A case of atypical tardive seizure activity during an initial ECT titration series.

Electroconvulsive therapy (ECT) has been used in this country for more than 70 years, is still the most effective treatment in all of psychiatry, and is considered a very safe procedure to have under general anesthesia. Although most patients tolerate this procedure very well without complications, prolonged and/or tardive seizures or even status epilepticus can develop, which is a rare but serious complication of ECT. Tardive seizures are typically associated with electroencephalographic evidence of ictal activity and motor manifestations of the tonic-clonic activity. Whereas there are instances of nonconvulsive status epilepticus after ECT, this is the first report of a patient developing autonomic and motor manifestations of a tardive seizure without electroencephalographic evidence of seizure activity during the initial titration series to establish seizure threshold for a course of ECT.

Alexithymia, emotional empathy, and self-regulation in anorexia nervosa.

BACKGROUND: Individuals with anorexia nervosa (AN) who are starved have poor awareness (alexithymia), reduced understanding of others' mental states (cognitive empathy), and difficulty regulating personal emotions (self-regulation). Despite its important role in social interaction, sympathy for others (emotional empathy) has not been measured in AN. Furthermore, it is unknown how restoring weight affects the relationship among alexithymia, empathy, and self-regulation in AN. METHODS: Women with AN were tested longitudinally during their starvation period (N = 26) and after weight was restored (N = 20) and compared with 16 age-matched healthy women. Alexithymia, empathy, and self-regulation were assessed with the Toronto Alexithymia Scale, the Interpersonal Reactivity Index, and items measuring self-regulation from the Minnesota Multiphasic Personality Inventory-2, respectively. RESULTS: Relative to comparison participants, individuals with AN during both starvation and weight restoration reported greater alexithymia and emotional empathy in one domain, personal distress (vicarious negative arousal to others' suffering). Among AN participants, personal distress was positively correlated with alexithymia and negatively correlated with self-regulation, when accounting for depression. CONCLUSIONS: High levels of alexithymia and personal distress may be persistent features of AN because they do not resolve upon weight restoration. Greater personal distress in AN may be a function of poor emotional awareness and regulation.

Mirror neuron function, psychosis, and empathy in schizophrenia.

Processing of social and emotional information has been shown to be disturbed in schizophrenia. The biological underpinnings of these abnormalities may be explained by an abnormally functioning mirror neuron system. Yet the relationship between mirror neuron system activity in schizophrenia, as measured using an electroencephalography (EEG) paradigm, and socio-emotional functioning has not been assessed. The present research measured empathy and mirror neuron activity using an established EEG paradigm assessing the integrity of the Mu rhythm (8-13Hz) suppression over the sensorimotor cortex during observed and actual hand movement in 16 schizophrenia-spectrum disorder (SSD) participants (n=8 actively psychotic and n=8 in residual illness phase) and 16 age- and gender-matched healthy comparison participants. Actively psychotic SSD participants showed significantly greater mu suppression over the sensorimotor cortex of the left hemisphere than residual phase SSD and healthy comparison individuals. The latter two groups showed similar levels of mu suppression. Greater left-sided mu suppression was positively correlated with psychotic symptoms (i.e., greater mu suppression/mirror neuron activity was highest among subjects with the greater severity of psychotic symptoms). SSD subjects tended to have significantly higher levels of Personal Distress (as measured by the Interpersonal Reactivity Index) than healthy participants. The present study suggests that abnormal mirror neuron activity may exist among patients with schizophrenia during the active (psychotic) phase of the illness, and correlates with severity of psychosis.

Beyond alcoholism: Wernicke-Korsakoff syndrome in patients with psychiatric disorders.

OBJECTIVE: Wernicke encephalopathy and Korsakoff syndrome (the combined disorder is named Wernicke-Korsakoff syndrome [WKS]) are preventable, life-threatening neuropsychiatric syndromes resulting from thiamine deficiency. WKS has historically been associated with alcoholism; more recently, it has been recognized in patients who have anorexia nervosa or have undergone bariatric surgery for obesity. However, patients with nutritional deficiencies of any origin are at risk for WKS. We present clinical histories and neuroimaging data on 2 young adults with underlying psychiatric disorders who became malnourished and developed WKS. METHODS: A young woman with bipolar disorder and somatization disorder was hospitalized for intractable vomiting. A young man with chronic paranoid schizophrenia developed delusions that food and water were harmful, and was hospitalized after subsisting for 4 months on soda pop. RESULTS: Acute, life-threatening Wernicke encephalopathy was confirmed in both patients by brain magnetic resonance imaging showing classic thalamic injury. The patients were left with persistent cognitive and physical disabilities that were consistent with Korsakoff syndrome. CONCLUSIONS: Failure to suspect a vitamin deficiency led to permanent cognitive and physical disabilities that may necessitate lifelong care for these patients. The neuropsychiatric consequences could have been prevented by prompt recognition of their thiamine deficiency.

