Magnetic seizure therapy (MST) for major depressive disorder.

Electroconvulsive therapy (ECT) is effective for major depressive disorder (MDD) but its effects on memory limit its widespread use. Magnetic seizure therapy (MST) is a potential alternative to ECT that may not adversely affect memory. In the current trial, consecutive patients with MDD consented to receive MST applied over the prefrontal cortex according to an open-label protocol. Depressive symptoms and cognition were assessed prior to, during and at the end of treatment. Patients were treated two to three times per week with high-frequency MST (i.e., 100 Hz) (N = 24), medium frequency MST (i.e., 60 or 50 Hz) (N = 26), or low-frequency MST (i.e., 25 Hz MST) (N = 36) using 100% stimulator output. One hundred and forty patients were screened; 86 patients with MDD received a minimum of eight treatments and were deemed to have an adequate course of MST; and 47 completed the trial per protocol, either achieving remission (i.e., 24-item Hamilton Rating Scale for Depression score <10 and a relative reduction of >60% at two consecutive assessments; n = 17) or received a maximum of 24 sessions (n = 30). High-frequency (100 Hz) MST produced the highest remission rate (33.3%). Performance on most cognitive measures remained stable, with the exception of significantly worsened recall consistency of autobiographical information and significantly improved brief visuospatial memory task performance. Under open conditions, MST led to clinically meaningful reduction in depressive symptoms in patients with MDD and produced minimal cognitive impairment. Future studies should compare MST and ECT under double-blind randomized condition.

Prevalence of psychiatric disorders among Toronto hospital workers one to two years after the SARS outbreak.

OBJECTIVE: This study aimed to determine the incidence of psychiatric disorders among health care workers in Toronto in the one- to two-year period after the 2003 outbreak of severe acute respiratory syndrome (SARS) and to test predicted risk factors. METHODS: New-onset episodes of psychiatric disorders were assessed among 139 health care workers by using the Structured Clinical Interview for DSM-IV and the Clinician-Administered PTSD Scale. Past history of psychiatric illness, years of health care experience, and the perception of adequate training and support were tested as predictors of the incidence of new-onset episodes of psychiatric disorders after the SARS outbreak. RESULTS: The lifetime prevalence of any depressive, anxiety, or substance use diagnosis was 30%. Only one health care worker who identified the SARS experience as a traumatic event was diagnosed as having PTSD. New episodes of psychiatric disorders occurred among seven health care workers (5%). New episodes of psychiatric disorders were directly associated with a history of having a psychiatric disorder before the SARS outbreak (p=.02) and inversely associated with years of health care experience (p=.03) and the perceived adequacy of training and support (p=.03). CONCLUSIONS: Incidence of new episodes of psychiatric disorders after the SARS outbreak were similar to or lower than community incidence rates, which may indicate the resilience of health care workers who continued to work in hospitals one to two years after the SARS outbreak. In preparation for future events, such as pandemic influenza, training and support may bolster the resilience of health care workers who are at higher risk by virtue of their psychiatric history and fewer years of health care experience.

Electroconvulsive therapy for depression with comorbid borderline personality disorder or post-traumatic stress disorder: A matched retrospective cohort study.

BACKGROUND: The impact of comorbid borderline personality disorder (BPD) or post-traumatic stress disorder (PTSD) on clinical and cognitive outcomes of electroconvulsive therapy (ECT) in patients with major depressive episodes (MDE) is unknown. OBJECTIVE: Compare clinical response and adverse cognitive effects for MDE patients with comorbid BPD or PTSD to MDE only. METHODS: In a matched retrospective cohort study of 75 patients treated with ECT at an academic psychiatric hospital with DSM-IV MDE and either comorbid BPD, PTSD or both (MDE + BPD/PTSD), 75 MDE patients without BPD or PTSD (MDE-only) were matched. We reviewed clinical records to determine treatment response by estimating clinical global impression of improvement (c-CGI) and presence of adverse cognitive effects based on subjective distress or objective impairment. We explored factors associated with response and cognitive effects in the MDE + BPD/PTSD group. RESULTS: There was no difference in c-CGI response rates between groups (p > 0.017). Secondary analysis of inpatients found lower response rates for MDE + BPD (55.4%) and MDE + BPD + PTSD (55.8%) than MDE-only (82.5%), but not MDE + PTSD (65.0%). There was no difference in adverse cognitive effects in the MDE + BPD/PTSD (23.3%-26.8%) group compared to MDE-only (25.0%). In the MDE + BPD/PTSD group, factors associated with higher response rate were: referral indications other than failed pharmacotherapy, greater number of ECT treatments, presence of adverse cognitive effects, and seizure duration >30 s. CONCLUSIONS: Despite a lower c-CGI response for inpatients with MDE + BPD, ECT is a viable treatment option for patients in the MDE + BPD/PTSD group with similar adverse cognitive effect profiles to MDE-only.

Community treatment orders in Toronto: the emerging data.

OBJECTIVE: Over a 4-year period in Toronto, this study aimed to compare individuals on a community treatment order (CTO) with individuals not on a CTO in terms of sociodemographic and clinical variables, hospital use, and continued engagement with health services on exit from the case management program. Hospital stay reductions from preadmission into the program to various postadmission periods were compared across the 2 groups. METHODS: Descriptive statistics and tests of statistical significance (chi-square and t test) were run on regularly collected administrative data for both groups. RESULTS: Categorical data analysis indicated the 2 groups were statistically similar on a range of sociodemographic and clinical variables. Although both groups displayed reductions in hospital use, the CTO group displayed a significantly higher reduction in cumulative days in hospital per hospital admission within both the first and second 6-month period postadmission. This same group also had significantly greater reduction in hospital admissions during the second 6-month period postadmission. The CTO group also had a significantly higher portion of individuals exiting the program within these first two 6-month periods; as well, they were less likely to exit with support such as case management or assertive community treatment and more likely to continue with ongoing medical supervision than the comparison group. CONCLUSION: Although we were unable to rule out regression to the mean for hospitalization reductions, the Toronto experience has shown that CTOs are helpful in assisting individuals who historically refused services to remain engaged with treatment and support services. The study also calls for broadening operational measures of outcomes for CTO studies.

Long-term psychological and occupational effects of providing hospital healthcare during SARS outbreak.

Healthcare workers (HCWs) found the 2003 outbreak of severe acute respiratory syndrome (SARS) to be stressful, but the long-term impact is not known. From 13 to 26 months after the SARS outbreak, 769 HCWs at 9 Toronto hospitals that treated SARS patients and 4 Hamilton hospitals that did not treat SARS patients completed a survey of several adverse outcomes. Toronto HCWs reported significantly higher levels of burnout (p = 0.019), psychological distress (p<0.001), and posttraumatic stress (p<0.001). Toronto workers were more likely to have reduced patient contact and work hours and to report behavioral consequences of stress. Variance in adverse outcomes was explained by a protective effect of the perceived adequacy of training and support and by a provocative effect of maladaptive coping style and other individual factors. The results reinforce the value of effective staff support and training in preparation for future outbreaks.