The combined use of bupropion, lithium, and venlafaxine during ECT: a case of prolonged seizure activity

There is limited literature addressing the safety of administering electroconvulsive therapy (ECT) to patients concomitantly receiving bupropion monotherapy or in combination with other drugs that may alter the seizure threshold. We describe a prolonged seizure occurring during the first treatment of a course of ECT in an adult patient receiving long-term bupropion therapy, lithium, and venlafaxine.     

Seizure threshold estimation by formula method: a prospective study in unilateral ECT

Formula methods of estimating seizure threshold in bilateral electroconvulsive therapy (ECT) have been successful in 75% (at the first ECT) and 80% (at the sixth ECT) of treatments (Gangadhar et al., 1998). This study showed the same results for unilateral (UL) ECT patients. Its aim was to compare formula and titration methods for threshold determination. The seizure threshold (dependent variable) was determined by the titration method used at the first ECT in consecutive consenting patients (n = 80) prescribed UL ECT under general anesthesia. The independent variables were age, gender, diagnosis, illness severity, concurrent drugs, head circumference, and inion-nasion distance. Forward, step-wise, linear regression analysis showed age as the only significant predictor of seizure threshold (15% of variance). A formula based on regression analysis was prospectively applied in an independent sample (n = 30) of patients receiving UL ECT using the titration method for threshold determination. The results calculated a higher threshold than the actual threshold used in 14 patients, a threshold level in 8 patients, and below threshold in 8 patients. Formula-based estimates would have been successful in 22 (73%) patients, but the majority of them would have received higher than the recommended stimulus dose. Titration is the method preferred for clinical use. However, if a patient's doctor wishes to use the formula-based method, he or she should do so with specific considerations.     

文拉法辛合并舒必利治疗精神分裂症对照研究

目的:探讨文拉法辛合并舒必利治疗精神分裂症的疗效和安全性。方法:将68例精神分裂症患者随机分为研究组与对照组,研究组给予文拉法辛合并舒必利治疗,对照组用利培酮治疗,疗程8周,用阳性与阴性症状量表(PANSS)、简明精神病评定量表(BPRS)以及治疗中出现的症状量表(TESS)评定疗效和安全性。结果:治疗8周研究组总有效率为88.24%,对照组为67.65%,两组比较差异有统计学意义(P<0.05)。治疗后两组PANSS及BPRS评分均有明显下降(P<0.05或P<0.01),研究组下降更显著(P<0.05)。结论:文拉法辛合并舒必利治疗精神分裂症阴性与阳性症状疗效可靠,不良反应小。     

文拉法辛联合奋乃静治疗伴有精神病性症状的抑郁症对照研究

目的 探讨文拉法辛(venlafaxine)联合奋乃静治疗伴有精神病性症状抑郁症的疗效及其安全性。方法 将64例伴有精神病性症状的抑郁症随机分配至研究组和对照组各32例。研究组予以文拉法辛联合奋乃静治疗,对照组予以阿米替林联合奋乃静治疗。文拉法辛及阿米替林的治疗剂量均为100～200mg/d,奋乃静为12～24mg/d,观察时间均为6周。疗效评定采用HAMD、BPRS及CGI。安全性评价采用TESS、实验室检查及体检。结果 治疗第6周末,对抑郁症状,研究组显效率为65.6％,有效率为87.5％,与对照组的59.4％及84.4％相近;对精神症状,研究组显效率为68.8％,有效率为87.5％,亦与对照组的68.8％及90.6％相近,差别均无显著性意义(P>0.05)。研究组常见不良反应为恶心呕吐、口干、便秘、出汗及静坐不能等,不良反应程度均轻微,病人依从性好。结论 文拉法辛联合奋乃静治疗伴有精神病性症状的抑郁症疗效肯定,且不良反应较少,病人依从性好。     

Seizure parameters in depressed patients receiving electroconvulsive therapy: a pilot study

Although the seizure is generally considered responsible for the clinical efficacy of electroconvulsive therapy (ECT), its specific role remains unclear. Reviewing the literature on seizure parameters in ECT, Fink¹ noted that many variables may influence the seizure, such as the patient's diagnosis, method of administration of the treatment, and drugs that the patient is receiving. The relationship between seizure duration and outcome remains unclear. Short seizures are thought to be less efficacious than longer seizures, but this point has not been thoroughly documented. Ottosson² observed that the duration of the grand mal seizure per se was not related to efficacy, but the duration of the lidocaine modified portion of the seizure had a direct relationship to the efficacy of ECT. Thus, he concluded that diencephalic spread of the seizure was necessary for efficacy in ECT. Recently, Maletzky³ studied 110 patients receiving multiple-monitored ECT (MMECT). These patients had a mean age of 45.4 yr, and a mean seizure duration of 85.1 sec. Improvement did not occur until they had a cumulative total of 210 sec of seizure. Above 1000 sec of cumulative seizure time, no further improvement was likely to be seen. This was the first attempt at structuring a dose response curve for ECT based on seizure time. Previously, the measure of the amount of treatment a patient received was based on the number of treatments.In the following pilot study, we attempted to look at the individual as well as the cumulative seizure parameters in patients receiving ECT.     

