Administration Of ECT Research Articles

The use of electroconvulsive therapy for children and adolescents in general hospitals: A 2019 kids' inpatient database analysis

ObjectiveElectroconvulsive therapy (ECT) devices are classified as class II (moderate risk) for the treatment of depressive disorders and catatonia in patients aged 13 and older, but it is unknown how often the treatment is utilized by child and adolescent patients. The aim of this study was to examine the demographics of child and adolescent hospitalizations involving ECT, the medical and psychiatric comorbidities of these hospitalizations, and the overall number of treatments administered per hospitalization. MethodThe 2019 Kids' Inpatient Database, a national sample of pediatric discharges from 3998 acute care hospitals, was analyzed for hospitalizations involving patients aged 19 and younger receiving ECT based on inpatient procedural codes. Results315 (95% confidence interval 275 to 354) discharges among child and adolescent patients, or 0.03% of youth hospitalizations, involved the administration of ECT in the KID in 2019. Hospitalizations in the Northeast, those involving patients residing in ZIP codes in the top income quartile, and those for commercially insured patients had higher odds of ECT administration. Primary discharge diagnoses among ECT recipients were major depressive disorder (143; 46.4%), schizophrenia and other psychotic disorders (71; 23.1%) and bipolar disorder (59; 19.2%). In total 153 (48.6%) of ECT recipients had a coded diagnosis of suicidal ideation. Hospitalizations involved a median of 2 (IQR 1 to 5) ECT treatments before discharge. ConclusionsECT is rarely utilized in the inpatient treatment of child and adolescent patients, but is most often administered to patients with mood and psychotic disorders. Commercial insurance and higher income were associated with higher odds of ECT administration, suggesting that access to care may be limited.

ECT: An essential therapy in psychiatry

At a time when innovations in psychiatry are booming, particularly in the field of medical devices, we thought it necessary, as members of French Society for Biological Psychiatry and Neuropsychopharmacology (AFPBN), to reconsider one of the oldest medical devices in psychiatry: the ECT apparatus. First, we recall the regulatory aspects of ECT. National guidelines define means of implementation and conditions of administration of ECT. Second, we remind of the indications and levels of evidence of ECT in the main psychiatric disorders, including catatonia. Then, we synthetize the place of ECT alongside other brain stimulation therapies, especially repetitive Trancranial Magnetic Stimulation (rTMS). Furthermore, we explain the general effects of ECT: increased neuronal plasticity and neurogenesis, enhancement of the stress axis, resistance to oxidative stress, improved vascular endothelial function, activation of microglia and astrocytes, decrease in inflammatory events by upregulation of neuroinflammatory cytokines, and production of mitochondrial ATP. These effects appear from the first sessions and continue during the course of ECT treatment, suggesting activation of endogenous neuroprotection. Finally, we remember that most patients perform as well or better on neuropsychological assessments after ECT, relative to pre-ECT results, and this improvement continues over the following months. Memory disorders reported post-ECT are not all attributable to ECT. They may be subjective in nature or linked to residual depressive (and possibly comorbid neurogenerative) symptoms later attributed to ECT, on the basis of preexisting negative representations. We urgently need to reemphasize the crucial role of ECT in psychiatric treatment strategies as well as the need to update ECT recommendations.

