Allan I. F. Scott

Quick recovery of orientation after magnetic seizure therapy for major depressive disorder

BACKGROUND Magnetic seizure therapy, in which seizures are elicited with a high-frequency magnetic field, is under development as a new treatment for major depressive disorder. Its use may be justified if it produces the antidepressant effects of electroconvulsive therapy (ECT), coupled with limited cognitive side-effects. AIMS To evaluate the usefulness of a new 100 Hz magnetic seizure therapy device. METHOD We induced seizures with 100 Hz magnetic transcranial stimulation in 11 patients with major depressive disorder during one session of a regular course of ECT. Recovery times after seizures induced by magnetic seizure therapy and ECT were compared. RESULTS Seizures could be elicited in 10 of the 11 patients. Stimulation over the vertex produced tonic-clonic activity on 9 out of 11 occasions. Stimulation over the prefrontal midpoint elicited seizures on 3 out of 7 occasions. The mean duration of magnetically induced seizures was 31.3 s, ranging from 10 to 86 s. All patients had an exceptionally quick recovery of orientation: mean of 7 min 12 s (s.d.=2 min 7 s, range 4 min 20 s to 9 min 41 s). The recovery times were on average 15 min 35 s shorter with magnetic seizure therapy than with ECT in the same patients (paired-samples t-test: P<0.0001). Patients reported feeling less confused after magnetic seizure therapy. Side-effects were confined to myoclonic movements, associated with the use of etomidate. CONCLUSIONS The new 100 Hz magnetic stimulator elicits seizures in the majority of patients when administered over the vertex. Magnetic seizure therapy was associated with shorter recovery times and less confusion following treatment. Subsequent work will be required to assess the safety and effectiveness of magnetic seizure therapy in the treatment of depression.

Short-term effects of electroconvulsive treatment on the uptake of99mTc-Exametazime into brain in major depression shown with single photon emission tomography

Fifteen patients with major depression who were being treated with bilateral electroconvulsive treatment (ECT) were investigated before and 45 min after a single ECT using split-dose Single Photon Emission Tomography (SPET or SPECT) with 99mTc-Exametazime. All patients suffered from unipolar depressive illness and were rated on the Newcastle scale and with the 17-item Hamilton scale. They completed tests of orientation and verbal memory on the day of ECT. For comparison, verbal memory was also tested on the preceding day. The uptake of 99mTc-Exametazime was expressed relative to calcarine/occipital cortex. Significant decreases in tracer uptake were confined to the inferior anterior cingulate cortex. The changes were correlated with the severity of depressive symptoms and more weakly with decrements of memory function produced by ECT; there was no significant correlation with stimulus intensity or electroencephalographic measures of seizure duration.

Rates of electroconvulsive therapy use in Edinburgh (1992–1997)

BACKGROUND The number of ECT treatments given each year is a topic of interest for psychiatrists, users and politicians, but there are major methodological problems in reported studies of rates of ECT use in the British Isles. The aim was to establish whether or not the use of ECT had fallen between 1992 and 1997. METHOD A computerised database of ECT treatments in Edinburgh and relevant population data were used to calculate annual indices of ECT usage. These indices were calculated separately for the population aged 18-64 years and those 65 years or older. RESULTS In the general adult population, the rate of ECT use fell progressively and significantly (p < 0.01) from 2.90 to 1.37 treatments per 1000 population. This fall was commensurate with the falls in other indices of ECT use. Among the elderly population, the rate of ECT use was three times that in the general adult population. There was no significant change, although the number of courses of treatment fell by 40% (p = 0.06). CONCLUSIONS There continues to be a progressive fall in the use of ECT in general adult psychiatry. ECT is used substantially more often in the elderly. Reports of ECT use ought to include numbers of both treatments and patients treated. LIMITATIONS There was no investigation of the possible causes of the fall in ECT use. The extent to which these findings can be generalised to the rest of the British Isles will require further study.

Variation in rates of electroconvulsive therapy use among consultant teams in Edinburgh (1993–1996)

BACKGROUND Critics of electroconvulsive therapy (ECT) have expressed concern about variations in ECT use among consultant teams within the same hospital. The aim was to establish whether or not there was a significant variation in rates of ECT use among consultant teams in the same hospital when in-patient workload was taken into account. METHODS A computerised database was used to calculate annual and aggregate rates of ECT use by consultant team, expressed as the number of individual in-patients treated per 100 in-patients discharged between 1993 and 1996. RESULTS The variation in aggregate rates of ECT use varied approximately 18-fold among the 11 general adult psychiatric teams (P<0.001), and twofold among the three sector old-age psychiatric teams (P<0.05). CONCLUSIONS Substantial variation in the rates of ECT use was confirmed, but only among general adult psychiatric teams. LIMITATIONS The extent to which findings from one teaching hospital can be generalised was unknown. Possible explanations of the variations were not assessed.