齐拉西酮联合文拉法新治疗难治性抑郁症对照研究

目的探讨齐拉西酮联合文拉法新治疗难治性抑郁症的疗效和安全性。方法将84例难治性抑郁症患者随机分为2组,研究组应用齐拉西酮联合文拉法新,对照组单用文拉法新,观察8周。第2、4、8周末采用汉密尔顿抑郁量表（HAMD）、汉密尔顿焦虑量表（HAMA）评定疗效,副反应量表（TESS）评定不良反应。结果 2组在第2周末HAMD和HA-MA评分较治疗前均显著下降（P〈0.05）,研究组更为明显（P〈0.01）。至第8周末研究组有效率88.10%,对照组66.67%,研究组明显高于对照组（P〈0.05）。不良反应两组间无明显差异（P〉0.05）。结论齐拉西酮联合文拉法新治疗难治性抑郁症,疗效明显优于单一应用文拉法新治疗起效快,不良反应轻,安全性好。     

Neurotrophic factors in serum following ECT: A pilot study

We examined changes in serum levels of a selection of neurotrophic factors, TSH, HGH and cortisol in conjunction with ECT treatment. Fifteen patients suffering from affective disorders were included, all were treated with antidepressants and psychotherapy and 10 also with ECT. The patients were examined clinically and with blood samples during treatment. Serum levels of cortisol, thyroid stimulating hormone (TSH), nerve growth factor (NGF), brain-derived neurotrophic factor (BDNF), neurotrophin-3 (NT3), neuropetide Y (NPY) and human growth hormone (HGH) were studied. No significant changes were found in levels of NGF, BDNF, NT3, HGH and TSH. A change in NPY levels was statistically significant, but of uncertain clinical value as it affected only two patients. Levels of cortisol rose significantly during treatment. We did find significant correlations between the base values of NGF and HAM-D scores at inclusion and between the end-values of NT3 and NPY and the HAM-D scores prior to discharge. We were unable to reproduce findings from animal studies suggesting that a range of neurotrophic factors rise during ECT treatment. This may be because of physiological differences between animals and humans or, possibly, a result of the small number of patients included in this pilot study.     

Seizure models: anticonvulsant effects of ECT and rTMS

1. 1. A variety of enzymes, peptides, neurotrophic factors and their receptors show complex cascades of alterations with amygdala-kindled seizure progression; some represent compensatory adaptations that could become new targets of therapeutics.

2. 2. Non-convulsant brain stimulation with repetitive transcranial magnetic stimulation (rTMS) may be able to engage some of the neuro-adaptive effects of ECT without the necessity of inducing a seizure.

3. 3. Data from preclinical and clinical studies raise the possibility that non-convulsant stimulation achieved by high or low frequency rTMS may be able to alter neurotransmitters, neuropeptides, and neurotrophic factors, leading to frequency- and region-dependent changes in neural excitability.

4. 4. Individual depressed patients show differential responses to two weeks high vs. low frequency rTMS, as revealed by the inverse correlation of degree of improvement in depression achieved by these two frequencies.

5. 5. Preliminary data from rTMS and positron emission tomography (PET) studies reveal moderately sustained differential effects of rTMS frequency on regional cerebral neural activity in depressed patients.

6. 6. These data suggest the possibility that an individual's level of baseline rCBF or rCMRglu on PET would help predict which rTMS frequency might be the most appropriate treatment for their depression.

     

文拉法新缓释片合并认知行为疗法治疗广泛性焦虑症效果观察

目的探讨文拉法新缓释片合并认知行为疗法治疗广泛性焦虑症(GAD)的临床效果。方法采用随机数字表法将92例符合《中国精神障碍分类与诊断标准(第3版)》(CCMD-3)的GAD患者分为研究组和对照组各46例,研究组给予文拉法新合并认知行为疗法治疗,对照组给予文拉法新治疗,疗程8周。所有患者均采用汉密尔顿焦虑量表(HAMA)评定疗效。结果治疗2周后,研究组HAMA总评分与治疗前比较差异有统计学意义(P0.01),4周后对照组HAMA总评分与治疗前比较差异有统计学意义(P0.01);治疗后4、6、8周末两组HAMA总评分差异有统计学意义(P0.01)。治疗8周后研究组与对照组有效率分别为93.0%和78.3%,差异有统计学意义(χ2=3.93,P0.05)。结论文拉法新合并认知行为疗法的起效时间和疗效可能均优于单用文拉法新治疗。     

