RESUMO
BACKGROUND: Electroconvulsive therapy (ECT) and subanesthetic intravenous ketamine are both currently used for treatment-resistant major depression, but the comparative effectiveness of the two treatments remains uncertain. METHODS: We conducted an open-label, randomized, noninferiority trial involving patients referred to ECT clinics for treatment-resistant major depression. Patients with treatment-resistant major depression without psychosis were recruited and assigned in a 1:1 ratio to receive ketamine or ECT. During an initial 3-week treatment phase, patients received either ECT three times per week or ketamine (0.5 mg per kilogram of body weight over 40 minutes) twice per week. The primary outcome was a response to treatment (i.e., a decrease of ≥50% from baseline in the score on the 16-item Quick Inventory of Depressive Symptomatology-Self-Report; scores range from 0 to 27, with higher scores indicating greater depression). The noninferiority margin was -10 percentage points. Secondary outcomes included scores on memory tests and patient-reported quality of life. After the initial treatment phase, the patients who had a response were followed over a 6-month period. RESULTS: A total of 403 patients underwent randomization at five clinical sites; 200 patients were assigned to the ketamine group and 203 to the ECT group. After 38 patients had withdrawn before initiation of the assigned treatment, ketamine was administered to 195 patients and ECT to 170 patients. A total of 55.4% of the patients in the ketamine group and 41.2% of those in the ECT group had a response (difference, 14.2 percentage points; 95% confidence interval, 3.9 to 24.2; P<0.001 for the noninferiority of ketamine to ECT). ECT appeared to be associated with a decrease in memory recall after 3 weeks of treatment (mean [±SE] decrease in the T-score for delayed recall on the Hopkins Verbal Learning Test-Revised, -0.9±1.1 in the ketamine group vs. -9.7±1.2 in the ECT group; scores range from -300 to 200, with higher scores indicating better function) with gradual recovery during follow-up. Improvement in patient-reported quality-of-life was similar in the two trial groups. ECT was associated with musculoskeletal adverse effects, whereas ketamine was associated with dissociation. CONCLUSIONS: Ketamine was noninferior to ECT as therapy for treatment-resistant major depression without psychosis. (Funded by the Patient-Centered Outcomes Research Institute; ELEKT-D ClinicalTrials.gov number, NCT03113968.).
Assuntos
Antidepressivos , Transtorno Depressivo Resistente a Tratamento , Eletroconvulsoterapia , Ketamina , Humanos , Transtorno Depressivo Maior/diagnóstico , Transtorno Depressivo Maior/tratamento farmacológico , Transtorno Depressivo Maior/terapia , Eletroconvulsoterapia/efeitos adversos , Ketamina/administração & dosagem , Ketamina/efeitos adversos , Ketamina/uso terapêutico , Qualidade de Vida , Resultado do Tratamento , Antidepressivos/administração & dosagem , Antidepressivos/efeitos adversos , Antidepressivos/uso terapêutico , Transtorno Depressivo Resistente a Tratamento/diagnóstico , Transtorno Depressivo Resistente a Tratamento/tratamento farmacológico , Transtorno Depressivo Resistente a Tratamento/terapia , Administração Intravenosa , Transtornos PsicóticosRESUMO
The current paper evaluates psychiatric needs of voluntary admissions in a large urban psychiatric hospital through a retrospective chart review, as this research is limited within the United States. A total of 581 voluntary adult psychiatric admission charts were reviewed. Continuous variables were evaluated using an ANOVA while associations between variables were examined by an unadjusted Pearson correlation coefficient a stepwise linear regression analysis. Men were significantly more likely to have a past admission for psychiatric services (p = .016), suicidal ideation (p < .001) and test positive for substances (p < .001) than women, and were more likely to be unemployed, homeless and without insurance. Women were more likely to have a past suicide attempt and a depressive disorder. A significant relationship between gender and rationale for seeking voluntary admission (p < .001) was found. This study offers understanding of male and female voluntary admissions, and a foundation for improving treatment interventions to reduce recurrent readmissions.