ECT practice in England from 2012/13 to 2018/19: a retrospective analysis

AimsThe purpose of this study was to look longitudinally at ECT practice in England over the past 7 years: namely over the following key time periods; 2012/13, 2014/15, 2016/17, 2017/18, and 2018/19. A previous study by Chaplin et al, published in 2016, found that there had been a striking decline observed in the number of courses of ECT prescribed to patients from 2006 to two time points i.e. 2012/13 and 2014/15.In this study we investigated whether or not this trend had continued. Hence we looked at the change in frequency of ECT use, the length of ECT courses, patient demographics and clinical outcomes; between 2012/13 and 2018/19.BackgroundElectroconvulsive therapy (ECT) is an effective treatment for Major Depression, Treatment-Resistant Depression, Catatonia, and Clozapine-resistant psychosis. There have been regular improvements in the administration of ECT, over the past two decades. Increases in the volume of the hippocampus and the amygdala have consistently been observed in ECT studies. Stigma has been the major barrier to patients receiving ECT in a timely fashion. The Royal College of Psychiatrists (RCPsych) Centre for Quality Improvement (CCQI) established the ECT Accreditation Service (ECTAS) back in 2006. ECTAS had the aim of standardising ECT practice through the production of evidence-based standards that all member ECT Clinics could use to support their practice.MethodWe looked at the minimum dataset of information collected from ECTAS Members within England for the following years; 2012/13, 2014/15, 2016/17, 2017/18, 2018/19. In 2012/13, 2325 adjusted courses of ECT treatment were given to patients in England. In 2014/15 it was 2302.ResultBetween 2012/13 and 2018/19; two thirds of ECT patients continue to be female. The modal age of patients has also remained the same at 70 years. The number of patients detained under the Mental Health Act 1983 receiving ECT has gone up by 12%; suggesting that the patients receiving ECT were more clinically unwell. After treatment, CGI scale scores (i.e. the very much improved and much improved scores) slightly reduced by 6% from 2012/3 to 2018/19.ConclusionThe use of ECT in England notably declined from 2006 to 2012/13 and 2014/15. However, from 2012/13 to 2018/19, ECT use has remained relatively stable; suggesting that it is currently being used appropriately on patients, who are amongst the most severely unwell. The clinical effectiveness of ECT remains high however, it has slightly dipped by 6%.

Electroconvulsive therapy is associated with lower readmission rates in patients with schizophrenia

BackgroundElectroconvulsive therapy is an important somatic treatment for severe mental disorders with established efficacy and safety. However, data on the relationship between ECT and the readmission rate of patients with schizophrenia are scarce. This study will explore the association between the administration of ECT and readmission rates using a machine learning method. MethodsInpatient medical records from the year of 2016 in one large psychiatric hospital in Beijing, China, were analyzed using a machine learning algorithm to determine the most important variables affecting readmission of patients with schizophrenia. ResultsThe medical records of 2131 inpatients with schizophrenia were reviewed. 1099 patients were followed up within 3 months of their index admission (642 ECT cases and 457 non-ECT cases) and 1032 patients were followed up within 6 months (596 ECT cases and 436 non-ECT cases) after discharge. The 3- and 6-month readmission rates in the ECT group (11.37% and 17.94%, respectively) were significantly lower than that of the patients who did not receive ECT (18.79% and 29.36%, respectively, both p < 0.001). The risk of readmission was significantly associated with male sex, older age, being married, having a lower income, a shorter inpatient length of stay, and receiving specific antipsychotic medications including olanzapine, paliperidone, clozapine, and haloperidol during the index admission. In the ECT group, patients who received 9 or more treatments were significantly less likely to be readmitted. ConclusionReceiving ECT may be associated with a lower risk of readmission in patients with schizophrenia.

Network neurobiology of electroconvulsive therapy in patients with depression

Graph theory, a popular analytic tool for resting state fMRI (rsfMRI) has provided important insights in the neurobiology of depression. We aimed to analyze the changes in the network measures of segregation and integration associated with the administration of ECT in patients with depression and to correlate with both clinical response and cognitive deficits. Changes in normalised clustering coefficient (γ), path length (λ) and small-world (σ) index were explored in 17 patients with depressive episode before 1st and after 6th brief-pulse bifrontal ECT (BFECT) sessions. Significant brain regions were then correlated with differences in clinical and cognitive scales. There was significantly increased γ and σ despite significant increase in λ in several brain regions after ECT in patients with depression. The brain areas revealing significant differences in γ before and after ECT were medial left superior frontal gyrus, left paracentral lobule, right pallidum and left inferior frontal operculum; correlating with changes in verbal fluency, HAM-D scores and delayed verbal memory (last two regions) respectively. BFECT reorganized the brain network topology in patients with depression and made it more segregated and less integrated; these correlated with clinical improvement and associated cognitive deficits.

