Moral injury (MI) involves distress over having transgressed or violated core moral boundaries, accompanied by feelings of guilt, shame, self-condemnation, loss of trust, loss of meaning, and ...spiritual struggles. MI is often found in Veterans and Active Duty Military personnel with posttraumatic stress disorder (PTSD). MI is widespread among those with PTSD symptoms, adversely affects mental health, and may increase risk of suicide; however, MI is often ignored and neglected by mental health professionals who focus their attention on PTSD only.
A review of the literature between 1980 and 2018 conducted in 2018 is presented here to identify scales used to assess MI. Databases used in this review were PsychInfo, PubMed (Medline), and Google Scholar. Search terms were "moral injury," "measuring," "screening," "Veterans," and "Active Duty Military." Inclusion criteria were quantitative measurement of MI and health outcomes, Veteran or Active Duty Military status, and peer-review publication. Excluded were literature reviews, dissertations, book chapters, case reports, and qualitative studies.
Of the 730 studies identified, most did not meet eligibility criteria, leaving 118 full text articles that were reviewed, of which 42 did not meet eligibility criteria. Of the remaining 76 studies, 34 were duplicates leaving 42 studies, most published in 2013 or later. Of 22 studies that assessed MI, five used scales assessing multiple dimensions, and 17 assessed only one or two aspects (e.g., guilt, shame, or forgiveness). The remaining 20 studies used one of the scales reported in the first 22. Of the five scales assessing multiple dimensions of MI, two assess both morally injurious events and symptoms and the remaining three assess symptoms only. All studies were cross-sectional, except three that tested interventions.
MI in the military setting is widespread and associated with PTSD symptom severity, anxiety, depression, and risk of suicide in current or former military personnel. Numerous measures exist to assess various dimensions of MI, including five multidimensional scales, although future research is needed to identify cutoff scores and clinically significant change scores. Three multidimensional measures assess MI symptoms alone (not events) and may be useful for determining if treatments directed at MI may both reduce symptoms and impact other mental health outcomes including PTSD.
Objective
To review the published literature on the efficacy of ketamine for the treatment of suicidal ideation (SI).
Methods
The PubMed and Cochrane databases were searched up to January 2015 for ...clinical trials and case reports describing therapeutic ketamine administration to patients presenting with SI/suicidality. Searches were also conducted for relevant background material regarding the pharmacological function of ketamine.
Results
Nine publications (six studies and three case reports) met the search criteria for assessing SI after administration of subanesthetic ketamine. There were no studies examining the effect on suicide attempts or death by suicide. Each study demonstrated a rapid and clinically significant reduction in SI, with results similar to previously described data on ketamine and treatment-resistant depression. A total of 137 patients with SI have been reported in the literature as receiving therapeutic ketamine. Seven studies delivered a dose of 0.5 mg/kg intravenously over 40 min, while one study administered a 0.2 mg/kg intravenous bolus and another study administered a liquid suspension. The earliest significant results were seen after 40 min, and the longest results were observed up to 10 days postinfusion.
Conclusion
Consistent with clinical research on ketamine as a rapid and effective treatment for depression, ketamine has shown early preliminary evidence of a reduction in depressive symptoms, as well as reducing SI, with minimal short-term side effects. Additional studies are needed to further investigate its mechanism of action, long-term outcomes, and long-term adverse effects (including abuse) and benefits. In addition, ketamine could potentially be used as a prototype for further development of rapid-acting antisuicidal medication with a practical route of administration and the most favorable risk/benefit ratio.
•Psychosis has a huge impact globally in regards to both quality of life as well as healthcare costs.•Several risk factors have already been identified, including substance use, paternal age, and ...trauma history.•This literature review examined epigenetic effects on first-episode psychosis.•Seventeen studies were included in this literature review and several epigenetic alternations were found. Many reviewed studies looked at alterations in the LINE-1 portion of the genome; however, the results were not consistent. Therefore, more research is needed in this area to clarify changes and then be able to translate this data in a clinically practical manner.
Schizophrenia has a large disease burden globally. Early intervention in psychosis, and therefore a decreased duration of untreated psychosis, has a positive clinical impact. There are several recognized risk factors for psychosis, including trauma history and substance use. This systematic review examined the literature for studies related to epigenetic changes in first-episode psychosis, with the goal of identifying future research directions.
A literature review was conducted from inception to October 3, 2021 using MedLine/PubMed, Web of Science, and PsycInfo searches with the keywords ("first-episode schizophrenia" OR "first-episode psychosis" OR "drug-naive schizophrenia" OR "drug-naive psychosis") AND (epigenetic OR methylation OR hydroxymethylation OR "histone modification" OR "miRNA") as well as a search of the bibliography of the identified papers.
Seventeen studies that examined various portions of the genome were included in this systematic review. There were two studies that showed hypomethylation at the LINE-1 portion of the genome and two that showed hypermethylation at LINE-1. Additionally, two studies showed hypomethylation specifically at the GRIN2B promoter (part of LINE-1).
Although sample sizes were small, these studies provide evidence for epigenetic alterations in early psychosis. Further research in this area is warranted for more definitive epigenetic correlations.
