[Electroconvulsive therapy. Indications, procedure and treatment results]. / Elektrokrampftherapie. Indikation, Durchführung und Behandlungsergebnisse.

Electroconvulsive therapy (ECT) is one of the most effective forms of treatment for severe and persistent psychiatric disorders. ECT is used for a broad spectrum of diseases; however, it has proven particularly helpful in the treatment of therapy-resistant depressive episodes. In addition it has also been successfully used in the treatment of other disorders, such as acute mania and acute psychotic states. Basically ECT should be considered in all cases of severe psychiatric disorder in which an adequate psychopharmacological and/or psychotherapeutic treatment strategy has failed or when the side-effects of medications have proven unbearable. As with other forms of psychiatric treatment ECT is not always used in the same manner and in different institutions in the same way and there are also differences in opinions between clinicians and researchers on various aspects of ECT. In this article the up-to-date standards for effective ECT treatment are outlined and discussed in the light of the current knowledge.

Comorbid anxiety and affective disorder in alcohol-dependent patients seeking treatment: the first Multicentre Study in Germany.

The goals of this study were to describe demographic variables, drinking history, and the 6-month prevalence of Axis I comorbidity among alcohol-dependent subjects in GERMANY: The variables: amount of alcohol consumption, age at onset of the first alcohol consumed, age at onset of daily alcohol consumption, age at onset of withdrawal symptoms and number of detoxifications were related to the different comorbid disorders and gender. In this study, 556 patients from 25 alcohol treatment centres were enrolled between 1 January 1999 and 30 April 1999. After a minimum of 10 days of sobriety patients who fulfilled ICD-10 and DSM-IV criteria of alcohol dependence were interviewed for data collection using the Mini-DIPS (German version of the Anxiety Disorders Interview Schedule) and a standardized psychosocial interview. The 6-month prevalence of comorbid Axis I disorders was 53.1%. Among the patients with comorbidity, affective and anxiety disorders were most frequent. Comorbid stress disorder was associated with an early start of drinking, an early beginning of withdrawal symptoms, highest number of detoxifications, and the highest amount of alcohol consumed. Female patients with anxiety disorder consumed more alcohol and started earlier than females without this comorbid disorder. The data do not answer the question of the pathogenesis of comorbid disorders and alcoholism, but indicate that stress disorders in alcoholic patients and anxiety disorders in female alcoholics influence the course and severity of alcoholism.

[Electroconvulsive therapy of depressive disorders]. / Elektrokrampftherapie bei depressiven Erkrankungen.

Electroconvulsive therapy (ECT) is the most effective treatment in all types of major depression. On the other side ECT has long suffered from controversial public image, a reputation that has effectively removed it as treatment option for many patients. Today ECT is an effective and safe treatment for those with severe mental illness. Electroconvulsive therapy has undergone fundamental changes since its introduction 65 years ago. It is no longer a memory-modifying, fearsome treatment pictured in films. Anesthesia, controlled oxygenation, and muscle relaxation make the ECT so safe that the risks are less as those which accompany the use of several psychotropic drugs. Indeed, for the elderly, the systematic ill, and pregnant women, electroconvulsive therapy is a safer treatment for mental illness than any alternative.

The cerebral hemodynamics of repetitive transcranial magnetic stimulation.

Repetitive transcranial magnetic stimulation (rTMS) has been shown to be effective in the treatment of affective disorders. However, only little is known about hemodynamic physiological and safety aspects of this method. We studied the cerebral hemodynamics as measured by transcranial Doppler sonography in 20 healthy subjects during different rTMS procedures. Mean cerebral blood flow velocity (CBFV), pulsatility index (PI), and oxygen consumption were recorded continuously and averaged directly after the rTMS procedure. RTMS did not influence blood pressure, pulse rate, or blood oxygenation. There was a maximal increase of CBFV in the middle cererbal artery (MCA) of 3.6% and 5.6% during 10 Hz and 20 Hz stimulation, respectively. This increase was only seen on the stimulated left hemisphere. The PI remained unchanged during the whole procedure. It is likely that the increase of CBFV is due to dilatation of the small resistance vessels rather than due to vasoconstriction of the MCA. In terms of cerebral hemodynamics, rTMS is a safe and well-tolerated technique with a lower increase of CBFV than that seen in electroconvulsive therapy.

Hallucinatory modalities in prelingually deaf schizophrenic patients: a retrospective analysis of 67 cases.