Subgenual cingulate theta activity predicts treatment response of repetitive transcranial magnetic stimulation in participants with vascular depression.

Repetitive transcranial magnetic stimulation (rTMS) is an effective treatment for depression. Increased metabolism in the anterior cingulate cortex (ACC) is a known predictor for antidepressant response. The authors assessed whether increased theta power within the ACC predicts rTMS response in participants with vascular depression. Sixty-five participants were randomized to active or sham rTMS. Outcome was assessed using the Hamilton Depression Rating Scale. Electroencephalography was obtained, and comparisons were made among each group with a normative database using low-resolution electromagnetic tomography. Results suggest that vascular depression participants respond well to rTMS and that increased low-theta power in the subgenual ACC predicts response to rTMS.

Pre- and post-electroconvulsive therapy multidomain cognitive assessment in psychotic depression: relationship to premorbid abilities and symptom improvement.

OBJECTIVES: Cognitive changes have been reported in patients after electroconvulsive therapy (ECT), but few studies have investigated post-ECT changes across multiple cognitive domains. Because cognitive dysfunction is presumed to be more salient in psychotic depression, we propose a brief pre-ECT multidomain cognitive assessment battery, assessing neurocognitive function in this population before and after ECT. We also compared performance to estimated premorbid levels and determined if neuropsychological functioning was related to symptom improvement. METHODS: Twenty participants with psychotic depression (12 females, 8 males) undergoing ECT for severe depression received the repeatable battery for the assessment of neuropsychological status (RBANS) and additional tasks. The wide range achievement test reading test provided an estimate of premorbid intellectual functioning. Depressive symptoms were assessed with the Hamilton Depression Scale-28, whereas negative and positive symptoms were assessed with the Scale for Assessing Negative and Positive Symptoms. RESULTS: There was a significant improvement in depressive symptoms with most measures of cognitive function showing net gains. When cognitive performances were compared with estimated premorbid abilities, findings indicated significant movement toward normalization in overall RBANS score, particularly involving the language index and attention index. Considered individually, 6 (30%) participants showed pre-ECT cognitive dysfunction (RBANS total score

Deep Brain Stimulation for Obsessive-Compulsive Disorder: A Long Term Naturalistic Follow Up Study in a Single Institution.

INTRODUCTION: Deep brain stimulation (DBS) is a proven, effective tool in the treatment of movement disorders. Expansion of indications for DBS into the realm of neuropsychiatric disorders, especially obsessive-compulsive disorder (OCD), has gained fervent interest, although data on appropriate clinical utilization remains limited. METHODS: A retrospective, naturalistic study followed nine severely affected OCD patients (average YBOCs score before implantation 34.2 ± 2.5) treated with DBS of ventral capsule/ventral striatum, with average follow up of 54.8 months. RESULTS: With chronic stimulation (years), a majority of the patients achieved significant benefits in obsessive-compulsive and depressive symptoms. Six patients experienced periods of OCD remission following implantation. Four of the six responders required more than 12 months to achieve response. Relief of major depressive symptoms occurred in four out of six patients with documented co-morbid depression. Settings required to achieve efficacy were higher than those typically utilized for movement disorders, necessitating increased impulse generator (IPG) battery demand. We found patients benefited from conversion to a rechargeable IPG to prevent serial operations for IPG replacement. For patients with rechargeable IPGs, the repetitive habit of recharging did not appear to aggravate or trigger new obsessive-compulsive behaviors or anxiety symptoms. CONCLUSIONS: Our study supports and builds upon other research suggesting that DBS for OCD in a real-world setting can be implemented successfully and provide long-term benefit for severely affected OCD patients. Optimal patient selection and DBS programming criteria are discussed. The use of rechargeable IPGs appears to be both cost effective and well-tolerated in this population.

