The biochemical processes involved in depression go beyond serotonin, norepinephrine, and dopamine. The N-methyl-D-aspartate (NMDA) receptor has a major role in the neurophysiology of depression. Ketamine, one of the prototypical NMDA antagonists, works rapidly in controlling depressive symptoms, including acutely suicidal behavior, by just a single injection. Ketamine may rapidly increase the glutamate levels and lead to structural neuronal changes. Increased neuronal dendritic growth may contribute to synaptogenesis and an increase in brain-derived neurotrophic factor (BDNF). Activation of the mechanistic target of rapamycin (mTOR), as well as increased levels of BDNF, may increase long-term potentiation and result in an improvement in the symptoms of depression. The mechanisms of ketamine’s proposed effect as an off-label treatment for resistant depression are outlined in this paper.

Recent trends in the legalization of marijuana in many states are increasing the popularity of recreational marijuana use. Since current data on hospitalizations in marijuana users is sparse, we evaluated the primary reasons for admissions, procedures and associated healthcare burden in hospitalized recreational marijuana users. The National Inpatient Sample (NIS) for the years 2010–2014 was queried for the hospitalizations with a history of recreational marijuana usage using applicable ICD-9 CM codes. Descriptive statistics were used to report frequency (N) and percentage (%). Discharge weights were applied to achieve national estimates. The predictors of in-hospital mortality in recreational marijuana users were assessed using a two-way hierarchical multivariate regression after adjusting for the confounders. We analyzed 465,959 (weighted n=2,317,343) hospitalizations with a history of recreational marijuana use. Among psychiatric disorders, most prominent primary discharge diagnoses were mood disorders (20.6%), schizophrenia/other psychotic disorders (10.6%), and substance/alcohol-related disorders (10.4%). Suicide and intentional self-inflicted injury (3.6%) was the leading cause of emergency admission. The most common non-psychiatric primary discharge diagnoses were diabetes mellitus with chronic complications (2.2%), acute myocardial infarction (AMI) (1.2%), nonspecific chest pain (1.1%), congestive cardiac failure (CHF) (1%), arrhythmia (0.8%), and hypertension (0.8%). Acute cerebrovascular diseases were noted in 1.1% and epilepsy in 1.8% of patients. Alcohol/drug rehabilitation and detoxification (6.9%) and psychiatric evaluation/therapy (3.9%) were the most evident psychiatric procedures whereas most frequent non-psychiatric procedures were diagnostic coronary arteriography (1%), percutaneous transluminal coronary angioplasty (0.7%), and echocardiogram (0.7%). Top independent predictors of in-hospital mortality were coagulopathy (OR 5.94), AMI (OR 4.59), pulmonary circulation disorder (OR 2.95), CHF (OR 2.02), renal failure (OR 1.91), coronary atherosclerosis (OR 1.34) and peripheral vascular disorder (OR 1.31). Major cardiovascular and cerebrovascular events also showed increasing trends among users. We established the most frequent psychiatric and non-psychiatric causes of admissions and procedures in recreational marijuana users, which may pose a significant healthcare burden and increase the odds of in-hospital mortality.

Objective: Our study aimed to compare the demographic characteristics of conduct disorder (CD) inpatients versus other psychiatric inpatients in children and adolescents, and assess the association between conduct disorder patients and the spectrum of substance use disorders (SUD). Methods: We included 800,614 psychiatric adolescent (12–18 years) inpatients, and this included 8885 inpatients (1.1%) primarily for conduct disorder in the Nationwide Inpatient Sample (2010–2014). ICD-9 codes were used to detect SUD, and a logistic regression model was used to evaluate the odds ratio (OR) for SUD in conduct disorder inpatients. Results: A higher proportion of conduct disorder inpatients were of 12–15 years of age (62.6%), male (64.4%), and White (45.7%). The lower median household income was correlated with a higher prevalence of conduct disorder (36.4%). Among SUD, cannabis use (23.7%) was most prevalent in conduct disorder inpatients followed by tobacco and alcohol use (10.1% each). Conduct disorder inpatients have 1.7-fold higher odds (95% confidence interval (CI) 1.52–1.82) for alcohol use and 1.4-fold higher odds (95% CI 1.31–1.49) for cannabis use compared to the non-conduct disorder inpatients. Cannabis use was seen significantly in adolescents (49.1%, 12–15 years), male (75.6%), and African Americans (45.6%). Conclusion: Conduct disorder inpatients have a higher risk of comorbid SUD compared to other psychiatric illnesses. The most common substance to be abused is cannabis followed by tobacco and alcohol. Varying pattern of substance use was seen by demographics and these predictors may help the clinicians for early diagnosis and treatment to improve overall health-related quality of life.

Objective To evaluate inpatient outcomes and the prevalence of psychiatric and medical comorbidities in bulimia nervosa. Methods We used the Nationwide Inpatient Sample (NIS) from the Healthcare Cost and Utilization Project (HCUP). We identified bulimia nervosa as the primary diagnosis and medical and psychiatric comorbidities using ICD­9-CM codes. The differences in comorbidities were quantified using the Chi-square (χ2) test, and a multinomial logistic regression model was used to quantify associations among comorbidities (odds ratio (OR)). Results The sample consisted of 3,319 inpatient admissions with bulimia nervosa between 2010–2014. Overall, 88% patients were younger than 40 years of age (p < 0.001). Bulimia nervosa was seen in a higher proportion of females (92.5%). The mean inpatient stay was 9.15 days and had a variable trend, whereas inpatient charges have been increasing (p < 0.001), averaging $34,398 (USD). The odds of having a longer hospitalization > 7 days (median) was seen in patients with comorbid fluid/electrolyte disorders (OR = 1.816; p < 0.001) and comorbid depression (OR = 1.745; p < 0.001). The most prevalent psychiatric comorbidities were psychosis (52.4%), followed by depression (23.5%). Females had three times higher odds of comorbid diabetes (OR = 3.374; p < 0.001), hypertension (OR = 2.548; p-value < 0.001), comorbid depression (OR = 1.670; p = 0.002), and drug abuse (OR = 2.008; p < 0.001). Conclusion Our study established psycho-socio-demographic characteristics, hospitalization outcomes, and comorbidities of bulimia nervosa patients. We believe that medical and psychiatric comorbidities of bulimia nervosa should be carefully investigated by clinicians as they can further complicate the management of bulimia nervosa and result in adverse inpatient outcomes.