Treatment outcome, seizure duration, and the neurophysin response to ECT

Serum concentrations of immunoreactive neurophysin (IRN) and vasopressin-associated neurophysin (hNpI) were measured before and after the first treatment in a course of electroencephalographically monitored electroconvulsive therapy (ECT) given to 19 depressed patients. The difference (DIFF) between the serum concentrations of IRN and hNpI is equivalent to the concentration of oxytocin-associated neurophysin. Before ECT the six patients who had a good outcome at 2 months after the course of ECT had a mean serum IRN concentration one-half (p less than 0.05) and a mean serum DIFF concentration one-third (p less than 0.05) that of the 13 patients who had a poor outcome. The increase in serum DIFF concentration (but not IRN or hNpI) after the first ECT correlated with the improvement on the Hamilton Rating Scale for Depression (r = -0.73, p less than 0.005) and the Montgomery and Asberg Depression Rating Scale (r = -0.49, p less than 0.05). The peak percentage increase in serum DIFF concentrations after ECT was 4 times greater (p less than 0.001) in the good outcome group than in the poor outcome group. None of the neurophysin responses to ECT correlated with electroencephalogram-measured seizure duration.

Electroconvulsive therapy, practice and evidence {

This issue includes the findings from the largest randomised controlled trial ever conducted with bilateral, unilateral and bifrontal electroconvulsive therapy (ECT). The background to the study and its findings are discussed.

A survey of methohexitone use by anesthetists in the clinical practice of ECT in Edinburgh.

The dosage of methohexitone (methohexital) administered by anesthetic staff was surveyed in a consecutive series of 52 patients referred for electroconvulsive therapy (ECT) in routine clinical practice in Edinburgh. Patients were weighed before the first treatment, and the ratio of administered dose to weight in kilograms calculated. Anesthesia was administered by three consultant staff and six nonconsultant staff. In only one patient (2%) was the administered dose within the range recommended by the Royal College of Psychiatrists (0.75–0.9 mg/kg), and in only four patients (8%) were the doses within the range recommended by the American Psychiatric Association (0.75–1.0 mg/kg). In all other patients the dose exceeded these recommended ranges; the average dose was 1.5 (± 0.3) mg/kg. The possible implications of these findings are discussed.

Improvement in depressive illness is not associated with altered release of neurophysins over a course of ECT

The hypothesis that the release of vasopressin-associated neurophysin (hNpI) or oxytocin-associated neurophysin (hNpII) is modified by a course of electroconvulsive therapy (ECT) was tested by the measurement of serum neurophysins before and after the first and last ECTs given to 17 unipolar depressed patients. Neither basal nor ECT-induced neurophysin release changed between the first and last ECTs. Data from the present study were combined with data from a previous published study to provide a sample of 29 unipolar depressed patients. In this extended sample, the release of hNpII after the first ECT was significantly correlated with improvement in symptoms of depression over a course of ECT as measured by the Hamilton Rating Scale for Depression and the Montgomery-Asberg Depression Rating Scale.

The effect of repeated bilateral electroconvulsive therapy on Seizure threshold

Seizure threshold was measured by empirical titration in 28 patients referred for bilateral electroconvulsive therapy to treat depressive illness at the outset of treatment and after another six treatments. No patient was given antiepileptic drug treatment, and anesthetic technique and concomitant psychotropic drug treatment were fixed. The average (± SD) initial seizure threshold measured by set charge was 79.5 mC (± 33.4 mC), and this increased to 95.5 mC (± 37.9 mC). The average percentage increase was 22.8% (95% confidence interval, 13.7% to 31.8%). The seizure threshold measured by set charge did not change in 15 patients (54%), and there was no significant relation between change in seizure threshold and patient sex, change in seizure duration measured by cuff technique, or global clinical improvement during the course of treatment.

Initial seizure threshold in the clinical practice of bilateral electroconvulsive therapy in Edinburgh, Scotland.

Initial seizure threshold was measured by empirical titration in 137 patients referred for bilateral electroconvulsive therapy (ECT) for the treatment of depressive illness. Treatment was given by an Ectron Series 5A ECT machine. The median and modal thresholds were 75 mC and the range was 50-200 mC. The only statistically significant relationship among initial threshold and age or gender was the correlation of age with threshold in men (rho = 0.46, p < 0.01). All patients (n = 22) younger than 30 years had an initial threshold < 100 mC, but age and gender did not predict threshold accurately for older men or women.