Assuntos
Hospitais Psiquiátricos , Admissão do Paciente , Adulto , Demografia , Feminino , Humanos , Pacientes Internados , Masculino , Cidade de Nova Iorque , Estudos Retrospectivos , Estados UnidosRESUMO
The purpose of this study was to examine the rate of 72-hour letters (written requests for discharge, with 72 hours indicating the time the hospital has to discharge or seek retention) placed by voluntary psychiatric inpatients at a New York City hospital and determine whether there are factors contributing to the rates of discharge requests. Charts from all voluntary psychiatric hospitalizations during the calendar year 2007 were retrospectively reviewed. Included were all single voluntary admissions by adults (age 18 years and older) to the hospital. A confirmatory factor analysis (CFA) was conducted with the following factors: urine toxicology, cigarette use on admission, suicidal ideation upon presentation, employment, past inpatient psychiatric admission, and admission day. A linear regression was used to evaluate the relationship between discharge requests and these factors. Of the total sample (N = 581), 119 (20.5%) patients submitted 72-hour letters. The stepwise linear regression analysis confirmed a positive relationship between letter placement and admission day (M = 3.5, SD = 1.7), unemployment (M = 4.7, SD = 2.1), suicidal ideation (M = .5, SD = .5), positive urine toxicology (M = .47, SD = .5), previous psychiatric hospitalization (M = .7, SD = .5) and cigarette usage (M = .5, SD.5) R2 = .043, (6, 461) = 3.42, p = .003). These specific variables accounted for 55.6% of likelihood of a patient submitting a 72-hour letter. Several factors, related to substance and tobacco use, employment, and recurrent use of inpatient services, likely contribute to requests for early discharge. Addressing these factors may help improve inpatient care, reduce costs and improve patient outcomes in the long term.
Assuntos
Hospitais Psiquiátricos/estatística & dados numéricos , Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricos , Admissão do Paciente/estatística & dados numéricos , Alta do Paciente/estatística & dados numéricos , Recusa do Paciente ao Tratamento/estatística & dados numéricos , Adolescente , Adulto , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Cidade de Nova Iorque , Estudos Retrospectivos , Adulto JovemRESUMO
OBJECTIVES: To determine what dose of succinylcholine falls outside the range of 2 SD above or below the mean optimal dose of 0.9 mg/kg used for electroconvulsive therapy (ECT). METHODS: In this retrospective chart review, for all patients who received ECT at our institution within the 5-year study period, the initial dose of succinylcholine in milligrams per kilogram was compared with subsequent doses after adjustments were made for individual patient responses. Mean and SD were calculated using the dose of succinylcholine, once the optimal dose for each patient had been determined, based on clinical response. RESULTS: Five hundred patients treated during the 5-year period met inclusion criteria, 180 (36%) of whom required an adjustment of the succinylcholine dosing either above (119 patients) or below (61 patients) the 0.9 mg/kg standard after their first treatment. CONCLUSIONS: In those patients who required an adjustment of 2 SD either above or below the mean dose of succinylcholine (29 patients, 5.8%), adequate neuromuscular blockade was only achieved with either an increased dose of up to 2.10 mg/kg or a decreased dose as low as 0.29 mg/kg.
Assuntos
Eletroconvulsoterapia/métodos , Transtornos Mentais/terapia , Relaxamento Muscular/efeitos dos fármacos , Bloqueio Neuromuscular/métodos , Fármacos Neuromusculares Despolarizantes/administração & dosagem , Succinilcolina/administração & dosagem , Adulto , Humanos , Estudos RetrospectivosRESUMO
Electroconvulsive therapy (ECT) remains an indispensable treatment for severe psychiatric illness. It is practiced extensively in the United States and around the world, yet there is little guidance for anesthesiologists involved with this common practice. Communication between the anesthesiologist and the proceduralist is particularly important for ECT, because the choice of anesthetic and management of physiologic sequelae of the therapeutic seizure can directly impact both the efficacy and safety of the treatment. In this review, we examine the literature on anesthetic management for ECT. A casual or "one-size-fits-all" approach may lead to less-than-optimal outcomes; customizing the anesthetic management for each patient is essential and can significantly increase treatment success rate and patient satisfaction.
Assuntos
Anestesia/métodos , Eletroconvulsoterapia , Anestesia/efeitos adversos , Anestesia/normas , Fármacos do Sistema Nervoso Central/efeitos adversos , Tomada de Decisão Clínica , Comorbidade , Eletroconvulsoterapia/efeitos adversos , Eletroconvulsoterapia/normas , Nível de Saúde , Humanos , Bloqueadores Neuromusculares/uso terapêutico , Equipe de Assistência ao Paciente , Segurança do Paciente , Seleção de Pacientes , Guias de Prática Clínica como Assunto , Respiração Artificial , Medição de Risco , Fatores de Risco , Resultado do TratamentoRESUMO
Urticaria pigmentosa is a rare disorder characterized by an abnormal systemic proliferation of mast cells. In this condition, various triggers can induce either cutaneous histamine release, resulting in rash, or generalized histamine release, resulting in symptomatic hypotension, syncope, or in its severest form, an anaphylactoid reaction resistant to most resuscitative measures. Many anesthetic agents and adjuncts are known potential triggers, and patients who require surgery or procedures under anesthesia must be managed carefully. In this review, we describe the safe use of general anesthesia for electroconvulsive therapy in a patient with urticaria pigmentosa and discuss the association between psychiatric disorders and mastocytoses.