Session 310 - Update on Recent Clinical Research in the Administration of ECT in the Elderly

Session 310 - Update on Recent Clinical Research in the Administration of ECT in the Elderly

A qualitative study of experience of parents of adolescents who received ECT.

To evaluate the experience of parents of adolescents who received ECT for severe mental illness. Using qualitative methods, 6 parents of 5 adolescents were interviewed by using a self-designed semi-structured interview after the completion of ECT course. The clinicians involved in the ECT procedure, i.e., seeking informed consent and administration of ECT were not aware about the study. All the interviews were recorded and the content was analysed and themes were generated. Parents of all the 5 adolescents expressed that their children were considered for ECT only after the patient had not responded to medication and were unmanageable. Prior to ECT the treating doctors did explain to them about the ECT procedure, they were given information booklet and they were not coerced to consent for ECT. Some of the parents reported that they had dilemma prior to giving consent and were scared prior to the first ECT. However, as the clinical condition of their children improved, they felt that ECT was a good treatment. Majority of the parents felt that ECT was delayed for their children. When asked about restriction in use of ECT in children and adolescents, the parents expressed that it is important for law makers to understand the distress of the parents,when their children are acutely ill. They expressed that decision of administration of ECT must be left to the family and the treating clinicians. Parents of adolescents considered for ECT are generally satisfied with the treatment procedure.

Re: Electroconvulsive therapy during pregnancy revisited

Our extended thanks to Donna Stewart for her comments (Stewart 2015) on our case report review about the use of electroconvulsive therapy during pregnancy (Leiknes et al. 2013). We understand the Blimits of knowledge^ based on earlier reviews influencing the 2001 text book (Stewart and Erlick Robinson 2001). We are sorry to hear that this important book on the interface between psychiatry and gynecology will not be updated into a later revised version. Stewart’s article on ECT treatment during pregnancy, with case vignette (Stewart 2011), express a reservation for ECT during pregnancy, alongside an awareness for careful ECT monitoring. This case vignette was not included in our review due to insufficient primary data. We are glad to hear Donna Stewart’s position on not to recommend ECT during pregnancy as a first-line treatment and without appropriate safeguards. We totally agree that existing guidelines need to be revised and systematic reviews revised, when appropriate, on this topic. Future growth in published reports, register data, and studies on the administration of ECT during pregnancy will no doubt add more body to our knowledge on both benefits and harms of the intervention. This again will be an aid to inform clinicians and women in complicated treatment decision making. Until then, bearing in mind potential harms as mentioned in our review, ECT during pregnancy will require a close monitoring of the fetus/baby and mother in a joint specialist treatment collaboration, between obstetrician and psychiatrist.

Treatment of Psychosis and Mania in the Postpartum Period

Postpartum psychosis is a severe disorder that warrants acute clinical intervention. Little is known, however, about what interventions are most effective. The authors present treatment response and remission outcomes at 9 months postpartum using a four-step algorithm in patients with first-onset psychosis or mania in the postpartum period. Treatment involved the structured sequential administration of benzodiazepines, antipsychotics, lithium, and ECT. The outcome of clinical remission was examined in 64 women consecutively admitted for postpartum psychosis. Remission was defined as the absence of psychotic, manic, and severe depressive symptoms for at least 1 week. Women who remitted on antipsychotic monotherapy were advised to continue this treatment as maintenance therapy, and women who required both antipsychotics and lithium to achieve remission were maintained on lithium monotherapy. Relapse was defined as the occurrence of any mood or psychotic episode fulfilling DSM-IV-TR criteria. Using this treatment algorithm, the authors observed that nearly all patients (98.4%) achieved complete remission within the first three steps. None of the patients required ECT. At 9 months postpartum, sustained remission was observed in 79.7%. Patients treated with lithium had a significantly lower rate of relapse compared with those treated with antipsychotic monotherapy. Multiparity and nonaffective psychosis were identified as risk factors for relapse. The authors conclude that a structured treatment algorithm with the sequential addition of benzodiazepines, antipsychotics, and lithium may result in high rates of remission in patients with first-onset postpartum psychosis and that lithium maintenance may be most beneficial for relapse prevention.

