ECT vs Ketamine for Major Depressive Disorder: New Data

 Electroconvulsive therapy (ECT) appears to have a small advantage over ketamine for improving depressive symptoms in adults with a major depressive episode, results of a new review show.

"Although ECT is superior to ketamine for patients with a major depressive episode (MDE), our findings suggest that the therapeutic advantage may be smaller than what was demonstrated in prior analyses," first author Vikas Menon, MD, Department of Psychiatry, Jawaharlal Institute of Postgraduate Medical Education & Research (JIPMER), Puducherry, India, told Medscape Medical News.

"This supports a recommendation for a trial of ketamine before a trial of ECT for patients with MDE, though this recommendation is limited by the small size and number of existing trials," Menon said.

The study was published online today in JAMA Psychiatry.

Questions Remain

The meta-analysis included five trials of 278 adults with MDE (141 treated with ketamine and 137 with ECT).

In the main analysis, posttreatment depression ratings showed a trend for lower scores with ECT compared with ketamine (standardized mean difference [SMD], −0.39; 95% CI, −0.81 to 0.02). 

In a sensitivity analysis of the two methodologically stronger trials, ECT was superior to ketamine (pooled SMD −0.45; 95% CI, −0.75 to −0.14).

ECT was also superior to ketamine in terms of response rates (risk ratio [RR] 1.27; 95% CI, 1.06 - 1.53) and remission rates (RR, 1.43; 95% CI, 1.12 - 1.82).

There were no significant between-group differences for number of sessions to response and remission and for cognitive outcomes.

Key limitations of the analysis were the small number of studies with limited sample sizes and a high risk of bias in all trials.

"There is a need for more comparative studies with adequate sample size in non-inferiority designs, examining a wider range of benefits and side effects, and followed up for longer durations, to answer clinically relevant questions about the nature and durability of observed benefits with ketamine," said Menon.

"In patients with MDE for whom the administration of ECT is limited by restricted availability of the treatment, concerns about its cognitive adverse effects, negative patient attitudes, and other issues, clinicians may consider a trial of ketamine," he added.

"Important Research"

Several experts offered perspective on the analysis in a statement from the UK-based nonprofit Science Media Centre, which was not involved with the conduct of this study.

Rupert McShane, MD, psychiatrist at the University of Oxford, UK, noted that ECT and ketamine are both "potent" treatments for depression and this meta-analysis shows that they are, "broadly speaking, equally as good as each other with perhaps a slight advantage for ECT."

"Whether or not there is a difference depends on exactly how you define it and how you cut the data. Despite the slight advantage for ECT in this analysis, the authors support using ketamine before ECT, especially in patients who are worried about the cognitive risks of ECT. This seems sensible," McShane said.

Allan Young, MBChB, clinical psychiatrist at King's College London, UK, noted that both ketamine and ECT have been shown to help some patients with treatment-resistant depression.

"Clearly the relative benefits of these two treatments need to be understood better, but this review of the existing literature suggests that ECT may benefit some more than ketamine," said Young.

"There is evidence that ketamine with ECT may add little extra benefit but much more work needs to be done to fully understand how these treatments fit best into the treatment pathway for major depressive episodes. However, based on this evidence, ECT clearly still merits a place in the treatment pathway," Young added.

George Kirov, PhD, clinical professor, Division of Psychological Medicine and Clinical Neurosciences, Cardiff University, Cardiff, UK, said while the study is conducted well, most of the evidence is coming from one large trial conducted in Sweden.

"The other studies add small numbers of patients and the authors even present a sensitivity analysis after removing studies of poor quality, thus leaving only two studies and exposing even further the dependence of the results on one single study." Kirov noted. 

"The small studies should not be blamed for their size, as this is very difficult research to perform. On the other hand, the trends were in the same direction," he added.

With those caveats in mind, Kirov said he still thinks this is "important research. It establishes the superiority of ECT against an active comparator (ketamine) which is very popular now and accepted to be quite effective."

