The efficacy of ECT in phencyclidine-induced psychosis

Four patients are described who had a history of PCP abuse, prolonged psychosis, and poor neuroleptic response. Three of these patients were given ECT; all showed a dramatic response after the third or fourth treatment. The authors recommend that ECT be tried in psychotic patients who have used PCP if they fail to respond to antipsychotic medications after 1 week of inpatient treatment.     

Phencyclidine in CSF and serum: a case of attempted filicide by a mother without a history of substance abuse

A previously healthy 30-year-old black woman with no history of substance abuse was hospitalized after she attempted to drown her 4-year-old son. She had become progressively confused and delusional after a flu-like illness 2 weeks before. Serum and lumbar CSF samples assayed for phencyclidine (PCP) by gas chromatography-mass spectrometry with d5 PCP as an internal standard were positive. The patient recovered rapidly after treatment with haloperidol and acidification of her urine. Suspicion of PCP abuse should remain high among patients with psychosis, even for those with no history of substance abuse.     

Maintenance electroconvulsive therapy (ECT) for treatment-resistant disorganized schizophrenia

Patients who have not responded to recommended antipsychotic medications should be considered for electroconvulsive therapy (ECT). However, there has been controversy about the standardized methods of continuation and maintenance ECT in the management of treatment-resistant schizophrenia. We describe a patient with a serious case of disorganized schizophrenia who had not responded well with any typical and atypical antipsychotic drug for seven years, but responded remarkably to acute ECT. Continuation ECT was necessary to sustain a positive therapeutic response. The patient showed dramatic improvement from 70 to 20 in the 18-item Brief Psychiatric Rating Scale (BPRS) score (71% reduction) after acute ECT and continuation ECT. Using maintenance ECT, she was able to live in the custody of her parents after 7-years hospitalization. This case report suggests that continuation and maintenance ECT benefits patients with serious cases of refractory schizophrenia.     

Metabolic correlates of antidepressant and antipsychotic response in patients with psychotic depression undergoing electroconvulsive therapy

OBJECTIVES: Although electroconvulsive therapy (ECT) is a very effective treatment of depression and psychosis, the mechanisms by which this occurs are not fully delineated. The objective of this study was to investigate the functional alterations in brain metabolism in response to ECT through the use of positron emission tomography assessment of cerebral glucose metabolism before and after a course of ECT. METHODS: Ten subjects with psychotic depression were studied with positron emission tomography using [F]fluorodeoxyglucose before and between 2 and 3 weeks after a course of ECT. Statistical parametric mapping and region of interest analyses of the anterior cingulate cortex (ACC) subregions (dorsal, rostral, subcallosal, and subgenual) and hippocampus were used to determine glucose metabolic changes from ECT. The Hamilton Depression Rating Scale and the Scale for Assessing Positive Symptoms were the primary measures used for assessing clinical changes from ECT. RESULTS: Electroconvulsive therapy led to significant increases in the left subgenual ACC and hippocampal metabolism, which were directly correlated with each other and to a reduction in depression as measured by total Hamilton Depression Rating Scale scores. Better antidepressant responders had increased, whereas poorer responders had a decreased left subgenual ACC and hippocampal metabolism. The decrease in positive symptoms was also correlated with increased left hippocampal metabolism. CONCLUSIONS: The antidepressant effect of ECT was correlated with increased metabolism in the left subgenual ACC and hippocampus, whereas the antipsychotic effect of ECT was only correlated with increased left hippocampal metabolism. This finding has implications to better understand the mechanism of antidepressant and antipsychotic effects of ECT.     