Use of lignocaine or nitroglycerine for blunting of hemodynamic stress response during electroconvulsive therapy

Background and aim of studyElectroconvulsive therapy (ECT) is one of the safest methods used for the treatment of patients with mental illness today. It is associated with surge in heart rate and blood pressure for a brief period of time. However, as an extreme complication, the hemodynamic response to ECT can produce myocardial ischaemia and even infarction, as well as transient neurological ischaemic deficits, intracerebral haemorrhages, and cortical blindness. This study is aimed towards finding a reliable drug that can prevent this untoward hemodynamic response in immediate post-ECT period.Place and duration of studyThe study was conducted at Combined Military Hospital Skardu after permission from the hospital ethics committee from January 2011 to December 2011.Study designOne thirty-four American society of Anaesthesiology (ASA) I & II patients of both genders were divided randomly in three groups named A, B and C. Patients were induced short general anaesthesia as per set protocol. Group A patients were given no additional drug, while group B patients had lignocaine 1 mg/kg and group C patients nitroglycerine (NTG) 3 μ/kg respectively just after induction. Heart rate (HR) and mean arterial pressure (MAP) were recorded 2 min after induction of anaesthesia just prior to ECT shock and then 1 min after ECT administration.Operation definitionsSignificant rise in heart rate was defined as an increase in heart rate of 10 or more beats per minute after administration of ECT shock from baseline.Significant rise in MAP was defined as the rise in MAP of 15 mm of Hg or more from the baseline after administration of ECT shock.ResultsThirty-three (75%) of 44 patients in group A showed significant rise in HR as compared to group B where no patient showed a significant increase in HR (p < .05). In terms of MAP 29 (65%) out of 44 patients showed a significant rise in group A and 22 (52%) out of 42 patients in group B showed similar results showing statically insignificant difference between the groups. When comparing patients of groups A and C, only 11 (22%) out of 48 patients showed significant rise in HR and 13 (27%) patients showed significant rise in MAP. The difference was statistically significant in both variables (p < .05).ConclusionNTG provided more hemodynamic stability in post-ECT period as compared to lignocaine which only prevented a surge in HR without any effect on MAP. We conclude that NTG can safely be instituted for anaesthesia in ECT patients for prevention of hemodynamic stress response.

Allopurinol May Prolong Seizure Duration on Electroconvulsive Therapy: A Case Report

