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Dipeptidyl-peptidase-like protein-6 (DPPX) antibody associated encephalitis, an unusual multifocal neurological disorder that can be severe regarding symptomatology, has been increasingly recognized over the last decade. There have been relatively few cases of anti-DPPX-encephalitis reported in the literature, and there are no studies or case reports reviewing this diagnosis from a psychiatric perspective. We present the case of a patient assessed by the psychiatry consultation service for depressed mood, psychosis and sleep disturbance in the setting of anti-DPPX encephalitis. The aim of this case report is to examine the psychiatric sequelae of anti-DPPX encephalitis as well as current and proposed treatment strategies.

Background Treatment futility and terminality discussions arise rarely in psychiatric practice, frequently instilling apprehension, as there is little written that defines these terms in relation to mental illness. It therefore remains uncertain how to deal with cases that are refractory to multimodal interventions and that demonstrate limited improvement or even a worsening trajectory. Any viable solution needs to respect patient autonomy and maintain both beneficence and nonmaleficence, while taking into account the strained resources of the mental health care system as a whole. Objective This article reviews historical conflicts surrounding the notion of futility in psychiatric disorders, and proposes and elaborates a set of six criteria that psychiatrists can use in working through these difficult cases. Given the potential controversy involving futility in psychiatry, it proves helpful to understand its similarity to the notion of futility in standard medical contexts. This article also works through some of the common concerns or objections regarding the application of futility in psychiatric contexts. Conclusions Futility in psychiatric illness is a concept that the psychiatric community needs to understand and address, given the limited treatment options available to our field, as well as the limitations of health care resources. The proposed framework allows for ethically appropriate treatment decisions for treatment-resistant patients-respecting their individual wishes while ensuring appropriate care.

Background Concurrent liothyronine treatment has been shown to accelerate time to response in patients treated for major depression. However, the relationship between genetic variation in deiodinase and T3 treatment response has received little investigation. Methods This is a post-hoc analysis of a randomized, double-blind, placebo-controlled trial of concurrent liothyronine (T3-Cytomel®, n = 23; mean dose 46.3 ± 3.3 mcg) in patients with major depression where a clinical recommendation was made to pursue ECT. The primary outcome measure was time to 50% reduction in depressive symptoms. Multivariable linear models were used to examine effect of T3 and placebo and genetic variants as predictors of change in HAMD24 and number of ECT treatments. Results Survival analysis did not show a significant effect for the T3 + ECT group achieving a faster time to response compared to placebo + ECT (p + ECT). Survival analysis for RUL lead placement alone showed a significant effect for the T3 + ECT group achieving a faster time to response compared to p + ECT (p = 0.01) with significantly fewer ECT treatments (p = 0.03). Carriers of the functional SNP rs11206244 gene DI01-C785T minor allele (TT and CT) vs. non-carriers (CC), showed fewer ECT treatments in the T3 + ECT group, compared to p + ECT (5.3 ± 1.0 vs. 8.3 ± 2.1, p = 0.045). Conclusions These pilot data identify clinically relevant genetic variation in DI01- C785T contributing to an accelerated response time, but not an overall greater symptom reduction. Exogenous T3 supplementation may be therapeutic by attenuating a baseline DI01 relative functional deficit which functionally reduces peripheral conversion of T4 to biologically active T3. Further work is encouraged to assess genetic variation of thyroid deiodinase enzymes in larger samples of depressed patients to better optimize accelerating strategies to ECT and more broadly, thyroid augmentation strategies in major depressive and bipolar disorders.

Suicide is the leading cause of death worldwide. The cause of suicidal behavior is multifactorial, and there is a deficiency in adequately recognizing the signs of suicide risk in patients, making it hard to predict. A history of prior suicide attempts is the strongest single prognostic factor of future suicide attempts. Other important risk factors include a history of mental disorders, age, sex, gender, race, sense of isolation, occupation, health, and family history as well as genetics. Currently, there is no universally accepted suicide risk assessment tool recognized as superior for use in acute crises. There are several tools that could be helpful in quick assessment of acute crises in emergency room, and it is important for psychiatrists to be aware of them. However, there is no one-size-fits-all intervention from a psychiatric perspective, as suicide is heterogeneous. Stabilizing the underlying psychiatric issue and addressing psychosocial stressors, when possible, are the first steps in the emergency department.