The treatment of hallucinations in schizophrenia spectrum disorders

This article reviews the treatment of hallucinations in schizophrenia. The first treatment option for hallucinations in schizophrenia is antipsychotic medication, which can induce a rapid decrease in severity. Only 8% of first-episode patients still experience mild to moderate hallucinations after continuing medication for 1 year. Olanzapine, amisulpride, ziprasidone, and quetiapine are equally effective against hallucinations, but haloperidol may be slightly inferior. If the drug of first choice provides inadequate improvement, it is probably best to switch medication after 2-4 weeks of treatment. Clozapine is the drug of choice for patients who are resistant to 2 antipsychotic agents. Blood levels should be above 350-450 μg/ml for maximal effect. For relapse prevention, medication should be continued in the same dose. Depot medication should be considered for all patients because nonadherence is high. Cognitive-behavioral therapy (CBT) can be applied as an augmentation to antipsychotic medication. The success of CBT depends on the reduction of catastrophic appraisals, thereby reducing the concurrent anxiety and distress. CBT aims at reducing the emotional distress associated with auditory hallucinations and develops new coping strategies. Transcranial magnetic stimulation (TMS) is capable of reducing the frequency and severity of auditory hallucinations. Several meta-analyses found significantly better symptom reduction for low-frequency repetitive TMS as compared with placebo. Consequently, TMS currently has the status of a potentially useful treatment method for auditory hallucinations, but only in combination with state of the art antipsychotic treatment. Electroconvulsive therapy (ECT) is considered a last resort for treatment-resistant psychosis. Although several studies showed clinical improvement, a specific reduction in hallucination severity has never been demonstrated.     

Improvement of cycloid psychosis following electroconvulsive therapy

Background: The treatment of choice for cycloid psychosis has traditionally been electroconvulsive therapy (ECT), but there is a lack of studies on its effectiveness.

Aims: The primary aim of this register study was to determine the rates of remission and response after ECT for cycloid psychosis. The secondary aim was to examine possible predictors of outcome.

Methods: Data were obtained from the National Quality Register for ECT in Sweden. The study population was patients (n?=?42) who received ECT for acute polymorphic psychotic disorder without symptoms of schizophrenia or for cycloid psychosis between 2011–2015 in 13 hospitals. Remission and response rates were calculated using Clinical Global Impression-Severity (CGI-S) and -Improvement scores, respectively. Variables with possible predictive value were tested using Chi-square and Fisher’s exact test.

Results: The response rate was 90.5%. The remission rate was 45.2%. Of 42 patients, 40 improved their CGI-S score after ECT (p?p?=?0.010). The mean number of ECT treatments did not differ significantly between remitters and non-remitters (7.2 vs 6.1, p?=?0.31). None of the other investigated potential predictors was statistically significantly associated with outcome.

Conclusions: ECT is an effective treatment for cycloid psychosis. Future studies need to compare the outcome of ECT to that of other treatment strategies. Clinical implications: The high response rate with ECT indicates that cycloid psychosis is a clinically useful diagnosis.     

Evidence Base for Using Atypical Antipsychotics for Psychosis in Adolescents

Atypical antipsychotic medications have been the first line of treatment for adolescents with psychosis in the past couple of decades. Till the late 90s, there were very few randomized controlled trials (RCTs) on the treatment of adolescents with psychosis, although a fifth of schizophrenia starts during adolescence. Most of the treatment guidelines for adolescents with psychosis were derived from data on adults. In the past 10 years, there has been increasing number of studies on adolescents with psychosis. The current paper summarizes the findings of trials on adolescents with psychosis in 4 groups: (a) atypical antipsychotic medications vs placebo, (b) atypical antipsychotic medication vs typical antipsychotic medications, (c) one atypical antipsychotic medication vs another atypical antipsychotic medication, and (d) Low dose vs standard dose of atypical antipsychotic medication. We included 13 RCTs, with a total of 1112 participants. Although our review suggest that atypical antipsychotic medications are as effective as typical antipsychotic medications as regards clinical efficacy, atypical antipsychotic medications have a preferred side effect profile and lesser drop-out rate from trials. Obviously, this is extremely important as treatment adherence is key to successful remission of psychotic symptoms and also in some case prevent relapse of illness. Treatment with olanzapine, risperidone, and clozapine is often associated with weight gain. Aripiprazole is not associated with increased prolactin or with dyslipidemia. Adolescents may respond better to standard-dose as opposed to lower dose risperidone, but for aripiprazole and ziprasidone, lower doses may be equally effective. Future trial should be longer term and have uniform ways of reporting side effects.Key words: atypical antipsychotic, medications, adolescents, psychosis, systematic review, meta-analysis, young people, pharmacology, schizophrenia     