Back to table of contents Previous article Next article LETTERFull AccessAllopurinol May Prolong Seizure Duration on Electroconvulsive Therapy: A Case ReportChih-Sung Liang M.D.Fei-Wen Yang M.D.,Chih-Sung Liang M.D.Search for more papers by this authorFei-Wen Yang M.D.Search for more papers by this author,Published Online:1 Jul 2010https://doi.org/10.1176/jnp.2010.22.3.352.e19AboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail To the Editor: Allopurinol is indicated not only for the management of patients with hyperuricemia but also as an add-on therapy for refractory epileptic patients because of its anticonvulsant effects. 1 We present a case report of a patient with schizophrenia who underwent ECT while concurrently receiving allopurinol to manage hyperuricemia. The patient’s seizure duration increased after the administration of allopurinol and decreased after the discontinuation of allopurinol. To our knowledge, there is no currently available literature addressing the possibility of prolonged seizure duration on concomitant administration of ECT and allopurinol. Case ReportA 40-year-old man with a history of schizophrenia was admitted to our hospital because of exacerbated psychosis and physical aggression. Bilateral ECTs three times a week were arranged, and risperidone was administered at a dose of 8 mg/day. The ECT device was Thymatron DGx model. We found that it was difficult to elicit a seizure with an electrical dose of 15% in first ECT treatment, but successful elicitation of a seizure occurred with an electrical dose of 20%. For subsequent ECT treatments, the electrical dose was maintained at 20%, and no further difficulty in the elicitation of seizures was observed. The analysis of the blood sample collected at admission (before the first ECT session) revealed the presence of hyperuricemia, and the patient was placed on allopurinol treatment (300 mg/day) after the fourth ECT session. Allopurinol was discontinued after the tenth ECT session because of the onset of a skin rash on both forearms and the restoration of serum uric acid to normal levels. Interestingly, the patient’s seizure duration increased, rather than decreased, after the administration of allopurinol, which may elicit an anticonvulsant effect. Finally, the patient’s seizure duration decreased after discontinuation of allopurinol.Discussion Allopurinol, which inhibits xanthine oxidase, decreases both uric acid formation and purine degradation. 2 Accumulation of hypoxanthine and xanthine may activate hypoxanthine-guanine phosphoribosyl transferase—which is responsible for purine salvage and possibly increase the levels of adenosine and guanosine neuromodulators. 3 Adenosine inhibits the release of glutamate from excitatory neurons and neuronal firing, so it has been proposed as an endogenous anticonvulsant agent. 3 In one retrospective study, 4 the seizure duration in two patients was significantly longer during treatment with lamotrigine when compared with treatment without lamotrigine, but the underlying mechanism was not mentioned. Evidence suggests that seizure duration is shorter when the electrical dosage is markedly suprathreshold than when it is barely suprathreshold. 5 An agent that increases threshold may prolong seizures, because increasing the threshold might imply that the stimulus used is closer to the threshold and that a stimulus near threshold elicits the longest seizures. 5 In the case reported here, the electrical dosage of 20% may be markedly suprathreshold. Consequently, the patient showed increased seizure duration after the administration of allopurinol, which was possibly caused by the anticonvulsant effect of this drug. In conclusion, physicians should be aware of the potential anticonvulsant effect of allopurinol when it is used in clinical practice.Department of Psychiatry, Beitou Armed Forces Hospital, Taipei, Taiwan

Allopurinol May Prolong Seizure Duration on Electroconvulsive Therapy: A Case Report

Back to table of contents Previous article Next article LETTERFull AccessAllopurinol May Prolong Seizure Duration on Electroconvulsive Therapy: A Case ReportChih-Sung Liang M.D.Fei-Wen Yang M.D.,Chih-Sung Liang M.D.Search for more papers by this authorFei-Wen Yang M.D.Search for more papers by this author,Published Online:1 Jul 2010https://doi.org/10.1176/jnp.2010.22.3.352.e19AboutSectionsView articleView PDFView EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail View articleTo the Editor: Allopurinol is indicated not only for the management of patients with hyperuricemia but also as an add-on therapy for refractory epileptic patients because of its anticonvulsant effects. 1 We present a case report of a patient with schizophrenia who underwent ECT while concurrently receiving allopurinol to manage hyperuricemia. The patient’s seizure duration increased after the administration of allopurinol and decreased after the discontinuation of allopurinol. To our knowledge, there is no currently available literature addressing the possibility of prolonged seizure duration on concomitant administration of ECT and allopurinol. Case ReportA 40-year-old man with a history of schizophrenia was admitted to our hospital because of exacerbated psychosis and physical aggression. Bilateral ECTs three times a week were arranged, and risperidone was administered at a dose of 8 mg/day. The ECT device was Thymatron DGx model. We found that it was difficult to elicit a seizure with an electrical dose of 15% in first ECT treatment, but successful elicitation of a seizure occurred with an electrical dose of 20%. For subsequent ECT treatments, the electrical dose was maintained at 20%, and no further difficulty in the elicitation of seizures was observed. The analysis of the blood sample collected at admission (before the first ECT session) revealed the presence of hyperuricemia, and the patient was placed on allopurinol treatment (300 mg/day) after the fourth ECT session. Allopurinol was discontinued after the tenth ECT session because of the onset of a skin rash on both forearms and the restoration of serum uric acid to normal levels. Interestingly, the patient’s seizure duration increased, rather than decreased, after the administration of allopurinol, which may elicit an anticonvulsant effect. Finally, the patient’s seizure duration decreased after discontinuation of allopurinol.Discussion Allopurinol, which inhibits xanthine oxidase, decreases both uric acid formation and purine degradation. 2 Accumulation of hypoxanthine and xanthine may activate hypoxanthine-guanine phosphoribosyl transferase—which is responsible for purine salvage and possibly increase the levels of adenosine and guanosine neuromodulators. 3 Adenosine inhibits the release of glutamate from excitatory neurons and neuronal firing, so it has been proposed as an endogenous anticonvulsant agent. 3 In one retrospective study, 4 the seizure duration in two patients was significantly longer during treatment with lamotrigine when compared with treatment without lamotrigine, but the underlying mechanism was not mentioned. Evidence suggests that seizure duration is shorter when the electrical dosage is markedly suprathreshold than when it is barely suprathreshold. 5 An agent that increases threshold may prolong seizures, because increasing the threshold might imply that the stimulus used is closer to the threshold and that a stimulus near threshold elicits the longest seizures. 5 In the case reported here, the electrical dosage of 20% may be markedly suprathreshold. Consequently, the patient showed increased seizure duration after the administration of allopurinol, which was possibly caused by the anticonvulsant effect of this drug. In conclusion, physicians should be aware of the potential anticonvulsant effect of allopurinol when it is used in clinical practice.Department of Psychiatry, Beitou Armed Forces Hospital, Taipei, Taiwan

