Psychiatric Consultations and Ethics Consultations

Psychosomatics 2013:54:502–507

© 2013 The Academy of Psychosomatic Medicine. Published by Elsevier Inc. All rights reserved.

Letters to the Editor

Consideration of the JT interval rather than the QT interval TO THE EDITOR: In the comprehensive review of QTc prolongation by Beach et al,1 one crucial consideration was left unmentioned: the validity of the QTc interval in patients with ventricular conduction defects (VCD). In patients with complete bundle branch block, the subsequent widening of the QRS complex artificially elongates the QT interval without necessarily representing an increase in myocardial repolarization time. The JT interval, rather than the QT interval, should be used as a more accurate measurement of repolarization time in the setting of complete bundle branch block. Zhou et al.2 found that the elongated QRS complex in the setting of complete bundle branch block can increase the QT interval by as much as 16%, whereas the widened QRS complex has no effect on the measurement of the JT interval. Moreover, although Zhou et al.2 conclude that the JT and QT intervals are of equivalent efficacy for measuring repolarization time in incomplete bundle branch block, the authors determine that the JT interval is the superior measurement in this setting because of the increased difficulty of calculating the QT interval in patients with incomplete bundle branch block. They propose the following simple equation for calculating the JT prolongation index (JTI): JTI ⫽ JT(HR ⫹ 100)/518, where JT ⱖ112 ms is considered to be prolonged. In conclusion, we suggest considering using the JT interval instead of the QT interval for any patient with VCD. Given the abundance of elderly psychiatric patients, a population in 502

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which the prevalence of cardiac abnormalities is quite high, and the occasional necessity of treating such patients with medications that may prolong the QT interval, the inadequacy of the QT interval to measure increased repolarization time in patients with VCD is of critical importance. The consideration of using the JT interval is a valuable addendum to Beach’s insightful article. Jonathan Salik Third year medical student Columbia University College of Physicians and Surgeons Philip R. Muskin, M.D. Professor of Clinical Psychiatry Columbia University College of Physicians and Surgeons

References

1. Beach SR, Celano CM, Noseworthy PA, et al: QTc Prolongation, Torsades de Pointes, and Psychotropic Medications. Psychosomatics 2013; 54:1–13 2. Zhou SH, Wong S, Rautaharju PM, et al: Should the JT rather than the QT be used to detect prolongation of ventricular Repolarization? An assessment in normal conduction and in ventricular conduction defects. J Electrocardiol 1992; 25(Suppl): 131–136

Psychiatric Consultations and Ethics Consultations TO THE EDITOR: Beyond Capacity: Identifying Ethical Dilemmas Underlying Capacity Evaluation Requests,1 in the March-April issue, provides a useful reminder about 2 important matters regarding requests for psychiatric consultations to evaluate decision-making capacity. First, the number of such requests significantly exceeds the number of cases in which capacity is the

real issue, and in which the determination of capacity cannot be made readily by the physician requesting the consult; and, second, these requests often mask ethical and other clinical issues.1 These 2 matters are distinct. The excessive number of requests to evaluate capacity is only partly explained by the masking of other issues. In some cases, institutional culture may inappropriately shift the primary responsibility for assessing capacity from attending physicians to psychiatric consultants. In one reported instance, hospital policy actually mandated psychiatric consultation “when it is felt that [patients] cannot understand the meaning of the consent.”2 This policy ultimately was recognized as a mistake, and it was revoked, to the betterment of all concerned. Even more important, the masking of ethical issues by requests for capacity assessment is a special case of a more general phenomenon, the masking of ethical issues by requests for a variety of different kinds of psychiatric consultation. Perl and Shelp3 reported 3 such cases, only one of which was for capacity assessment. Although the others were for “depression” and for unspecified distress, all 3 masked “conflicting notions of what action was morally required” when the patient disagreed with the doctor’s recommendation about the treatment to be pursued. Interestingly, as ethics consultation programs in hospitals have proliferated, the reverse phenomenon also has been occurring, the masking of psychiatric issues by requests for ethics consultation. I have reported a case in which an ethics consultation was requested for assistance in how to re-

