Brief Psychotherapy for the Treatment of Postpartum Depression: a systematic review and meta-analysis

Colleen Huml, MD; Loh Emi; Xue Geng, MS; Kean J. Hsu, PhD

Medstar Georgetown Psychiatry

Category: Research

Purpose: Postpartum depression (PPD) is a prevalent mental health challenge, yet existing treatment options fall short in meeting the needs of new mothers. The purpose of this study was to examine the effectiveness of brief psychotherapeutic interventions for PPD through meta-analysis of the existing literature.

Methods: This meta-analysis explored the effectiveness of brief psychotherapeutic interventions (defined as 8 sessions or fewer) for the treatment of PPD. Studies were assessed for change between pretreatment and post-treatment symptoms.

Results: 144 studies were originally identified, of which 14 were included in this review. Brief psychotherapeutic interventions were associated with significant decrease in depressive symptoms as measured by standardized mean change scores in Beck Depression Inventory (BDI) (SMCC=-2.6335, p<.0001) and Edinburgh Postnatal Depression Scale (EPDS) (SMCC=-2.5082, p<.0001), both with significant between-study heterogeneity. For BDI, between-study heterogeneity resolved after meta-regression analysis, with number of sessions as the most significant moderator. For outcome measures Beck Anxiety Inventory (BAI), State-Trait Anxiety Inventory (STAI), Hamilton Anxiety Rating Scale (HAM-A), and Hamilton Rating Scale for Depression (HRSD), sample size was insufficient to conduct meaningful analysis.

Conclusion: Overall, this meta-analysis finds that brief psychotherapeutic interventions hold promise in reducing symptoms of PPD. Future research should clarify the minimum number of sessions required and the type of psychotherapy most suitable for achieving this effect.

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Music and Motivation: a review of neuronal circuits and clinical application

Paula Gomes, MD; Ayyub Imtiaz, MD; Lauren Pengrin, DO

Saint Elizabeths Hospital

Category: Research

Introduction: Motivation is the pulling force that gives purpose or direction to behavior. It is correlated with various psychiatric diseases, cognitive and physical performance, and the subjective concept of well-being. Low motivation remains a persistent symptom in many patients on medications and psychotherapy. Music is not commonly prescribed but is readily available and can modulate motivation by promoting network changes in 3 circuits: reward, arousal, and movement. This poster summarizes the evidence of the link between music and motivation.

Methods: A review of multiple databases using keywords was conducted. All types of articles discussing the topic were selected and analyzed.

Results: The primary auditory cortex encodes the acoustic stimuli in a specific neuronal firing frequency. Through synchronization, connected networks are entrapped in a new neuronal depolarization rate. Therefore, music can stimulate or suppress neuronal firing in certain brain regions and promote long-term neuroplasticity based on the speed, rhythm, lyrics, and other factors. The pleasure circuit (mesocorticolimbic pathway) is activated by rewarding stimuli such as food, drugs, and sex by releasing dopamine and endogenous opioids. Fast beat music (140-150 beats per minute) and subjectively preferred songs likewise activates this pathway. Music also facilitates motivation by increasing central and systemic arousal by modulating firing the reticular activating system in the brainstem. These physiological changes can be measured by increased heart rate, respiratory rate, blood pressure, electrodermal skin conductivity, muscle tension, and peripheral temperature. Music similarly helps with movement by increasing subjective desire to move, stimulating facial muscles, and improved physical performance. This is due to firing in pre-motor and motor regions, such as basal ganglia, primary motor areas, supplementary motor areas, and cerebellum.

Conclusions: Music modulates several brain circuits, including circuits implicated in motivation. Increased consensus about treating motivation for improving quality-of-life for patients makes utilizing music as prescription imperative.

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Dexmedetomidine: A review of its use for the treatment and prevention of hyperactive delirium in intensive care units (ICU)

Brittany Booker, MS4; Ayyub Imtiaz, MD; Muhammad Zaidi, MD

Ross University School of Medicine

Category: Research

Introduction: Intensive Care Unit (ICU) delirium results in increased hospital stay and mortality. The effects of previously recommended antipsychotics are associated with no change in delirium. Dexmedetomidine, an adrenergic alpha 2 receptor agonist, reduces development and improves resolution of delirium. The aim of this review is to explore the evidence that supports the use of dexmedetomidine for treatment and prevention of hyperactive delirium in ICU patients.

Methods: A literature review was conducted to gather supporting evidence on the use of dexmedetomidine in ICU delirium. The main outcomes measured included a decrease in scales used to measure delirium and agitation, time spent in delirium, duration of mechanical ventilation, and incidence of delirium.

Results: A randomized control trial (RCT) of lorazepam versus dexmedetomidine in mechanically ventilated ICU patients demonstrated that dexmedetomidine resulted in more days without delirium. Another study found individuals receiving dexmedetomidine spent less time on the ventilator, developed delirium 20% less often, and were off mechanical ventilation almost 2 days sooner compared to midazolam. The Dexmedetomidine to Lessen ICU Agitation RCT, which involved adults in whom extubation was not done due to delirium severity, demonstrated that dexmedetomidine increased ventilator free hours by 17 hours compared to placebo. Another RCT of delirium-free ICU adults demonstrated a greater proportion of patients who remained delirium-free during the ICU stay after administration of nocturnal dexmedetomidine.

Conclusion: Delirium in ICU patients occurs at exceptionally high rates and there is a need for clear pharmacologic treatment. Current literature supports the use of dexmedetomidine for reduction of delirium in ICU patients with potential to eliminate risk associated with previously used antipsychotics, decreased risk of polypharmacy and overall mortality associated with ICU delirium.

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Factors Predisposing to Delirious Mania

Brittany Booker, MS4; Muhammad Zaidi, MD; Tzvetelina Dimitrova, MD; Mark Hallett, MD, DM(hon)

Saint Elizabeths Hospital

Category: Research

Lithium is reserved for patients with severe retractable Bipolar Disorder. When Patients with onset of mania, history of noncompliance and multiple comorbidities in this context develop mania, they are frequently predisposed to Delirious Mania. Delirious mania (DM) is a severe, life-threatening condition but the literature on its diagnosis and treatment remains sparse. We report three cases of DM presenting on an inpatient psychiatric service. The review of literature is focused on similar clinical cases that describe the onset of delirium in patients with other co-occurring conditions in addition to diagnosable mania, often elderly patients with multiple comorbidities. All three of the patients reported here had been treated with Lithium. Lithium remains the gold standard treatment for bipolar disorder, but due to its side effects and need for monitoring it is mostly reserved for patients with severe, difficult to control disease. In addition, all three patients had multiple comorbidities and were not compliant with the recommended treatment consistently. We speculate that DM is a severe complication after the onset of mania in patients with bipolar disorder in the context of medication noncompliance and multiple medical co-morbidities with resultant acute changes in drug blood levels.