Background: Single infusions of ketamine have been used successfully to achieve improvement in depressed patients. Side effects during the infusions have been common. It is not known whether serial infusions or lower infusion rates result in greater efficacy. Methods: Ten depressed patients were treated with twice weekly ketamine infusions of ketamine 0.5 mg/kg administered over 100 min until either remission was achieved or four infusions were given. Side effects were assessed with the Young Mania Rating Scale (YMRS) and the Brief Psychiatric Rating Scale (BPRS). Patients were followed naturalistically at weekly intervals for four weeks after completion of the infusions. Results: Five of 10 patients achieved remission status. There were no significant increases on the BPRS or YMRS. Two of the remitting patients sustained their improvement throughout the four week follow-up period. Conclusions: Ketamine infusions at a lower rate than previously reported have demonstrated similar efficacy and excellent tolerability and may be more practically available for routine clinical care. Serial ketamine infusions appear to be more effective than a single infusion. Further research to test relapse prevention strategies with continuation ketamine infusions is indicated.

Introduction: Depressive syndromes are common following cerebrovascular accident (CVA) and many patients do not respond to pharmacotherapy. Electroconvulsive therapy (ECT) is a safe and effective treatment for mood disorders arising with many comorbid medical conditions. In this paper, we describe the successful treatment of post-CVA depression with ECT.Methods: Retrospective chart review of 24 patients hospitalised for depression on an in-patient Medical Psychiatry unit between 2000 and 2010. Medical, neurologic and psychiatric histories, physical examination findings, results of laboratory, imaging and neurophysiologic investigations and treatment response with medications and ECT were recorded.Results: Twenty patients (83%) showed a positive response to treatment with ECT. None had worsening of depression after the ECT or experienced exacerbation of post-stroke neurological deficits. Three patients suffered from minor complications of ECT (prolonged confusion or short-term memory problems).Conclusions: This review supports the use of ECT after a stroke with appropriate clinical observation. The treatment was well tolerated and the majority obtained clinical benefit.

Background We aimed to establish a bipolar disorder biobank to serve as a resource for clinical and biomarker studies of disease risk and treatment response. Here, we describe the aims, design, infrastructure, and research uses of the biobank, along with demographics and clinical features of the first participants enrolled. Methods Patients were recruited for the Mayo Clinic Bipolar Biobank beginning in July 2009. The Structured Clinical Interview for DSM-IV was used to confirm bipolar diagnosis. The Bipolar Biobank Clinical Questionnaire and Participant Questionnaire were designed to collect detailed demographic and clinical data, including clinical course of illness measures that would delineate differential phenotypes for subsequent analyses. Blood specimens were obtained from participants, and various aliquots were stored for future research. Results As of September 2014, 1363 participants have been enrolled in the bipolar biobank. Among these first participants, 69.0 % had a diagnosis of bipolar disorder type I. The group was 60.2 % women and predominantly white (90.6 %), with a mean (SD) age of 42.6 (14.9) years. Clinical phenotypes of the group included history of psychosis (42.3 %), suicide attempt (32.5 %), addiction to alcohol (39.1 %), addiction to nicotine (39.8 %), obesity (42.9 %), antidepressant-induced mania (31.7 %), tardive dyskinesia (3.2 %), and history of drug-related serious rash (5.7 %). Conclusions Quantifying phenotypic patterns of illness beyond bipolar subtype can provide more detailed clinical disease characteristics for biomarker research, including genomic-risk studies. Future research can harness clinically useful biomarkers using state-of-the-art research technology to help stage disease burden and better individualize treatment selection for patients with bipolar disorder.

The recent rise in public access to illegitimate online pharmacies providing unrestricted access to psychotropic medications, in combination with the growing availability of substances that can produce legal highs, poses a significant risk to patients. This report describes a case of substance-induced depression and panic attacks associated with illegitimately obtained selegiline used in combination with the health supplement phenylethylamine (PEA).

Linezolid, a novel antimicrobial with activity against gram-positive bacteria including pathogens resistant to traditional antimicrobials, also inhibits monoamine oxidase. This latter property can cause potentially lethal adverse interactions with antidepressant medications. Long known to psychiatrists, monoamine oxidase inhibitors (MAOIs) and complications of their use may be unfamiliar to medical and surgical practitioners who may thus unwittingly precipitate a hypertensive crisis or serotonin syndrome. We review the pharmacology of MAOis and describe 3 clinical situations In which linezolid-selective serotonin inhibitor (SSRI) interactions, actual or potential, figured prominently.

Since its approval in 1985, the implantable cardioverter-defibrillator (ICD) has supplanted antiarrhythmic drugs as the standard of care for patients with potentially lethal ventricular arrhythmias. The increased popularity of ICDs stems primarily from their safety and tolerability compared with commonly used medications notorious for adverse drug reactions. As ICD indications have broadened, the number of implantations has increased substantially, and more attention has been directed to sequelae of implantation, particularly after ICD firing. Although scant, studies of quality of life and psychiatric symptoms in patients with ICDs consistently report assorted psychiatric disturbances affecting up to 87% of recipients. Depression and anxiety predominate: up to 38% of patients experience symptoms that meet diagnostic criteria for an anxiety disorder. Psychological theories such as the classic conditioning model, learned helplessness model, and cognitive appraisal model have been invoked to conceptualize these new-onset ICD-induced anxiety disorders. Small trials of psychosocial interventions, including support groups and cognitive behavioral therapy, have had mixed results. Little is known about preexisting anxiety disorders in ICD recipients, particularly which premorbid features predict a worse prognosis, other than suggestions that younger patients and those receiving multiple shocks are at greater risk. Prospective studies of the psychopathology of patients with ICDs, both before and after implantation, are warranted.