Seizure threshold in ECT: effect of stimulus pulse frequency

SUMMARY: Stimulus parameters, such as pulse width, frequency, and stimulus train duration, affect seizure threshold in electroconvulsive therapy (ECT), although variably. This study examined the effect of low- and high-pulse frequencies of stimulus on seizure threshold and physiological responses to ECT. Twenty-four consenting inpatients prescribed ECT by the treating psychiatrist received bilateral ECT. Threshold was reassessed at second and third ECT sessions in a crossover design. In the second ECT the pulse frequency was randomly either 50 pulses per second (PPS; n=13) or 200 PPS (n=11). In the third ECT, the same was reversed. The seizure threshold and number of subconvulsive stimulations were significantly lower with 50 PPS compared with 200 PPS. There was no significant difference in the cardiovascular responses between the two groups. Lower stimulus frequency is more efficient in inducing a seizure (smaller threshold) without compromising the physiological responses to ECT. Clinical effects of different doses of ECT stimulus must also consider the role of charge rate (frequency of pulses).     

ECT: Clinical Variables, Seizure Duration, and Outcome

The ability to predict treatment response in patients administered electroconvulsive therapy remains limited. Variables such as the duration of the individual seizure or the cumulative seizure duration have been reported to relate to outcome in a "threshold" or "therapeutic window" model. In this study, total seizure time, as measured by bifrontal electroencephalogram (EEG) electrodes, did correlate with outcome (r(s) = 0.43, p < 0.01). In addition, 88% of patients with a cumulative seizure time exceeding 300 s responded favorably (chi(2) = 6.80, p < 0.01). This provides support for the concept of a minimum threshold of accumulated seizure time necessary for clinical response. However, no evidence of an upper limit of benefit suggesting a "therapeutic window" was found.     

The effects of ECT on brain glucose: a pilot FDG PET study

BACKGROUND: Regional brain activity was measured before and after electroconvulsive therapy (ECT) using [18F]-fluorodeoxyglucose (FDG) positron emission tomography (PET). METHODS: 6 patients (4 females) with major depression were free of psychotropic medications for at least 2 weeks prior to baseline FDG scans. Patients were treated with bifrontotemporal ECT, and posttreatment scans were obtained after the last treatment. RESULTS: A region of interest (ROI) analysis of absolute metabolic rate showed a decrease in CMRglu after ECT in all 61 regions examined. In 17 of the 61 regions, the decrease was significant at the p < 0.05 level. In the right parietal lobe, and the right anterior and left posterior frontal lobes, the decrease in CMRglu significantly correlated with the decrease in Hamilton Depression Rating Scale (HDRS) scores (r = 0.83, 0.82, and 0.84, respectively). The analysis of CMRglu normalized to global metabolic rate showed significant increases in 8 of 61 regions, including basal ganglia, upper brainstem, and occipital lobe. DISCUSSION: The decreases in global glucose metabolism and correlation of changes in frontal metabolism with decreases in HDRS are consistent with earlier brain imaging studies of ECT. The relative increases in CMRglu observed in regions with known dopaminergic innervation (caudate and upper brainstem) have not been previously reported.     

Intensive early physiotherapy combined with dexamphetamine treatment in severe stroke: a randomized, controlled pilot study

BACKGROUND: The most severely disabled stroke patients are often excluded from studies evaluating effects of physiotherapy. This study intended to investigate the effect of an increased intensity of physiotherapy in combination with dexamphetamine the first week after ischemic stroke in patients with an impaired level of consciousness and severe motor dysfunction. METHODS: Thirty patients were enrolled within 96 h after onset of symptoms. Patients were randomized to 30-45 min of physiotherapy twice daily or to maximally 15 min per day for 5 days. All patients received dexamphetamine to achieve alertness. Functional outcome measures were assessed at baseline, the day after treatment discontinuation, and 3 and 12 months after stroke onset. Residence of living was registered at long-term follow-ups. RESULTS: No statistically significant differences were seen between groups in the outcomes measured at any time point. However, both groups improved over time in all outcomes at 3 and 12 months (p < 0.05), except for sensory functions at 3 months and motor functions at 12 months. The number of patients needed to treat (NNT) to achieve the desired improvement in Lindmark motor score was 8, with the 95% CI being NNT(harm) 10 to NNT(beneficial) 3. The fraction of patients who died was the same in both treatment groups, 47% (95% CI 28-65%). CONCLUSIONS: An increased intensity of physiotherapy in combination with dexamphetamine during the first week after stroke onset did not affect short- or long-term outcome in this limited sample of patients with severe stroke.     

ECT in the treatment of mania: a controlled study.