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Prevalence of Depression and Associated Factors among Post-Stroke Outpatients at a Teaching Hospital in Addis Ababa, Ethiopia

Enque Deresse Endeshaw MD; Surafel Worku Megersa, MD; Marishet Agumasia Tamen; Markos Tesfaye, MD

Saint Elizabeths Hospital

Category: Research

Background: Depression is a common complication following stroke, adversely affecting outcomes. Previous research has explored Post stroke depression (PSD's) impact, risk factors, and etiology, including cognitive impairment and psychological factors. Despite this, sub-Saharan African data are scarce. The study aims to fill this gap by investigating the prevalence and factors of PSD in a low-income setting.

Method: This cross-sectional study aimed to investigate depression prevalence and factors associated among post-stroke outpatients at a teaching hospital in Addis Ababa, Ethiopia. A total of 159 post-stroke patients aged 18 and above were included. Exclusions applied to those with pre-existing mood disorders, significant language impairment, or other central nervous system diseases. The Amharic and Affan Oromo versions of the PHQ-9 with a cutoff of ≥ 10 were used to identify depression. Bivariate and multiple logistic regression analyses were conducted to identify associations between various factors and post-stroke depression.

Results: Among 159 participants, 57.9% were male, with a mean age of 58.4 years. Of the participants, 56% had hemorrhagic strokes. The majority (54.7%) had right-side brain hemisphere strokes, while 38.4% had left-side strokes. The overall prevalence of post-stroke depression (PSD) was 43.4%. Among those with depression, 62.3% reported extreme difficulty in daily activities, emphasizing functional impairment. Significant associations were found between depression and age between 45 and 64, low monthly income (<17.5 USD), and diagnosis of stroke within the preceding six months. No significant association was observed for gender, residency, marital status, level of education, employment, stroke type, or stroke side.

Conclusion: This study's findings highlight a high prevalence of depression among post-stroke outpatients in Ethiopia, surpassing general population estimates. While this study aligns with global PSD prevalence trends, it emphasizes the need for enhanced attention to PSD in clinical care, given its implications for rehabilitation and overall quality of life.

Low Baseline Peripheral Glutamate Flux Strongly Predicts Ketamine Response in Treatment-Resistant Depression: Insights from Bulk RNA-Seq and METAflux Analysis

Gregory Jones, MD; Yoojin Lee PhD; Carlos A Zarate Jr., MD

NIMH (Clinical Fellowship)

Category: Research

Background: Glutamatergic signaling is implicated in both depression and ketamine response. However, peripheral markers aligned with ketamine's central effects remain inconsistent. Methods: We analyzed baseline, whole blood transcriptional profiles from Cathomas et al., 2022 (GSE18585526). 26 patients with treatment-resistant depression were treated with a single intravenous ketamine infusion. Preprocessing workflow reported by the original authors was replicated via DESeq2. Metabolic pathway scores were modeled from variance stabilized gene expression data with METAflux. Feature importance and predictive modeling were conducted through Random Forest regression (randomForest) with oversampling (ROSE) to address class imbalance, and k-folds cross validation. Lasso and Elastic Net regressions were applied to the top-five features using Leave-One-Out Cross-Validation (LOOCV) via glmnet. Results: The random forest results demonstrated remarkable accuracy (93.3%) and precision (96.0%) in predicting ketamine response versus non-response using ten metabolic pathways (average F1 score of 94.9% and area under the curve (AUC) of 92.5%). Performance was further assessed via a permutation test (1000 permutations), yielding a significant result (p < 0.001). Of the top five pathways, lasso regression refined a single predictive feature: alanine, aspartate, and glutamate metabolism (Î² = -0.41), showing an inverse association with response. This pathway maintained its sole predictive relevance (Î² = -0.23) within the optimal Elastic Net model, even after adjusting for age, sex, and BMI, highlighting its primary significance in predicting ketamine response.

Conclusions: Our preliminary findings suggest that reduced peripheral glutamate pathway flux at baseline could potentially influence antidepressant responses to ketamine. This aligns with findings of baseline glutamate receptor upregulation in responders from the original article, and patterns seen with central glutamatergic surrogates such as magnetoencephalographic (MEG) gamma power.

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Pseudo-Wellens’ Syndrome in Substance Use: A Scoping Review

Usman Bakshi, MS4; Ayyub Imtiaz, MD; Asmeret Berhane, MD; Nicholas Mahan, MD

American University of Antigua

Category: Research

Introduction: Pseudo-Wellens' Syndrome (PWS), characterized by ECG changes resembling Wellens' Syndrome without associated critical coronary artery stenosis, has diverse causes, including substance use. Amid the increase in drug decriminalization and legalization, this scoping review aims to identify specific drugs associated with PWS due to a notable absence of any such literature.

Methods: A systematic search on PubMed and Google Scholar yielded 67 articles, of which 24 duplicates were removed. Of the 43 articles remaining, 31 were excluded for not meeting inclusion criteria and 1 was not found. The final analysis included 11 articles spanning 2006 to 2023, where PWS cases, confirmed through ECG change reversal or catheterization, involving substance use were assessed based on specific substances mentioned.

Results: The study focused on 11 cases involving individuals aged 22 to 59 with a history of substance use. Nine cases had confirmed urine drug screening (UDS), two were reported, and all exhibited abnormal ECGs consistent with Wellens' Syndrome. Cardiac catheterization in 9 cases revealed no coronary artery obstruction, confirming PWS diagnosis and two cases showed symptom resolution without further intervention. Six cases involved marijuana, five cocaine, one PCP, two opiates, and one methamphetamine. Polysubstance use was common, and although marijuana and cocaine exhibited stronger associations, the study suggests considering any substance, illustrated by cases solely involving PCP and methamphetamine.

