The state of electroconvulsive therapy in Texas. Part I: reported data on 41,660 ECT treatments in 5971 patients.

The Texas Legislature in 1993 mandated a quarterly reporting requirement for hospitals and physicians performing electroconvulsive therapy (ECT) in the state (United States Government hospitals were excluded). The Texas Department of Mental Health and Mental Retardation (TDMHMR) was designated as the agency responsible for collecting and maintaining the data. This paper reviews the ECT data from 16 quarterly reports (09/01/93 through 08/31/97). The reports contained data on 41,660 ECT treatments in approximately 5971 patients. The results of this study support the proposition that ECT is an extremely safe and effective treatment for those individuals suffering from a serious mental illness. In Texas, ethnic groups other than non-Hispanic Anglo-Americans appear to be underserved in regards to ECT. Those patients without appropriate insurance or adequate personal finds are also underserved as a result of the few county and state hospitals performing ECT and the relatively small number of patients treated with ECT at those hospitals. Recommendations are suggested to improve the quality of the database and in informing the public as to the safety and efficacy of this valuable treatment modality. What, at first, was seen as an unwarranted legislative foray into the practice of medicine, has, in the end, become a source of valuable data supporting the use of ECT as an important treatment modality.

The state of electroconvulsive therapy in Texas. Part 2: contact with physicians, hospitals, medical liability insurance companies, and manufacturers of stimulus generating equipment.

Since mid-1993, all ECT treatments performed in the state of Texas (except for United States government hospitals) must be reported every quarter to the Texas Department of Mental Health and Mental Retardation (TXMHMR) on a data collection form provided by the Department. Part 1 of this paper reviewed that data. This paper reviews the responses to questionnaires and contacts made with physicians, hospitals, medical liability insurance companies, and manufacturers of stimulus generating devices regarding their experience with ECT in Texas. Questionnaires were sent to physicians and hospitals that had not performed ECT during the final two quarters of the review period. Medical liability insurance companies and the manufacturers of the stimulus generating equipment used in ECT were contacted regarding their experience with liability claims. The results indicate that medical liability in regards to the performance of ECT is extremely low. Physicians and hospitals that stopped performing ECT did so for reasons other than medical liability.

SPECT image analysis using statistical parametric mapping: comparison of technetium-99m-HMPAO and technetium-99m-ECD.

UNLABELLED: The goal of this study was to examine the apparent differences in regional cerebral blood flow (rCBF) between two groups of normal individuals who received either of the two tracers, 99mTc-D,L-hexamethylpropylene amine oxide (99mTc-HMPAO, or exametazime) or 99mTc-ethylene-dicysteine diethylester (99mTc-ECD, or bicisate). METHODS: Individuals were screened for drug use, head injury, medication status and other psychiatric and medical illnesses. The two groups were matched for age, sex and race. SPECT measurement of brain perfusion was performed in 35 individuals who received 99mTc-HMPAO and in 55 who received 99mTc-ECD. Subsequent analysis of these scans was done using computer software including Statistical Parametric Mapping and Analyze. Images were intensity-thresholded and spatially normalized to a standardized stereotactic (Talairach) space. This allowed for the objective, quantitative analysis of these data, demonstrating the extent and magnitude of rCBF changes. RESULTS: Our results showed significant changes between these two groups of normal individuals, presumably due to differences in pharmacokinetics between the two radiolabeled tracers. Specifically, large areas of the parietal, occipital and superior temporal cortices were significantly lower in the 99mTc-HMPAO group than in the 99mTc-ECD group. Increases were seen in the subcortical nuclei, parts of the brain stem, hippocampus and small areas of the cerebellum in the 99mTc-HMPAO group as compared to the 99mTc-ECD group. CONCLUSION: We present a method of image analysis to semiquantitatively measure rCBF in SPECT images and the changes seen due to differences between the two radiotracers.

Temporal lobe perfusion asymmetries in schizophrenia.

