Dennis M. Popeo

Depression severity in electroconvulsive therapy (ECT) versus pharmacotherapy trials.

Objective We sought to compare the level of severity of depressive symptoms on entry into electroconvulsive therapy (ECT) clinical trials versus pharmacotherapy clinical trials. Data Sources English-language MEDLINE/PubMed publication databases were searched for ECT literature (search terms: ECT, electroconvulsive therapy, depression, and Hamilton) for clinical trials in which depressed patients had baseline Hamilton Rating Scale for Depression (HRSD) scores. For comparison, we used a convenience sample of 7 large pharmacotherapy trials in major depression (N = 3677). The search included articles from 1960 to 2011. Study Selection We included 100 studies that met the following criteria: ECT trial for depression, patients adequately characterized by diagnosis at baseline, and patients rated at baseline by 15-item HRSD (HRSD15), HRSD17, HRSD21, HRSD24, or HRSD28, with mean (SD) and sample size (n) reported. For the comparator pharmacotherapy trials, we chose to use a subset of the studies (excluding one study of minor depression) in the widely publicized meta-analysis of Fournier et al, as well as the STAR*D study and one additional study by Shelton et al. This provided 7 studies of major depression using HRSD17 (total N = 3677). Data Extraction Data extracted included number of subjects and baseline and final HRSD scores, with mean (SD) values. Results Of 100 ECT studies, 56 studies (N = 2243) used the HRSD17 version. The mean baseline HRSD17 score in the ECT trials was 27.6, the mean in the pharmacotherapy trials was 21.94, a statistically, and clinically, significant difference. In a subanalysis of the 16 ECT studies that used the HRSD24 version, the mean baseline score was 32.2. Conclusions This selective literature review confirms that patients who entered ECT clinical trials were more severely ill than those who entered the selected comparator pharmacotherapy trials. Such data highlight the critical role of ECT in the treatment of severe and treatment-resistant mood disorders.

A resident rotation in collaborative care: learning to deliver primary care-based psychiatric services.

To the Editor: Psychiatry residents’ clinical experiences in primary care settings have historically focused on either the trainee delivering primary care services as an intern rotating on family or internal medicine, or the trainee performing ambulatory psychiatry consultations as a senior resident (1, 2). Collaborative care is a well-studied model of integrated psychiatric and primary care that can effectively treat some psychiatric disorders, such as depression, commonly encountered in primary care settings (3). Collaborative care interventions are population-based, highlighting screening and case-identification, with the goal of increasing the total number of people exposed to evidenced-based psychiatric treatment. Collaborative care uses a teamof psychiatrists, primary care physicians, and care managers tomanage a clinic-wide population of patients, and a patient registry to track outcomes. The collaborative care psychiatrist becomes involved in the care ofmore patients than he or shewould be involvedwith in the traditional consultation model (4). The clinical work in collaborative care differs from the clinical work performed in traditional primary care-based ambulatory psychiatric consultations (2, 5). Also, collaborative care embraces measurement-based care with tools such as the Patient Health Questionairre-9 (PHQ-9) (5). Additional details of collaborative care are described in a review article (5). To find published reports in English of any resident rotations in collaborative care, we searched PubMed, using the following term combinations in September 2011: collaborative care, AND resident education, education, resident, elective, rotation. Our search yielded no publications describing resident rotations in collaborative care models. We created a year-long, longitudinal elective in collaborative care for one PGY-4 resident at Mount Sinai School of Medicine in New York City during the 2011–2012 academic year. The resident aimed to learn one model of collaborative care—IMPACT (6)—and the associated skill-set, including ambulatory consultation and supervision skills, techniques in teamwork, the use of standardized rating scales, and the leadership and communication skills specific to one geriatric primary care setting. The IMPACTmodel of collaborative care focuses on the recognition and treatment of late-life depression. Eachweek, the resident directly cared for patients, supervised the care manager, and attended IMPACT team meetings. The resident spent 1⁄2 day per week doing ambulatory psychiatric consultations and long-term psychiatric care for some patients in the geriatrics primary care clinic. Caring directly for patients in this clinic helped the resident learn the day-to-day functioning of the clinic, meet the clinic staff and physicians (which aided coordination of care), and further develop clinical skills in the treatment of geriatric patients. Also, the resident met with the collaborative care team weekly for 1 hour to assess the progress of the collaborative care implementation project and troubleshoot problems. The resident and attending psychiatrist cosupervised a depression care specialist for 1 hour weekly. Depression care specialist supervision by a psychiatrist is a key component in successful collaborative care programs (3, 6). It is notable that this resident’s elective co-occurred with implementation of collaborative care in the medical center’s geriatrics clinic, making it possible for the resident to observe and participate in project implementation. For example, the resident helped prepare and participated in the training and introduction of the collaborative care model to other trainees and geriatrics faculty. Part of the rotation involved preparing reports for, and sitting in on meetings with, members of the foundation who funded IMPACT implementation at the institution. Scholarly work was also expected. The resident and attending physician developed a poster presentation for a national meeting. To our knowledge, this is the first description of a resident rotation in collaborative care. The future clinical responsibilities of many psychiatrists may involve integrated care work. Through electives in well-studied models, such as collaborative care, we hope that more residents will have the opportunity to learn the skills needed to deliver integrated services.