Antipsychotic effect of electroconvulsive therapy is related to normalization of subgenual cingulate theta activity in psychotic depression.

OBJECTIVE: Electroconvulsive therapy (ECT) is one of the most effective options available for treating depressive and psychotic symptoms in a variety of disorders. While the exact mechanism of ECT is unclear, it is known to increase metabolism and blood flow specifically in the anterior cingulate cortex (ACC). The ACC is a cortical generator of theta rhythms, which are abnormal in patients with depression and psychotic disorders. Since patients with psychotic depression are known to respond particularly robustly to ECT, we investigated whether the therapeutic effect of ECT in this population was related to normalization of abnormal theta activity in the ACC. METHOD: We obtained 19-lead electroencephalography (EEG) data from 17 participants with psychotic depression before and 2-3 weeks after a full course of ECT. EEG data was analyzed with quantitative measures and low-resolution electromagnetic tomography (LORETA) compared to an age-adjusted normative database. RESULTS: Quantitative EEG analyses revealed that theta band (4-7 Hz) activity was the only frequency band that changed with ECT. LORETA analyses revealed that the primary site of theta activity change was within the subgenual ACC (Brodmann area 25). There was a positive association between increased subgenual ACC theta activity and decreased psychotic symptoms. The degree of low theta activity in the subgenual ACC prior to ECT predicted the antipsychotic response of ECT. CONCLUSIONS: The antipsychotic effect of ECT is related to normalization of subgenual ACC theta hypoactivity.

Relative ineffectiveness of ultrabrief right unilateral versus bilateral electroconvulsive therapy in depression.

OBJECTIVE: Bilateral (BL) electrode placement delivered at 2.5 times the initial seizure threshold (ST; 2.5 x ST) is the gold standard method for seizure delivery during electroconvulsive therapy (ECT). However, there is a growing interest in using a high dose (6 x ST) with ultrabrief right unilateral (UB-RUL) electrode placement to reduce the incidence of possible short-term memory problems associated with BL ECT. Although studies have found UB-RUL ECT to have similar effectiveness to BL ECT, the objective of this study was to determine potential differences in efficiency (ie, the number of treatments needed to reach remission). METHODS: Electroconvulsive therapeutic data for 56 patients with depression treated during 2006 and 2007 were analyzed via retrospective chart review. A total of 26 patients were started on UB-RUL ECT, whereas 30 patients were started on brief pulse BL ECT. RESULTS: The patients started on high-dose UB-RUL ECT required significantly more treatments than the patients started on BL ECT (9.4 [3.3] vs 7.7 [2.8] treatments). Of the 26 patients started on UB-RUL ECT, 12 (46%) experienced a lack of effectiveness and/or insufficient seizure induction and were thus switched to BL ECT; the 8 patients switched because of lack of effectiveness received a mean (SD) of 12.2 (2.9) treatments, whereas the 4 patients switched because of insufficient seizure induction received a mean (SD) of 11.3 (3.6) treatments. CONCLUSIONS: These findings add to an emerging story of reduced efficiency of UB-RUL versus BL electrode placement for an index course of ECT for the treatment of depression.

Aging and alexithymia: association with reduced right rostral cingulate volume.

OBJECTIVES: Previous studies have linked alexithymia to an inability to process emotions appropriately. Older persons show changes in emotion processing and have higher alexithymia scores. Because the anterior cingulate cortex (ACC) is one of the regions showing earlier decline in late-life, and alexithymia seems to be related to a dysfunction in right hemisphere regions including the ACC subserving affective processes, the present study sought to test the hypothesis that reduced ACC volume accounts for the association between older age and alexithymia. DESIGN: Correlation analyses between functionally distinct ACC subregions, age and alexithymia features. SETTING: University of Iowa. PARTICIPANTS: Twenty-four healthy volunteers aged between 24 and 79 years. MEASUREMENTS: Psychiatric and neuropsychological assessment and assessment of alexithymia using the 20-item Toronto Alexithymia Scale. High-resolution magnetic resonance imaging, and in-house developed methods for ACC parcellation. RESULTS: Older age directly correlated with higher overall alexithymia and reduced bilateral rostral and right dorsal ACC gray matter volume. Furthermore, higher alexithymia scores correlated with reduced right rostral ACC volume. This correlation seems to be influenced primarily by Factor 3 of the alexithymia scale measuring diversion of attention to external details in place of internal feelings. CONCLUSIONS: These results suggest that alexithymia in older age may be a result of structural changes in the right rostral ACC.

