SOURCE: American Academy of Neurology
September 24, 2014

New research suggests that people without dementia who begin reporting memory issues may be more likely to develop dementia later, even if they have no clinical signs of the disease.

“What’s notable about our study is the time it took for this transition to dementia or clinical impairment to occur -- about 12 years for dementia and 9 years for clinical impairment -- after the memory complaints began,” said Richard J. Kryscio, PhD, University of Kentucky, Lexington, Kentucky. “These findings suggest that there may be a window for intervention before a diagnosable problem shows up.”

For the study, published in the online edition of the journal Neurology, 531 people with a mean age of 73 years and free of dementia were asked yearly if they noticed any changes in their memory. They were also given annual memory and thinking tests for an average of 10 years. After death, 243 of the participants’ brains were examined for evidence of Alzheimer’s disease.

Of the participants, 56% reported changes in their memory, at an average age of 82 years. The study found that people who reported memory complaints were nearly 3 times more likely to develop memory and thinking problems. About 1 in 6 participants developed dementia during the study, and 80% of those first reported memory changes.

“Our study adds strong evidence to the idea that memory complaints are common among older adults and are sometimes indicators of future memory and thinking problems,” said Dr. Kryscio. “Doctors should not minimise these complaints and should take them seriously. However, memory complaints are not a cause for immediate alarm since impairment could be many years away. Unfortunately, we do not yet have preventive therapies for Alzheimer’s disease and other illnesses that cause memory problems.”

I've been practicing as a psychiatric nurse practitioner just long enough to understand why people become jaded, but not so long as to give in to that tendency. 

Working in any field where you help others in need on a daily basis can be draining. You not only share your time and expertise, but you also potentially offer up your own emotional resources - hope, optimism, compassion, motivation, etc... 

In my time as an APRN, I have learned that my emotional reserves are not limitless or even quick to renew. There are days I leave work drained with little motivation to accomplish anything more and I 'tune-out' on my own life until I get the chance to sleep. What drains my reserves the quickest is not what I assumed it would be. I expected that my clients' difficult stories and their consequent suffering would have me fatigued, but that isn't the case. 

Instead, I find myself feeling tapped with a host of other events, such as (but not limited to): 

• A message with a vague complaint that makes me feel as though I've failed the client somehow or fills me with anticipatory dread about not having the right answer at the right time
  
• Deciding when to prescribe (and withhold) controlled substances 
• Determining that a client's symptoms are primarily characterological and medications have reached their maximum effectiveness

In the beginning, I could rely on my successes at work to replenish my emotional reserves, but as I have progressed this has become less the case. I'm finding that positive patient outcomes have become the new "normal" and are quickly dismissed by my overachieving brain to focus on more problematic matters. 

Efficient? Yes.  Fulfilling? No.

So... where do I go from here? How do I learn to appreciate the little victories again? I haven't quite figured that out, but I have a sneaking suspicion that it starts with mindfulness. 

I know I need to do something. I know that being fully present as a provider is important to me and leads to a better rapport with my clients. I also know that pulling away from genuine empathy and compassion will lead to a cold demeanor and robotic-like care. 

So the task ahead... find out what nurtures my emotional reserves and brings a sense of fulfillment to my life. Easier said than done, I think.

Here, watch this video to feel some warm and fuzzies 

SOURCE: MGH Center For Women's Mental Health
October 27, 2014 | Ruta Nonacs, MD PhD

Augmentation strategies can be used to optimize response in patients with major depressive disorder (MDD) who have not responded adequately to antidepressant monotherapy; however, we have no data on the use of adjunctive treatments in women with postpartum depression (PPD).   A recent study tested the effectiveness of antidepressant augmentation with aripiprazole (Abilify) in a cohort of 10 women with onset of a depression within 3 months of the birth of a healthy, close-to-term baby.

The open-label study included 10 women who had failed to respond adequately to treatment with antidepressant.   Aripiprazole was added to the antidepressant at 2 mg/day at the second visit and increased weekly in 1- to 2-mg increments as needed to a maximum of 10 mg/day.