Conclusion: A notable absence of large-scale studies on the correlation between substance use and PWS underscores the importance of this scoping review. While marijuana and cocaine presented stronger associations, polysubstance use challenges attributing PWS to specific drugs. Tailored clinical approaches informed by substance-specific associations are crucial to guide decision-making, prevent unnecessary interventions, and mitigate harm. Two cases had favorable outcomes without catheterization, exemplifying the practical application of these insights thus emphasizing the need for further research in this area.

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Effectiveness of Buprenorphine and Methadone in the Treatment of Tianeptine Abuse

Usman Bakshi, MS4; Ayyub Imtiaz, MD; Ihechi Akwuole, MS4 ; Nicholas Mahan, MD

American University of Antigua

Category: Research

Introduction: Tianeptine, an atypical Tricyclic Antidepressant (TCA) with opioid-like properties, has become a concern due to its affordability and increasing abuse. Unlike opioids, there are no comprehensive guidelines for managing Tianeptine abuse. This narrative review assesses the effectiveness of medications used for opioid use disorder (OUD), such as buprenorphine, buprenorphine/naloxone, and methadone, in treating Tianeptine Use Disorder.

Methods: A literature review was conducted using PubMed, Google Scholar, and Scopus to analyze articles on Tianeptine abuse, employing keywords like "Tianeptine", "buprenorphine", "naloxone", and "methadone". The review focused on four case reports, assessing the efficacy of buprenorphine, buprenorphine/naloxone, and methadone in managing Tianeptine abuse in both inpatient and outpatient settings.

Results: This review involved four case reports of middle-aged patients (24-38 years) with Tianeptine abuse. In the first case, a patient consuming 8-20g daily was initially treated with sublingual buprenorphine/naloxone and later switched to methadone, showing significant improvement. The second case involved a polysubstance overdose, with methadone administered for Tianeptine withdrawal symptoms. The third case used buprenorphine/naloxone along with mirtazapine, risperidone and clonidine resulting in cessation of withdrawal symptoms. The fourth case demonstrated successful use of a micro dosing technique with buprenorphine, leading to the complete cessation of Tianeptine use.

Conclusion: This narrative review highlights promising outcomes with methadone, buprenorphine/naloxone, and buprenorphine in managing Tianeptine abuse. However, the study's limitations, such as the small number of cases, highlight the need for larger-scale investigations. The potential effectiveness of methadone, with its TCA-like properties, suggests it could be preferred for acute withdrawal, while buprenorphine taper may be suitable for maintenance treatment in outpatient settings. The findings advocate for further research to validate the observed outcomes and establish comprehensive guidelines for managing Tianeptine Use Disorder.

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A Review of Pharmacologic Treatments for Ultra-High-Risk Psychosis

Keti Kutidze, MD; Ayyub Imtiaz, MD; Ashwin Mathai, MD

David Tvildiani Medical University

Category: Research

Introduction: The success of first-episode psychosis studies led to the extension of early intervention strategies in clinically high-risk individuals who do not meet syndromal psychotic disorder criteria. Various research groups have been working on developing distinct early detection tools and have devised criteria for Ultra-High-Risk (UHR) for psychosis. Despite the development of early detection tools, there is not enough high-quality evidence regarding the role of pharmacologic interventions in schizophrenia prevention. This review will summarize the current evidence on the effects of different pharmacological modalities.

Methods: A literature review using specific keywords was conducted via Google Scholar and PubMed databases. Inclusion criteria included non-review articles in English, with a minimum 12-month follow-up. Key measures extracted were the rate of transition to psychosis and longitudinal assessments of symptom severity and functional improvement.

Results: This review focuses on the 2 most assessed pharmacologic interventions: antipsychotics and omega-3 fatty acids. Antipsychotics were investigated in 5 clinical trials, where most of them failed to demonstrate statistically significant effects. One study indicated reduced transition rates at 6 months, but not at 12 months, suggesting a possible temporary delay in the onset of psychosis. Conversely, another study suggested using low-dose haloperidol or risperidone to delay or prevent transition to psychosis. However, this study lacked control intervention, and the transition definition wasn't specified. A study on omega-3 fatty acids showed reduced conversion to psychosis and psychiatric morbidity over a 7-year follow-up; however, further attempts to replicate the effect were inconclusive due to limitations of sample size and statistical power.

Conclusion: Antipsychotic medication may delay the onset of psychosis and alleviate pre-psychotic symptoms, but current data does not support its widespread use. Omega-3 fatty acids show promise; however, more research is needed to confirm their efficacy. This may be in part to its theorized neuroprotective effects.

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Psilocybin for Treatment of Depression: Neuro-objective or Neuro-subjective?

Adil Elahi, MD; Ayyub Imtiaz, MD; Muhammad Zaidi, MD

Aga Khan University

Category: Research

Introduction: Depression causes disability globally due to unsatisfactory results with current therapies taking up time and resources. Psilocybin-assisted psychotherapy offers a promising alternative with its rapid onset and enduring efficacy. However, there is debate underlying psilocybin's antidepressant mechanisms. Some suggest the effects are due to objective changes in the brain, whereas others argue the importance of the patient's subjective experiences. We aim to explore the various explanations for psilocybin's antidepressant effects and to increase awareness about this up-and-coming modality.

Methods: We conducted a narrative review of databases using keywords to find relevant articles and extract data for analysis.

Results and Discussion: Psilocybin's antidepressant effect was first thought to be due to its receptor profile, partial agonism on 5HT-2A, but this is counterintuitive to available antidepressant medications that have 5HT-2A antagonism such as mirtazapine and trazodone. Neuroplasticity was considered as a possible mechanism for psilocybin, but this is also seen with long-term use of SSRIs. Psilocybin causes rapid-acting neuroplasticity, different from current treatments. This is also seen with esketamine and dextromethorphan/bupropion via NMDA modulation and Brain-Derived Neurotrophic Factor (BDNF) release, resulting in anti-inflammatory and increased cerebral blood flow. However, other rapid-acting antidepressants do not produce acute changes in perception like psilocybin. These altered states of consciousness are a result of psilocybin's action on the Default Mode Network. These introspective states lead to intense emotional breakthroughs and can be augmented with psychotherapy. Several studies have suggested that mystical-type subjective effects were responsible for many of the positive effects of psilocybin.

Conclusion: Although subjectivity and science do not always mix, exceptions should be considered. The mystical experiences unique to psilocybin could be central to psilocybin's efficacy and should be promoted in the treatment setting. Balancing these psilocybin effects can create effective treatment plans, improve patient safety, determine dosage guidelines, and minimize side effects.