Assuntos
Anestesia Geral/métodos , Eletroconvulsoterapia/métodos , Urticaria Pigmentosa/complicações , Transtorno Depressivo/complicações , Transtorno Depressivo/psicologia , Feminino , Humanos , Urticaria Pigmentosa/psicologia , Adulto JovemRESUMO
We present a case in which a piece of chewing gum was discovered adhering to the oral airway when it was removed after an ECT procedure. We suggest that careful examination of the patient's mouth for foreign objects be a standard part of the pre-ECT protocol.
Assuntos
Obstrução das Vias Respiratórias/etiologia , Goma de Mascar/efeitos adversos , Eletroconvulsoterapia , Idoso de 80 Anos ou mais , Manuseio das Vias Aéreas , Anestesia Geral , Feminino , Corpos Estranhos , Humanos , Pneumonia AspirativaRESUMO
We present a case of transient right hemifacial rash after right unilateral electroconvulsive therapy. This phenomenon may have similarities with the cranial dysautonomia, Harlequin syndrome.
Assuntos
Doenças do Sistema Nervoso Autônomo/etiologia , Eletroconvulsoterapia/efeitos adversos , Eritema/etiologia , Rubor/etiologia , Hipo-Hidrose/etiologia , Adulto , Transtorno Bipolar/psicologia , Transtorno Bipolar/terapia , Face , Lateralidade Funcional , Humanos , MasculinoRESUMO
OBJECTIVE: To provide additional data about the clinical efficacy and dosing range for ketamine used as the induction agent in electroconvulsive therapy (ECT). METHOD: We reviewed the clinical data in our academic hospital ECT service over the last four years for patients who had received ketamine as the sole, or adjunctive, anesthesia induction agent. We extracted clinical data about antidepressant response as well as absolute and weight-based dosing for ketamine. RESULTS: We found nine patients who were treated with ketamine as the anesthetic at some point during the course of their treatment (eight as the sole agent, one as adjunctive). The median induction dose for ketamine was 1.1 mg/kg. For most patients, there was demonstrable clinical benefit. CONCLUSIONS: Ketamine has a role as an alternative induction anesthetic agent in ECT. Our case series adds to the literature on the concomitant use of ECT and ketamine.
Assuntos
Anestesia Intravenosa/métodos , Anestésicos Dissociativos/farmacologia , Eletroconvulsoterapia/métodos , Ketamina/farmacologia , Idoso , Idoso de 80 Anos ou mais , Anestésicos Dissociativos/administração & dosagem , Feminino , Humanos , Ketamina/administração & dosagem , Masculino , Pessoa de Meia-IdadeAssuntos
Anestesia Geral , Transtorno Depressivo Maior/terapia , Eletroconvulsoterapia/métodos , Mastocitose Sistêmica/complicações , Agonistas Adrenérgicos/uso terapêutico , Adulto , Transtorno Depressivo Maior/complicações , Transtorno Depressivo Resistente a Tratamento/complicações , Transtorno Depressivo Resistente a Tratamento/terapia , Epinefrina/uso terapêutico , Antagonistas dos Receptores Histamínicos/uso terapêutico , Humanos , Masculino , Mastocitose Sistêmica/tratamento farmacológico , Síncope/complicações , Síncope/tratamento farmacológicoRESUMO
This report describes the electroconvulsive therapy (ECT) course of a 15-year-old male with severe bipolar disorder unresponsive to medical management. After his first treatment, the patient exhibited fever, elevated creatine phosphokinase levels, and leukocytosis. Treatment was halted although the patient reported an improvement in symptoms, which was not maintained with pharmacotherapy alone. Subsequent treatments were completed without adverse reactions, and the patient entered remission. We discuss the possible causes of this reaction and remind the reader that a single adverse event does not always require the abandonment of a treatment modality.
Assuntos
Transtorno Bipolar/terapia , Creatina Quinase/sangue , Eletroconvulsoterapia/efeitos adversos , Febre/etiologia , Adolescente , Anestesia Geral , Transtorno Bipolar/psicologia , Humanos , Leucocitose/sangue , Leucocitose/etiologia , MasculinoRESUMO
This report compares the actual doses of methohexital and succinylcholine used for optimal anesthesia and muscle relaxation in electroconvulsive therapy with written guidelines for dosing. The initial doses of methohexital and succinylcholine in milligrams per kilogram were reviewed and compared with subsequent doses of each agent after adjustments were made for individual patient responses during treatment. The dose of methohexital required to induce general anesthesia for most patients is 1.0 mg/kg. The dose of succinylcholine required to provide adequate muscle relaxation during electroconvulsive therapy is 0.9 mg/kg, although there is considerable variability in patient response to this drug.