Methohexital and succinylcholine dosing for electroconvulsive therapy (ECT): actual versus ideal.

Abstract This report compares the actual doses of methohexital and succinylcholine used for optimal anesthesia and muscle relaxation in electroconvulsive therapy with written guidelines for dosing. The initial doses of methohexital and succinylcholine in milligrams per kilogram were reviewed and compared with subsequent doses of each agent after adjustments were made for individual patient responses during treatment. The dose of methohexital required to induce general anesthesia for most patients is 1.0 mg/kg. The dose of succinylcholine required to provide adequate muscle relaxation during electroconvulsive therapy is 0.9 mg/kg, although there is considerable variability in patient response to this drug.

Low-dose right unilateral electroconvulsive therapy (ECT): effectiveness of the first treatment.

Background Electroconvulsive therapy (ECT) is a widely used, highly effective antidepressant treatment. Except for the most severely ill patients, right unilateral (RUL) electrode placement is the most frequent initial treatment choice. In current practice, RUL ECT is administered at several multiples of seizure threshold (ST) based on reports that lower stimulus intensity results in lower response/remission rates. Many patients, as part of an initial dose titration to determine ST, will receive a single treatment with low-dose RUL ECT and subsequent treatments with a stimulus at a multiple of ST. Objective To assess response to the first ECT. Methods A retrospective analysis of charts from clinical practice at Mount Sinai Medical Center was performed. Results A single treatment with low-dose (presumably near ST) RUL ECT had a significant and immediate antidepressant effect in our sample of patients with major depression. We determined that this response is similar to that of patients receiving a single initial treatment with high-dose RUL ECT (at a multiple of ST). Conclusions These data suggest, contrary to commonly held belief, that RUL ECT may be effective at a low stimulus dose. This argues against restimulating at 6 times ST in the initial session, based on the belief that the near-threshold seizure has no antidepressant efficacy. Our findings suggest a need for further investigation of cases in which low-dose RUL ECT may be an effective antidepressant treatment. Further prospective studies, including larger numbers of patients who receive randomized treatment with low- or high-dose RUL with longer follow-up, are indicated.

Resolution of Severe Suicidality With a Single Electroconvulsive Therapy

Electroconvulsive therapy is a rapid and effective treatment of severe depression that has been shown to quickly decrease or eliminate suicidal thoughts and behaviors. We describe the case of an 88-year-old man hospitalized for a carefully premeditated suicide attempt with highly lethal means. He was treated with a single electroconvulsive therapy (ECT) and improved markedly. His suicidal ideation remitted, and the patient was still free of suicidal ideation at 5 months of follow-up. We discuss the effect of ECT on suicidal ideation, the benefit of minimizing the number of total ECT treatments, and the possible biological markers of change after a single treatment in an ECT-naive patient.

