taking prescribed lithium and sertraline. Pertinent studies showed elevated creatine kinase, WBC count, a 4.09 lactate level, and QTc prolongation of 505. Despite a negative UDS, poison control was consulted, the patient was monitored in the ICU for 24 hours, and she received IV bicarbonate and IV Fluids. Once stabilized, the patient was transferred to the psychiatric unit on involuntary status and maintained on 1:1 observation due to her confusion, disorganized behavior, intrusiveness, and heightened agitation and physical aggression. After several attempts at sedation with haloperidol 5mg and lorazepam 2mg, the patient remained rambling, tangential, delusional, and responsive to internal stimuli. She was placed in open seclusion with physical leg restraints. Her admission stay was repeatedly characterized by elevated lactate levels and prolonged QTc. After consistent evaluation and medication management, the patient began to respond to titrated olanzapine 15mg at bedtime and lithium 450mg BID. Her mood and insight began to improve, and the patient was discharged 14 days after admission with a lactate level of 1.1.
Elevated lactate as a presentation of SS illustrates a significant cause of concern, as it creates metabolic abnormalities that can exacerbate the psychosis experience(2). Lactate can decrease cardiac contractility, furthering prolongation of the QTc interval (3). Lactic acidosis can persist when physical restraints are placed due to enforcement of isometric muscle contractions (1).
While discontinuation of serotonergic agents and stabilization of vitals are first steps to treatment of serotonin syndrome, this case probes interest into specialized management protocol for rare, debilitating lactate involvement in psychiatric patients.
References:
(1) Boyer EW, Shannon M. The serotonin syndrome. N Engl J Med. 2005 Mar 17;352(11):1112–1120. Erratum in: N Engl J Med. 2007 Jun 7;356(23):2437. N Engl J Med. 2009 Oct 22;361(17):1714.
(2) Volpi-Abadie, J., Kaye, A. M., & Kaye, A. D. (2013). Serotonin syndrome. The Ochsner journal,13(4), 533–540.
(3) Adamo, L., Nassif, M. E., Novak, E., LaRue, S. J., & Mann, D. L. (2017). Prevalence of lactic acidaemia in patients with depressed cardiac output. European journal of heart failure, 19(8), 1027–1033. doi:10.1002/ejhf.628.
Avish K. Jain, OMS-IV, Rowan University School of Osteopathic Medicine
Stoff E, Sedky K. Assessing the Efficacy of Safe Injection Facilities. In: American Psychological Association Annual Meeting; April 28 2020; Philadelphia, PA.
In 2017, there were 70,273 deaths due to drug overdoses, which was a 9.6% increase from 2016. It is important for healthcare systems to consider how to minimize drug overdose-related deaths. The US has mobilized some harm reduction strategies, such as needle exchange programs and needle disposal locations. Syringe services programs such as these have been linked to a 50% reduction in HIV and HCV. Some other countries have adopted the harm reduction strategy of opening facilities where people can go to use substances under the supervision of staff with emergency medical training, known as Supervised Injection Facilities or Safer Injection Facilities. The goal of these sites is to decrease overdose related mortality and morbidity by providing sterile equipment, training clients in safer use, and providing educated staff that can respond to basic medical needs, such as administering Narcan. The first SIF opened in Berne, Switzerland in June 1986, and there are centers across Europe and in Canada and Australia. Currently, there are no SIF’s in the US. Therefore, this review of the literature assesses the efficacy of SIF’s in sites outside of the US. We also address how current harm reduction efforts in the United States that are similar to SIF’s.
Elsa Stoff, M3, Cooper Medical School at Rowan University
Ackerman N, Soal V, Pradhan B, Sedky K. Cost and Treatment Effectiveness of Electroconvulsive Therapy (ECT) in the Uninsured Patient: An updated literature review and case based illustration. In: American Psychiatric Association 2020 Annual Convention; April 28, 2020; Philadelphia, Pennsylvania.
Background:
Electroconvulsive therapy (ECT) is an alternative treatment option for severe and treatment-resistant depression (TRD), as well as for management of catatonic symptoms. However, it remains an underutilized treatment option due to the perceived cost, lack of access to this treatment, the negative portrayal of this treatment modality by the media, and the legal restrictions to consenting. Therefore, we sought to examine the cost and treatment effectiveness of ECT in the uninsured patient with TRD. We hypothesize that ECT is both cost and treatment effective in this patient population.
Methods:
We investigated our hypothesis through a literature review and case-based illustration. A systematic computerized search of English articles using PubMed was performed. In addition, an extensive chart review and analysis was completed, utilizing the electronic medical record of an uninsured, Hispanic female from one of the poorest cities in the US.