In order to examine the effect of congenital or early acquired deafness on hallucinatory modalities in schizophrenia, we interviewed 67 prelingually deaf schizophrenic patients (using sign language) about their hallucinatory experiences over the entire course of their illness. We also analysed the clinical records of our subjects' previous hospitalizations. In our deaf sample, visual and tactile hallucinations were plainly over-represented as hallucinatory modalities in comparison with hearing schizophrenic samples. Although some patients reported visual hallucinatory perceptions of sign language messages, the hallucinatory reception of meaningful information in deaf patients seems also to remain affiliated to the 'auditory' modality. It was concluded that the different representation of hallucinatory modalities reflects in particular the influence of 'the deaf way' of sensory experience on imagery processes.

[Occupational rehabilitation of chronic psychiatric patients. Results of a prospective study over 3 years]. / Arbeitsrehabilitation chronisch psychisch Kranker. Ergebnisse einer prospektiven Untersuchung über 3 Jahre.

Vocational rehabilitation of mentally ill patients is now focused outside the psychiatric hospital. Three types of programmes play a major role: outpatient work therapy programmes at psychiatric hospitals, jobs in (partly) sheltered employment facilities as in companies specially adapted for employing mentally ill persons, and workshops for the mentally disabled. In the north-western German region of Westphalia-Lippe (population: 9 million) we carried out a three-year prospective study on a regionally representative sample from such rehabilitation institutions to assess the course and outcome of vocational rehabilitation. The sample comprised 295 men and 176 women with a mean age of 36.1 year (+/- 9.6). The majority were chronically ill patients with a history of frequent long-term hospitalisation. 61% of all probands were suffering from schizophrenic disorders. The outcome of vocational rehabilitation differs substantially among the three programme types, primarily due to varying baseline conditions, subjective expectations or goals, and courses of illness. The programmes are not alternatives but should be seen as supplementary components of a care system which has to meet a wide range of patient requirements. Vocational integration into the open labour market is a desirable and realistic objective for only some of those concerned.

Cerebral hemodynamics during electrically induced seizures.

Electroconvulsive therapy (ECT) is an appropriate clinical model to investigate blood flow during seizures. In this study cerebral blood flow velocity (CBFV) was measured during 40 ECTs in 10 patients by means of transcranial Doppler sonography. EEG was recorded continuously. Under general anesthesia, the pre-convulsive blood flow velocity (Vmean) decreased significantly. After ECT, we measured a dramatic increase in Vmean which was significantly greater in the left MCA than in the right MCA. After termination of seizures, flow velocities returned to baseline levels. The striking increase in cerebral blood flow velocity reflects excessive cerebral metabolism during convulsive neuronal activation. The left hemisphere seems to be more sensitive to electrical stimuli as was indicated by its predominant augmentation of CBFVs.

Electroconvulsive therapy vs. paroxetine in treatment-resistant depression -- a randomized study.

Failure to respond to adequate pharmacological treatment for major depression is now the most common indication for the use of electroconvulsive therapy (ECT). The advantages of ECT with respect to both speed and quality of response are clinically important issues, but surprisingly few studies have examined the efficacy of ECT in relation to newer antidepressant agents such as selective serotonin reuptake inhibitors (SSRIs). A total of 39 subjects with major depression and with at least two failed antidepressant trials (mean 4.9 trials) were randomized to either paroxetine treatment (n=18) or right unilateral (RUL) ECT (n=21). Up to the end of the study treatment we found a reduction in the HAMD score of 59% for the ECT group and of 29% for the paroxetine group (P<0.001 paired t-test). In the ECT group, 71% of subjects fulfilled the response criteria (at least a 50% decrease in total HAMD score). The present study found ECT to be superior to paroxetine in medication-resistant major depression, in terms of both degree and speed of response.

[Prevalence of psychiatric disorders and outcome of social integration of homeless men]. / Prävalenz psychischer Störungen und Verlauf der sozialen Integration bei wohnungslosen Männern.

All 52 regular users of a shelter in a medium-sized German city underwent a baseline psychiatric examination in 1990. Mental disorders, especially alcohol addiction and schizophrenic disorders, were recorded among 40 (77%). After four years the residential situation and the number and duration of psychiatric hospitalisations was recorded for 42 of these men. 33 of them mentally ill and 9 with no mental disorders. The four-year follow-up revealed that half the mentally ill men were still living in a homeless environment or had died, whereas most users with no mental disorder had a home of their own again. Longer-term hospitalisation or guardianship was found to have a favourable impact on social integration of the homeless mentally ill. Although psychiatric help without the consent of those concerned cannot solve the social problem of homelessness, it can often improve the living situation of homeless mentally ill patients.