Rocuronium as muscle relaxant for electroconvulsive therapy in a patient with adult-onset muscular dystrophy.

Abstract Adult-onset muscular dystrophy is an inherited myopathy characterized by a variable degree of progressive muscle weakness and degeneration. Although not usually fatal, significant muscle weakness results in an up-regulation of acetylcholine receptors on the less responsive postjunctional muscles. The resulting profound potassium release when these receptors are stimulated by the depolarizing muscle relaxant succinylcholine can result in potentially fatal cardiac arrhythmias. We report a case of electroconvulsive therapy safely administered in a 61-year-old man with adult-onset muscular dystrophy requiring muscle relaxation with rocuronium.

Development of Geriatric Mental Health Learning Objectives for Medical Students: A Response to the Institute of Medicine 2012 Report

America is aging as the population of older adults increases. The shortage of geriatric mental health specialists means that most geriatric mental healthcare will be provided by physicians who do not have specialty training in geriatrics. The Institute of Medicine Report of 2012 highlighted the urgent need for development of national competencies and curricula in geriatric mental health for all clinicians. Virtually all physicians can expect to treat older patients with mental health symptoms, yet currently there are no widely accepted learning objectives in geriatric mental health specific for medical students. The authors describe the development of a set of such learning objectives that all medical students should achieve by graduation. The iterative process included initial drafting by content experts from five medical schools with input and feedback from a wider group of geriatric psychiatrists, geriatricians, internists, and medical educators. The final document builds upon previously published work and includes specific knowledge, attitudes and skills in six key domains: Normal Aging, Mental Health Assessment of the Geriatric Patient, Psychopharmacology, Delirium, Depression, and Dementia. These objectives address a pressing need, providing a framework for national standards and curriculum development.

Febrile Reaction With Elevated CPK After a Single Electroconvulsive Therapy (ECT) in an Adolescent Patient With Severe Bipolar Disorder

This report describes the electroconvulsive therapy (ECT) course of a 15-year-old male with severe bipolar disorder unresponsive to medical management. After his first treatment, the patient exhibited fever, elevated creatine phosphokinase levels, and leukocytosis. Treatment was halted although the patient reported an improvement in symptoms, which was not maintained with pharmacotherapy alone. Subsequent treatments were completed without adverse reactions, and the patient entered remission. We discuss the possible causes of this reaction and remind the reader that a single adverse event does not always require the abandonment of a treatment modality.

Prolonged succinylcholine action during electroconvulsive therapy (ECT) after cytarabine, vincristine, and rituximab chemotherapy.

Succinylcholine is a depolarizing neuromuscular blocker frequently used during electroconvulsive therapy. In most patients, the duration of paralysis is brief, allowing for spontaneous respiration shortly after the therapy. We report a case of delayed return of neuromuscular function after succinylcholine administered during electroconvulsive therapy in a 72-year-old man receiving cytarabine, vincristine, and rituximab chemotherapy for chronic lymphocytic leukemia. We hypothesize that an interaction between succinylcholine and one of the chemotherapeutic agents caused the prolongation of paralysis and believe that this is the first reported case of prolonged duration of succinylcholine following this regimen of chemotherapy. Despite this unexpected prolonged neuromuscular blockade, the patient could be treated uneventfully, with attention paid to his respiratory support and with subsequent succinylcholine dose titration to effect.

Cases of catatonia on an academic electroconvulsive therapy service: lessons to learn.

Catatonia is a well-described neuropsychiatric syndrome that has been the subject of several texts. We present 4 cases seen on our academic service in the past 18 months and discuss significant features of each case.