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Depression Severity in Respiratory Disease Patients Admitted to Intensive Care Units (ICU) and High Dependency Units (HDU)

Ayyub Imtiaz, MD; Amun Mustafa, MS; Asifa Karamat, MBBS, MRCP, FCPS; Wajeeha Mustansar Toor, MBBS, MCPS; Tehmina Mustafa, MD, PhD

Saint Elizabeths Hospital

Category: Research

Introduction:
Depression is prevalent among hospitalized patients, contributing to poorer health outcomes. However, limited data exists on depression in patients admitted to ICU or HDU, especially those with respiratory conditions requiring ventilator support.

Methods:
Patients with respiratory conditions in Gulab Devi Teaching Hospital, Pakistan, admitted to ICU or HDU were assessed using the Hamilton Depression Rating Scale (HDRS). Data analysis was conducted using IBM SPSS Version 20 and Microsoft Excel 365. Patients were categorized into respiratory condition groups, and statistical tests were performed to assess differences in depression severity.

Results:
185 cases were analyzed, with 85.9% overall prevalence of depression (Severity: Mild = 40.0%, Moderate = 27.0%, and Severe = 18.9%). Patients were categorized into Obstructive (n= 70), Restrictive (n= 44), Infectious (n= 44), and Other (n= 27) lung conditions, with a prevalence of depression of 53.8%, 80.8%, 73.1%, and 92.3% given each category respectively. However, no significant differences were found in depression severity between disease categories.

Discussion and Conclusion:
Post-ICU depression studies typically report lower prevalence of depression (46.5%) than our study, potentially due to resolution of depressive symptoms alongside the respiratory symptoms after ICU admission. While no significant differences were found in depression severity between respiratory disease categories, future research could investigate the role of tuberculosis exposure, considering its prevalence and potential chronicity in Pakistan.

Adjunct Treatments of Antipsychotic-Induced Hyperprolactinemia: A Review

Sebastian Heine, MS3, MSc; Ayyub Imtiaz, MD; Muhammad Zaidi, MD

American University of Antigua

Category: Research

Antipsychotic medications are notorious for causing many adverse effects, including hyperprolactinemia (HPRL). An increase in prolactin levels can lead to many short- and long-term consequences including amenorrhea, gynecomastia, sexual dysfunction, osteoporosis, and even breast cancer. Reducing antipsychotic dosages or changing antipsychotic treatment regimens are effective in reducing Prolactin levels, but risk provoking psychosis. Changing antipsychotic medications can lead to other adverse side effects, like metabolic syndrome, extrapyramidal effects, and sedation. Adjunctive medicines, such as aripiprazole, metformin, vitamin B6, bromocriptine, and a Chinese herb called Peony Glycyrrhiza Decoction (PGD) are interesting alternative treatments that show promise in treating antipsychotic induced HPRL. Indeed, all aforementioned adjunctive treatments reduced prolactin levels in psychotic patients along with symptoms of HPRL. Aripiprazole has the most robust evidence in treating HPRL in psychotic patients and is a first-line adjunct. Metformin is effective in lowering prolactin levels and should be considered in psychotic patients with comorbid Type 2 Diabetes (T2DM). Vitamin B6 and Peony Glycyrrhiza Decoction (PGD) are effective in reducing prolactin but lack the scientific evidence in psychotic patients while increasing the risk of rebound psychosis. In conclusion, aripiprazole is the most effective adjunctive treatment in reducing prolactin levels and in maintaining patient compliance to antipsychotic treatment regimens. Adjunct aripiprazole should be considered as an alternative therapy for HPRL before changing antipsychotic drugs or reducing antipsychotic dosages.

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Exploring Imposter Phenomenon during Onboarding into a Military Medical School

Eungjae Kim, BS; Steven J. Durning, MD, PhD; Jezreelyn Bulaklak; Abigail Crosier; Jinbum Dupont, MS; Michael Soh, PhD

Uniformed Services University of the Health Sciences

Category: Research

Introduction: Impostor phenomenon (IP) is an experience where an individual believes that their success was because of chance or luck and was not associated with the mastery of skills. Prevention, or early intervention, of IP may reduce potential effects on a medical trainee's confidence and competence in their profession, which may ultimately enhance health care team performance and impact patient outcomes. This study explores military medical students experience with IP during orientation into a military medical school.

Methods: The study participants were medical students at a military medical school. Researchers conducted semi-structured interviews to explore if and why students experienced IP and deployed the Clance IP Scale (CIPS) as a measure with validity evidence for ascertaining the presence and magnitude of IP. Researchers calculated scores from the CIPS and thematically analyzed interview transcripts.

Results: Researchers interviewed 29 matriculating military medical students. Twenty-one (75%) students reported frequent or intense IP experiences on the CIPS indicating that IP was present in our study sample. Thematic analysis identified six themes that drove one's experience with IP: reevaluation of merit, individualized diversity and inclusion experiences, administrative and financial support, preconceived expectations, building relationships, and new community roles.

Discussion: Our identified themes provide us with a better understanding of if and why military medical students experience IP during onboarding. Our findings are also consistent with the situated learning theory, which places emphasis on the sense of belonging and may provide a unique and insightful lens through which IP can be further explored and studied, particularly at a military medical school where various identities, dynamics, and aspirations can converge simultaneously. Our findings suggest that existing practices may benefit from improvements on tailoring onboarding activities to entail more reflective discussion using small groups, reevaluating administrative and financial supports, and ensuring cultural coherence (organizational alignment of mission) among faculty, staff, and upperclassmen.

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Brain or Breast? Breast Implant Illness: A Review for Psychiatrists

Karla Chamoun, MD; Ayyub Imtiaz, MD; Peter Nguyen, DO

Saint Elizabeths Hospital

Category: Research

Introduction: Breast Implant Illness (BII) is a condition affecting individuals who have breast augmentation. Symptoms are variable, vague, and are often multisystemic, including psychiatric, neurologic, gastrointestinal, and connective-tissue systems. BII remains a controversial diagnosis as inconsistent literature is published regarding whether breast implants are the cause of the symptoms. As a result, BII is theorized to be psychosomatic but is not discussed in psychiatric circles. The authors aim to summarize and synthesize the existing literature on BII from a psychiatric perspective.

Methods: A comprehensive review of various databases using keywords was conducted, and relevant articles were selected for thematic analysis.