Clozapine in schizophrenia patients with recurrent catatonia: report of two cases

Prolonged catatonia can be a source of extremely serious morbidity and mortality. Lorazepam is effective in rapidly relieving most cases of catatonia. Reports have also shown that second-generation antipsychotic drugs are also efficacious in relieving catatonia. This report describes two schizophrenia patients who demonstrated recurrent catatonic features mutism and stupor. Both patients were treated with lorazepam, diazepam or electroconvulsive therapy (ECT). Patient 1 responded well and rapidly to lorazepam each time catatonia happened; but catatonia recurred once a year under treatment with many antipsychotic drugs. Patient 2 had catatonia features associated with discontinuing or decreasing clozapine. With each recurrent episode, the duration of catatonia increased, requiring an increased dosage of benzodiazepine. The patient's response to lorazepam and ECT gradually decreased, until the patient had almost no response to lorazepam, diazepam or ECT. Both patients had no recurrence during a period of 2-year follow up with continuous clozapine therapy.     

Augmentation of haloperidol by ascorbic acid in phencyclidine intoxication

The authors studied 40 white men with acute phencyclidine (PCP) intoxication. On a random basis, 10 were treated with ascorbic acid, 10 with placebo, 10 with haloperidol, and 10 with a combination of ascorbic acid and haloperidol. While haloperidol was significantly more effective than ascorbic acid, the combination was significantly more effective than either used alone. This combination may have a specific antipsychotic role in the emergency treatment of PCP psychosis.     

Successful use of continuation electroconvulsive therapy in a case of late-onset Leonhard's confusion psychosis

A 56-year-old married woman with late-onset Leonhard's confusion psychosis was treated successfully with acute electroconvulsive therapy (ECT) after failing to respond to antidepressants, neuroleptics, and benzodiazepines. Symptoms relapsed within 1 year despite the combined use of olanzapine and paroxetine. The patient responded to a second course of acute ECT, but a second relapse occurred within 3 months despite her use of olanzapine and paroxetine. The symptoms resolved with continuation ECT and lithium combined with paroxetine after response to a third course of acute ECT. To date, relapse has been prevented for 2 years. Continuation ECT and lithium combined with paroxetine after response to acute ECT may be effective in maintaining remission of Leonhard's confusion psychosis.     

Electroconvulsive Therapy and Neuroleptic Medication in Therapy-Resistant Positive-Symptom Psychosis

Eight patients with persistent psychosis and positive symptoms, who had not improved with at least two courses of neuroleptic medications, were treated with electroconvulsive therapy (ECT) combined with an antipsychotic medication. Seven of the eight patients improved; the improvement was sustained in five patients after 6 and 12 months. ECT and neuroleptic drugs appear to be synergistic in antipsychotic activity. This enhancement may result from greater brain levels of neuroleptic drugs secondary to increased permeability of the blood-brain barrier accompanying seizures. Our experience is consistent with other recent clinical reports, and encourages trials of ECT combined with neuroleptic medications in therapy-resistant psychotic patients, including those classified as having schizophrenic disorders.     

Utility of electroshock therapy in epilepsy-associated psychosis

Psychiatric disorders which indicate the use of electroconvulsive therapy (ECT) also occur in epileptic patients, but there is a lack of medical authority concerning the use of ECT in epileptic patients. This is surprising because in recent years it has been proved that ECT has an anti-convulsive effect to some degree. A case study of an epileptic patient is presented whose progress has been monitored for several years. Antiepileptic drugs were seemingly able to control his epilepsy but at the same time progressive behavioural disturbance (schizophreniform psychosis) accompanied by agitation and violent behaviour developed. Considering the recurrent psychotic decompensations and the relative ineffectiveness of antipsychotics, the authors decided to administer ECT. As a result they were able to bring about the longest symptom free balanced period in the patient. According to the data based on previous medical studies and the experience they can suppose that ECT is not immediately contraindicated by the presence of epilepsy with active interictal focus if the psychopathological condition makes it necessary. In view of the epileptogenic risk factors of classical neuroleptics, the epileptogenic effects of accompanying psychosis and the probable anticonvulsive potential of ECT in cases of severe psychiatric complications accompanying epilepsy ECT could be used more frequently.     

