Speed of response to bilateral ECT: an examination of possible predictors in two controlled trials.

Speed of response to bilateral electroconvulsive therapy (ECT) was defined as the number of ECTs required to induce a 50% reduction in Hamilton Depression Scale score and was established in 48 patients who had participated in two controlled trials of twice versus three times weekly ECT and were responders to treatment. Potential clinical predictors of response were examined dichotomously by comparing early (up to and including ECT 4) and late (ECT 5-9) responders and by correlation. Younger patients manifested a more rapid response (p = 0.03), but no other clinical variables were significantly related to speed of response. Because speed of response affects choice of ECT schedule, biological predictors should be sought.     

Verbal perseveration after right-unilateral ECT.

After electroconvulsive therapy (ECT), many patients experience a decrement in their mnestic capacity. We studied episodic memory in eight severely depressed patients treated with a course of right-unilateral ECT. For this purpose, a testing instrument was constructed by the authors. It was made of paper cards that held four pieces of information, namely a word, a number, a figure, and the color of the card. One of the cards was presented to the patients and the respective information was asked for on the subsequent day. Patients were tested every morning during the first two weeks of the ECT course. About half of the responses were correct. Patients did best in recalling the color; they did worst in recalling the number. Seven of the patients showed verbal perseverations. This is in accordance with the literature on perseveration in patients with neurologic deficits, especially in proactive-inhibitory tasks. Perseveration may be attributed to a deficit in selective attention, producing an arousal of irrelevant cues.     

Comparison of MRI white matter changes with neuropsychologic impairment in Cockayne syndrome.

The neuropsychologic function and white matter changes observed on magnetic resonance imaging (MRI) in Cockayne syndrome were studied. MRI with T2-weighted sequences revealed periventricular hyperintensity and white matter hyperintensity in all 3 Cockayne syndrome patients examined; in contrast, 8 age-matched controls had no periventricular or white matter hyperintensity. MRI scans were graded according to the severity of periventricular or white matter hyperintensity using a scale applied to an elderly patient population. There was no difference in the severity of MRI white matter changes in these 3 Cockayne syndrome patients, 2 of whom had severe neuropsychologic functions and one a relatively milder one. There was no correlation between neuropsychologic impairment and MRI white matter changes.     

Neurological asymmetries immediately after unilateral ECT.

Twenty-nine right handed patients were examined neurologically before and immediately after each of 62 unilateral ECTs to the dominant and non-dominant hemispheres. Most convulsions were followed by signs of transitory neurological dysfunction referable to the treated hemisphere. These signs included deep tendon reflex asymmetry, hemiparesis, tactile and visual inattention, and homonymous hemianopia. After treatment to the right hemisphere some patients had left visuospatial neglect, while all patients who had dominant hemisphere ECT were transiently dysphasic. All neurological abnormalities tested resolved within 20 minutes of treatment.     

Compulsive eating: a neuropsychologic approach to certain eating disorders.

The view advanced here suggests that compulsive eating should be regarded as a separate psychiatric syndrome and not as an integral part of other eating disorders. The syndrome is characterized, in general, by a primary neurologic dysregulation and secondary psychological reactive disorder, which varies among different patients. This variation has led to considerable conceptual confusion and deprived these patients of a possible successful pharmacologic intervention. The confusion stems in part from the fact that persons who appear to be very different (vis. fat or thin) may be quite similar in that they both suffer from some common neurologic disease. They appear different because they resort to different psychological defense mechanisms. In contrast, confusion is more easily elicited when persons who appear to be very similar (viz. obese) are so for very different reasons. That is, excessive weight gain (or loss) is the final common pathology resulting from more than one possible etiology. It may now be possible to distinguish between neurogenic compulsive eating and other psychogenic or medically based eating disorders. The former may be amenable to successful pharmacologic treatment as well as psychological.     

Depression in old age: Prognosis after ECT

One hundred and sixty-three patients treated with electroconvulsive therapy (ECT) in a district psychogeriatric unit during 1981 were followed up after 3 years. After the original course (mean 11·2 treatments) 51% were rated as fully recovered and 23% as much improved. Two-thirds experienced one or more relapse within 3 years but half of these regained full remission. Of the 113 patients alive at 3 years 59% were free of depression and 29% showed mild symptoms only. Those making full initial recoveries had fared best subsequently. It is suggested that ECT has an important and generally underestimated place in the management of depression in the elderly.     