The study had no specific funding. Menon reports no relevant financial relationships. McShane is former chair of the ECT and Related Treatments Committee, Royal College of Psychiatrists and runs a ketamine clinic and an ECT service. Young has received compensation for lectures and advisory boards for AstraZeneca, Eli Lilly, Lundbeck, Sunovion, Servier, Livanova, Janssen, Allergan, Bionomics, Sumitomo Dainippon Pharma, COMPASS, and Sage; and has served as principal investigator on a trial of intranasal esketamine in treatment-resistant depression. Kirov has no interest to declare other than running the ECT service in Cardiff.

JAMA Psychiatry. Published online April 12, 2023. Abstract

https://www.medscape.com/viewarticle/990668

US-run free electronic tax-filing system for all still just idea

 It’s that time of year when throngs of taxpayers are buckling down to file their income tax returns before Tuesday’s filing deadline. Many often pay to use software from private companies such as Intuit and H&R Block.

Almost one-quarter of Americans wait until the last minute to file their taxes.

There could be a new, free option in future years. The IRS has been tasked with looking into how to create a government-operated electronic free-file tax return system for all. But that doesn’t sit well with the big tax-prep companies.

The idea has been batted around and hotly debated for a long time. Congress now has directed the IRS to report in on how such a system might work.

The order came as part of the $80 billion infusion of money for the tax agency over the next 10 years under the Democrats' flagship climate and health care measure, known as the Inflation Reduction Act, that President Joe Biden signed last summer. It gave the IRS nine months and $15 million to report in on how it might implement such a program and how much it would cost.

Next month, the IRS will release the first in a series of reports looking into how it might be done.

The possibility of an electronic free-file system operated by Washington is being celebrated by some taxpayer advocates who for years have said that would reflect good governance and well serve taxpayers. Critics voice skepticism about the IRS taking on the dual roles of both tax collector and tax preparer, arguing that the new service could create a power imbalance between taxpayers and the government.

Robert Marvin, an IRS spokesperson, said in an email that a key goal of the study is to “look for ways to make filing taxes as easy as possible.”

“It’s important that Americans have choices that work best for them when preparing their taxes, whether it’s by using a tax professional, tax software or free options,” he said.

But big tax preparation companies have millions of dollars to lose if the program comes to fruition. Last year, more than 60 million taxpayers were serviced between Intuit, the parent company of TurboTax, and H&R Block.

Tens of millions of dollars have been spent trying to influence policymakers on the issue, and lobbying data shows that the big tax companies in particular have spent heavily.

An analysis shows that Intuit, H&R Block, and other private companies and advocacy groups for large tax preparation businesses, as well as proponents in favor of electronic free file, have reported spending $39.3 million since 2006 to lobby on “free-file” and other matters. Federal law doesn’t require domestic lobbyists to itemize expenses by specific issue, so the sums are not limited to free-file.

Intuit has spent $25.6 million since 2006 on lobbying, H&R Block about $9.6 million and the conservative Americans for Tax Reform roughly $3 million.

Derrick Plummer, a spokesman for Intuit, said taxpayers can already file their taxes for free through the mail and there are other online free-file programs available to some people.

A “direct-to-IRS e-file system is a solution in search of a problem, and that solution will unnecessarily cost taxpayers billions of dollars,” he said. “We will continue unapologetically advocating for American taxpayers and against a direct-to-IRS e-file system because it’s a bad idea.”

Starting in 2006, an agreement between the IRS and some commercial tax preparation companies, known as the Free File Alliance, prevented the IRS from creating its own free tax return filing system. In exchange, tax preparation companies agreed to provide free services to taxpayers making $73,000 or less.

The provision that barred the IRS from exploring a free-file system expired in 2019, but the Free File Alliance agreement to provide free services for low-income taxpayers remains in effect.

Ariel Jurow-Kleiman, a tax law professor at Loyola Law School, and the New America think tank have been selected by the IRS to conduct the congressionally mandated study for the agency. Jurow-Kleiman said their mandate is “evaluating the feasibility, approach, schedule, cost, organizational design, and IRS capacity to deliver a possible direct e-file system.”

But she has faced pushback from Republicans who say she does not fit the law’s requirement that an independent third party assess what it would take to deliver a direct file program.