[Parkinson syndrome after CO poisoning. Unexpected late manifestation and favorable prognosis]. / Parkinson-Syndrom nach CO-Vergiftung. Unerwartet spätes Auftreten und günstige Prognose.

Although individual extrapyramidal symptoms as a consequence of carbon monoxide intoxication have frequently been reported, typical (complete) Parkinson's syndrome has very rarely been documented. This report presents for the first time a case of acute Parkinson's syndrome with delayed manifestation after the initially occurring organic psychosis. A 53-year-old man with a long history of schizoaffective psychosis first developed a severe acute organic psychosis with disturbances of orientation and marked amnestic disturbances after carbon monoxide intoxication as a result of a suicide attempt. On the 21st day after intoxication, acute Parkinson's syndrome with right accentuation was recorded, with CCT identification of lesions on both sides of the basal ganglia area. Full remission of the Parkinson's syndrome was achieved with rheological treatment and L-dopa therapy.

The ictal electroencephalogram as a marker for the efficacy of electroconvulsive therapy.

The question of how to define a therapeutically adequate electroconvulsive therapy (ECT) has been under discussion since the early days of ECT. Although convention has asserted a demand for minimum seizure times, the complex electrophysiological conditions involved in developing a generalized seizure make it problematic for therapeutic efficacy of ECT to be linked only with seizure duration. Within the framework of an open clinical study of 40 patients, selected parameters of the ictal electroencephalogram (EEG) have now been examined with respect to differentiation between therapeutically effective and ineffective treatments. For this purpose a rating scale covering both quantitative and qualitative features of the ictal EEG was used. Although this study recorded no correlations between seizure duration and clinical improvement, correlations were established between clinical improvement, on the one hand, and the frequency of epileptic discharges and their slowing during the spike-wave phase as well as the stereotypy of the discharge or a "stable" pattern of rhythmic spike-wave or sharp wave complexes, on the other. The results suggest that several of these EEG parameters might be combined to form a marker for therapeutically adequate ECT, and that treatment might be controlled accordingly.

Migraine after electroconvulsive therapy.

The first detailed case report of recurrent common migraine after electroconvulsive therapy (ECT) is presented; it involves a 52-year-old woman with major depressive disorder. The migraine symptoms corresponded to those of the infrequent spontaneous migraine attacks she had. After a change to propofol as the anesthetic because of methohexital intolerance, the migraine attacks ceased, apparently due to seizure generalization being inhibited by propofol. In patients with migraine, ECT may be expected to trigger a migraine attack, probably in the same way as spontaneous seizures. The possible reasons and significance are discussed.

[Electroconvulsive therapy in neurologic diseases]. / Elektrokrampftherapie bei neurologischen Krankheiten.

Numerous developments have improved the safety and efficacy of electroconvulsive therapy (ECT) in recent years, so that ECT is now one of the safest forms of treatment under anesthesia. The indications for psychiatric patients are clearly defined. ECT is also under discussion with respect to certain neurological disorders. This discussion has, however, been largely ignored by the German medical profession. Critical evaluation of previous experience, especially in the United States and in Scandinavia, reveals some clinical situations (e.g., akinetic crisis in Parkinson's disease) in which a primary neurological indication for ECT might be present. ECT is frequently indicated in other brain diseases if pronounced psychopathological disturbances (especially of a depressive type) occur and fail to respond to conventional treatment with psychotropic drugs. ECT may then be indicated on a case-by-case basis. ECT should not be withheld from such patients; on the other hand, there is the risk of uncontrolled expansion of these indications for ECT.

Suspension therapy in acute schizophrenia. Clinical and neuroendocrine/biochemical effects of abrupt discontinuation of neuroleptic medication.