Results: BII symptoms include chronic fatigue, sleep disturbances, cognitive difficulties, anxiety, depression, and memory loss that cause significant functional impairment and may result in suicide. It is unclear if BII is medical or psychiatric in nature. BII could be triggered by chronic immune activation in response to adjuvants present in the breast implants, with some cases showing resolution of psychiatric symptoms after explantation. However, symptom recurrence has been noted and large studies have found no evidence between breast implants and connective tissue disorders. BII can also be psychosomatic given the degree of dysfunction and disability that is disproportionate to visible tissue abnormalities. Cognitive behavioral therapy has demonstrated success in various psychosomatic conditions and may be useful in BII as well. BII could also be due to pre-existing psychiatric conditions. They have higher substance use and psychiatric hospitalization rates before cosmetic surgery compared to other cosmetic surgery patients.

Conclusion: BII has a considerable psychiatric burden on many individuals. While the pathophysiology is unknown, a holistic management approach is required. BII symptoms have been reported preceding the onset media globalization, thus clinicians should be considerate before dismissing symptoms as medical misinformation because of unclear etiologies of the condition.

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From Toxic to Therapeutic: A Review of The Shifting Perception of MDMA Research

Renzo Costa, MD; Ayyub Imtiaz, MD; John Echevarria, MD; Peter Nguyen, DO

Saint Elizabeths Hospital

Category: Research

Introduction: Within the psychiatric community, the last few decades have culminated into what some consider to be a "psychedelic renaissance". N-3,4-Methylenedioxymethamphetamine (MDMA) is one of the medicines at the forefront of this movement, with FDA approval being anticipated soon. However, prior to the scientific community's more sympathetic approach to MDMA, compiled evidence established this drug's neurotoxicity. To investigate this change of heart, we conducted a literature review for all articles related to MDMA and either its toxicity or its therapeutic potential.

Methods: Medical Subject Headings (MeSH) terms were first reviewed to find suitable headings and subheadings for the PubMed search. Two separate search strategies were created to search for MDMA adverse effects (617 articles) and MDMA therapeutic effects (434 articles). The articles were imported into Excel for analysis.

Results: Until the early 2000s, the publications available on PubMed concerning MDMA's effects showed an overwhelming preponderance for its adverse effects as opposed to its therapeutic use. In the 2000s, the number of publications focusing on MDMA's therapeutic use reached double digits, though most articles focused on adverse effects. In 2011, the number of publications focusing on therapeutic use outnumbered the ones focusing on adverse effects. This quickly reversed. Since 2017, however, the publications focusing on therapeutic use have outnumbered those focusing on adverse effects.

Discussion and Conclusion: In 2017, MDMA research shifted its focus from toxicity to its therapeutic potential. However, there is over 30 years of research indicating potential for harm. Just as MDMA's medicinal purposes should not have been ignored in the second half of the 20th century, neither should its potential for harm be ignored in the current day. As with any medicine, we must remain objective to uncover MDMA's benefits and its risks for the safety of our patients.

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Evaluating Evidence to Administer Supratherapeutic Doses of Antipsychotics in Patients with Schizophrenia and Schizoaffective Disorder

Jingxiong Pu, MD; Akbar Salman, MD; Quddarat Mushtaq, MS; Abhishek Wadhawan, MD

Saint Elizabeths Hospital

Category: Research

Introduction: Antipsychotic medications are the first-line treatment for schizophrenia and schizoaffective disorder. Regardless of class, many patients don't respond adequately to standardized treatment options and may need dosage adjustments and/or augmentation with additional medications. Supratherapeutic doses of antipsychotics remain an option, and we attempt to establish efficacy and safety of this treatment modality.

Methods: A literature search was performed using relevant keywords on PubMed/MEDLINE, including the terms "high dose", "supratherapeutic dose", "higher than recommended dose", "antipsychotic", and "high plasma levels", limiting the results to English only. All possible studies, including case reports, meta-analyses, and literature reviews, were included.

Results: Evidence on high dosage use of first-generation and second-generation antipsychotics (FGAs and SGAs) appears to be mixed. Several meta-analyses have examined differences in PANSS and BPRS scores, emphasizing how supratherapeutic dosing can result in an increase in adverse effects without a concomitant rise in efficacy. Other case series and literature reviews discuss how high dosing may be of value in agents such as clozapine, olanzapine, quetiapine, and ziprasidone, particularly among treatment-resistant individuals. Factors associated with trial of supratherapeutic doses include younger age, multiple psychiatric admissions, presence of active delusions, aggressive behavior, and being in a forensic setting.

Conclusion: Currently available data suggests that high dose antipsychotics may be effective and appropriate in certain patients, given there is good tolerability. However, we must be careful not to apply this practice uniformly across all patients with primary psychotic disorders, given that the evidence base also demonstrates that a typical patient may experience more side effects rather than increased efficacy. Additionally, we must consider interindividual variability in terms of dose-response associations, alongside patient preferences such as whether to prioritize remission of symptoms versus reduction of adverse effects.

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A comparison of virtual and in-person forensic evaluations

Lindsay Poplinski, DO; Etuajie Oiyemhonlan Halbert, DO, MS

Saint Elizabeths Hospital

Category: Research

The rate at which persons diagnosed with mental illness encounter the judicial system continues to increase. The need for more forensic evaluations after COVID calls for access to defendants that is low in infective risk, for maintaining civil rights by minimizing time in detention, and for preserving access to defendants for an over-taxed forensic workforce. Virtual platforms offer a solution to these challenges.

This investigation compares in-person and virtual evaluations in the inpatient forensic setting at Saint Elizabeths Hospital, Washington DC.

Utilizing competency to stand trial reports – the most common US court evaluation – we conduct a retrospective chart analysis. Reports are reviewed with an anonymized checklist assessing competence outcomes, length of interview, refusals/no-shows, charges, and demographics. The study compares periods before and after the pandemic when virtual platforms gained popularity.

A power analysis using two related studies indicates that 40 reports in each sample are sufficient to pick up large differences between the groups, while samples of up to 110 reports are required to pick up smaller differences.

Preliminary results do not yet distinguish the samples in any of the study’s hypotheses:
1. There is no difference between virtual and in-person evaluations in the length and number of evaluations before a final recommendation.
2. There is no difference between virtual and in-person evaluations outcomes, (e.g., “competent,” “incompetent”).
3. The number of times technology is mentioned in virtual assessments (a proxy for barriers to virtual assessment) does not affect the kind and number of opinions required for a final recommendation.
4. Evaluee demographics and evaluators’ years of experience do not affect assessment outcomes using the virtual platform.

