A Retrospective Matched Comparison Study of Prolonged Seizures in ECT.

OBJECTIVE: This study assessed the incidence of and risk factors for prolonged seizures (>180 sec) in electroconvulsive therapy (ECT). METHOD: In 611 adult patients undergoing 6697 ECT treatments administered over a 2.5-year study period, 29 individuals experienced 42 prolonged seizures. A comparison sample (n = 29) was matched on sex, age, and treatment, and compared on psychiatric and medical diagnoses, as well as current medications. To examine the association between the characteristics and prolonged seizure, conditional logistic regression models or exact McNemar tests were conducted. RESULTS: Prolonged seizures occurred on average in 1 of every 167 treatments. No specific psychiatric disorders or medical conditions were associated with the prolonged seizure group. Antipsychotic drugs were used in a higher proportion of the comparison group than in the prolonged seizure group, suggesting a protective effect. Atropine was used in a lower proportion of the long seizure group than in the comparison group. No untoward sequelae occurred, and no progression to status epilepticus was observed. CONCLUSIONS: Prolonged seizures appear to be an uncommon complication of ECT in adults. The characteristics examined in this study suggest limited association of psychotropic medications with prolonged seizures. Treatment of prolonged seizures was straightforward. Prolonged seizures had no impact on the course of treatment. Further exploration of prolonged seizures would enhance the generalizability of the findings from this single site study.

Neuropathological evaluation of an 84-year-old man after 422 ECT treatments.

Concern remains among many that electroconvulsive therapy (ECT) causes "brain damage." This ambiguous term presumably refers to lesions that could, in principle, be observed either grossly or microscopically in postmortem studies, and the assertion that it occurs appears to be based largely on old reports with dubious relevance to modern practice. Fortunately, using modern technique, ECT is so safe that mortality around the time of treatment is extraordinarily rare and as a result there has been little opportunity for postmortem examination of individuals who had recently had ECT. We report a case in which postmortem brain examination was performed roughly a month after the patient's last treatment.

Resident education in electroconvulsive therapy.

OBJECTIVE: In 2001, the American Psychiatric Association's Task Force on electroconvulsive therapy (ECT) recommended that psychiatry residents should receive at least 4 hours of didactic instruction on ECT, participate in at least 10 treatments, and assist in the care of at least 3 patients receiving ECT. Residency accreditation requirements as of 2007, however, require only that training programs ensure competency in "understanding the indications and uses" of ECT. Anecdotally, training in ECT is said to vary widely between residency programs. The purpose of the study was to obtain more systematic information about ECT training. METHOD: A survey was e-mailed to directors of all accredited psychiatry residency programs in the United States and Puerto Rico in early to mid 2008, requesting information regarding their didactic and clinical instruction in ECT and estimates of number of treatments provided by their institutions. RESULTS: Responses were obtained from 91 training programs. Of these programs, 75% reported that some clinical exposure to ECT was required of their residents, but 37% estimated that the typical resident would participate in fewer than 10 treatments and 27% estimated that the typical resident would care for fewer than 5 patients receiving ECT. Most programs devoted less than 4 hours of lecture time to ECT. Most respondents believed that ECT was underused nationally; this perception did not differ based on the theoretical orientation of the training program. CONCLUSIONS: This study suggests that resident education in ECT varies considerably between programs but is often less than that suggested by the American Psychiatric Association's Task Force.

The course of myalgia and headache after electroconvulsive therapy.

BACKGROUND: Headache and myalgia seem to be common, though generally mild, complications of electroconvulsive therapy. Relatively little is known regarding the usual severity and time course of these complaints. OBJECTIVE: This study examines the incidence, severity, and time course of myalgia and headache after electroconvulsive therapy. METHODS: Patients rated severity of myalgia and headache immediately before treatment and again after recovery and at 2, 6, 12, and 24 hours posttreatment on a 10-point visual analog scale. Data were analyzed using random-effects linear models. RESULTS: Severity of headache peaked 2 hours after treatment, returning to baseline by 24 hours and was relatively consistent within individuals between treatments. More severe posttreatment headache was reported by patients with a history of incapacitating headache and by those younger than 45 years. Headache was associated with increased duration of seizure. By contrast, myalgia was substantially more pronounced and lasted longer after the first treatment as compared with subsequent treatments. Severity of myalgia was not predicted by degree of fasciculations or motor activity, but was worse in patients younger than 45 years. CONCLUSIONS: Posttreatment headache and myalgia are common but usually mild. Routine pretreatment using non-depolarizing agents is probably unnecessary in most cases but may have a role during the first treatment in a series. By contrast, preventive treatment may be warranted in those with history of severe headache and those who previously have had significant post-ECT headache.

Electroconvulsive therapy in a patient with multiple sclerosis and recurrent catatonia.