Rep. Jason Smith, chairman of the House Ways and Means Committee, sent a letter to the IRS in March questioning Jurow-Kleiman’s ability to be an independent reviewer, saying her work indicates “a clear preference for an expansive government-run system.”

Smith, R-Mo., said the selection of Jurow-Kleiman and New America shows that “the Administration has already predetermined that a government-directed e-file system should exist regardless of what might be found in a truly nonpartisan, independent, third-party review.”

Jurow-Kleiman said the GOP pushback to her selection was based on an unpublished draft of an article about tax compliance costs and that none of her writings have “addressed the questions that we are assessing in the feasibility study.”

Molly Martin, director of strategy at New America, referred requests for comment to the IRS, saying the organization “is still working on its report.”

David Williams, at the right-leaning, nonprofit Taxpayers Protection Alliance, says the “government preparing taxes is problematic.”

“The taxpayer is looking for the biggest refund possible, but for the IRS that’s not their job to look for the biggest refund for filers,” he said. “We’re concerned about that conflict of interest, but also really the ability of the IRS to do this.”

To Gabriel Zucker, who helped create the tool to help families access the Advance Child Tax Credit during the pandemic, successfully setting up a free-file program is possible. "It is a really great way for government to better serve people,'' said Zucker, associate policy director for tax benefits at Code for America.

https://www.marketscreener.com/quote/stock/H-R-BLOCK-INC-12975/news/New-push-on-US-run-free-electronic-tax-filing-system-for-all-43509987/

Gunmen storm Mexican resort, kill 7, including child

 Armed men on Saturday killed a child and six others after storming a resort in the central Mexican state of Guanajuato, authorities said, in a region increasingly plagued by drug cartel violence.

Footage widely shared on social media showed the aftermath of the attack in a palm-studded resort in the small town of Cortazar, about 65 km (40 miles) south of the Guanajuato city.

It was not clear who was behind the shooting that killed the seven-year-old, three men and three women, Cortazar's local security department said. One person was seriously injured in the La Palma resort.

But in recent years rival drug cartels have been waging brutal battles to control territory and trafficking routes through the state.

Video taken soon after the attack showed shocked adults and children walking past piles of dead bodies near a swimming pool.

"Heavily armed sicarios arrived and this is what happened," said an unidentified man, using a word for hired assassins as he filmed at the resort in a video shared on the internet.

Reuters could not independently verify the contents of the video.

"After the attack, (the attackers) fled, but not before causing damage to the resort store and taking the security cameras and the monitor," Cortazar's security department said in a statement.

https://www.marketscreener.com/news/latest/Gunmen-storm-Mexican-resort-kill-7-including-child--43509948/

Supreme Court considers Christian mail carrier's refusal to work Sundays

An evangelical Christian former mail carrier's fight with the U.S. Postal Service over his refusal to work on Sundays gives the Supreme Court another chance to widen religious rights but also has led to a debate over whether religious people are more legally deserving than others to weekend days off from work.

The justices are set to hear arguments on Tuesday in an appeal by Gerald Groff, a former mail carrier in Pennsylvania, of a lower court's ruling rejecting his claim of religious discrimination against the Postal Service for refusing to exempt him from working on Sundays, when he observes the Christian Sabbath. Groff sued after being disciplined for repeatedly failing to show up when assigned a Sunday work shift.

The court, with its 6-3 conservative majority, has a track record of expanding religious rights in recent years, often siding with Christian plaintiffs. A ruling favoring Groff could make it harder for businesses to deny a variety of religious accommodations to employees.

"The whole point of religious accommodation is you have to make special or favored arrangements in order to have an inclusive workforce," said Alan Reinach, one of Groff's attorneys.

Boston University School of Law employment law expert Michael Harper said that a ruling favoring Groff could "give a preference to the religious because they get to stay home on their Sabbath or their day of rest" that would be denied to nonreligious people.

Harper added, "Whenever you depart from neutral standards it creates the potential for greater friction in the workplace."