We expect that ongoing data collection will continue to support virtual evaluations as an avenue for limiting time in detention and meeting the needs of vulnerable persons who require forensic assessment.

Keywords: Competence to stand trial, forensic assessment, civil rights

References:
1. Hobart KS, Krishnan S, Cleary SD, Candilis PJ. Assessing Racial Effects on Adjudicative Competence. J Am Acad Psychiatry Law. 2023 Dec 8;51(4):542-550. doi: 10.29158/JAAPL.230074-23. PMID: 37788863.

2. Xu Y, Parkin JA, Cunningham N. The impact of COVID-19 on clinical forensic medicine and forensic psychiatry: A literature review. Med Sci Law. 2024 Feb 12:258024241229830. doi: 10.1177/00258024241229830. Epub ahead of print. PMID: 38347724.

3. Lexcen FJ, Hawk GL, Herrick S, Blank MB. Use of video conferencing for psychiatric and forensic evaluations. Psychiatr Serv. 2006 May;57(5):713-5. doi: 10.1176/ps.2006.57.5.713. PMID: 16675769.

4. Manguno-Mire GM, Thompson JW Jr, Shore JH, Croy CD, Artecona JF, Pickering JW. The use of telemedicine to evaluate competency to stand trial: a preliminary randomized controlled study. J Am Acad Psychiatry Law. 2007;35(4):481-9. PMID: 18086740.

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Imposter Syndrome Among Ethnic Minority Medical Students who are Underrepresented in Medicine

Francois Williams, MD; Jayne Rice, MD; Beverlin Rosario-Williams, MA; Alden Landry, MD

Medstar Georgetown Psychiatry

Category: Research

Objectives: Impostor syndrome (IS) is prevalent in medical professionals. However, little is known about the prevalence of IS among medical trainees and those who are underrepresented in medicine (UiM). Even less is known about the experiences of UiM students at predominantly white institutions (PWIs) and historically black colleges/universities (HBCUs) relative to their non-UiM peers. The purpose of this study is to investigate differences in impostor syndrome among UiM and non-UiM medical students at a PWI and a HBCU. We additionally explored gender differences in impostor syndrome among UiM and non-UiM students at both institutions.

Method: Medical students (N = 278) at a PWI (N = 183, 107 (59%) women) and a HBCU (N = 95, 60 (63%) women), completed an anonymous, online two-part survey. In part one, students provided demographic information, and in part two, students completed the Clance Impostor Phenomenon Scale, a 20-item self-report questionnaire that assessed feelings of inadequacy and self-doubt surrounding intelligence, success, achievements, and one's inability to accept praise/recognition. Based on the student's score, the level of IS was measured and placed into one of two levels: few/moderate IS feelings, or frequent/intense IS feelings. We conducted a series of chi-square tests, binary logistic regression, independent sample t-tests, and analysis of variance to test the main aim of the study.

Results: The response rate was 22% and 25% at the PWI and HBCU, respectively. Overall, 97% of students reported moderate to intense feelings of IS, and women were 1.7 times more likely than men to report frequent or intense feelings of IS (63.5% vs 50.5%, p = 0.03). Students at PWI were 2.7 times more likely to report frequent or intense IS than HBCU students (66.7% vs 42.1%, p< 0.01). In addition, UiM students at PWI were 3.0 times more likely to report frequent or intense IS compared to UiM students at HBCU (68.6 % vs 42.0%, p = 0.01). Computation of a three-way ANOVA with gender, minority status, and school type revealed a two-way interaction indicating that UiM women scored higher on impostor syndrome than UiM men at the PWI and HBCU. This trend was not observed among non-UiM students.

Conclusions: Impostor syndrome is informed by gender, UiM status, as well as environmental context. Efforts to provide supportive professional development for medical students should be directed towards understanding and combatting this phenomenon at this critical juncture of their medical career.

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LSD and Neuroplasticity: Epigenetic, Anxiolytic, and Metabolic Mechanisms

Quddarat Ullah Mushtaq, MD; John Echevarria, MD; Ossama Naveed, M4

Saint Elizabeths Hospital

Category: Research

Objective: To compile and analyze the field's current understanding of the mechanism of LSD's clinical effect, with a focus on available data on the effects of LSD on neuroplasticity, anxiety, depression, and its metabolic mechanisms in humans.

Background: Lysergic acid diethylamide (LSD) has long been associated with profound alterations in consciousness and is currently being re-evaluated for its therapeutic potential, especially in treating anxiety and depression. However, the underlying mechanisms are still not fully understood.

Methods: We analyzed primary literature employing diverse methodologies including whole genome bisulphite sequencing, proteomics profiling, systematic reviews, and in vitro assays to uncover the impact of LSD on DNA methylation, protein expression, anxiolytic effects, and the metabolic process.

Results: LSD modulates DNA methylation in the prefrontal cortex, impacting neurotropic, neurotrophic, and neuroplasticity signaling. In conditions of stress, repeated doses of LSD show anxiolytic effects, potentially through enhanced serotonin neurotransmission and increased cortical synaptogenesis. No direct clinical studies were found on LSD for depression treatment, though it's evident that other "classic psychedelics" like psilocybin and DMT have shown efficacy. LSD also metabolizes into several compounds, with enzymes like cytochrome P450 playing a pivotal role.

Discussion: LSD has a multi-faceted impact on the brain, influencing epigenetic markers, neuroplasticity, and neurotransmission. Its metabolic pathways and the potential influence of genetic polymorphisms and drug interactions on its pharmacokinetics suggest a complexity in its mechanism of action.

Conclusion: LSD shows promising therapeutic potential in the realm of mental health, particularly for anxiety. A deeper understanding of its mechanisms at the genetic, cellular, and neural levels can pave the way for targeted therapeutic applications and safer clinical use. Further research, especially direct clinical studies, is imperative.