We report the occurrence of unilateral cerebral hemisphere edema with subsequent cortical laminar necrosis in the setting of familial hemiplegic migraine (FHM) and permanent neurologic sequelae after resolution of an attack in 1 patient. Contemporaneous with this severe attack of FHM, the patient was found to exhibit multiple systemic and neurological symptoms referable to Erdheim-Chester disease (a rare non-Langerhans cell histiocytosis) that was confirmed by bone biopsy. This case demonstrates the severity possible with a migrainous infarction associated with FHM. The co-occurrence of two such rare entities in 1 patient suggests a possible relationship.

The authors determined the efficiency of electronic documentation in consultation-liaison psychiatry. An electronic note system was customized for a psychiatric consultation note. Specific attention given to common diagnoses permitted rapid documentation. Residents learned the system quickly. The standardized nature of the system ensured thorough documentation. Notes were immediately available and more legible. A survey indicated that this system was well received and saved time. Among the eight residents who used both handwriting and typing, an estimated average of 17.5 minutes per note was saved by typing. This program had clear benefits in reinforcing more complete documentation.

Anti-NMDA receptor (NMDAR) encephalitis, formally recognized in 2007, has been increasingly identified as a significant cause of autoimmune and paraneoplastic encephalitis. Approximately 80% of the patients are females. The characteristic syndrome evolves in several stages, with approximately 70% of the patients presenting with a prodromal phase of fever, malaise, headache, upper respiratory tract symptoms, nausea, vomiting and diarrhoea. Next, typically within two weeks, patients develop psychiatric symptoms including insomnia, delusions, hyperreligiosity, paranoia, hallucinations, apathy and depression. Catatonic symptoms, seizures, abnormal movements, autonomic instability, memory deficits may also develop during the course of the disease. Presence of antibodies against the GluN1 subunit of the NMDAR in the CSF and serum confirm the diagnosis of NMDAR encephalitis, which also should prompt a thorough search for an underlying tumor. Age, gender, and ethnicity may all play a role, as black females older than 18 years of age have an increased likelihood of an underlying tumor. Treatment is focused on tumor resection and first-line immunotherapy [corticosteroids, plasma exchange, and intravenous immunoglobulin]. In non-responders, second- line immunotherapy [rituximab or cyclophosphamide or combined] is required. More than 75% of the patients recover completely or have mild sequelae, while the remaining patients end up demonstrating persistent severe disability or death. There is a paucity of literature on the management of psychiatric symptoms in this population. Given the neuropsychiatric symptoms in the relatively early phase of the illness, approximately 77 % of the patients are first evaluated by a psychiatrist. Earlier recognition of this illness is of paramount importance as prompt diagnosis and treatment can potentially improve prognosis. We describe two patients diagnosed with NMDAR encephalitis presenting with two different psychiatric manifestations. The first patient presented with psychotic mania and catatonic symptoms, while the second suffered from depression with psychotic and catatonic features refractory to psychotropic medications. We review of the use of psychotropic medications and ECT to address insomnia, agitation, psychosis, mood dysregulation and catatonia in NMDAR encephalitis.

Tacrolimus has been associated with severe neurotoxicity in organ transplant patients. Catatonia can be a rare manifestation of tacrolimus-induced neurotoxicity as we report two cases of catatonia in solid organ transplant patients on tacrolimus. Catatonic symptoms completely resolved in these patients after reducing the tacrolimus dosage or switching it to alternative immunosuppressants. Catatonia symptoms in organ transplant patients should alert clinicians to look for tacrolimus-induced neurotoxicity despite normal serum tacrolimus levels and neuroimaging findings.