Is successful electroconvulsive therapy related to stimulation of the vagal system?

BackgroundElectroconvulsive therapy (ECT) has been shown to exhibit strong beneficial effects in the treatment of major depressive disorder (MDD). While the exact underlying mechanisms are under debate, a role for the sympathetic response upon ECT has been suggested. When assessing patients with MDD for autonomic function, however, a loss of vagal function is prominent. ObjectiveHere, we aimed to assess the immediate effects of ECT on vagal activity and to test the hypothesis that surrogates of the latter correlate with therapeutic outcome. MethodsTwenty patients with MDD who underwent ECT treatment were assessed regarding their vagal function using electrophysiological measures and determination of pancreatic polypeptide (PP), which is known to be released upon vagal stimulation. Parameters were correlated to the improvement of disease severity upon ECT treatment. ResultsPatients showed a significant increase of PP shortly after ECT which correlated with clinical improvement. Furthermore, the described association with the sympathetic phase after ECT could be verified. ConclusionECT increases vagal activity which might be associated with the beneficial effect seen following this treatment. PP elevation after administration of ECT might be a useful parameter to estimate the degree of such vagal stimulation after treatment.

Successful Retrial of ECT Two Months After ECT-Induced Takotsubo Cardiomyopathy

heart failure; however, recovery of cardiac function is often complete within the first week following the insult. Cardiac enzymes may be mildly elevated, but on cardiac catheterization there is usually no evidence of coronary artery disease, or only "mild luminal irregularities" may be noted (7). Contraction band necrosis may be seen on biopsy in the more serious cases. The cause of takotsubo cardiomyopathy is unknown, but several mechanisms have been suggested, including ischemia from coronary artery spasm, microvascular spasm, and direct myocyte injury (5).

Prescribing practices of clozapine in India: Results of a opinion survey of psychiatrists