UNLABELLED: Structural and functional neuroimaging techniques have consistently demonstrated that abnormal lateralization of temporal lobes may be important in identifying the pathophysiologic processes in schizophrenia. The exact nature of these reported abnormalities has not been consistent. METHODS: We examined temporal lobe perfusion using HMPAO-SPECT in 22 individuals with schizophrenia in an effort to establish whether temporal lobe perfusion asymmetry is seen in these individuals, as compared to a group of 22 age- and sex-matched controls. RESULTS: We found that the asymmetry index, a measure of perfusion differences between two homologous compared areas, was lower (more negative) in schizophrenic individuals. The asymmetry indices of patients considered with the results from globally corrected ROI means indicated that the left temporal lobes of individuals with schizophrenia were significantly hypoperfused when compared to controls. This finding does not appear to be caused by medication effects, demographic variables, handedness, imaging artifacts or analysis techniques. CONCLUSION: In our sample, patients with schizophrenia appear to have significant left hypoperfusion relative to right of their temporal lobes. Abnormal lateralization of temporal lobe blood flow may have important clinical implications by assisting with diagnosis and appropriate treatment for individuals with schizophrenia.

Visual attention in obsessive-compulsive disorder.

Performance on neuropsychological tasks was compared in 15 subjects with obsessive-compulsive disorder (OCD) and 15 age- and sex-matched psychiatrically screened control subjects. The tasks chosen are known from studies in other patient groups to demonstrate lateralized abnormalities of visual and limited capacity attentional impairment. The Posner task performance of the OCD group demonstrated decreased inhibition of return for left visual field targets and no inhibition of return for right visual field targets. The OCD group's spatial-linguistic conflict task responses were significantly slowed in the conflict condition, as predicted. The results are discussed in relation to the phenomenology of OCD and prior neuropsychological evaluations.

The ICD-10 symptom checklist: a companion to the ICD-10 classification of mental and behavioural disorders.

The ICD-10 Symptom Checklist is a semi-structured diagnostic instrument intended for clinicians' assessment of F0-F6 categories in the ICD-10 Classification of Mental and Behavioural Disorders. The instrument was preliminarily tested at the St. Louis site during its participation in the field trials of the ICD-10 Diagnostic Criteria for Research. The Checklist was found to be a reliable diagnostic tool (overall kappa 0.72) within the constraints of the interviewer/observer reliability study design. More rigorous tests of the psychometric properties of the instrument are necessary.

Subcortical dopamine and serotonin turnover during acute and subchronic administration of typical and atypical neuroleptics.

The effects of acute (1 day) and subchronic (28 days) treatment with three atypical antipsychotic drugs [clozapine, (+/-)-sulpiride and (-)-3-PPP] on dopamine and serotonin turnover in both the nucleus accumbens (NA) and corpus striatum (CS) of rodents was compared to haloperidol and saline treatment. The equivalent doses of all drugs were determined based upon their ability to compete in vivo for 3H-spiperone binding in the NA and CS. All three atypical drugs, compared to haloperidol, produced preferential elevations of dopamine turnover in the NA. Further, the development of tolerance of this effect was more apparent for the three atypical drugs than for haloperidol. Surprisingly, all three atypical drugs, but not haloperidol, produced changes in serotonin turnover, despite the fact that (+/-)-sulpiride and (-)-3-PPP have no known direct effects on brain serotonin systems. All three atypical drugs produced acute increases in serotonin turnover in both the NA and CS, followed by later diseases.

Lateralized attentional abnormality in schizophrenia is correlated with severity of symptoms.

Numerous studies have demonstrated a lateralized impairment of attention in schizophrenia. In this study, attention in schizophrenia is investigated with a task that involves centering a rod while blindfolded. Symptoms were rated on the Brief Psychiatric Rating Scale (BPRS) for each of the 20 schizophrenic subjects. The more symptomatic patients demonstrated a right-sided hemineglect compared to the less symptomatic patients (p = 0.013). Furthermore, the difference between more and less symptomatic patients was even more distinct when they were categorized by the BPRS schizophrenia subscale alone (p = 0.0025). These findings support the hypothesis that the pathophysiology of schizophrenia involves a lateralized defect in the control of attention, and that this defect is associated with the severity of symptoms. This raises the possibility that effects of neuroleptic medication may be asymmetric, which could account for some of the inconsistencies in studies of hemispheric dysfunction in schizophrenia.

Comparison of Composite International Diagnostic Interview and clinical DSM-III-R criteria checklist diagnoses.

This article describes a comparison of Composite International Diagnostic Interview (CIDI) diagnostic results and results based on clinicians' observation of CIDI assessments. Psychiatrists scored a DSM-III-R criteria checklist either while observing or after administering 20 CIDI interviews. Overall diagnostic concordance between the checklist and CIDI diagnoses was found to be good (kappa = 0.78). Good diagnostic agreement was also found for 3 groups of DSM-III-R disorders: depressive disorders (kappa = 0.84), psychoactive substance use disorders (kappa = 0.83) and anxiety phobic disorders (kappa = 0.76). These results are consistent with the results from a similar comparison between the CIDI and checklist results for ICD-10 diagnoses.

