Electroconvulsive therapy is equally effective in unipolar and bipolar depression.

OBJECTIVE: To determine the relative efficacy of electroconvulsive therapy (ECT) in the treatment of bipolar (BP) and unipolar (UP) depressive illness and clarify its role in BP depression. METHOD: Patients referred for ECT with both UP and BP depressions. [classified by Structured Clinical Interview for DSM (SCID-I) criteria for history of mania] were included in a multi-site collaborative, double-masked, randomized controlled trial of three electrode placements - right unilateral, bifrontal or bitemporal - in a permutated block randomization scheme. RESULTS: Of 220 patients, 170 patients (77.3%) were classified as UP and 50 (22.7%) as BP depression in the intent-to-treat sample. The remission and response rates and numbers of ECT for both groups were equivalent. CONCLUSION: Both UP and BP depressions remit with ECT. Polarity is not a factor in the response rate. In this sample ECT did not precipitate mania in depressed patients. Treatment algorithms for UP and BP depression warrant re-evaluation.

ECT remission rates in psychotic versus nonpsychotic depressed patients: a report from CORE.

OBJECTIVE: To compare the relative efficacy of electroconvulsive therapy (ECT) in psychotic and nonpsychotic patients with unipolar major depression. METHODS: The outcome of an acute ECT course in 253 patients with nonpsychotic (n = 176) and psychotic (n = 77) unipolar major depression was assessed in the first phase of an ongoing National Institute of Mental Health-supported four-hospital collaborative study of continuation treatments after successful ECT courses. ECT was administered with bilateral electrode placement at 50% above the titrated seizure threshold. The remission criteria were rigorous: a score

Comparison of bifrontal and bitemporal ECT for major depression.

OBJECTIVE: The authors compared the clinical and cognitive effects of bifrontal electrode placement with standard bitemporal electrode placement in the treatment of patients with major depression. METHOD: Forty-eight patients with unipolar or bipolar depression were treated with a course of bifrontal or bitemporal ECT. The Hamilton Rating Scale for Depression and the standardized Mini-Mental State were administered at baseline and repeated during the course of treatment. RESULTS: Forty-seven of the 48 patients who completed the course of treatment met remission criteria by the 12th treatment. There were no differences between the patients given bifrontal ECT and those given bitemporal ECT in the number of treatments required to reach remission criteria. The standardized Mini-Mental State scores of the patients given bitemporal ECT worsened more after treatment than did those of the patients given bifrontal ECT. CONCLUSIONS: Bifrontal electrode placement was as efficacious as bitemporal placement and resulted in less cognitive impairment. A study of the two placements with more cognitive measures is indicated.

Reimbursement and documentation issues in an ambulatory ECT program.

In this era of decreased health resources and the strong influence of third-party payers, the financial advantages of ambulatory electroconvulsive therapy (ECT) should be well recognized by all concerned parties. However, to a large degree, third-party payers are only minimally aware of the availability and potential cost savings associated with this treatment modality. Also, documentation has been problematic, because reviewers unfamiliar with ECT have not been able to find the necessary data even when they are present in the chart. This article illustrates some of these problems and how they have affected our ambulatory ECT program.

Flumazenil reversal of benzodiazepine-induced sedation for a patient with severe pre-ECT anxiety.

We describe various measures to reduce severe anxiety that interfered with much-needed maintenance electroconvulsive therapy in a 32-year-old man. Treatment with ketamine met with moderate success, and then large doses of lorazepam and midazalam were used. The potential anticonvulsant effect of these drugs was successfully reversed by the administration of intravenous flumazenil just prior to the treatments.

Opening the door on a locked psychiatric unit.

A therapeutic milieu on acute locked psychiatric units is difficult to establish and maintain. The stigma of being on a locked unit and the absence of a sufficiently compelling goal around which patients can mobilize as a group are two factors that contribute to this difficulty. By opening the door under specific conditions, we were able to affect both these factors significantly. In this article, we describe the issue of feasibility, the technical devices employed, and seven months' experience with this system.

Clozapine: plasma levels and prolactin response.

Serial plasma clozapine levels and serum prolactin levels were determined in two schizophrenic patients receiving clozapine, a novel antipsychotic drug. Despite marked therapeutic response and substantial clozapine blood levels, prolactin levels obtained 11--12 h after the last oral dose were unaffected or only minimally elevated. This confirms previous evidence of clozapine's unusual characteristics.

Mini-groups: maximizing the therapeutic milieu on an acute psychiatric unit.

The authors have found small groups (called mini-groups) an effective way to work with patients who are too regressed or disturbed to benefit from individual psychotherapy and who find larger groups overwhelming and confusing. Mini-groups were formed in 1974 on a 20-bed acute inpatient service of a private psychiatric hospital, where traditional treatment approaches have been altered because of a more disturbed patient population and a shorter length of stay. A high staff-to-patient ratio, sometimes almost one to one, lends stability to the groups.