Implications of starvation-induced change in right dorsal anterior cingulate volume in anorexia nervosa.

OBJECTIVE: Converging evidence suggests a role for the anterior cingulate cortex (ACC) in the pathophysiology of anorexia nervosa (AN). This study sought to determine whether ACC volume was affected by starvation in active AN and, if so, whether this had any clinical significance. METHOD: Eighteen patients with active AN and age- and gender-matched normal controls underwent magnetic resonance imaging (MRI). Sixteen patients (89%) with AN had intelligence quotients (IQ) testing at intake, 14 (78%) had repeat MRIs after weight normalization, and 10 (56%) had outcome data at 1-year posthospitalization. RESULTS: Right dorsal ACC volume was significantly reduced in active AN patients versus controls and was correlated with lower performance IQ. While ACC normalization occurred with weight restoration, smaller change in right dorsal ACC volume prospectively predicted relapse after treatment. CONCLUSION: Reduced right dorsal ACC volume during active AN relates to deficits in perceptual organization and conceptual reasoning. The degree of right dorsal ACC normalization during treatment is related to outcome.

Larger hippocampus size in women with anorexia nervosa who exercise excessively than healthy women.

Exercise has been shown to increase hippocampal volume in healthy older adults. Observations from animal models of diabetes and hypertension suggest that the combination of exercise and caloric restriction may exert greater neuroprotection in the hippocampus than either behavior alone. Yet, in humans, the effects of exercise and caloric restriction on the hippocampus are not known. We measured the volume of the hippocampus prior to clinical treatment in women with anorexia nervosa (AN) who were restricting calories and engaging in excessive exercise, women with AN who did not exercise excessively, and healthy women who did not engage in either behavior. Women with AN were also examined longitudinally (once weight was restored and 6 months later). In the present report, we found that women with AN engaged in caloric restriction and excessive exercising prior to clinical treatment had larger hippocampal volumes than healthy comparison women. After weight restoration, women with AN who had engaged in food restriction and excessive exercise prior to treatment had hippocampal volumes similar to that of women with AN who only engaged in caloric restriction. These results advance the field by showing for the first time that hippocampal volume may be increased by exercise alone or exercise interacting with food restriction in AN.

Depressive symptoms related to low fractional anisotropy of white matter underlying the right ventral anterior cingulate in older adults with atherosclerotic vascular disease.

We sought to characterize the relationship between integrity of the white matter underlying the ventral anterior cingulate (vAC) and depressive symptoms in older adults with atherosclerotic vascular disease (AVD), a condition associated with preferential degeneration of the white matter. The vAC was defined as including white matter underlying ventral Brodmann Area 24 and Brodmann Area 25, corresponding with the "subcallosal" and "subgenual" cingulate respectively. This region of interest was chosen based on the preponderance of evidence that the white matter in the region plays a critical role in the manifestation of depressive symptoms. Participants had current unequivocal diagnoses of AVD and were between 55 and 90 years-old. Fractional anisotropy (FA) was used as an index of white matter integrity and organization. Whole-brain mean diffusivity (MD) was used as an index of global white matter lesion burden. Depressive symptoms were measured using the Symptom Checklist-90-Revised (SCL-90-R) Depression Scale. Depressive symptoms were significantly related to low FA in the right vAC (r = -0.356, df = 30, p = 0.045) but not the left vAC (r = 0.024, df = 30, p = 0.896) after controlling for total brain MD (a statistical control for global white matter lesion burden). Further, depressive symptoms were significantly related to low FA in the right vAC (r = -0.361, df = 31, p = 0.039), but not the left vAC (r = 0.259, df = 31, p = 0.145) when controlled for the contralateral vAC FA. The correlation coefficients for this follow-up analysis were found to be significantly different between left and right vAC (Z = 2.310, p = 0.021). Poor white matter health in the vAC may be a biological mechanism for depressive symptoms in older adults with vascular disease. Further studies may corroborate that the right vAC plays a unique role in depressive symptom manifestation in cases where the white matter is preferentially affected, as is the case in AVD. This could lead to future targeting of the region for somatic antidepressant treatment, as well as the development of a precise approach for patients with white matter damage, which could produce significant improvement in quality of life, medical morbidity, and mortality.