Eight of ten women completed the trial.  Six of the women (75%) experienced remission, defined as a MADRS score of less than 10.  Seven of the women (88 %) showed a positive response, defined as having 50% or greater reduction in MADRS score.  Aripiprazole was well tolerated; patients reported mild side effects such as sleeplessness (n=3), headaches (n=2), and nausea (n=2). There were no switches to hypomania or mania during treatment with aripiprazole.  All participants remaining in the study at week 8 were receiving a dose of 2 mg aripiprazole at their final visit.

While this is a very small study and needs to be replicated in a larger sample, the results are promising.  The response and remission rates observed in this study were higher than those observed in open-label studies of antidepressants for PPD.  In addition, the women responded to low doses of aripiprazole and experienced no serious side effects.

Sharma V, Sommerdyk C, Xie B.  Aripiprazole augmentation of antidepressants for postpartum depression: a preliminary report.  Arch Womens Ment Health. 2014 Sep 17. [Epub ahead of print]

SOURCE: Reuters  
Anne Harding

Well conditioned muscles make it easier for the body to purge a harmful protein associated with depression, a new study in mice suggests.

“If you consistently exercise and your muscle is conditioned and adapted to physical exercise, then you acquire the ability to express this class of enzymes that have the ability to detoxify something that accumulates during stress and that will be harmful for you,” senior study author Dr. Jorge Ruas of the Karolinska Institutet in Stockholm said in a telephone interview with Reuters Health.

The body metabolizes this substance, kynurenine, from tryptophan, a process that is activated by stress and by inflammatory factors, Dr. Ruas and his team explain in their report, published in Cell. Studies have linked high levels of kynurenine - which readily crosses the blood-brain barrier - to depression, suicide and schizophrenia.

Their new study was done in skeletal muscle-PGC-1alpha1 transgenic mice, which were genetically modified to express high levels of this protein in their muscles, mimicking the effects of aerobic muscle conditioning. The researchers subjected these mice, as well as a control group of wild-type mice, to five weeks of mild stress. The normal mice developed signs of depression, but the PGC-1alpha1 mice didn’t.

In addition to higher levels of kynurenine in their blood, the transgenic mice also had higher levels of KAT enzymes, which convert kynurenine into kynurenic acid, a more easily mebabolized form that can’t cross the blood-brain barrier.

When the researchers directly administered kynurenine to the PGC-1alpha1 mice, their blood levels of the substance did not increase, because the KAT enzymes were able to break it down so quickly. However, giving kynurenine to the wild-type mice increased their blood levels of the chemical, and also caused depressive symptoms.

To ensure that the findings in mice would apply to people, the researchers recruited a group of adult volunteers to participate in three weeks of moderate exercise. At the end of the exercise program, the volunteers had more PGC-1alpha1 and KAT enzymes in their muscle.

Dr. Ruas and his colleagues are now planning a study in people with depression who have been prescribed physical exercise as therapy. The study would investigate how much patients actually exercised, whether the physical activity was helpful in treating their depression, and also the correlation among exercise, depression and kynurenine levels.

Clinicians can use the findings to help their patients understand why physical activity can fight off depression, Dr. Ruas said, which may improve their compliance with exercise recommendations.

SOURCE: MPR
March 9, 2015

The Food and Drug Administration (FDA) has announced that the labeling for varenicline (Chantix; Pfizer) has been updated to include information on changes to alcohol tolerance and risk of seizures associated with use of the drug. Varenicline is approved as a smoking cessation aid in adults over the age of 18.

The updated Warning and Precautions section of the label is based on a case series submitted by Pfizer and cases in the FDA Adverse Event Reporting System (FAERS) database, which describe patients who consumed alcohol during varenicline treatment and experienced adverse reactions including decreased tolerance to alcohol, unusual or aggressive behavior, or no memory of past events. 

A review of FAERS and the medical literature also identified cases of seizures with varenicline treatment in patients with no history of seizures or a seizure disorder that had been well-controlled. These seizures occurred within the first month of varenicline therapy in most cases.

The labeling will also include information on several studies investigating the risk of neuropsychiatric side effects on mood, behavior, or thinking occurring with varenicline. While these studies did not show an increased risk of neuropsychiatric side effects with varenicline, they did not examine all types of neuropsychiatric side effects and had limitations that prevented the FDA from drawing reliable conclusions. Pfizer is currently conducting a large clinical safety trial to investigate the risk and the study results are expected in late 2015.