Is clinical intervention in the ultra high risk phase effective?

Recent research suggests that early intervention in psychosis might improve the chances of recovery and may even be able to prevent the onset of psychotic disorders. Clinical intervention in subjects at ultra high risk (UHR) of psychosis can have three different objectives. The first aim is to improve the 'prodromal' symptoms and problems that subjects usually present with. The second is to reduce the risk of the subsequent onset of frank psychosis. The third objective is to minimize the delay before the initiation of antipsychotic treatment in the subgroup of UHR subjects that go on to develop a first episode of psychosis. Both pharmacological and psychological interventions appear to be effective in reducing the severity of presenting symptoms in UHR subjects. Clinical trials of the impact of these interventions on the risk of subsequent transition to psychosis have been positive, but have involved small samples, and thus the issue of whether the effects persist in the long term remains to be determined. The monitoring of UHR subjects for the first signs of frank psychosis is an effective means of reducing the delay between the onset of the first episode and the start of antipsychotic treatment. Follow-up studies are required to test whether the reduction in this delay leads to an improved long term outcome. To date, the majority of the interventions that have been used in UHR subjects, such as case management, antipsychotic medication, and cognitive behavior therapy have previously been employed in patients with established psychosis. However, it is possible that treatments that are not normally used in patients with psychotic disorders may prove effective when applied at this stage.     

Uni- Versus Bilateral ECT in the Treatment of Mania

Recent reports have challenged the assumption that unilateral and bilateral electroconvulsive therapy (ECT) are equally effective in all cases. In a prospective study, hospitalized manic patients were randomly assigned to treatment with either lithium or ECT. The first six patients received nondominant unilateral treatment but failed to respond. However, they rapidly remitted when switched to bilateral ECT. Accordingly, the next 11 manic patients to receive ECT were assigned to bilateral treatment. They were compared with the first six patients on weekly ratings of mania and other psychopathology. Both ECT groups improved but therapeutic responses were delayed until after switchover to bilateral treatment in the patients who began with unilateral ECT. We conclude that patients in the manic state should receive bilateral rather than unilateral ECT.     

ECT in elderly patients with schizophrenia.

Five female patients with chronic schizophrenia and schizoaffective disorder received electroconvulsive therapy (ECT). Patients were 58 to 74 years old when ECT began. Three patients followed the acute course of ECT with a course of maintenance ECT. Four patients were considered treatment-resistant to medication. One patient objected to any use of medication and opted for ECT when she became psychotic. Four patients received concurrent antipsychotic medication during and after the course of ECT. All five patients experienced improvement in their psychosis.     

Treating Psychotic Symptoms in Elderly Patients

Research has shown that elderly patients are especially at risk for the development of psychotic symptoms. A combination of factors contributes to the increased risk for psychosis in this patient population. Various DSM-IV diagnostic categories including delirium, schizophrenia, delusional disorder, mood disorders, dementia, substance abuse, and medical-neurologic conditions can be associated with psychotic symptoms. In general, medications are prescribed for specific target symptoms, started at low doses, and titrated gradually. Although buspirone, trazodone, valproic acid, and carbamazepine have been used with some success, antipsychotic medications have been the primary treatment of psychosis in the elderly. Because the atypical antipsychotics offer effective management of psychotic symptoms combined with low liability of extrapyramidal symptoms, these agents may be the current treatment of choice for psychotic symptoms in the elderly when used cautiously.     