Hippocampal and left subcallosal anterior cingulate atrophy in psychotic depression.

BACKGROUND: Psychotic depression is arguably the most diagnostically stable subtype of major depressive disorder, and an attractive target of study in a famously heterogeneous mental illness. Previous imaging studies have identified abnormal volumes of the hippocampus, amygdala, and subcallosal region of the anterior cingulate cortex (scACC) in psychotic depression, though studies have not yet examined the role of family history of depression in these relationships. METHODS: 20 participants with psychotic depression preparing to undergo electroconvulsive therapy and 20 healthy comparison participants (13 women and 7 men in each group) underwent structural brain imaging in a 1.5 T MRI scanner. 15 of the psychotic depression group had a first-degree relative with diagnosed affective disorders, while the healthy control group had no first-degree relatives with affective disorders. Depression severity was assessed with the Hamilton Depression Rating Scale and duration of illness was assessed in all patients. Automated neural nets were used to isolate the hippocampi and amygdalae in each scan, and an established manual method was used to parcellate the anterior cingulate cortex into dorsal, rostral, subcallosal, and subgenual regions. The volumes of these regions were compared between groups. Effects of laterality and family history of affective disorders were examined as well. RESULTS: Patients with psychotic depression had significantly smaller left scACC and bilateral hippocampal volumes, while no group differences in other anterior cingulate cortex subregions or amygdala volumes were present. Hippocampal atrophy was found in all patients with psychotic depression, but reduced left scACC volume was found only in the patients with a family history of depression. CONCLUSIONS: Patients with psychotic depression showed significant reduction in hippocampal volume bilaterally, perhaps due to high cortisol states associated with this illness. Reduced left scACC volume may be a vulnerability factor related to family history of depression.

Case report: stimulation of the right amygdala induces transient changes in affective bias.

BACKGROUND: Sensitive outcome measures are needed to quantify the effects of neuromodulation in mood disorders. OBJECTIVE: This study examined the utility of a novel affective bias (AB) task in identifying transient mood changes induced by amygdala stimulation in a single rare participant. METHODS: Localized, pulsed electrical stimulation was delivered for 8 min during measures of AB and self-reported mood. Responses were compared with those gathered without stimulation on the same day in the same setting, using paired t-tests. RESULTS: Stimulation of the basolateral nucleus of the right amygdala at 50 Hz, 15 V, and 200 µs pulse-width produced a significant positive shift in AB (t = -2.864, df = 53, P = .006), despite equivocal findings on self-reported mood (t = -.184, df = 12, P = .857). CONCLUSION: Affective bias may be more sensitive to stimulation-induced fluctuations in mood than subjective report, suggesting utility as an outcome measure in neuromodulation studies.

Longitudinal examination of decision-making performance in anorexia nervosa: before and after weight restoration.

BACKGROUND: This study aimed to extend previous work on decision-making deficits in anorexia nervosa (AN) by using a longitudinal design to examine decision-making before and after weight restoration. METHODS: Participants were 22 women with AN and 20 healthy comparison participants who completed the Iowa Gambling Task (IGT). Decision-making was assessed both before and after weight restoration in a subset of 14 AN patients. Self-report and interview assessments were used to measure psychological correlates of decision-making performance including depression, anxiety, and eating disorder symptoms, and magnetic resonance imaging (MRI) scans were conducted to explore associations between brain volume in the orbitofrontal cortex (OFC) and decision-making in individuals with AN. RESULTS: Currently ill AN patients performed worse on the IGT compared to the control group. Although decision-making performance did not improve significantly with weight restoration in the full AN sample, AN patients who were poor performers at baseline did improve task performance with weight-restoration. When actively ill, lower body mass index (BMI) and decreased left medial OFC volume were significantly associated with worse IGT performance, and these associations were no longer significant after weight restoration. CONCLUSIONS: Findings suggest that decision-making deficits in AN in the acute phase of illness are associated with low weight and decreased left medial OFC volume, but increases in brain volume and BMI may not have been sufficient to improve decision-making in all patients. Findings contribute to a model for understanding how some patients may sustain self-starvation, and future work should examine whether decision-making deficits predict relapse.

Rostral anterior cingulate cortex volume correlates with depressed mood in normal healthy children.