Byline: Amresh. Shrivastava, Nilesh. Shah Sir, Clozapine has emerged as a gold standard for treatment resistant schizophrenia. It is also effective in a variety of clinical conditions. It is additionally approved for suicide in schizophrenia. However practice of clozapine therapy is complex due to its side effect profile, need for regular blood monitoring, continued clinical monitoring and requirements of logistical support system for the same. Indian conditions are diverse not only socio-economically but also in pattern of prescribing. Practice of psychiatry in India is therefore challenging. Internationally clozapine is a centrally monitored and guided therapy involving a number of agencies. The present report attempts to examine prescribing and monitoring practices of clozapine in Indian context. Clozapine is an atypical antipsychotic, which is credited to have the distinction of bringing in the second revolution in psychopharmacology. It has been main focus of management for treatment-resistant schizophrenia. It has also provided a probe for the biological mechanism of schizophrenia. Many patients became functional with clozapine therapy and have returned to college and work.[sup] [1] After several deaths due to agranulocytosis, the drug was approved with a condition of stringent blood monitoring, and this practice is strictly adhered to in each and every western countries. Clinical practice in India does not have the benefit of a centralized blood monitoring system. The present study is aimed to explore the prescribing practice of clozapine in this context. Serum level monitoring is also not available in routine clinical practice. These constrains may change the practice of clozapine therapy.[sup] [2],[3] The study was done using a specifically prepared semi- structured performa containing 32 items and the questionnaire circulated to about 500 psychiatrists in India. A sizable number of posting was done in urban areas besides metro cities and the survey was voluntary. The responses received were analyzed. A total of 117 responses were received in this study, 9.4% of the psychiatrists have reported using clozapine even before it was launched in Indian Market. Antipsychotic prescribing practices are influenced by several factors. Chong et al. noted that Japan had a high frequency of prescribing high doses and polypharmacy; Singapore had a high utilization of depot injections, while China had a higher prescription of clozapine. First-generation drugs were mainly for controlling aggressive behavior, while second-generation drugs were targeted at the alleviation of positive, negative psychotic symptoms as well as disruptive behavior in schizophrenia. The pattern of antipsychotic medication use varies in different countries and is likely to be influenced by the prevailing health-care system, the availability and cost of the drugs.[sup] [4] Most of the psychiatrists using clozapine have an experience of more than 10 years (51%, between 10 and 20 yrs; 28%> 20 years). In the present study, 50% doctors have been using clozapine because they had one more option, and only 28% doctors felt that the knowledge of efficacy has guided their clinical decision.[sup] [5] Further, 43% doctors felt that clozapine provides very good and excellent outcome. The majority opinion was that clozapine provided an efficacy from 40 to 70% in terms of symptom reduction. Switching to clozapine is recommended under strict monitoring with a definite washout period either on outpatient or on inpatient basis.[sup] [6] However, in this study, only 39% preferred stopping ongoing antipsychotic before starting clozapine. A majority of them used the gradual introduction method, 41% preferred to start clozapine gradually, while gradually withdrawing the existing antipsychotic. Eighty-four percent preferred to maintain patients on single drug clozapine as per best practices norm. …

A survey of psychiatrists in northwest England concerning their use of maintenance electroconvulsive therapy

Dr. Lim's practice audit of maintenance electroconvulsive therapy (M-ECT) in the elderly (Lim, 2006) describes a group of older people treated with M-ECT in Australia but does not describe the views of Australian psychiatrists regarding the use of this form of treatment. We explored the views of psychiatrists in northwest England regarding the use of M-ECT in the 1990s: our study group was a subset of the cohort reported in Benbow et al. (1998), namely those respondents to a first-stage questionnaire who stated that they had used M-ECT (25%) or were prepared to consider its use (67%). A second-stage questionnaire inquired specifically about practice in relation to M-ECT, defined as the regular administration of ECT in order to minimize the likelihood of further episodes of illness, and was sent to 85 individuals of whom 77 responded, giving a response rate of 87.5%. Of these respondents, 49% stated that they had not prescribed maintenance treatment within the past 10 years; 42% estimated that they had prescribed one or two courses; 8% three to four courses and 1% five to six courses. None had prescribed more than six courses, so the experience of any one individual was relatively limited.

What Happened to Ethics?

