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A new option in treatment of refractory depression

 MD-FM Thursday May 23, 2013 





GENERIQUE

Carillon

 

Sarah:

MD-FM, Medical News from around the world with Peter Goodwin

 

P1

PETER:

Hello, and with me is Sarah Maxwell. To begin with, news fresh from the annual meeting of the American Psychiatric Association, which took place this week in San Francisco. Firstly, for patients with refractory depression, who currently have very few therapy options, a commonly prescribed anaesthetic dramatically improved treatment...

 

SARAH:

Yes, ketamine, administered as a single infusion, improved symptoms of depression in less than a day, which is unheard of with traditional antidepressant therapy. 73 patients who’d previously been resistant to at least three antidepressants were given either ketamine or another anaesthetic without antidepressant qualities:

 

Murrough: We give it as an infusion over 40 minutes by an anesthesiologist, these are done in the hospital. 24 hours after the injection, we observed a response rate of 64 percent in the ketamine arm and with medazoline it was 28% and that effect was maintained through 72 hours after the injection, and by day 7 the arms were no longer different 

 

SARAH:

That was study co-author Dr. James Murrough from New York, who said the drug works differently from traditional antidepressants in that it influences glutamate signalling. Ketamine was well tolerated and further research will now investigate long-term use…

 

Murrough: “Well the next step would be to understand whether this drug, if we give it for example once a week or a few times a week for a few weeks, whether it could really engender a sustained antidepressant effect, get someone out of a major depressive episode and then the clinician could institute some kind of treatment, psychotherapy or medications that could then maintain that. So we are really thinking: could this be added to an armamentarium for refractory patients 

 

SARAH:

Dr. James Murrough, from Mount Sinai Hospital in New York.



VIRGULE MUSICALE



P2

PETER:

More big news from the APA meeting now?time for a fanfare? the fifth version of the Diagnostic and Statistical Manual of Mental Disorders? or the DSM-5? has been released!

It’s a huge achievement, with plenty of new analysis and science that will help improve practice, in ongoing way now through internet collaborative work

 

SARAH:

Yes, this is the first significant update in nearly two decades of the American reference manual used to diagnose mental disorders. And one of the updates has been subject to a lot of controversy: it concerns grief and bereavement associated with the loss of a loved one…

 

PETER:

In the previous DSM, bereavement was an “exclusion criterion” used to help experts identify individuals experiencing “normal” grief, and avoid misdiagnosing them with depression…

 

SARAH:

Yes and now this exclusion criterion has been removed! So some argue this could lead to over-diagnosis of depression and to the unnecessary medicalization of normal grief. David Kupfer, chair of the DSM task force gave his response:

 

Kupfer: “ Bereavement exclusion prevented us from diagnosing clinical depression during the first two months following the death of a loved one or any form of bereavement. We wanted to clarify several things: one, sadness bereavement and grief are not mental disorders nor should they be mental disorders, secondly, the ability to diagnose, when appropriate, clinical depression, and to treat it with various modalities, which might include watchful waiting, psychotherapy or medication, should be left to the judgement of clinicians and families. And so therefore we are now in a much better position to clarify what we have done with sadness and bereavement, which is not therefore limited to the perception that it is only two months long, and we’ve also clarified the fact that clinical depression can be diagnosed and should be treated at any point, with respect to any patient who may be suffering from it 

 

SARAH:

That was Dr. David Kupfer, from the Univrsity of Pittsburg.

P3

PETER:

A final piece of news in psychiatry now, from a study led in Korea. It found that adolescents who overuse smartphones had more severe psychopathologies, just as it’s been seen with the overuse of internet and computers. Using two different diagnostic surveys, the team analysed 11 different symptoms associated with smartphone overuse, for instance: withdrawal, depression and anxiety, attention problems or delinquency!



VIRGULE MUSICALE

 

P4

PETER:

For children with sleep apnea, tonsillectomy compared to watchful waiting, reduced symptoms and improved secondary outcomes of behaviour. But, it didn’t significantly improve attention or executive function...

 

SARAH:

Yes, that’s according to a study published in the New England Journal of Medicine that showed, tonsillectomy resolved sleep apnea in 79% of children, whereas watchful waiting and standard care over seven months only resolved it in 46% of them. Those who had tonsillectomy had markedly improved behavioural outcomes. But there was no difference in measures of cognition between the two groups, an important point since there’ve been concerns that sleep apnea might lead to irreversible changes in brain functions…



Redline-1: I think that’s somewhat reassuring for parents and pediatricians that there really was no deterioration of cognition in either group. However, we want to stress the other measures of behavior, mood, social functioning, quality of life they may more realistically reflect how the children act in everyday situations, whereas the cognitive tests may be more reflective of what might happen in a more structured controlled environment

 

SARAH:

That was senior author Dr. Susan Redline who concluded that tonsillectomy or watchful waiting are both reasonable options…

Redline-2: The decision needs to be individualized and our data suggests that for children with symptoms, especially behavior problems, sleepiness for example, tonsillectomy should potentially be considered as the first option whereas perhaps for the less symptomatic children, watching them and re-evaluating them would not be an unreasonable option

 

SARAH:

Susan Redline from Brigham and Women’s Hospital in Boston.

VIRGULE MUSICALE

 

P5

PETER:

For patients with acute decompensated heart failure, fluid and sodium restrictions may not be beneficial at all...

 

SARAH:

Yes, these are the conclusions of a clinical trial that looked at the effects of a diet restricted to 800 mg of sodium, and 800 mL of fluid per day, in 37 patients with decompensated heart failure, compared to a liberal diet in another 37 patients. The results at three days show that weight loss was similar in both groups, as well as changes in clinical congestion score. Moreover, such aggressive intervention was associated with significantly higher rates of thirst in patients.

 

PETER:

Hmm, but such restrictions are recommended by current guidelines, aren’t they?

 

SARAH:

They are. But Dr. Luis Beck da Silva, lead author of the study presented this week at the European Society of Cardiology’s Heart Failure meeting and published in JAMA Internal Medicine, said this might eventually change:

 

Beck-da-Silva: This time-honored medical advice may have become outdated. The heart failure therapies have changed in the last two decades: We have much more medications, modalities and therapies to offer the patients nowadays than we had in the 90s. So this restriction of water and sodium may not have any place anymore in patients hospitalized for acute decompensated heart failure

 

SARAH:

That was Dr. Luis Beck da Silva, from Porto Alegre Brazil, who said a larger multicenter trial would be necessary to confirm his findings.



BREVE 1 Sur fond musical  

 

PETER:

Finally, in brief:

 

For patients with chronic obstructive pulmonary disease, long-acting bronchodilators β-agonists and anti-cholinergics, while effective, were both associated with increased risk of cardiovascular events. That’s according to a nested case control analysis of a retrospective cohort study with nearly 200,000 older people with chronic obstructive pulmonary disease, published in JAMA Internal Medicine.

 

And …..

 

BREVE 2

 

For children with cystic fibrosis, free neutrophil elastase activity in bronchoalveolar lavage fluid detected at age three months, increased the odds of persistent bronchiectasis at both one and three years of age. That’s according to a longitudinal study, reported in the New England Journal of Medicine, with 127 infants diagnosed with cystic fibrosis after newborn screening.

That's all from MDFM for now. Sarah Maxwell and I will be back with more next week, so until then from me Peter Goodwin, goodbye!

 

JINGLE FIN      

 

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