BACKGROUND: The rostral anterior cingulate cortex (rACC) has been implicated as a structural neural correlate of familial major depressive disorder, raising the possibility that the structure of this region may act as a biologic marker of depression vulnerability. The aim of the current study was to determine whether children and adolescents with depressive symptoms have lower rACC volume relative to those without symptoms and examine how a positive family history of depression affects this relationship. METHODS: One hundred twelve normal healthy children (59 boys, 53 girls), age 7 to 17, without a current diagnosis or history of depression or other psychiatric illness, were recruited from the community. Mood symptoms were collected using the Pediatric Behavior Scale, a parent- and teacher-reported questionnaire. Volumetric measures of the rACC were generated using structural magnetic resonance imaging (MRI). The relationship of depressive symptoms and rACC volume was examined. RESULTS: 1) The rACC volume was significantly lower in boys with subclinical depressive symptoms compared with boys with no depressive symptoms, particularly on the left side (14.6% reduction; F = 8.90, p = .005). 2) There was a negative correlation of rACC volume and depressive symptoms in boys, a finding that was more robust in subjects with a positive family history of depression. 3) In girls, there was not a significant association of depressive symptoms and rACC volume. CONCLUSIONS: These findings lend further support to the notion that rACC structure may act as a biologic marker of vulnerability or trait marker of depression.

Aging, grey matter, and blood flow in the anterior cingulate cortex.

The anterior cingulate cortex (ACC) is thought to be the neuroanatomical interface between emotion and cognition. Because effective emotion-cognition interactions are essential to optimal decision making, clarifying how the functionality of the ACC changes in older age using functional imaging holds great promise for ultimately understanding what contributes to the psychological changes occurring in late life. However, the interpretation of functional imaging studies is complicated by the fact that aging is associated with changes in grey matter volume and in the cerebral vasculature. In the present study, we obtained high-resolution structural magnetic resonance (MR) imaging data and quantitative blood flow images to examine the association between aging, blood flow, and grey matter volume in the ACC. Twenty-six healthy individuals between 25 and 79 years of age underwent quantitative [15O]water positron emission tomography (PET) imaging. The ACC was traced onto tissue-classified images derived from T1- and T2-weighted MRIs using previously defined methods. The ACC was divided into dorsal, rostral, and subgenual regions. Age was negatively correlated with blood flow in dorsal and rostral ACC regions. Effects were weaker but in a similar direction for the subgenual ACC. While older age and lower blood flow were both associated with smaller rostral ACC grey matter volumes, mediation analysis revealed that grey matter volume only partially mediated the effect of age on blood flow in the rostral ACC. Neural alterations not detectable on MR images may lead to reduced blood flow due to fewer and/or less metabolically active neurons. Alternatively, lower blood flow may be a cause, rather than a consequence, of smaller grey matter volume in the ACC.

Metabolic correlates of antidepressant and antipsychotic response in patients with psychotic depression undergoing electroconvulsive therapy.

OBJECTIVES: Although electroconvulsive therapy (ECT) is a very effective treatment of depression and psychosis, the mechanisms by which this occurs are not fully delineated. The objective of this study was to investigate the functional alterations in brain metabolism in response to ECT through the use of positron emission tomography assessment of cerebral glucose metabolism before and after a course of ECT. METHODS: Ten subjects with psychotic depression were studied with positron emission tomography using [F]fluorodeoxyglucose before and between 2 and 3 weeks after a course of ECT. Statistical parametric mapping and region of interest analyses of the anterior cingulate cortex (ACC) subregions (dorsal, rostral, subcallosal, and subgenual) and hippocampus were used to determine glucose metabolic changes from ECT. The Hamilton Depression Rating Scale and the Scale for Assessing Positive Symptoms were the primary measures used for assessing clinical changes from ECT. RESULTS: Electroconvulsive therapy led to significant increases in the left subgenual ACC and hippocampal metabolism, which were directly correlated with each other and to a reduction in depression as measured by total Hamilton Depression Rating Scale scores. Better antidepressant responders had increased, whereas poorer responders had a decreased left subgenual ACC and hippocampal metabolism. The decrease in positive symptoms was also correlated with increased left hippocampal metabolism. CONCLUSIONS: The antidepressant effect of ECT was correlated with increased metabolism in the left subgenual ACC and hippocampus, whereas the antipsychotic effect of ECT was only correlated with increased left hippocampal metabolism. This finding has implications to better understand the mechanism of antidepressant and antipsychotic effects of ECT.