Catatonia is a rare complication of multiple sclerosis (MS). We present a case of a 28-year-old inpatient with MS successfully treated with electroconvulsive therapy (ECT) after developing a catatonic syndrome. A subsequent relapse also responded to ECT, after which the patient received maintenance ECT for 13 months without complications. Follow-up 18 months later did not reveal any evidence of neurological deterioration. We conclude that ECT was a safe and effective treatment in this MS patient.

Association between self-reported childhood sexual abuse and adverse psychosocial outcomes: results from a twin study.

BACKGROUND: Increased risk for serious adverse outcomes has been associated with a history of childhood sexual abuse (CSA). Whether these risks are directly attributable to CSA rather than family background remains controversial. METHODS: Structured psychiatric telephone interviews were conducted from February 1996 to September 2000 with both members of 1991 same-sex pairs (1159 female and 832 male pairs) from a young adult Australian volunteer twin panel (mean [SD] age, 29.9 [2.5] years). A binary composite CSA variable was constructed from responses to 5 component questions. The association between CSA and adverse psychosocial outcomes was examined, controlling for family background. RESULTS: A history of CSA, reported by 16.7% of the women and 5.4% of the men, was more common among those reporting parental alcohol-related problems. Significantly increased risk was observed in women reporting a history of CSA for subsequently occurring major depression, suicide attempt, conduct disorder, alcohol dependence, nicotine dependence, social anxiety, rape after the age of 18 years, and divorce; most similar risks reached statistical significance in men. The greatest risks were associated with CSA involving intercourse. Childhood sexual abuse-negative twins (ie, those who denied having experienced CSA) from CSA-discordant pairs compared with other CSA-negative individuals had increased risk for many adverse outcomes suggesting correlated family background risk factors. Childhood sexual abuse-positive members (ie, those who reported having experienced CSA) of CSA-discordant pairs had significantly greater risk for all 8 examined adverse outcomes than their co-twins. CONCLUSIONS: Self-reported CSA was associated with increased risk for adverse outcomes, controlling for family background. Family background risk factors also were associated with adverse outcome risk. Discordant pair analysis seems to provide an effective means of controlling for family background risk factors.

Prevalence of hepatitis C among psychiatric patients in the public sector.

OBJECTIVE: This study estimated the seroprevalence of hepatitis C virus in a public-sector psychiatric hospital. METHOD: Patients admitted between Jan. 1, 1998, and Dec. 30, 2000, were routinely screened for hepatitis C virus antibody on admission. RESULTS: A total of 133 (8.5%) of 1,556 patients admitted were positive for the hepatitis C virus. Aminotransferase levels were elevated but rarely abnormal among patients positive for the hepatitis C virus. Hepatitis B surface antibody was found in 27.8% of the patients positive for the hepatitis C virus. These patients were more likely to receive a diagnosis of psychoactive substance use disorder but no other psychiatric diagnoses. CONCLUSIONS: The prevalence of hepatitis C virus is high among psychiatric patients in the public sector. Much needs to be learned about the role of universal screening and effective techniques for primary prevention and antiviral treatment in this population.

The effect of propofol-remifentanil anesthesia on selected seizure quality indices in electroconvulsive therapy.

BACKGROUND: Use of a short-acting opiate to potentiate anesthetic induction agents has been shown to increase seizure duration in electroconvulsive therapy (ECT), but little is known of the effect of this combination on indices of seizure quality. OBJECTIVE: To determine whether anesthetic modality affects commonly provided indices of seizure quality. METHODS: Twenty-five subjects were given propofol 2 mg/kg body weight for their first ECT session, at which time seizure threshold was titrated. Subjects thereafter alternated between that anesthetic regimen or propofol 0.5 mg/kg plus remifentanil 1 mcg/kg. Linear mixed models with random subject effect, adjusting for electrode placement, electrical charge, and number of treatments, were fit to estimate effect of anesthesia on seizure duration and several standard seizure quality indices (average seizure energy, time to peak electroencephalography (EEG) power, maximum sustained power, interhemispheric coherence, early and midictal EEG amplitude, and maximum sustained interhemispheric EEG coherence). RESULTS: Propofol-remifentanil anesthesia significantly lengthened seizure duration and was associated with longer time to reach maximal EEG power and coherence as well as maximal degree of interhemispheric EEG coherence. No effect was seen on early ictal amplitude or average seizure energy index. CONCLUSIONS: Propofol-remifentanil anesthesia prolongs seizure duration and has a significant effect on some, but not all, measures of seizure quality. This effect may be of some benefit in cases where adequate seizures are otherwise difficult to elicit. Varying anesthetic technique may allow more precise investigation of the relationships between and relative impacts of commonly used seizure quality indices on clinical outcomes and ECT-related cognitive side effects.

Mask ventilation, hypocapnia, and seizure duration in electroconvulsive therapy.