Assuntos
Anestesia Intravenosa , Anestésicos Intravenosos/administração & dosagem , Eletroconvulsoterapia/métodos , Metoexital/administração & dosagem , Fármacos Neuromusculares Despolarizantes/administração & dosagem , Succinilcolina/administração & dosagem , Androstanóis , Anestésicos Dissociativos , Humanos , Ketamina , Fármacos Neuromusculares não Despolarizantes , Propofol , Estudos Retrospectivos , RocurônioRESUMO
A 44-year-old man with a previously resected right parietal oligodendroglioma received left unilateral electroconvulsive therapy (ECT). We present images of his brain magnetic resonance imaging, ECT electrode placement, and the electroencephalogram tracing from his ECT.
Assuntos
Neoplasias Encefálicas/complicações , Transtorno Depressivo/complicações , Transtorno Depressivo/terapia , Eletroconvulsoterapia , Oligodendroglioma/complicações , Neoplasias Encefálicas/terapia , Eletroencefalografia , Humanos , Imageamento por Ressonância Magnética , Masculino , Oligodendroglioma/terapiaRESUMO
Catatonia is a well-described neuropsychiatric syndrome that has been the subject of several texts. We present 4 cases seen on our academic service in the past 18 months and discuss significant features of each case.
Assuntos
Catatonia/terapia , Eletroconvulsoterapia , Idoso , Idoso de 80 Anos ou mais , Transtornos de Ansiedade/complicações , Transtornos de Ansiedade/psicologia , Transtornos de Ansiedade/terapia , Catatonia/psicologia , Transtorno Depressivo/complicações , Transtorno Depressivo/psicologia , Transtorno Depressivo/terapia , Transtorno Depressivo Maior/psicologia , Transtorno Depressivo Maior/terapia , Eletroencefalografia , Feminino , Humanos , Hipnóticos e Sedativos/uso terapêutico , Lorazepam/uso terapêutico , Masculino , Midazolam/uso terapêutico , Pessoa de Meia-Idade , Escalas de Graduação Psiquiátrica , Transtornos Psicóticos/complicações , Transtornos Psicóticos/psicologia , Transtornos Psicóticos/terapiaRESUMO
We present the case of a 69-year-old woman with psychotic depression who suffered a non-ST segment elevation myocardial infarction at her first electroconvulsive therapy (ECT). Her course of ECT was resumed 19 days later, and she was able to complete it without further problems. Her depression remitted fully. We report the details of her cardiac management during subsequent treatment sessions and review the literature on cardiac adverse events with ECT.
Assuntos
Transtorno Bipolar/complicações , Transtorno Bipolar/terapia , Eletroconvulsoterapia , Infarto do Miocárdio/complicações , Idoso , Eletroconvulsoterapia/efeitos adversos , Feminino , Humanos , SegurançaRESUMO
Succinylcholine is a depolarizing neuromuscular blocker frequently used during electroconvulsive therapy. In most patients, the duration of paralysis is brief, allowing for spontaneous respiration shortly after the therapy. We report a case of delayed return of neuromuscular function after succinylcholine administered during electroconvulsive therapy in a 72-year-old man receiving cytarabine, vincristine, and rituximab chemotherapy for chronic lymphocytic leukemia. We hypothesize that an interaction between succinylcholine and one of the chemotherapeutic agents caused the prolongation of paralysis and believe that this is the first reported case of prolonged duration of succinylcholine following this regimen of chemotherapy. Despite this unexpected prolonged neuromuscular blockade, the patient could be treated uneventfully, with attention paid to his respiratory support and with subsequent succinylcholine dose titration to effect.
Assuntos
Anticorpos Monoclonais Murinos/uso terapêutico , Citarabina/uso terapêutico , Quimioterapia Combinada , Eletroconvulsoterapia , Fármacos Neuromusculares Despolarizantes , Succinilcolina , Vincristina/uso terapêutico , Idoso , Antineoplásicos/uso terapêutico , Humanos , Masculino , Fármacos Neuromusculares Despolarizantes/farmacocinética , Fármacos Neuromusculares Despolarizantes/uso terapêutico , Rituximab , Succinilcolina/farmacocinética , Succinilcolina/uso terapêutico , Fatores de TempoRESUMO
Adult-onset muscular dystrophy is an inherited myopathy characterized by a variable degree of progressive muscle weakness and degeneration. Although not usually fatal, significant muscle weakness results in an up-regulation of acetylcholine receptors on the less responsive postjunctional muscles. The resulting profound potassium release when these receptors are stimulated by the depolarizing muscle relaxant succinylcholine can result in potentially fatal cardiac arrhythmias. We report a case of electroconvulsive therapy safely administered in a 61-year-old man with adult-onset muscular dystrophy requiring muscle relaxation with rocuronium.