Psychosomatics 54:5, September-October 2013

Letters to the Editor spond to a patient’s confrontational behavior, without addressing the diagnosis or treatment of possible mental illness; another in which the patient died of respiratory failure after his treatment was stopped when he persuaded his wife that he was suffering too much to go on, and his depression was left untreated; and a third in which the communication problems between the physician and the mother of a child who was dying from leukemia prevented agreement on a reasonable plan of treatment.4 Sometimes expertise in both psychiatry and ethics is required.5 Clinical care can be enhanced when both psychiatrists and ethicists are attuned to the relevance and importance of each other’s expertise, and when hospital administrators are sensitive to the value and limitations of both. Disclosure: The authors disclosed no proprietary or commercial interest in any product mentioned or concept discussed in this article. Cavin Leeman, M.D. Department of Psychiatry, SUNY Downstate Medical Center, NY

References

1. Kontos N, Freudenreich O, Querques J: Beyond capacity: identifying ethical dilemmas underlying capacity evaluation requests. Psychosomatics 2013; 54:102–110 2. McKegney FP, Schwartz BJ, O’Dowd MA: Reducing unnecessary psychiatric consultations for informed consent by liaison with administration. Gen Hosp Psychiatry 1992; 14:15–19 3. Perl M, Shelp EE: Psychiatric consultation masking moral dilemmas in medicine. N Eng J Med 1982; 307:618 – 621 4. Leeman CP: Ethics consultation masking psychiatric issues in medicine. Arch Intern Med 1995; 155:1715–1717 5. Leeman CP: Psychiatric consultations and ethics consultations: similarities and differences. Gen Hosp Psychiatry 2000; 22:270 –275

Flunarizine- and TopiramateAssociated Depression Responsive to Mirtazapine TO THE EDITOR: We report a case of flunarizine- and topiramate-associated depression in a complex neurological patient. Mirtazapine therapy facilitated the patient being able to continue flunarizine and topiramate. Case Report Mrs. C, a 54-year-old, had no psychiatric history until her early 40s, when she underwent unsuccessful in-vitro fertilization (IVF). In that context, she developed an episode of major depression, treated with escitalopram 20 mg/d. Her episode resolved and she continued escitalopram, which was maintained during her perimenopausal years. At age 50 years, she developed a complex seizure and hemiplegic migraine disorder. This required various medications with incomplete relief. At age 54 years, she had a hospitalization for IV valproate and initiation of oral flunarizine 5 mg daily and topiramate 100 mg bid. Her migraine symptoms were thereafter wellcontrolled. Two months later, Mrs. C developed a recurrence of depression (despite continued escitalopram), including depressed mood, decreased sleep, decreased appetite with 15-pound weight loss, decreased concentration, poor memory, ruminations of “being too much trouble” to her family, and suicidal ideation with a plan to overdose, which precipitated a brief psychiatric admission. Mirtazapine 15 mg qhs was started and escitalopram was tapered to 10 mg daily, and her mood symptoms improved. During the admission, a neurologist recommended discontinuing flunarizine (out of concern for its association with the depressive episode) while continuing topiramate.

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However, her migraine symptoms recurred and she restarted flunarizine 4 days later, with subsequent control of her migraine symptoms. Her mood continued to be improved on her new medication regimen and she had no further suicidal ideation. On post-discharge follow-up at 1 week and, subsequently, at 1 month, Mrs. C’s mood continued to improve, while sleep, appetite, and energy normalized. Escitalopram was discontinued and mirtazapine was continued. Under direction of her neurologist, flunarizine and topiramate were continued with close monitoring of symptoms. Discussion Mrs. C had a history of depression, which was responsive to a selective serotonin reuptake inhibitor (SSRI). She developed a recurrence of depression years later when treated with flunarizine and topiramate for her complex migraines. With the development of the second depression episode, flunarizine was initially held and topiramate continued, but prompt recurrence of migraine symptoms led to resumption of flunarizine. Her response to mirtazapine (while tapering escitalopram) facilitated her restart of flunarizine without recurrence of mood symptoms. It would be expected that indefinite treatment with mirtazapine concurrent with topiramate and flunarizine would be recommended. A bidirectional relationship between depression and migraine has been described, suggesting a common biological substrate.1,2 Flunarizine, a calcium-channel antagonist, is among the medication choices for complex migraine. However, flunarizine has been associated with depression and extrapyramidal symptoms.1,2 The risk of flunarizine-associated depression has been estimated as approximately www.psychosomaticsjournal.org

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