1)H&P/Soap Note

H&P:Schizophrenia

2)Summary of Article

The effect of a single dose of intravenous ketamine on suicidal ideation: a systematic review and individual participant data meta-analysis

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5794524/

The present study is a systematic review/meta-analysis, published in 2018 in the American Journal of Psychiatry and currently indexed for Medline. It examined the effects of a single dose of Ketamine on suicidal ideation. Suicide is a public health crisis and the rates of suicide has increased over the last two decades. Studies have shown that approximately 90% of individuals who commit suicide suffer from a treatable psychiatric disorder with the most common being a mood disorder (Major Depression Disorder, Bipolar Disorder).

Treatment options to help reduce suicide deaths, suicide attempts and suicide risk long term include lithium and clozapine, dialectical behavioral therapy (DBT) and cognitive behavioral therapy (CBT). These treatments have not been shown to be effective in acute settings and this highlights the importance of utilizing a fast-acting intervention in acute situations. Ketamine has rapid antidepressant effects, so it has potential in stabilizing patients suffering mood disorders with acute risk of suicide. In this study, active or passive suicidal ideation was assessed via two clinician-administered and two self-reported rating scales:

Clinican-administerd:

1) Montgomery-Asberg Depression Rating Scale (MADRS) item 10;

2) 17-item Hamilton Depression Rating Scale (HAM-D) item 3;

Self-reported rating scales

• Quick Inventory of Depressive Symptomatology-Self Report (QIDS-SR) item 12;
• and/or Beck Depression Inventory (BDI) item 9).

There were (N=167) subjects that met the criteria for baseline suicidal ideation and the treatment assignments for this study were ketamine or control. Data was collected from each investigator for baseline and Days 1, 2, 3, and 7 post-ketamine. The results of the study showed that Ketamine rapidly reduced one day suicidal ideation with moderate to large effect (Cohen’s d=0.51–0.85), more rapidly than was observed in the control group on both the clinician-administered (p<0.001) and self-reported outcome measures (p<0.001). Significant benefits appeared as early as Day 1 and extending up to Day 7. 54.9% of patients were free of suicidal ideation 24 hours after a single ketamine infusion, and 60.0% were free of suicidal ideation at one-week post-ketamine.

These results show promising effects of ketamine on suicidal ideation in acute settings. There are limitations to this study, however. The first is that a relatively small sample size was included in the study which can affect the reliability of the result of this study. Another important limitation is that all of the studies focused on the effects of ketamine on suicidal ideation but not on ketamine’s effect on suicidal behavior. Whether ketamine’s effect on suicidal ideation translate to suicidal behavior is not known in this study and therefore future studies should research the effects of ketamine on actual suicidal behavior.

 

3)Site Evaluation: My Summary

For Psychiatry Rotation evaluation, I had the opportunity to present some cases to my evaluator. This was my favorite case to present between the two.

The first was of a 24-year- old African American male with psychiatric history of Bipolar Disorder. He presented to the psychiatric unit after his brother reported him to NYPD/EMS for bizarre and aggressive behavior towards him. The patient went to his brother’s house and reportedly was banging on the door and demanding for entry to his brother’s apartment, refusing to leave. The patient presented to the psych unit with hypomanic mood, labile affect,  grandiose, disorganized,  and had pressured speech. He stated that he even worked in the psych unit   as a computer analysis, and also stated that he was working on a project to benefit the world. This patient had poor insight into his condition of Bipolar disorder and was non-adherent to his medications which brought upon this current episode.

While writing the H and P, I learned that it is good to paint a good picture of the patient when writing the HPI. It helps the reader to understand more about the patient and their current circumstance. The main focus of the presentation other than the HPI was the mental status exam which is very important in psychiatry. The part I thought was key for this patient was his mood and affect. He definitely had a hypomanic mood and his labile affect. He was agitated and anxious. He also had poor impulse control and judgment since he was compelled to want to get access to his brothers house even though he was not allowed. He also displayed poor insight into his disorder of bipolar due to his non- adhering to his medications.

My evaluator agreed with my differentials which were as follows:

• Acute psychosis: patient has impaired reality for less than 1 month as he has been having grandiose delusions of working on a project to benefit the world, going to his brother’s house to do work he is destined to do and believing he works as a computer analysis at CPEP.
• Schizophreniform/Schizoaffective disorder: the patient exhibited a grandiose delusion “ believing that he has a divine plan to accomplish a goal to benefit the world, plan to his brothers house to do the work he is destined to do, and believing he is a computer analysis for the hospital. PT also presents with hypomania with flight of ideas and thoughts. Duration or past of history of psychosis greater than 6 months is unknown.
• Major Depressive Disorder: the patient exhibits > 5 depression symptoms, which have been present for more than 2 weeks. (hx of depression, suicidal ideation without a plan, angry/irritable mood, labile mood, psychomotor agitation, substance abuse hx -cannabis)

• Borderline Personality Disorder: the patient appears unstable, with unpredictable mood & affect, suicidal and lacks impulse control.