Psychological trauma is unique in that it is an environmental event that could induce biological changes and post-traumatic stress disorder (PTSD), depression, or other mood disorders in some ...patients. On the other hand, there may be no psychopathology (in most cases), or even sometimes post-traumatic growth and resilience. According to the DSM-5, trauma is a prerequisite for PTSD and traumatic stress disorder, but not for depressive episodes or mood disorders, or other psychiatric conditions. This paper brings attention to the preliminary literature on transgenerational inheritance due to trauma exposure and its societal and cultural implications. There is accumulating evidence that exposure to trauma can be passed transgenerationally through epigenetic inheritance leading to changes in gene expression and possible disorders or resilience. The effects of resilience from transgenerational inheritance have not been studied, but should be, for a full understanding not only of the disease risk across generations, but also of its social and cultural implications. The epigenetic pathologic effects across generations also need further studies, as the current research is preliminary; larger replications are needed for definitive and more complete understanding. I present here a glimpse of where we are, a vision of where we should go in terms of future research direction for disease risk transmission, and recommend studies of resilience and post-traumatic growth across generations, as well as other studies related to the societal implications at the population level.
Current pulse amplitude used in clinical ECT may be higher than needed. Reducing pulse amplitude may improve focality of the electric field and thus cognitive adverse effects. Here we examine the ...feasibility, safety, and whether Low Pulse Amplitude Seizure Therapy (LAP-ST, 0.5–0.6A) minimizes cognitive adverse effects while retaining efficacy.
Patients with treatment-resistant primary mood (depressive episodes) or psychotic disorders who were clinically indicated to undergo ECT were offered to be enrolled in an open-label study. The study consisted of a full acute course of LAP-ST under standard anesthesia and muscle relaxation. The primary outcome was feasibility of seizure induction. Clinical outcome measures were: time to reorientation (TRO), Mini Mental State Examination, Montgomery Aberg Depression Scale, and Brief Psychiatric Rating Scale, and Clinical Global Impression Scale.
Twenty-two patients consented for enrollment in the study. LAP-ST was feasible, and all patients had seizures in the first session. Participants had a quick orientation with median TRO of 4.5min. Treatment was efficacious for both depressive and psychotic symptoms.
Relatively small sample size, non-blinded, and no randomization was performed in this initial proof of concept study.
This first human preliminary data of a full course of focal LAP-ST demonstrates that seizure induction is feasible. These results, although preliminary, suggest that the LAP-ST compared to the standard ECT techniques may result in less cognitive side effects, but comparable efficacy. Larger studies are needed to replicate these findings.
•This first human preliminary data of a full course of LAP-ST was feasible with no serious adverse effects.•All patients had seizure in the first session of LAP-ST.•LAP-ST had favorable reorientation time & cognitive profile, suggesting less cognitive adverse effects then standard ECT.•Treatment seems to be efficacious for both depressive and psychotic symptoms.•Larger studies are needed to replicate these findings.
•There exists a higher prevalence of suicidal ideations and attempts in adolescent inpatients for unipolar versus bipolar depression.•Females have higher odds for suicidal attempt but lower odds for ...suicidal ideations compared to males in hospitalized settings.•After controlling for demographics and psychiatric comorbidities, unipolar depression increases the likelihood of suicidal ideations by 18% compared to bipolar depression.
Objective To evaluate the risk of suicidal ideation and suicidal attempt in adolescents with unipolar depression (UD) versus bipolar depression (BD).
Method We included 131,740 adolescents (12-17y), with primary diagnoses of UD (92.6%) and BD (7.4%) from the nationwide inpatient sample. We calculated odds ratio (OR) for suicidal behaviors using logistic regression adjusted for demographic confounders and comorbidities.
Results Suicidal ideation and suicidal attempt were seen in 14.5% and 38.6% respectively of total inpatients and both were seen in higher proportion of UD. Females have higher odds for suicidal attempt (OR 1.13, 95%CI 1.09–1.16) compared to males. After adjusting for confounders, UD had a marginally higher odds (OR 1.06, 95%CI 1.02–1.11) of suicidal attempt and 1.2 times higher odds (95%CI 1.11–1.26) of suicidal ideation compared to BD. Among adolescents with suicidal attempt, 93.2% had bipolar depression and 6.8% had unipolar depression.The majority of suicidal attempt in the inpatient setting was seen in females, with bipolar depression (74.6% vs. 67.3% in unipolar).
Conclusion Our finding is clinically relevant and accentuates the need for early identification of BD, accurate differentiation of UD versus BD for targeted and adequate treatment to minimize suicidal behaviors, treat and manage them per treatment guidelines, and evolving research.
Lithium is a helpful adjunct to patients undergoing ECT. However, only case reports and limited data suggest increase risk of delirium. Thus, this continues to be a controversial issue.
In this ...study, we examine 1) The association and odds of delirium and cognitive problems with ECT and lithium (ECT + Li) combination compared to ECT alone, 2) If positively associated, would this association vary by both type of mood episode and type of disorder?