Unions representing postal workers urged the Supreme Court to carefully consider the issue of hardship that religious accommodations for some employees could have on co-workers.

"A day off is not the special privilege of the religious. Days off, especially on the weekend, are when parents can spend the day with children who are otherwise in school, when people can spend time on the other necessities of life, when the community enjoys a common day of rest for churchgoers and the nonreligious alike," the American Postal Workers Union said in a brief.

Groff's case centers on a federal anti-discrimination law called Title VII of the Civil Rights Act of 1964, which prohibits employment discrimination based on religion and other factors including race, sex and national origin.

Under Title VII, employers must make allowances for a worker's religious observance or practices unless that would cause the business "undue hardship" - which the Supreme Court in a 1977 case called Trans World Airlines v. Hardison determined to be anything imposing more than a minor, or "de minimis," cost.

Groff's attorneys have asked the Supreme Court to overturn the Hardison precedent and require companies to show a "significant difficulty or expense" before denying an accommodation.

Groups representing some religions that are in the minority in the United States including Islam, Judaism and Hinduism told the Supreme Court that the Hardison standard has disproportionately impacted them and should be revised.

"By allowing employers to refuse to accommodate employees' beliefs for almost any reason, Hardison forces devout employees to an impossible daily choice between religious duty and livelihood," the Muslim Public Affairs Council wrote in a brief.

Representing the Postal Service, President Joe Biden's administration told the justices there is no need to reverse Hardison because the Equal Employment Opportunity Commission (EEOC), the agency that enforces Title VII, and many lower courts already have interpreted that ruling to provide substantial protection for religious employees.

James Phillips, a law professor at Chapman University in California, said a "strong majority" or even all the justices could side with Groff.

"This may be one of those religious liberty cases where the right and the left are actually aligned," Phillips said.

SUNDAY DELIVERIES

Groff worked as a "rural carrier associate" in the towns of Quarryville and Holtwood in Pennsylvania's Lancaster County, a job that required him to fill in as needed for absent career carriers, including on weekends. The Postal Service in 2013, in a bid to remain profitable, contracted with Amazon.com to deliver packages, including on Sundays.

Groff failed to report for assigned Sunday shifts. Postal officials sought to accommodate Groff by attempting to facilitate shift swaps, but were not always successful. His absences caused tension among other carriers who had to cover his shifts, the Postal Service said. Groff received several disciplinary letters and resigned in 2019.

"I hope the Supreme Court reaffirms our nation's commitment to providing equal opportunity and fair treatment in the workplace," Groff said in a statement provided by his lawyers.

University of Miami School of Law professor Caroline Mala Corbin, who specializes in law and religion, said that while the case could help minorities fully participate in the workforce, it also could tee up clashes between religious and secular values or LGBT rights.

For instance, Corbin said, a conservative Christian employee might have a better chance seeking a religious accommodation to refuse to use a transgender co-worker's preferred pronoun.

"My worry is that the Supreme Court will use this case as an opportunity to cement its privileging of religion over equally important, competing interests - especially to the detriment of vulnerable groups," Corbin said.

A ruling is due by the end of June.

https://www.marketscreener.com/news/latest/US-Supreme-Court-considers-Christian-mail-carrier-s-refusal-to-work-Sundays--43509947/

Poor Sleep After COVID Hospitalization: Breath Shortness Part of the Equation

 Poor sleep may be traced back to lingering shortness of breath and decreased lung function from prior COVID-19 illness in patients requiring hospitalization, the CircCOVID study found.

Approximately half a year following hospitalization for COVID-19, 62% of patients reported that they experienced poor sleep quality, while 53% felt their sleep had gotten worse since leaving the hospital. This was supported by actigraphy results showing that these individuals had longer duration of sleep but lower sleep regularity and lower sleep efficiency compared with matched U.K. Biobank participants, reported John Blaikley, MBBS, PhD, of the University of Manchester, England, and co-authors.

In turn, poor sleep quality, worsening sleep quality, and low sleep regularity following hospital discharge were associated with higher dyspnea scores and impaired lung function by forced vital capacity, according to the multicenter, prospective study published in The Lancet Respiratory Medicine

opens in a new tab or window. These findings were also presented at European Congress of Clinical Microbiology & Infectious Diseasesopens in a new tab or window in Copenhagen, Denmark.