22 acutely schizophrenic patients with partial remission under standard haloperidol therapy (reduction in BPRS total score by 50% or less) were included in this prospective study. There was a significant correlation between the BPRS total score or the BPRS factors Anxiety/depression and Anergia and extrapyramidal side effects at the end of the 3-week neuroleptic treatment phase. In these patients abrupt discontinuation of neuroleptic medication (suspension therapy) brings about a significant further reduction in BPRS total scores together with a favorable effect on the BPRS factors Anxiety/depression, Anergia and Thought disturbance. There was a trend towards low serum prolactin values before neuroleptic discontinuation being linked with a favorable effect of subsequent suspension therapy. Urinary dopamine and homovanillic acid excretion before neuroleptic discontinuation did not predict the clinical suspension effect. Thus peripheral neuroendocrine and biochemical effects of haloperidol-induced dopamine blockade and their changes after discontinuation of neuroleptic medication seem not to be linked with the clinical effect of suspension therapy in acute schizophrenia. There was, however, a significant relationship between low urinary epinephrine, norepinephrine, vanillylmandelic acid and cortisol excretion before suspension therapy and a favorable suspension effect. On the other hand, the more pronounced a nonspecific stress constellation (catecholamines, cortisol) was in patients with an unsatisfactory remission under neuroleptics, the less favorable was the clinical effect of suspension therapy. Until now, the treatment courses of suspension therapy have been evaluated in 43 schizophrenic patients. According to both clinical aspects and observer rating, three types of therapeutic suspension effects have been distinguished in one-third of the cases respectively; none (at best temporary remission, no improvement in the overall treatment situation); partial (substantial remission, neuroleptic medication resumed for therapeutic reasons), and favorable (almost complete remission, neuroleptic medication resumed for prophylactic reasons).

Virus-induced changes in airway responsiveness, morphology, and histamine levels in guinea pigs.

A significant increase in airway responsiveness to histamine was observed in vitro and in vivo 4 days after intratracheal inoculation of parainfluenza Type 3 (PI-3) virus to guinea pigs. Light microscopic and ultrastructural examination of the central airways of animals inoculated with virus revealed stratification of the epithelial lining, with pronounced loss of cilia and granule-depleted goblet cells. In the peripheral airways, typical lesions of patchy alveolitis and bronchiolitis were found. The alveolar epithelium often lacked Type I alveolar cells and was lined merely by cells containing osmiophilic lamellar bodies typical of Type II alveolar cells. PI-3 virus inoculation resulted in a reduction in the number of airway mucosal mast cells, particularly in the bronchioles, and in a change of density of the granules of mast cells. Further, a significant rise (100%) in histamine concentration was observed in lung lavage fluid after virus inoculation. The prostaglandin E2 (PGE2) content in the lavage fluid was not changed. After stimulation with histamine, the tracheae of animals inoculated with control solution or PI-3 virus produced similar amounts of PGE2. These data indicate that PI-3 virus activates airway mast cells and increases the histamine content in the respiratory tract. Neither the virus-induced lung damage nor the increased levels of histamine in the airways influence the release of the epithelially derived relaxing factor PGE2. It is suggested that mast cell-derived products, in particular histamine, are involved in virus-induced airway hyperresponsiveness.

[Automobile driving capacity of the elderly from the psychiatric viewpoint]. / Fahreignung älterer Menschen aus psychiatrischer Sicht.

BASIC REMARKS: As the percentage of senior citizens in the general population increases, the number of elderly drivers is also increasing. This raises the general question as to the fitness of the elderly to participate in road traffic; the answer to this question must be considered within the larger context of ageing. Main points discussed: Acute psychiatric conditions (schizophrenic psychosis, melancholia, mania, organic psychosis, neurosis, addictive diseases) and decompensated neurosis and progressive dementia all render the victim unfit to drive. However, when the acute phase has been overcome, driving ability may well be re-established. Here, consideration must be given to psychopharmacological therapy. CONCLUSIONS: An elderly person's fitness to drive does not depend per se on chronological age or a given diagnosis. Rather, an individual assessment must take account of such parameters as psychopathology, personality, the ability to come to an agreement, the course of any psychiatric illness, and the effects of other somatic diseases and drugs.

[Psychotic episode caused by prevention of malaria with mefloquine. A case report]. / Psychotische Episode infolge Malariaprophylaxe mit Mefloquin. Eine kasuistische Mitteilung.

We report on a 41 year old woman, who after 750 mg mefloquine, a newer antimalarial agent, developed a psychosis with dizziness, confusion and delusions. The symptoms were more intensive and remained longer than hitherto reported in the literature. A total of 23 patients are known to have had psychiatric adverse effects under mefloquine. Psychotic episodes are undoubtedly though rarely associated with the intake of mefloquine.