A national sample of 64,728 adult psychiatric inpatients across the US (identified from a total data of about 70 million total discharges annually) was analyzed using linear-by-linear association and logistic regression to assess the odds ratio (OR) for delirium and cognitive impairment for those treated with lithium (N = 158), ECT (N = 64148), or ECT + Li (N = 422) after adjusting for demographics and psychiatric diagnoses.
The prevalence of delirium was higher in the ECT + Lithium group (5.7%) vs. ECT only (0.6%) or lithium only groups (0%). Patients managed with ECT + Lithium have 11.7-fold higher odds (95% CI 7.55–17.99, P < 0.001) of delirium compared to ECT alone. In the ECT + Li group, delirium prevalence was 7.8% in unipolar depression, 3.4% in bipolar depressed, 0% in bipolar mania.
These results are surprising given the fading concern about delirium association with ECT + lithium combination. The high odds in the combination group warrant clinical caution, use of lower lithium doses (if combinations cannot be avoided), and vigilance regarding early signs of delirium. These results warrant replication in future studies.
•ECT + lithium is associated with 12-fold higher odds of delirium compared to ECT alone.•Delirium is much higher in depressive episodes of mood disorders than manic episodes.•The odd for cognitive impairment is 542% higher for ECT + lithium compared to ECT only.•Thus, it is crucial to assess the cost-benefit ratio in the combination group.•Avoidance of lithium during acute ECT course should be highly considered, if possible.
The authors sought to determine whether targeted treatment of insomnia with controlled-release zolpidem (zolpidem-CR) in suicidal adults with insomnia would provide a reduction in suicidal ideation ...superior to placebo.
Reducing Suicidal Ideation Through Insomnia Treatment was an 8-week three-site double-blind placebo-controlled parallel-group randomized controlled trial of zolpidem-CR hypnotic therapy compared with placebo, in conjunction with an open-label selective serotonin reuptake inhibitor. Participants were medication-free 18- to 65-year-olds with major depressive disorder, insomnia, and suicidal ideation. Suicidal ideation was the main outcome, measured first by the Scale for Suicide Ideation and second by the Columbia-Suicide Severity Rating Scale (C-SSRS).
A total of 103 participants were randomly assigned to receive zolpidem-CR (N=51) or placebo (N=52) (64 women and 39 men; mean age=40.5 years). Zolpidem-CR had a robust anti-insomnia effect, especially in patients with the most severe insomnia symptoms. No significant treatment effect was observed on the Scale for Suicide Ideation (least squares mean estimate=-0.56, SE=0.83, 95% CI=-2.19, 1.08), but the reduction in scores was significantly positively related to improvement in insomnia after accounting for the effect of other depression symptoms. The C-SSRS indicated that zolpidem-CR had a significant treatment effect (least squares mean estimate=-0.26, SE=0.12, 95% CI=-0.50, -0.02). The advantage for zolpidem-CR in reducing suicidal ideation on the C-SSRS was greater in patients with more severe insomnia. No deaths or suicide attempts occurred.
Although the results do not support the routine prescription of hypnotic medication for mitigating suicidal ideation in all depressed outpatients with insomnia, they suggest that coprescription of a hypnotic during initiation of an antidepressant may be beneficial in suicidal outpatients, especially in patients with severe insomnia.
Posttraumatic stress disorder (PTSD) is not recognized as an indication for electroconvulsive therapy (ECT). However, research indicates promise for this treatment modality. To elucidate the effects ...of ECT for treating PTSD, prospective research is needed. The first step in assessing the feasibility of such research is to determine if many patients being treated with ECT have comorbid PTSD. This study examined the PTSD comorbidity rates and compared demographic data among patients with major depressive disorder (MDD) who were treated with ECT vs patients with MDD who were not treated with ECT.
Data from patients with MDD were obtained from the Nationwide Inpatient Sample.
Approximately 10% of patients undergoing ECT for MDD also had PTSD. The difference in comorbidity of PTSD in those treated with ECT vs those not treated with ECT was approximately 1%.
Prospective naturalistic studies that examine the response of PTSD to ECT are feasible because a sizable number of patients with PTSD are receiving ECT.
•Clinicians lack reliable biomarkers predictive of response to electroconvulsive therapy (ECT) in treating patients with mood disorders, likely due to a complex pathophysiology with close interplay ...between environmental insults and genetics.•Epigenetics, the study of heritable genetic modifications that do not affect gene sequence, provides a promising link between environment and genes. Initial limited studies show potential for use as a treatment response biomarker in ECT.•The use of precision medicine via epigenetic predictors will save time, frustration, and money for both clinicians and patients.
While electroconvulsive therapy (ECT) is the gold standard for the treatment of depression, there is currently a lack of clinically useful biomarkers predictive of treatment response. Epigenetics provides reasonable potential as a biomarker for treatment response for ECT, given that the study of epigenetics combines both the impact of biology and environment in the shaping of psychopathology. Initial limited studies are promising. Further studies to establish precision medicine in term of ECT treatment response using epigenetics predictors can provide great benefit to both patients and physicians in saving time, money, and frustration.
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