Results:
The literature review revealed that ECT is both cost and treatment effective. One retrospective observational cohort study found a decline in the mean number of hospitalizations per year (0.64 vs 0.32, P = 0.031) as well as in the average number of inpatient days per year (23.7 vs 6.1 days, P <0.001), and the mean duration of hospital stays (41.6 vs 22.1 days, P = 0.031) for patients who received maintenance ECT. Furthermore, our cased-based illustration indicated similar findings. The patient’s 17-item Hamilton Depression Rating Scale (Ham-D17) score decreased 4 points after one ECT session. Additionally, the patient’s inability to continue maintenance ECT due to her uninsured status resulted in a cost to the hospital of $115,763. In comparison, one outpatient ECT treatment was found to cost between $300-$1120.
Discussion:
Through a literature review and case-based illustration, we showed that ECT is both effective and economical in treating TRD in the uninsured patient. While our patient initially responded favorably to electroconvulsive therapy, the feasibility of continuing it due to associated cost led to its discontinuation and subsequent patient relapse. These findings suggest that physicians should strongly consider ECT as an economical and effective treatment option for uninsured patients with treatment-resistant depression.
Nicole Ackerman, M4, Cooper Medical School at Rowan University
Victoria Soal, M4, Cooper Medical School at Rowan University
Shukla, K., Trivedi, K., Khan, M., Ugorji, U. Prevention of Adverse Social and Clinical Events through Early Psychiatry Involvement in Adolescent Pregnancies. In: APA 2020 Annual Meeting; April 27, 2020; Philadelphia, PA.
Major depressive disorder (MDD) with peripartum onset is a complex psychopathology extensively linked to causing adversities endangering both mothers and children. While the incidence of this disorder is approximately 10% in adults, the statistic devastatingly increases to 15-50% in adolescent populations (Lodores & Corcoran, 2019). This poster highlights a case of MDD with peripartum onset in an 18-year-old female with past psychiatric history of ADHD status post uncomplicated Caesarean section. The consultation-liaison (CL) psychiatry service was consulted for mild-moderate catatonia within the first 24 hours after delivery, as well as flat affect and lack of mother-baby bonding efforts.
Upon evaluation by the CL psychiatry team, the patient was observed to be minimally interested in the newborn and lacked engagement throughout the encounter. She denied suicidal/homicidal ideations; however, the team found the patient to possess poor insight into her current depressive state. Patient history was collected primarily from family who reported that she had become increasingly tearful, withdrawn from social interactions and exhibited a decreased appetite in the weeks preceding labor. Based on this presentation, the CL psychiatry team recommended overnight hospital stay with psychiatric reevaluation in 24 hours. This decision was based on nursing reports of improvement in the patient’s depressive symptoms since postpartum day one combined with the fact that she did not meet involuntary inpatient commitment criteria. The treatment plan also involved connecting her to outpatient psychiatry to prevent worsening depression or progression to brief psychotic disorder with peripartum onset. However, the patient vehemently objected to psychiatric intervention, and her family became verbally abusive towards the psychiatry team despite immense efforts to educate the patient and family regarding the grave consequences that could occur if her symptoms remained untreated. Due to the noncompliance, the CL psychiatry team was forced to involve the Division of Child Protection and Permanency who mandated that the patient comply to home wellness checks and outpatient psychiatric care in order to maintain custody of her child.
This case emphasizes the importance of early psychiatry involvement in adolescent reproductive care. While pregnancy itself is a stressor to women at any age, the time period may be considerably more stressful to adolescents, an age group more prone to having lesser social support (Barnet, 1996). In fact, adolescent pregnancy itself increases the risk for MDD with peripartum onset by twofold (Lodores & Corcoran, 2019). It is critical to provide early education to youth and their families regarding psychiatric disorders that adolescents may be particularly susceptible to, as this measure could conceivably prevent adverse outcomes in adolescent pregnancies and optimize the psychiatric support and care needed both throughout and after pregnancy.
References:
- Barnet, B. (1996). Depressive Symptoms, Stress, and Social Support in Pregnant and Postpartum Adolescents. Archives of Pediatrics & Adolescent Medicine, 150(1), 64. doi: 10.1001/archpedi.1996.02170260068011.
- Ladores, S., & Corcoran, J. (2019). Investigating Postpartum Depression in the Adolescent Mother Using 3 Potential Qualitative Approaches. Clinical medicine insights. Pediatrics, 13, 1179556519884042. doi:10.1177/117955651988404.
Krupa Shukla, OMSIV, Rowan University School of Osteopathic Medicine
Komal Trivedi, OMSIV, Rowan University School of Osteopathic Medicine