In a chart review study of manic patients, the author found that ECT remarkably improved outcome variables of condition at discharge, duration of hospitalization, and social recovery in comparison with an untreated matched control group. More conclusive evidence would depend on a prospective trial with random assignment of manic patients to ECT, lithium carbonate, and major tranquilizers and blind evaluation of outcome.     

长春西汀对抑郁症的辅助治疗作用

目的：探讨文拉法辛联合长春西汀对复发性抑郁症的疗效和不良反应。方法：复发性抑郁症患者78例,按就诊及确诊顺序编号,单号为合用组（文拉法辛联合长春西汀）;双号为单用组（单用文拉法辛）。疗程4周。采用汉密尔顿抑郁量表（HAMD）和治疗中出现的症状量表（TESS）评定疗效和不良反应。结果：两组HAMD评分均较治疗前显著下降（P〈0.01）;治疗4周,以合用组HAMD评分显著低于单用组（P〈0.01或P〈0.05）。两组不良反应差异无显著性（P〉0.05）。结论：文拉法辛联合长春西汀治疗抑郁症的效果优于单用文拉法辛,长春西汀对复发性抑郁症有辅助治疗作用。     

Effects of ECT on brain structure: a pilot prospective magnetic resonance imaging study

The authors describe a pilot prospective investigation of the effects of ECT on brain structure using magnetic resonance imaging (MRI). In nine patients with major depression, a course of ECT produced no acute changes in brain structure according to blind raters' assessments of cortical atrophy and global comparison of pre- and post-ECT studies. There were also no significant changes in the ventricle-brain ratios. Pre-ECT brain abnormalities were common in these patients yet were also unaffected by ECT. Future MRI studies of ECT should include more subjects and should address long-term changes and subtle brain abnormalities.     

EEG-Monitored ECT: A Comparison of Seizure Duration under Anesthesia with Etomidate and Thiopentone

Electroencephalogram-monitored electroconvulsive therapy (ECT) was carried out in 20 depressed inpatients. Before treatment, patients were randomly allocated to treatment using etomidate (Hypnomidat) (n = 10) or thiopentone (n = 10) for anesthesia. The groups were matched for sex, age, weight, and type and severity of depression. The seizure duration (seconds) was measured by electroencephalography (EEG), and the electrical energy (Joules, J) was determined for each treatment. A ratio of seizure duration:electrical energy (s/J) was computed. Both seizure duration and seizure duration:electrical energy were greater in the etomidate group than in the thiopentone group, whereas electrical energy did not differ significantly. The number of treatments in the etomidate group did not differ from that in the thiopentone group, as may be expected, perhaps because of the small size.     

Resting electrocortical activity in adults with dysfunctional anger: a pilot study

Although dysfunctional anger is not a DMS diagnosis, some individuals present with dysfunctional anger, to the exclusion of other psychiatric disorders, as the primary clinical feature. However, our understanding of the neural basis of dysfunctional anger is limited. Though previous work has examined electroencephalographic (EEG) activity in individuals with high trait anger, and in youth with disorders consistent with dysfunctional anger, no studies have assessed EEG activity in adults with dysfunctional anger. This study examined resting EEG by way of relative power in the beta and alpha bands, as well as absolute frontal and parietal alpha(1/2) asymmetry, in 15 adults with psychiatrist-assessed and psychometrically rated dysfunctional anger (Anger) and 14 control participants (Control). The Anger group had increased overall relative beta(1) power during both eyes-open and closed conditions. Inconsistent with most precedent literature, the Anger group also exhibited greater relative right fronto-cortical activation (alpha(1)-indexed frontal asymmetry) during the eyes-closed condition. This may reflect greater anxious arousal and/or compensatory activation of inhibitory tendencies associated with right frontal activation in individuals with dysfunctional anger. Enhanced beta(1) activity may index greater tonic cortical arousal or a chronic hypervigilant state, which may predispose individuals with dysfunctional anger to over-react to relatively innocuous stimuli.     

Efficacy and safety of donepezil in the treatment of executive dysfunction in Parkinson disease: a pilot study

Cognitive disturbances in Parkinson's disease (PD) are dominated by troubles in executive functions which affects to a vast majority of parkinsonian patients since the onset of the disease. A common clinical observation is that parkinsonian patients, who eventually develop dementia, exhibit subtle cognitive disturbances quite earlier. The main biochemical substrate of cognitive dysfunction in PD, even of the early dysexecutive syndrome, might be a cholinergic deficiency. The aim of this pilot study was to determine the efficacy and safety of donepezil in the treatment of 10 patients with PD and dysexecutive alterations without dementia. All the items of the Clinical Global Impression were significantly improved. An improvement on both the modified Wisconsin Card Sorting Test and DIGIT Span was found. Parkinsonism remained unchanged during the study. Only 1 out of 10 patients experienced transient and mild gastrointestinal side effects. This study suggests that donepezil may be useful in the treatment of the dysexecutive syndrome associated with PD.