Back to table of contents Previous article Next article Letters to the EditorFull AccessWhat Happened to Ethics?Sreenivasa R. Desai, M.D.Sreenivasa R. DesaiSearch for more papers by this author, M.D.Published Online:6 Oct 2006https://doi.org/10.1176/pn.41.19.0034I am writing this letter after much thought and anguish. The last straw was the recent news reported in the New York Times that a senior scientist was found to have sold his laboratory's CSF samples to a drug company for profit.Hippocrates must be turning in his grave over the state of affairs of medicine in all specialties. I am sure there are honest physicians, but many appear to be in the silent majority.Physicians are doing procedures with no regard for indication, treatments are recommended without adequate consideration of alternatives, and the lecture circuit is getting crowded by people who call themselves“ experts.” In psychiatry, I encounter such problems as overmedication, inadequate time for evaluation, quick med checks with no regard for outcome, and administration of ECT on even the most demented elderly with the hope it will keep them well. A new option—the vagus nerve stimulation system—and another one expected to be approved soon—transcranial magnetic stimulation—will probably be overused as well.Where is the limit? What happened to medical ethics and the Hippocratic Oath? I am sure I will encounter the wrath of my colleagues as I raise these questions, but I am willing to accept the consequences. Having resigned from managed care panels and Medicare, I am free as a bird doing the work I enjoy, albeit with meager remuneration since fees figured on a sliding-scale basis have been declining along with the economy.There are many reasons for the trends I described, and the most important is the financial crunch created by managed care organizations and physicians who want to make the most money in the least amount of time. Procedures come in handy to boost income. The patient's psyche gets scant attention, and sometimes patients are advised to seek therapy elsewhere. This is a sad situation, but I have hope it can be rectified if enough physicians speak up.Binghamton, N.Y. ISSUES NewArchived

Clinical and cerebral blood flow changes in catatonic patients treated with ECT

Objective: To determine changes in clinical manifestations and cerebral blood flow (CBF) before and after administration of ECT to patients with catatonia due to schizophrenia or mood disorders. Methods: A sample of nine patients who met DSM-IV criteria for catatonia was studied. Patients received between 5 and 15 sessions (thrice per week) of ECT. Severity of catatonia was measured with the Modified Rogers Scale (MRS). Changes in CBF were measured with a brain single positron emission computer tomography (SPECT) that was performed 1 week before the first ECT and 1 week after the last ECT. Results: Catatonia was due to schizophrenia in five patients and mood disorders in four patients. There were no significant clinical and brain SPECT differences between these two groups before treatment. Pre- vs. post-ECT comparisons showed significant reduction of catatonic symptoms in both groups. However, patients with mood disorders needed less ECT sessions and showed greater clinical improvement. Brain SPECT showed significant increase in CBF in parietal, temporal, and occipital regions in patients with mood disorder and no significant changes in patients with schizophrenia. Conclusions: These results support the efficacy of ECT for treatment of catatonic patients, especially secondary to mood disorders, which seem to be correlated with improvements in CBF.

ECT FOR PATIENTS WITH DEMENTIA AND AGITATION

Purpose: To identify community standards for the administration of ECT to patients with agitation and dementia. Abstract: Though the primary indications for ECT are major affective disorder in cognitively intact individuals, there is growing experience in the use of ECT in older adults with more clinically ambiguous illnesses. This clinical dialogue focuses on the use of ECT with agitated patients with dementia. The author presents a synopsis of the research literature and then explores how the participants are using this intervention in this context.

A retrospective audit of electroconvulsive therapy at King Khalid University Hospital, Saudi Arabia

The case records of patients receiving ECT at King Khalid University Hospital over a 10-year period were reviewed for all aspects of ethical and technical administration of ECT. The audit of 127 patients showed some deficiencies in the early years: no seizure monitoring, no training or education for staff (particularly psychiatrists and anaesthetists), and the use of atropine as a premedication for all patients. Recently, regular education and staff training have been organized and seizure timing regularly monitored. Use of an ECT machine with EEG monitoring and the systematic and scaled monitoring of complications is recommended. Results show the necessity of ECT auditing, including an unbiased external audit for effective monitoring of the practical administration of ECT. Similar audits in other mental health institutions in Saudi Arabia are recommended.