"The associations described in this study between sleep disturbance and reduced muscle function, anxiety, and dyspnea suggest that sleep disturbance could be an important driver of the post-COVID-19 condition," the group wrote. "If this is the case, then interventions targeting poor sleep quality could be used to manage multimorbidity and convalescence following hospital admission for COVID-19, with the aim of potentially improving patient outcomes."

The authors did note that accounting for patient anxiety and muscle function could impact some of the observed impacts of dyspnea. An estimated 39% of the relationship between poor sleep quality and dyspnea was mediated by anxiety, and 36% by reduced muscle function. Similarly, anxiety mediated 36% of the relationship between sleep quality deterioration and dyspnea, whereas reduced muscle function mediated 27% of the relationship.

"Sleep disturbance following hospital admission is common regardless of the original reason for admission. Despite its prevalence, the clinical implications of sleep disturbance during recovery from an acute illness are not well understood. In experimental settings, sleep disturbance is causally associated with two recognised causes of dyspnea: anxiety and muscle weakness," Blaikley and colleagues wrote.

Based on the current report, it is still unclear whether sleep disturbance is causing anxiety or whether anxiety is contributing to poor sleep, according to W. Cameron McGuire, MD, of the University of California San Diego, and co-authors of an accompanying editorialopens in a new tab or window.

Other questions to be answered, they said, include whether the documented abnormalities in pulmonary microvasculature in previous studies are contributing to dyspnea, and for clinicians, whether certain therapies may mitigate dyspnea during COVID-19 recovery.

Approximately 13.9% of COVID-19 patientsopens in a new tab or window currently report long COVID-19 symptoms, with 31% of those patientsopens in a new tab or window citing disrupted sleep among their symptoms. Sleep plays a vital role in overall health, with poor sleep habits associated with increased stroke riskopens in a new tab or window, asthmaopens in a new tab or window, and worsening mental healthopens in a new tab or window.

CircCOVID was a substudy of the Post-hospitalisation COVID-19 study (PHOSP-COVID) that enrolled 2,468 adults hospitalized for COVID-19 in the U.K. who were discharged from March 2020 to October 2021.

There were 638 individuals included who completed both the Pittsburgh Sleep Quality Index questionnaire and numerical rating scale for sleep quality. Participant sleep quality worsened by, on average, three points on the index when followed-up at 2 to 7 months, and two points at 10 to 14 months post-discharge.

The 729 participants who provided device-based measures of sleep had been instructed to wear an accelerometer on their wrist for 14 days straight. These patients were then matched with similar U.K. Biobank participants, some without hospitalization and some with a recent hospitalization for pneumonia, for comparison.

Besides the minority of patients providing follow-up data, the CircCOVID study was also limited by the potential for recall and selection bias.

"In theory, the most severely affected patients would be least likely to present for follow-up. Conversely, patients who are sometimes labeled as having psychosomatic complaints might be those most likely to seek follow-up care," McGuire and colleagues noted.

Disclosures

PHOSP-COVID is jointly funded by a grant from the MRC-UK Research and Innovation and the Department of Health and Social Care through the National Institute for Health Research (NIHR).

Blaikley declared support to his institute from an MRC Transition Fellowship, Asthma + Lung U.K., NIHR Manchester BRC, and UKRI; grants paid to his institution from the Small Business Research Initiative Home Spirometer and the National Institute of Academic Anaesthesia; personal support for attending meetings from Teva and Therakos; and serving as a committee member of the Royal Society of Medicine.

McGuire had no disclosures. A co-editorialist reported NIH funding and medical education-related income from Zoll, LivaNova, Jazz, and Eli Lilly.

Primary Source

The Lancet Respiratory Medicine

Source Reference: opens in a new tab or windowJackson C, et al "Effects of sleep disturbance on dyspnoea and impaired lung function following hospital admission due to COVID-19 in the UK: a prospective multicentre cohort study" Lancet Respir Med 2023; DOI: 10.1016/S2213-2600(23)00124-8.