Predicting neuropsychologic outcome after traumatic brain injury in children

The ability to predict long-term neurologic and neuropsychologic outcomes in 22 children, ages 1 week to 14 years at the time of traumatic brain injury, was investigated using proton magnetic resonance spectroscopy acquired post injury and compared with standardized neurologic, intellectual, and neuropsychologic testing done 1-7 years later. Clinical indicators of acute injury severity including age at injury, electroencephalography, spectroscopy metabolite ratio variables (N-acetyl aspartate/choline, choline/creatine) and lactate presence accurately classified children as functioning above or below the average range for most intellectual and neuropsychologic outcome measures. Combined clinical and spectroscopy variables accounted for approximately 50% of the variance in cognitive and neuropsychologic outcome confirming the validity of their predictive use. Of the injury severity indictors, presence of lactate is a particularly important prognostic marker of poor long-term intellectual and neuropsychologic functioning. Our findings indicate the potential for providing accurate estimates of long-term intellectual and neuropsychologic function after traumatic brain injury in infants and children using proton magnetic resonance spectroscopy in combination with clinical variables.     

The sham ECT literature: implications for consent to ECT

The author reviewed the placebo-controlled literature on electroconvulsive therapy (ECT) for depression. No study demonstrated a significant difference between real and placebo (sham) ECT at 1 month posttreatment. Many studies failed to find a difference between real and sham ECT even during the period of treatment. Claims in textbooks and review articles that ECT is effective are not consistent with the published data. A large, properly designed study of real versus sham ECT should be undertaken. In the absence of such a study, consent forms for ECT should include statements that there is no controlled evidence demonstrating any benefit from ECT at 1 month posttreatment. Consent forms should also state that real ECT is only marginally more effective than placebo.     

The efficiency of ECT: II. Correlation of specific treatment variables to response rate in unilateral ECT

Determining the most efficient use of electroconvulsive therapy (ECT) for treating depression hinges on defining the crucial variable(s) related to the maximal efficacy of an individual seizure. In this study, we examined the relationships of several treatment variables to antidepressant effect of 109 individual unilaterally induced seizures. The seizures occurred during the maximal response phase of 39 courses of ECT judged to have been effective. The patients were divided according to whether or not they were receiving antidepressants during ECT. The variables were treatment number, seizure length, and type of seizure end point. In the total group, earlier treatments were significantly related to antidepressant effect. Seizure length and type of seizure end point appeared to be of little consequence. Further studies of ECT should focus particularly on the effects of the first treatment in order to define optimal ECT efficiency.     

Relapse of depression after ECT: a review

Relapse of severe depression after successful treatment with electroconvulsive therapy (ECT) continues to be a major problem. We review the literature on relapse after ECT and factors that predict relapse. Early studies showed that the relapse rate was approximately 50% without follow-up treatment and that the majority of these relapses occurred in the first 6 months. More recent studies have found even higher rates in delusional depression and possibly in "double depression." Studies of biological markers as predictors of relapse were examined. Six of nine studies of the dexamethasone suppression test and one study of cortisol hypersecretion show that post-ECT nonsuppressors are at higher risk; although insensitive for diagnostic purposes, this test may be useful, when persistently abnormal, as a predictor of relapse. Studies of the thyrotropin-releasing hormone stimulation test and shortened rapid eye movement sleep latency are inconclusive. Medication resistance pre-ECT has been shown to predict relapse in two studies and highlights the need for more aggressive and effective treatment in this group. Further research into the prediction and prevention of depressive relapse after ECT is needed, and the field anxiously awaits current trials comparing ECT with combination lithium and nortriptyline.     

EEG correlates of the response to ECT: a possible antidepressant role of brain-derived neurotrophic factor

Studies on the relationship of electroencephalographic (EEG) data to the therapeutic response to electroconvulsive therapy (ECT) have been carried out since the 1940s, but for many years they did not yield any consistent correlates. Recent studies, however, are providing a growing body of evidence of relationships between the antidepressant response to ECT and both the ictal (recorded during ECT seizures) and interictal (recorded during waking) EEG. These studies appear to be consistent in pointing to the importance of electrophysiologic changes in the prefrontal cortex as a potential mediator of the antidepressant response to ECT. The available findings are reviewed and discussed in light of recent neurophysiologic and neuropsychiatric research, including that related to neurotrophic factors.     