Successful ECT in a case of Leonhard's cycloid psychosis

In Leonhard's nosological system, acute, episodic psychoses with good short-term and long-term prognoses, characterized by mixed affective and schizophrenic features, confusion, and alternating psychomotor retardation and excitement are called cycloid psychoses. According to clinical lore, patients with cycloid psychoses show an excellent and prompt response to electroconvulsive therapy (ECT). We describe a patient with typical motility psychosis, a subtype of cycloid psychoses, who failed to respond to a combination of antipsychotic and benzodiazepine medication but quickly recovered after the administration of ECT.     

Neural basis of the potentiated inhibition of repeated haloperidol and clozapine treatment on the phencyclidine-induced hyperlocomotion

Clinical observations suggest that antipsychotic effect starts early and increases progressively over time. This time course of antipsychotic effect can be captured in a rat phencyclidine (PCP)-induced hyperlocomotion model, as repeated antipsychotic treatment progressively increases its inhibition of the repeated PCP-induced hyperlocomotion. Although the neural basis of acute antipsychotic action has been studied extensively, the system that mediates the potentiated effect of repeated antipsychotic treatment has not been elucidated. In the present study, we investigated the neuroanatomical basis of the potentiated action of haloperidol (HAL) and clozapine (CLZ) treatment in the repeated PCP-induced hyperlocomotion. Once daily for five consecutive days, adult Sprague-Dawley male rats were first injected with HAL (0.05 mg/kg, sc), CLZ (10.0 mg/kg, sc) or saline, followed by an injection of PCP (3.2 mg/kg, sc) or saline 30 min later, and motor activity was measured for 90 min after the PCP injection. C-Fos immunoreactivity was assessed either after the acute (day 1) or repeated (day 5) drug tests. Behaviorally, repeated HAL or CLZ treatment progressively increased the inhibition of PCP-induced hyperlocomotion throughout the five days of drug testing. Neuroanatomically, both acute and repeated treatment of HAL significantly increased PCP-induced c-Fos expression in the nucleus accumbens shell (NAs) and the ventral tegmental area (VTA), but reduced it in the central amygdaloid nucleus (CeA). Acute and repeated CLZ treatment significantly increased PCP-induced c-Fos expression in the ventral part of lateral septal nucleus (LSv) and VTA, but reduced it in the medial prefrontal cortex (mPFC). More importantly, the effects of HAL and CLZ in these brain areas underwent a time-dependent reduction from day 1 to day 5. These findings suggest that repeated HAL achieves its potentiated inhibition of the PCP-induced hyperlocomotion by acting on the NAs, CeA and VTA, while CLZ does so by acting on the mPFC, LSv and VTA.     

The use of electroconvulsive therapy in postpartum affective disorders

Postpartum affective disorders continue to be a major health issue for women. There is a general belief that electroconvulsive therapy (ECT) is effective in treating severe or treatment-refractory postpartum affective illnesses, but evidence to support this assertion is lacking. In this case series, we present 5 cases of women with postpartum depression and psychosis, all of whom had failed prior pharmacological therapy. All 5 women had a significant response within 3 to 6 treatments with ECT. Our findings suggest that ECT is overall an effective treatment of postpartum illnesses. In addition to being an excellent choice for women who have failed prior medication trials, ECT may also be considered for women whose severity of illness necessitates rapid symptom resolution.     

Neuroleptic-induced supersensitivity psychosis: retrospective study of schizophrenic inpatients

Chouinard has suggested that a significant number of schizophrenic outpatients may rapidly relapse after discontinuing or abruptly reducing antipsychotic drugs, and he has hypothesized that this relapse reflects a supersensitivity psychosis related to mesolimbic postsynaptic dopamine supersensitivity caused by drug therapy. Using Chouinard's criteria, the authors found 12 probable but no definitive cases of this syndrome while conducting a chart review of 265 hospitalized schizophrenic patients. Six of the 12 patients were subsequently rediagnosed as schizoaffective. Four patients had tardive dyskinesia, but this condition did not worsen after the drug dosage was decreased. Although supersensitivity psychosis was not common among this population, further study of the syndrome is needed to determine if neuroleptics are causing a subgroup of patients to relapse early or if the early relapses are a manifestation of the natural course of illness in these patients.