Minimum Effective Doses of Succinylcholine and Rocuronium During Electroconvulsive Therapy: A Prospective, Randomized, Crossover Trial.

BACKGROUND: Neuromuscular blockade is required to control excessive muscle contractions during electroconvulsive therapy (ECT). In a crossover, assessor-blinded, prospective randomized study, we studied the minimum effective dose (MED) of succinylcholine and rocuronium for ECT. The MED was the lowest dose to provide a predefined qualitative measure of acceptable control of muscle strength during induced convulsions. METHODS: Succinylcholine (0.8 mg kg) or rocuronium (0.4 mg kg) was randomly administered in 227 ECT sessions to 45 patients. The dose was incrementally increased or decreased by 10% based on 2 psychiatrists' (blinded to treatment) assessment of "acceptable" or "not acceptable" control of evoked muscle contractions (sufficient versus insufficient or excessive paralysis). The neuromuscular transmission was monitored quantitatively until full recovery. RESULTS: In our study, the MEDs of succinylcholine and rocuronium to produce acceptable ECT conditions in 50% of patients (MED50ECT) were 0.85 mg kg (95% confidence interval [CI], 0.77-0.94) and 0.41 mg kg (95% CI, 0.36-0.46) and in 90% of patients (MED90ECT) were 1.06 mg kg (95% CI, 1.0-1.27) and 0.57 mg kg (95% CI, 0.5-0.6), respectively. Nadir twitch height for acceptable muscle activity was 0% (0-4) and 4% (0-30; P < 0.001), respectively, and the time to recovery of the neuromuscular transmission was 9.7 ± 3.5 and 19.5 ± 5.7 minutes, respectively. CONCLUSIONS: A twitch suppression of >90% is needed for control of motor contractions during ECT. The initial ECT dose of succinylcholine should be selected based on each patient's preprocedural condition, ranging between 0.77 and 1.27 mg kg to produce acceptable muscle blockade in 50% to 90% of patients. Rocuronium-neostigmine combination is a safe alternative if appropriately dosed (0.36-0.6 mg kg) and monitored.

Common Use of Electroconvulsive Therapy for Chinese Adolescent Psychiatric Patients.

PURPOSE: Little is known about the use of electroconvulsive therapy (ECT) for adolescent psychiatric patients in China. This study examined the frequency of ECT and the demographic and clinical correlates of adolescent psychiatric patients hospitalized in a tertiary psychiatric hospital in China. METHODS: This was a retrospective chart review of 954 inpatients aged between 13 and 17 years treated over a period of 8 years (2007-2013). Sociodemographic and clinical data were collected from the electronic chart management system for discharged patients. RESULTS: The rate of ECT use was 42.6% in the whole sample (46.5% for patients with schizophrenia, 41.8% for major depressive disorder, 57.8% for bipolar disorders, and 23.9% for other diagnoses). Use of ECT was independently and positively associated with older age, high aggression risk at time of admission, and use of antipsychotics and antidepressants. Compared with patients with schizophrenia, those with other psychiatric diagnoses were less likely to receive ECT. The above significant correlates explained 32% of the variance of ECT use (P < 0.001). Limitations of this study included the lack of data regarding the efficacy and side effects of ECT. Furthermore, the high rate of ECT applied only to 1 setting which limits the ability to extrapolate the implications of the results to other populations. CONCLUSIONS: The use of ECT was exceedingly high in adolescent patients treated in a tertiary clinical centre in China. It is unlikely that such a high rate of ECT use is found across China or that such practice reflects standard of care for psychiatrically ill adolescents. The underlying reasons for the high use of ECT at this center warrant urgent investigations.

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.

Depression and costs of health care.

BACKGROUND: In spite of its global importance, the interaction between depression and chronic comorbid diseases remains incompletely understood with regard to prevalence, severity of disease, and potential causative factors mediating this interaction. OBJECTIVE: The authors sought to compare overall medical costs in nondepressed and depressed individuals. METHOD: Insurance claims for 618,780 patients were examined for total annual non-mental health cost of care in 11 chronic diseases. In each disease cohort, median annual non-mental health cost was calculated for individuals with and without depression. RESULTS: Patients with depression had higher median per-patient annual non-mental health costs than patients without depression in all 11 diseases studied. There was a higher-than-random comorbidity between depression and all 11 chronic comorbid diseases. CONCLUSION: Even when controlling for number of chronic comorbid diseases, depressed patients had significantly higher costs than non-depressed patients, in a magnitude consistent across 11 chronic comorbid diseases.

Encephalitis and catatonia treated with ECT.

OBJECTIVE: To describe 2 cases of encephalitis with neuropsychiatric symptoms including catatonia, compounded by neuroleptic use for delirious agitation culminating in malignant catatonia responsive to electroconvulsive therapy (ECT). BACKGROUND: Neuropsychiatric symptoms including catatonia can be manifestations of limbic encephalitis and encephalitides of unidentified etiology, including encephalitis lethargica. Catatonic features are often difficult to appraise in this context. This can easily lead to the use of neuroleptics, which may precipitate worsening of catatonia. METHOD: Medical, neurologic, and psychiatric histories, physical examination findings, results of laboratory, imaging and neurophysiologic investigations, and treatment response with medications and ECT were recorded. RESULTS: Both patients showed significant improvement with ECT. CONCLUSIONS: Malignant catatonia can complicate encephalitis lethargica and idiopathic limbic encephalitis, which already carry high mortality rates. When neuroleptics are used for agitation in cases of encephalitis, physicians must be wary of precipitating malignant catatonia and neuroleptics should be discontinued when such a danger emerges. Although lorazepam is helpful in treating catatonia, it may not suffice, as in the cases presented. ECT deserves serious consideration early in the course of malignant catatonia and for catatonia nested in encephalopathy secondary to encephalitis, unresolved with lorazepam.

Rapid improvement of depression and psychotic symptoms in Huntington's disease: a retrospective chart review of seven patients treated with electroconvulsive therapy.

Many patients with Huntington's disease (HD) develop psychiatric symptoms such as depression and psychosis. For severe symptoms, electroconvulsive therapy (ECT) can be a valuable treatment. In this case series, we identified seven patients with HD who received ECT at Massachusetts General Hospital in the past 20 years. In all cases, ECT was well tolerated and produced improvement in psychiatric and behavioral symptoms. Our case series supports the hypothesis of a positive risk-benefit ratio for ECT in patients with HD and severe depression or psychosis.

Atropine in Electroconvulsive Therapy.

Nineteen patients with major depression were alternately given intravenous atropine or saline immediately prior to anesthesia for electroconvulsive therapy (ECT). Atropine increased the heart rate, reduced the number of dropped beats, and reduced the number of premature atrial beats. These features may be advantageous in patients with cardiac hypodynamic states presenting for ECT, that is, with bradycardia, bradyarrhythmia, or hypotension. However, as atropine also increased the cardiac work, we recommend that it not be given to patients with hypertension, tachycardia, or who are at risk for cardiac ischemia.