Secondary Source

The Lancet Respiratory Medicine

Source Reference: opens in a new tab or windowMcGuire WC, et al "Sleep disturbances, dyspnoea, and anxiety in long COVID" Lancet Respir Med 2023; DOI: 10.1016/S2213-2600(23)00138-8.

https://www.medpagetoday.com/pulmonology/sleepdisorders/104034

Let’s be blunt — legal weed is turning New York workers into zombies

 The Big Apple is now the Big Blunt.

Not just because decriminalized marijuana led to proliferating mayhem in the five boroughs.

Not just because stinky smoke hangs everywhere, seeping into subway cars and even Broadway theaters — the acrid odor I detected in the crowded men’s room of the Majestic Theatre a few weeks ago was not from “The Phantom of the Opera” smoke machine.

It’s also because of a forbidden-to-utter truth, in an age where raising the minimum wage ever higher has become mantra — namely, a license to get high has turned service employees into zombies.

I’ve lived in the city nearly all my life. I never had to repeat my highly complex Starbucks order — a “tall” coffee — three times to get a response from the bummed-out barista, the way I do now.

Bob Dylan’s lyric, “Everybody must get stoned,” is now apparently in the employees’ handbook at most every place requiring customer interaction.

My friend Shelley Clark, a restaurant consultant, observed, “Too often, any question or request is met with a vacant look and a very much by-rote ‘no problem.’”

Getting your order correct at Starbucks seems to be more difficult than ever.

Corbis via Getty Images

Streets, subway cars, even Broadway theaters now stink like weed.

AP

That’s actually nice compared to the hostile glares I get for interrupting stay-out-of-my-space reveries.

It’s time to lower the minimum wage.

Why not, when many workers in stores, restaurants, dry cleaners — you name it — have turned hopelessly stunad, as the Italian people say.

The word means dumb, but sounds eerily similar to so many service employees’ doped-up conditions.

They’re stoned up the wazoo, hollow-eyed, disengaged from their tasks, their breath reeking of weed.

Doped up delivery workers are too stoned to remember whose Doordash order is whose.

AP

Did GrubHub bring you General Tso’s chicken when you ordered chicken burritos?

Blame the delivery guys’ favorite hangouts — e.g., the “Smoke & Draft” shop across from my building on First Avenue at East 75th Street, where a sidewalk knife fight recently sent two of them to the hospital.

I gave a guy at Pret a Manger a $20 bill for an $8 cup of soup. I asked for a bag. He took the $20 and promptly forgot the soup, my change, the bag — and me. He wandered off, inexplicably waving my Andrew Jackson like a flag, until I appealed to his colleagues.

I haven’t seen so much pot-induced lethargy since my Vietnam-era college days, when so many fellow students were high that their panicked weed-flushing during a rumored police raid overwhelmed the campus pipes.

Now, our whole pot-pickled city is that campus.

Delivery workers can often be seen congregating at the city’s host of pot shops — each of them a magnet for crime.

Helayne Seidman

At Upper East Side gourmet food emporium Agata and Valentina, one cashier was “so out of it, staring into space while people waited in line,” a bank executive who’s a regular customer there told me.

“She forgot to give me my change. She closed the register. I had to wait for someone to come with the dreaded key. After ten minutes for a 30-second transaction, she didn’t even apologize.”

Responding to a tweet I posted about discombobulated workers, a follower wrote to say that “The woman running the service desk” at a major Sunset Park auto dealer “was clearly high … had no idea what was going on. Lost my car twice during routine service.”

With every kind of marijuana-related product widely available, New York is no longer the Big Apple — call it the Big Blunt.

Shutterstock
Real estate man Jordan Cohn tweeted, “I just had a restaurant server lose my credit card. Yep, gone, never to be seen again. My best guess is that it went into the trash by accident.”

Our “progressive” pols are throwing our city into the trash — and it’s no accident.

https://nypost.com/2023/04/16/how-new-yorks-legal-weed-is-turning-workers-into-stoned-zombies/