During the past 2 years the number of studies examining psychopathology and quality of life after ICD implantation has increased dramatically. Variables assessed have included recipient age, gender, and social support network. How recipients respond to having the device, particularly after experiencing firing, has been evaluated in light of new depression and anxiety disorder diagnoses as well as premorbid personality structure. Now the picture of what is known is, if anything, cloudier than it was 2 years ago, with little definitive and much contradictory data emerging in most of these categories. It still seems clear that in a significant minority of ICD recipients the device negatively affects quality of life, probably more so if it fires. Education about life with the device before receiving it remains paramount. Reports continue to appear of patients developing new-onset diagnosable anxiety disorders such as panic and posttraumatic stress disorder. Until recently the strongest predictors of induced psychopathology were considered to be the frequency and recency of device firing. It now seems that preimplantation psychologic variables such as degree of optimism or pessimism and an anxious personality style may confer an even greater risk than previously thought. Certainly many variables factor into the induction of psychopathology in these patients. Among these factors are age, gender, and perception of control of shocks, as well as the predictability of shocks and psychologic attributions made by the patient regarding the device. Another source of variability is this population's medical heterogeneity. Some patients receive ICDs after near-death experiences; others get them as anticipatory prophylaxis. Some have longstanding and entrenched heart disease; others were apparently healthy before sudden dangerous arrhythmias. Diagnoses as diverse as myocardial infarction in the context of advanced coronary artery disease and dilated cardiomyopathy after acute viral infection may warrant ICD placement. Moreover the course of cardiac disease after ICD placement may vary from relative stability to continuing disease progression and severe functional compromise. Unless these and other pre- and postimplantation differences are taken into account, it is almost impossible to make meaningful comparisons between studies. Ideally, future research would consist either of large-scale, randomized, prospective studies using validated structured-interview tools to supplement a literature dominated by self-report measures, unstructured assessments, and anecdotal reports, or of smaller studies designed to focus on particular diagnostic subsets. As ICDs become the standard of care for potentially life-threatening arrhythmias, the rate of implantations continues to increase. Because negative emotions have been linked to an increased incidence of arrhythmias, and untreated or unrecognized psychiatric illness can interfere with adaptation to an ICD, assessing and managing both pre-existing and induced psychiatric disorders becomes even more critical. Greater research attention should be paid to determining which patients meet criteria for anxiety disorders before and after implantation and what premorbid traits predispose to postimplantation psychopathology. The authors predict that psychiatrists will be involved increasingly in caring for this population, offering insights into treatment options that increase the likelihood of successful ICD acceptance and decrease the psychosocial costs of these devices.

Background: Profoundly depressed states of awareness classified as either catatonia or akinetic mutism have been reported in patients with various general medical conditions including encephalitis, frontal lobe tumors, or paraneoplastic limbic encephalitis. Catatonic features are often difficult to apprise in this context. This can result in electroconvulsive therapy (ECT) discontinuation, although it remains the most effective treatment of catatonia. Case Report: We describe the case of a patient with a history of unresectable right retroorbital squamous cell carcinoma, status poststereotactic radiation and cisplatin, and subsequent pneumococcal meningitis of the temporal lobe with abscess formation who became catatonic after receiving 3 bitemporal treatments with ECT for severe depression and whose catatonia improved with continued ECT. Furthermore, she demonstrated progressive improvement in mood, interactivity, and overall neurologic function after ECT treatment was completed. Conclusions: The search for an etiology of a profound catatonic state should include the probability of underlying medical disorder. Although lorazepam may be helpful in some cases, ECT deserves early consideration in catatonia, especially in cases where the underlying cause seems to be uncertain, even if the catatonia begins in the midst of treatment.

Limbic encephalitis is characterized by the subacute progression of short-term memory loss, disorientation, confusion, and agitation. Hallucinations, behavioral and personality changes, temporolimbic seizures, sleep disturbances, and dysautonomia may also occur. The pyramidal layer of the hippocampus and the amygdaloid nuclei are particularly susceptible and demonstrate neuronal loss, reactive gliosis, and perivascular lymphocytic cuffing. Magnetic resonance imaging (MRI) typically reveals increased signal in limbic structures on T2, fluid-attenuated inversion recovery (FLAIR), and diffusion-weighted imaging (DWI). Historically, limbic encephalitis has been conceptualized as a paraneoplastic process characterized by autoantibodies associated with underlying neoplasms: small cell lung, lymphoma, thymoma, testicular, breast, teratoma, prostate, rectal, retinoblastoma, oligodendroglioma, melanoma, and leiomyosarcoma. Although a definitive pathophysiologic mechanism for autoimmune limbic encephalitis remains unknown, multiple autoantibodies are implicated, including voltage-gated potassium channel complex antibodies (VGKC-complex Ab.) Idiopathic autoimmune limbic encephalitis also occurs. We present the longitudinal course of a man who developed cognitive and behavioral disturbances ultimately attributed to VGKC complex autoimmunity.

Post-stroke depression is a potentially persistent complication of stroke. Electroconvulsive therapy (ECT) is an effective treatment for depression, but with limited data regarding safety in stroke patients. We report the case of a 30-year-old woman with a history of stroke and antiphospholipid syndrome, who became depressed and suicidal. Neurologic and Internal Medicine consults did not reveal any contraindications to ECT, but stroke risk factor management was identified as an important measure for patient safety. The patient tolerated ECT well, reporting improvement of mood and abatement of hopelessness. This case suggests that ECT may be a safe and well-tolerated treatment for post-stroke depression.