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Indigenous Population and Coal Transportation Railway as Lethal Means of Suicide

Anna M. Spector, MD, MPH; Martha Escobar Lux MD, Sebastian Daniel Leon Giraldo, MPP, PhD candidate, German Ricardo Casas Nieto, MD

Saint Elizabeths Hospital

Category: Research

Suicide by train is increasing in Wayuu indigenous peoples in northern Colombia spurring studies to discover associated factors and preventive measures to reduce deaths. The Wayuu live close to a coal mine railway leading from the largest open pit coal mine in the Americas to a Caribbean seaport in northern Colombia. The entire railway line is flanked by fencing and private armed guards, and each train is preceded by company vehicles with rescue workers who scan the tracks for people who are in danger of being struck by the train. Through a mixed methods approach, factors associated with suicide and suicidal behavior among the Wayuu indigenous population were investigated. The data included quantitative data from national databases, qualitative data from field visits to municipalities and villages, social mapping, and community dialogue. Alcohol use was found to be the most common factor associated with rescue cases along the railway. On the other hand, emotional issues, violence, changes in cultural identity, and cross-border trading were the top structural categories related to suicidal behavior identified from the qualitative data. The study identified the need for culturally adapted surveillance and monitoring programs for suicide and proposes an intervention plan to address the issue.

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Gas Station Heroin: Tianeptine Misuse and Implications

Ihechi Akwuole, MS3; Ayyub Imtiaz, MD; Ankur Sah Swarnakar, MD; Ashwin Mathai, MD

Saint Elizabeths Hospital

Category: Public Health

Background: Tianeptine, also known as "gas station heroin" is a TCA-like medication approved in some countries but not in the USA. However, it is marketed over the counter as a nootropic (cognitive enhancer) in several states. At high doses, tianeptine acts on opioid receptors and induces euphoric effects. As a result, the incidence of tianeptine use in the United States has multiplied. Tianeptine builds tolerance quicker than other medications, thus requiring higher doses with each use, increasing the potential for misuse. The purpose of this review is to consolidate the current literature regarding tianeptine misuse in the United States.

Methods: A literature search was performed using relevant keywords on PubMed, PsycInfo, and Google Scholar. Qualitative analysis was performed to assess common factors, symptoms, and themes that were present within the selected cases.

Results: Tianeptine comes in 2 salt forms, sodium and sulfate, with sulfate being more potent and longer lasting. Despite the longer-lasting action, its half-life is only 2.5 hours. This is due to metabolism by beta-oxidation rather than cytochrome enzymes in the liver, unlike other TCAs. Both TCA and opioid overdoses have respiratory suppression, but the former has pupil dilation and the latter has pupil constriction. Tianeptine overdose resembles opioid overdose but is often complicated with TCA withdrawal symptoms too due to the short half-life. The common symptoms seen in TCA withdrawal are due to cholinergic overdrive, which is also present in tianeptine withdrawal. It is speculated that individuals presenting with opioid overdose symptoms concurrently exhibiting agitation and severe abdominal pain, or other TCA withdrawal symptoms, may be indicative of tianeptine overdose.

Conclusion: With the ongoing opioid crisis and the demand to achieve opioid-like effects increasing, psychiatrists should factor in the use of tianeptine when assessing patients displaying clinical signs of opioid use despite negative urine drug screens.

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Increasing Trainee Exposure to Proactive C-L Psychiatry: Lessons Learned from a Resident-Led Pilot on Two Surgical Units

Dan Powell, MD & Jungeun Choi, MD; Martekuor Dodoo, MD, Ted Liao, MD, Jennifer Schreiber, MD

Medstar Georgetown Psychiatry

Category: Public Health

Many trainees do not receive clinical exposure to Proactive C-L Psychiatry during residency. This project aimed to create a resident elective experience in Proactive C-L Psychiatry in a hospital without a previously established proactive service. Utilization data was gathered to identify services that frequently request psychiatric consultation. Educational objectives were identified, and the structure of a proactive screening process was developed in close consultation with the leadership of two surgical services. Two residents piloted the proactive model two days per week over a six-week block. Additionally, Psychiatry residents were administered a voluntary, anonymous survey which included brief educational material about Proactive C-L Psychiatry to assess knowledge/interest about this model. Consultee satisfaction data was being collected through summer 2023. The authors' review of utilization data identified limb salvage and transplant teams as two of the most common services to request psychiatric consultation, accounting for 43% of consultations from all surgical teams. These services were highly receptive to host Psychiatry residents for a proactive elective, and qualitative data collected regarding consultees' experience was very positive.

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Steroid-Induced mania: Risk factors, prevention strategies, and treatment challenges

Hina Makkar, MD; Abhishek Wadhawan, MD, Erica M. Richards, MD

Medstar Georgetown Psychiatry

Category: Case Report

Steroids can induce a wide range of psychiatric symptoms, spanning the cognitive, affective, and psychotic domains. Early recognition of these symptoms is crucial to initiating effective and timely interventions. We present a case of a 37-year-old male with a history of astrocytoma (status-post resection), who was discharged from another facility on a dexamethasone taper. He presented to the emergency room with manic and psychotic symptoms. The patient's manic symptoms included insomnia, grandiosity, religious preoccupation, and pressured speech. He was initially admitted to the medical floor for care but was involved in two incidents of aggression and attempt to elope. Labs were significant for an elevated white blood cell count of 26,000 cells/mL. A computed tomographic scan of his head showed soft tissue thickening of his scalp which was deemed to be secondary to bleeding or infection. His symptoms resolved with the administration of psychotropic medications and the discontinuation of dexamethasone. This poster will discuss pathophysiology, risk factors, prevention strategies, and treatment options for steroid-induced psychiatric symptoms. We will also highlight the challenges and propose solutions in managing patients with steroid-induced psychiatric symptoms in both medical and psychiatric wards.

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Obsessive Thoughts and Psychotic Features Following Glioblastoma Treatment in an Elderly Patient: A Case Report

Caroline Meuser, BA; Mira Johnson, BA; Rachel M. Treat, MA; Misty Embrey, MD; Christina Prather, MD

The George Washington University School of Medicine and Health Sciences

Category: Case Report

Psychiatric manifestations following glioblastoma multiforme (GBM) treatment, particularly those involving obsessive thoughts and psychotic features, are not commonly documented, posing challenges in diagnosis and management. Both GBM and its standard treatment modalities, including maximal safe resection followed by radiotherapy and chemotherapy, have direct impact on brain functioning. Existing research has focused mainly on the cognitive and neurological sequelae in GBM patients and highlights psychiatric symptoms as a primary manifestation of brain cancer; however, little attention has been given to the psychiatric impairment some GBM survivors experience after treatment. Here, we report the case of an 80-year-old woman with a history of GBM and no past psychiatric history. She developed obsessive thoughts, hallucinations, anorexia, and dysgeusia after undergoing a craniotomy of the right frontotemporal lobe, followed by radiotherapy and chemotherapy for treatment of glioblastoma. Certain symptoms, like anorexia, were initially attributed to chemotherapy but failed to resolve, even when nausea, vomiting, and other chemotherapy-induced symptoms had subsided. The patient was referred for psychiatric, palliative care, and integrative medicine evaluation after the onset of symptoms, and has shown improvement in obsessive thoughts, though certain psychotic features including hallucinations have been difficult to manage, despite antipsychotic treatment. This case highlights the importance of a holistic approach when caring for patients with GBM, and the need for timely recognition of psychiatric disorders in patients following GBM treatment to ensure appropriate treatment and enhanced quality of life.