Medical student knowledge and attitudes regarding ECT prior to and after viewing ECT scenes from movies

We surveyed samples of medical students in the United Kingdom (U.K.) and Australia, prior to their psychiatry placement, to ascertain views about electroconvulsive therapy (ECT) and the effect on those views of watching ECT scenes in movies. A 26-item questionnaire was constructed by the authors and administered to the students. At set times during the questionnaire, students were asked to view five movie clips showing, or making reference to, ECT. The clips were from Return to Oz, The Hudsucker Proxy, Ordinary People, One Flew Over the Cuckoo's Nest, and Beverly Hillbillies. Ninety-four students participated in the study. Levels of knowledge about the indications, side effects, and mode of administration were poor, and attitudes were generally negative. Viewing the ECT scenes influenced attitudes toward the treatment; after viewing, one-third of the students decreased their support for ECT, and the proportion of students who would dissuade a family member or friend from having ECT rose from less than 10% to almost 25%.     

Multiple sclerosis and ECT: possible value of gadolinium-enhanced magnetic resonance scans for identifying high-risk patients.

Electroconvulsive therapy (ECT) has been used effectively in treating depressed patients with multiple sclerosis (MS). However, several reports have observed that some patients with MS may suffer neurological deterioration during ECT. The authors describe the outcomes of 3 depressed patients with MS who were treated with ECT. Consistent with previous works, ECT effectively treated the psychiatric symptoms; however, 1 patient deteriorated neurologically during ECT. The brain MRI findings and clinical courses of all 3 patients are discussed, along with the possible value of gadolinium-contrast MRI scans for identifying high-risk patients.     

Behavioral and hippocampal changes after prenatal invasive interventions with possible relevance to schizophrenia

In an attempt to model neurodevelopmental defects that may contribute to the outbreak of schizophrenia after adolescence, the present study examined the effects of prenatal interventions in rats, including injections of kainic acid, on motor, cognitive and social behaviour, which was assessed repeatedly between PDs 56-62 (week 8) and 168-174 (week 24), as well as on hippocampal morphology. As compared to untreated controls (n=5-9), the offspring (n=12 or 16) of treated mothers exhibited shorter latencies to leave a dark box and enter an illuminated field on weeks 12, 16 and 20, a higher number of perseverations in a T-maze alternation task on weeks 16 and 20, longer nose contacts with strange and familiar partners in a social interaction test on weeks 12 and 16 and lower weight gains over the course of testing. They also had shorter pyramidal cells in hippocampal area CA3. Thus, the prenatally treated offspring showed certain alterations in their brains and behaviour that resembled the human condition of schizophrenia (e.g., changes at cell level in the hippocampus, perseverative behaviour, lower weight gains), although others (e.g., increased social contacts) did not.     

ECT in a depressed patient after craniotomy

ECT was successfully administered to a depressed woman who had had a craniotomy and had postoperative seizures. For ECT after craniotomy, the authors recommend postneurosurgical stabilization, continuation of anticonvulsants if a seizure disorder is present, and proper electrode placement.     

ECT in mental retardation: a review.

The use of electroconvulsive therapy (ECT) in patients with mental retardation and a psychiatric disorder seems to be infrequent, and controlled studies are not available. We reviewed the literature on the use of ECT in mental retardation, using Medline, Embase, and the Cochrane Library. References were checked and ECT experts consulted. The reported case studies were examined on patients' characteristics and illness, treatment, and outcome variables. Forty-four patients, mostly with a diagnosis of psychotic depression, were found. In 84% (n = 37) of them, ECT was effective and without important side effects. However, relapse occurred frequently, in 48% (n = 21) of the patients. In 16% (n = 7), side effects and/or no improvement were noted. The reported case studies suggest that ECT may be of value in treating severe psychiatric disorders in mentally retarded patients, with similar indications as in general psychiatry. However, the lack of strong scientific evidence, besides complicated psychiatric assessment as well as ethical and legal issues, probably cause an unnecessarily limited use of ECT in these patients. Further controlled trails are needed to firmly establish the efficacy and safety of ECT in mental retardation.