Clinical observation of assessment using the Composite International Diagnostic Interview (CIDI). An analysis of the CIDI Field Trials--Wave II at the St Louis site.

Two clinicians scored the ICD-10 Research Criteria Checklist either while observing or after administering CIDI interviews to a sample of 20 subjects. Overall diagnostic concordance between clinical and CIDI assessments was found to be good (overall kappa = 0.77). Assessment of the specific diagnoses could be done only for the three most commonly represented in the studied sample: anxiety/phobic disorders (kappa = 0.73), depressive disorders (kappa = 0.78), and psychoactive substance use disorders (kappa = 0.83). While the lack of independence of the two assessments and the small, non-randomly selected sample might have exaggerated the concordance, this study shows that the CIDI provides all the data needed to score diagnoses in the ICD-10 nomenclature, as indicated by the small number of questions clinicians needed to ask following completion of the CIDI.

Left striato-pallidal hyperactivity in schizophrenia. Part II: Phenomenology and thought disorder.

Our previous paper summarized abundant evidence that schizophrenic patients show forms of sensory and motor hemineglect compatible with a left striato-pallidal hyperactivity model of schizophrenia. In this paper we discuss how the model may also account for some of the cognitive and phenomenological aspects of this disorder. Hemineglect can be associated with pallidal hyperactivity through its mediation of the anterior attention system of the frontal lobe. We postulate that this same attentional deficit can also affect higher functions such as the control of language and thought by internal motivations. Many symptoms of schizophrenia can be explained as a form of hemineglect of these higher functions.

Hyperactivity of the left striato-pallidal projection. Part I: Lower level theory.

We have observed increased relative blood flow to the left globus pallidus and evidence for subtle forms of right-sided hemineglect in neuroleptic-naive schizophrenic patients. These findings occur in animals following certain lesions such as unilateral destruction of midbrain dopaminergic neurons, and are presumed to be due to left striato-pallidal hyperactivity. A survey of the literature reveals many similarities between animals with unilateral dopaminergic denervation and schizophrenic patients. It has previously been suggested that available evidence does not preclude the possibility that schizophrenic patients have something like a dopaminergic deficiency. Other studies demonstrate that neuroleptics reverse asymmetries in indices of dopamine turnover. A model based upon dopaminergic hemideficiency is outlined, and can potentially explain other abnormalities in schizophrenic patients including eye movement abnormalities and the link between temporal lobe epilepsy and psychosis. A companion article describes how this model can account for some of the phenomenological symptoms of psychosis.

Asymmetries in hemispheric control of attention in schizophrenia.

Investigators have long suggested that schizophrenia might be related to an impairment in the regulation of attention. In this report, the performance of schizophrenic patients was compared with nonschizophrenic control subjects in their ability to direct visual attention. In the first experiment, patients were distinguished from controls by a slower response to a target in the right visual field than to a target in the left visual field when attention was not first directed to the target location. In the second experiment, patients were distinguished from controls by a stronger bias in favor of symbolic information over language information about spatial direction. In both experiments, the patients demonstrated deficits in attention similar to patients from previous studies who had unilateral lesions of the left hemisphere. The identification of performance abnormalities using tasks that are simple, have dissectable cognitive components, have been related to discrete neural systems, and control for nonspecific variables provide the basis for constructing reasonable hypotheses about the cognitive psychology and functional neuroanatomy of schizophrenia.

Left globus pallidus abnormality in never-medicated patients with schizophrenia.

Schizophrenia is a severe psychiatric disorder characterized by onset in young adulthood, the occurrence of hallucinations and delusions, and the development of enduring psychosocial disability. The pathophysiology of this disorder remains unknown. Studies of cerebral blood flow and metabolism designed to identify brain abnormalities in schizophrenia have been limited by inadequate methods of anatomical localization and the possibility of persistent medication effects. We have now used positron emission tomography and a validated method of anatomical localization in an attempt to identify abnormalities of regional cerebral blood flow in newly diagnosed never-medicated patients with schizophrenia. An exploratory study of 5 patients and 10 normal control subjects identified abnormally high blood flow in the left globus pallidus of patients with schizophrenia. A replication study of 5 additional patients and 10 additional control subjects confirmed this finding. No other abnormalities were found.