References

Keng A, Stewart DE, Sheehan KA. Examining the Neuropsychiatric Sequelae Postsurgical Resection of Adult Brain Tumors Through a Scoping Review. Psychosomatics. 2020;61(3):209-219. doi:10.1016/j.psym.2019.12.008.

Regli LKP, Huijs SMH, Pasmans RCOS, et al. Incidence of clinically relevant psychiatric symptoms during glioblastoma treatment: an exploratory study. J Neurooncol. 2023;163(1):185-194. doi:10.1007/s11060-023-04326-2

Ribeiro M, Benadjaoud MA, Moisy L, et al. Symptoms of Depression and Anxiety in Adults with High-Grade Glioma: A Literature Review and Findings in a Group of Patients before Chemoradiotherapy and One Year Later. Cancers (Basel). 2022;14(21):5192. Published 2022 Oct 22. doi:10.3390/cancers14215192

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A Review of Developing TMS Applications in 2024

Rachel M. Treat, MA; Caroline Meuser, BA; Mira Johnson, BA; Bhusan Neupane, MD

The George Washington University School of Medicine and Health Sciences

Category: Research

Background: Since the advent of transcranial magnetic stimulation (TMS) circa 1985, the technique has increasingly been implemented as an intervention for treatment resistant major depressive disorder (MDD) without psychosis. TMS for MDD has proven to be extremely effective, resulting in 33% of patients achieving complete remission. Additionally, 67% of patients sustain their antidepressant response after 3 months and 46% maintain their response 1 year after treatment. Repeated application of TMS can influence brain plasticity and cortical reorganization through stimulation-induced alterations in neuronal excitability with only a minor risk for seizures (1:30,000 in post market research, and this is due primarily to operator error). Given the decades of research and success using TMS for treatment resistant MDD, understanding the potential uses and current landscape of TMS for other neuropsychiatric illnesses is of tantamount importance for the advancement of psychiatric care.

Methods: A literature review was conducted using the PubMed database to access meta analysis and systematic review abstracts published in 2024 describing innovative applications of TMS beyond depression. This review includes information from 23 selected studies that met predetermined inclusion criteria. The articles address TMS as an intervention for the following: bipolar disorder, Alzheimer’s disease, Parkinson’s disease, epilepsy, chronic traumatic brain injury, phantom limb pain, substance use disorder, cerebellar ataxia, schizophrenia, post-stroke rehabilitation, and chronic daily headaches.

Clinical Outcomes: Pathology Sample Size Response to TMS Bipolar disorder 18 studies, N = 617 Improved depression symptoms Alzheimer’s disease 191 studies, N > 7,458 Functional improvement, global cognitive improvement Parkinson’s disease 31 studies, N = 408 Improved balance, mobility, and gait Epilepsy 18 studies, N = 1224 Improved antiepileptics drugs' efficacy and cognitive function Chronic TBI 22 studies, N > 313 Decreased anxiety and headaches, improved function in disorders of consciousness Phantom limb pain 6 studies (2 RCTs, 4 case reports) Decreased perceived pain (analgesia) Substance use disorder 102 studies, N > 253 Reduced cravings Cerebellar ataxia 7 studies (all RCTs) Improved balance with decrease in ataxia Schizophrenia 55 studies, N = 2,712 Improvement in depressive, negative affective symptoms Post-stroke rehabilitation 111 studies, N > 2,735 Improved global cognition, motor function, balance, walking, ADL function, language function Chronic daily headaches 13 studies, N = 538 Decreased intensity and frequency of headaches RCT= randomized controlled trial, TBI = traumatic brain injury

Conclusion: Clinical Impact TMS is a noninvasive neuromodulatory therapy which has been FDA-approved with demonstrated effectiveness for treatment resistant depression without psychosis. TMS offers hope for treatment of a myriad of neuropsychiatric disorders in the future, and it is incumbent upon future clinicians to understand the shortcomings and successes of this technology in the context of its ever-expanding applications.

Keywords: Transcranial magnetic stimulation, neuromodulatory therapy, neuropsychiatric disorders

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Exploring the Association between Depression Severity and Outdoor Exposure

Anh Le; Katrina K Le, MPH

George Washington University School of Medicine and Health Sciences

Category: Public Health

Depression is a prevalent mental health disorder globally, with various factors contributing to its onset and severity. Recent research suggests that environmental factors, particularly outdoor exposure, may play a significant role in influencing depressive symptoms. This study aims to investigate the association between depression severity and outdoor exposure among a diverse population sample. Using a collective American population data from 2017 to March 2020 from the National Health and Nutrition Examination Survey, we have employed standardized measures to assess depression and self-reported outdoor exposure frequency and duration. Both linear and logistic regression models controlled for confounding variables of age, gender/sex, race/ethnicity, income, education, smoking, and occupation. Adjusted regression analyses revealed outdoor exposure outside working hours was associated with PHQ-9 total numerical scores (β = -0.002, p-value = 0.0078) and with depression (OR = 0.993, p-value = 0.0329). Findings from this study supports and contributes to previous literature, shedding light on the role of outdoor exposure in mitigating or exacerbating depressive symptoms. Understanding this association may have implications for informing public health interventions and urban planning strategies aimed at promoting mental well-being. Furthermore, the study may contribute to the growing body of literature on ecotherapy and nature-based interventions for mental health treatment and prevention.

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75th Anniversary Gala Poster Competition

WPS is proud to announce our first ever poster competition to highlight research and case studies completed by our Medical Students, and Resident-Fellow Members!

75th Anniversary Gala
Poster Competition