STUDY OBJECTIVE: To compare the Mapleson D circuit and the bag-valve-mask device for mask ventilation of patients undergoing electroconvulsive therapy (ECT). DESIGN: Cross-over study. SETTING: Single-center academic medical center. PATIENTS: 18 patients undergoing ECT for major depressive disorder. INTERVENTIONS: Patients were randomized to undergo mask ventilation by the Mapleson D circuit or the bag-valve-mask device. MEASUREMENTS: End-tidal CO(2), seizure duration, and airway pressure values were recorded. MAIN RESULTS: End-tidal CO(2) was significantly lower with the bag-valve-mask device. When compared with the bag-valve-mask device, ventilation with the Mapleson circuit resulted in rebreathing of CO(2) in nearly all patients, shorter expiratory time, and lower pressure ramp slope. CONCLUSIONS: Hypocapnia was not associated with longer seizures, and the user-device interaction might affect device performance.

ECT in a man with FG syndrome.

We report on the use of electroconvulsive therapy (ECT) in a 20-year-old man with a history of FG syndrome and schizophrenia who demonstrated thought disorder and aggression refractory to pharmacological treatment. He received 71 ECT treatments over a period of 13 months and demonstrated a marked reduction in aggressive behavior. In the 14 months before beginning ECT, the patient spent 189 days in the hospital, whereas in the 13 months subsequent to his initial ECT series as an inpatient, he was able to be maintained in the community without psychiatric hospitalization. This case extends the findings of prior cases documenting the alleviation of aggressive behaviors with ECT.

A case of negative-pressure pulmonary edema after electroconvulsive therapy.

Pulmonary edema after electroconvulsive therapy (ECT) is a rarely reported condition that can result in serious morbidity and even death if not promptly recognized and treated. We report the case of 21-year-old man with FG syndrome and schizophrenia who developed negative-pressure pulmonary edema after his 28th ECT. The patient developed acute hypoxemia requiring positive-pressure ventilation and was observed overnight in the intensive care unit. He recovered fully and received 43 subsequent ECT treatments without complication. This case illustrates the importance of taking steps to prevent airway obstruction as well as recognizing this rare but serious complication.

Electroconvulsive therapy in a pediatric patient with malignant catatonia and paraneoplastic limbic encephalitis.

Paraneoplastic limbic encephalitis is a rare disorder that can cause memory loss, confusion, personality change, cognitive dysfunction, and psychosis. We present a case of an 11-year-old girl who was successfully treated with electroconvulsive therapy for a catatonic state associated with paraneoplastic limbic encephalitis caused by an ovarian teratoma.

Treatment of Phencyclidine-Associated Psychosis with ECT.

Phencyclidine (PCP) abuse usually causes a short, self-limited period of intoxication but may lead to a prolonged psychosis, poorly responsive to antipsychotic medications. Prior reports indicate that electroconvulsive therapy (ECT) is a safe, rapidly effective treatment in such cases, but longer-term outcome has not been studied. We report three cases of PCP-associated psychosis that did not respond to at least 2 weeks of antipsychotic treatment but subsequently responded rapidly to ECT. Follow-up at 14 to 21 months after treatment show that recovery was maintained except in one subject who relapsed after continuing to abuse PCP. ECT should be considered as a treatment early in the course of drug-associated psychoses in which an adequate trial of antipsychotic medication has not been effective.

Ethical issues in the use of genetic information.

Advances in molecular genetics promise to deepen our understanding of the biological basis of human behavior and shed light on the pathophysiology of mental illness. Genetic research is likely to improve our ability to develop somatic treatments for psychiatric syndromes as well as to identify targets for environmental intervention. However, population-screening tests for disorders with multifactorial inheritance may offer little clinical benefit to outweigh their potential for misuse. Relevant legal issues surrounding the use of genetic information in psychiatry include the perceived need for laws to prevent insurance and employment discrimination, and concerns about genetic status as a possible excuse for criminal behavior. Relevant ethical issues include threats to patient privacy and confidentiality and the importance of fairly distributing the benefits and burdens of genetic advances.

Combination propofol-alfentanil anesthesia for electroconvulsive therapy in patients receiving monoamine oxidase inhibitors.

Two patients who had failed outpatient treatment of depression were given electroconvulsive therapy while simultaneously being treated with monoamine oxidase inhibitors. Both were administered propofol-alfentanil anesthesia without complications.

Concurrent and Close Temporal Administration of Lithium and ECT.

The clinical effects of concurrent and close temporal administration of electroconvulsive therapy (ECT) and lithium (Li) were investigated by chart review. Three groups of patients were compared on the basis of ECT-related complications, total length of hospital stay (LOS), and post-ECT hospital stay. The groups consisted of patients administered concurrent ECT and Li (n = 27); patients administered Li within 24 h prior to ECT or within 48 h post-ECT (n = 49); and patients administered ECT without concurrent or close temporal administration of Li (n = 100). Prolonged or severe post-ECT confusion was significantly associated with close timing of administration of Li relative to the ECT course. The groups did not differ in the number of complications or the total LOS, although the post-ECT LOS was significantly longer in the group administered Li in close temporal association with ECT. These data suggest that caution should be exercised in the combined use of these treatment modalities.