The plan for this patient was to admit him for observation and stabilization, run basic labs and drug screening, continue his psychiatric meds which were Divalproex (Depakote) 500 mg tablet and Risperidone(Risperdal)  3 mg- take 1 tablet by mouth daily. Since this patient was non-adherent to his medication, a good plan for him was to switch his oral medication to long acting anti-injectable Risperdal consta 50 mg IM, and he could then follow up with his psychiatrist for the injections.

I enjoyed presenting this case. I got to explain each part of the mental status exam and also his plan.  In psychiatry, you really get to understand your patient’s story and past psychiatry history and how they are related. This made presenting the case more interesting for me since I felt it was like story telling.

 

4)Typhon Report

Psychiatry 08.24-09.18pdf

 

5)Rotation Reflection

I had the opportunity to complete my Psychiatry Rotation and Queens Hospital Center Comprehensive Psychiatric Emergency Services Program also known as “CPEP.” The opportunity to be in this environment, thanks to my preceptor Amil, with this level of psychiatric patients I must say was an eye-opening experience. From the patients I saw or spoke to, I realize there is a thin line between good and poor mental health. As one of the providers mentioned to my group at the start of the rotation, a person could be mentally and physically healthy but then gets into a car accident and suffers a severe head injury which then could cause the person to develop a mental health condition. That resonated with me and set the foundation for the rotation for me, to be able to listen to some of the stories of the patients I encountered in CPEP.

Exposure to new techniques or treatment strategies – how did that go?

There were 2 new techniques I learned in this rotation. The first dealt with how to write the H&P for this rotation. For the history of present illness, the format was different than what I was accustomed to from previous rotations. I liked the HPI for psych patients because it is more of a story that includes the patients past psychiatric history, current problem, and important information form the patient previous psych visits. The patients were usually referred from the ER so once they were admitted into CPEP unit, the HPI continues from this point to include the patient’s appearance, mood and affect, behavior, and reasons for admitting into the psychiatric unit. It was always important to note whether the patient had an auditory or visual hallucination, any suicidal or homicidal ideations w/without a plan and any feelings of depression.

The second technique I got to learn more about was the mental status exam.  This included the patient’s appearance, behavior, attitude, sensorium and cognition, mood and affect, motor, reasoning and control.  I didn’t realize how much you could assess about a patient’s mental health, background and personality just from the mental exam. The patient’s appearance, psychomotor activity, eye contact, alertness and mental status can help you understand more about the patient and their background.

What was a memorable patient or experience that I’ll carry with me?

This rotation was very eye opening for me. I realized more about how a patient past life experiences really can affect their future mental health.  I remember interviewing a 58 yo African American Female who was living in supportive housing and had a past psychiatric history of  Bipolar 1 Disorder, depression, cocaine and cannabis use. She was brought in by EMS picked up from the streets because she was hearing voices telling her to kill herself. As I spoke to her more, I learned about her recent stressors.  She was going through stages of grief and is mourning her father who recently passed away from COVID on April 16, 2020 and mother who passed away from COVID alittle earlier. She also talked to me more about her past. When asked about her depression, she said that some of it comes from her past experiences in the streets, doing drugs and dancing in clubs when she was younger. She said that doing cocaine and cannabis made her feel good and helped her feel good and not think about her problems. I went over a suicide relapse plan with her and she informed me that she gets more stressed out when she visits her old neighborhood and old friends there which reminds her of her troubled past. Her experiences made me understand more about her and how strong she was to continue to keep progressing in life while battling suicidal ideations, Bipolar disorder and living in supportive housing.

How your perspective may have changed as a result of this rotation?

I learned more about how important it is to treat patients with mental health problems or poor circumstances with respect and care as you may never know what someone is going through unless they are courageous enough to share their experiences. Seeing the extremes of poor mental health made understand how important it is to take care of my own mental health. As clinicians, we often will be put in the position of encouraging healthy lifestyle behaviors like eating healthy and exercising but I know for myself I have not always been able to practice these recommendations myself. This is something I will like to improve on for myself.