A double-blind, placebo-controlled study of the impact of galantamine on anterograde memory impairment during electroconvulsive therapy.

BACKGROUND: Electroconvulsive therapy (ECT) continues to be an effective treatment option for patients who fail to respond to pharmacological interventions, are unable to tolerate medications, and show a suboptimal response to behavioral and psychotherapeutic treatments. However, risks for cognitive impairment may contribute to some patients' refusal of ECT. METHODS: The present study examined galantamine as a pharmacological intervention to reduce cognitive adverse effects from ECT. Thirty-nine inpatients diagnosed with major depressive disorder; bipolar disorder, depressed type; or schizoaffective disorder, depressed type and admitted for ECT were randomized to galantamine or placebo. Study drugs were initiated 24 to 48 hours before starting ECT and continued throughout the course of ECT. A neuropsychological test battery was administered at baseline and 24 to 48 hours after completing a course of ECT treatments. Depression severity was monitored using the 17-item Hamilton Rating Scale for Depression and Clinical Global Impression Scale at baseline, weekly, and end point. Self-rated adverse effects were monitored weekly. RESULTS: Thirty participants (12 patients in the galantamine group, 18 patients in the placebo group) had both pretreatment and posttreatment neuropsychological ratings. Those in the galantamine group scored significantly higher at discharge for delayed memory (t28 = 2.44, P < 0.05). Hierarchical regressions examined if treatment condition predicted changes in delayed memory scores from baseline to discharge. Inclusion of the treatment condition in the final model made a significant incremental improvement in prediction (ΔR = 0.12, F1,27 change = 4.65, P < 0.05; ß = 0.37, t = 2.16, P < 0.05). Galantamine was well tolerated with no clinically significant bradycardia or prolonged paralysis when administered with ECT. CONCLUSIONS: Galantamine may be protective against impairment in retention of new learning. Galantamine exhibited minimal adverse effects and was safe when administered during ECT. The present findings require replication by future researchers using larger samples before broad conclusions can be drawn.

Antipsychotic polytherapy on an inpatient psychiatric unit: how does clinical practice coincide with Joint Commission guidelines?

OBJECTIVE: A recently developed quality measure set for inpatient psychiatric care includes measurement of antipsychotic polytherapy at discharge. Our objective was to use detailed chart reviews to assess the use of antipsychotic polytherapy and place this use in the context of these measures. METHODS: Patients (N=75) discharged on multiple antipsychotics and a comparable set (N=114) of comparison patients (a randomly selected set of all admitted inpatients) were identified from consecutive admissions to a psychiatric inpatient unit. Medical records were reviewed to ascertain the clinical rationale for antipsychotic polytherapy and assess differences in characteristics between these groups. RESULTS: Patients discharged on antipsychotic polytherapy were more likely to have public insurance, longer lengths of stay, psychotic illness, more prior admissions, and state-funded services for persons with chronic mental illness. We identified subgroups of patients based on the clinical rationale for the antipsychotic co-prescription (refractory illness, regimen unchanged from admission and use of antipsychotic for nonpsychosis symptoms). Some, but not all, such rationales appeared to be clinically justified. CONCLUSIONS: The majority of patients discharged on antipsychotic polytherapy had justifiable clinical rationales that were concordant with the new quality measures. However, two additional subsets were identified, one where quality improvement efforts may be warranted and another where revision of existing quality measure definitions should be considered. Given the implications of public reporting of quality measures, further study and refinement of these measures are required to provide meaningful information to all concerned stakeholders.