Graham Pluck

Apathy in Parkinson’s disease

Objective: To assess apathy in patients with Parkinson’s disease and its relation to disability, mood, personality, and cognition. Methods: Levels of apathy in 45 patients with Parkinson’s disease were compared with a group of 17 similarly disabled patients with osteoarthritis. Additional neuropsychiatric data were collected concerning levels of depression, anxiety, and hedonic tone. Personality was assessed with the tridimensional personality questionnaire. Cognitive testing included the mini-mental state examination, the Cambridge examination of cognition in the elderly, and specific tests of executive functioning. Results: Patients with Parkinson’s disease had significantly higher levels of apathy than equally disabled osteoarthritic patients. Furthermore, within the Parkinson sample, levels of apathy appear to be unrelated to disease progression. The patients with Parkinson’s disease with the highest levels of apathy where not more likely to be depressed or anxious than those with the lowest levels of apathy, though they did show reduced hedonic tone. No differences in personality traits were detected in comparisons between patients with Parkinson’s disease and osteoarthritis, or between patients in the Parkinson group with high or low levels of apathy. As a group, the patients with Parkinson’s disease tended not to differ significantly from the osteoarthritic group in terms of cognitive skills. However, within the Parkinson’s disease sample, the high apathy patients performed significantly below the level of the low apathy patients. This was particularly evident on tests of executive functioning. Conclusions: Apathy in Parkinson’s disease is more likely to be a direct consequence of disease related physiological changes than a psychological reaction or adaptation to disability. Apathy in Parkinson’s disease can be distinguished from other psychiatric symptoms and personality features that are associated with the disease, and it is closely associated with cognitive impairment. These findings point to a possible role of cognitive mechanisms in the expression of apathy.

A randomized controlled trial with 4-month follow-up of adjunctive repetitive transcranial magnetic stimulation of the left prefrontal cortex for depression.

BACKGROUND Effectiveness of repetitive transcranial magnetic stimulation (rTMS) for major depression is unclear. The authors performed a randomized controlled trial comparing real and sham adjunctive rTMS with 4-month follow-up. METHOD Fifty-nine patients with major depression were randomly assigned to a 10-day course of either real (n=29) or sham (n=30) rTMS of the left dorsolateral prefrontal cortex (DLPFC). Primary outcome measures were the 17-item Hamilton Depression Rating Scale (HAMD) and proportions of patients meeting criteria for response (50% reduction in HAMD) and remission (HAMD8) after treatment. Secondary outcomes included mood self-ratings on Beck Depression Inventory-II and visual analogue mood scales, Brief Psychiatric Rating Scale (BPRS) score, and both self-reported and observer-rated cognitive changes. Patients had 6-week and 4-month follow-ups. RESULTS Overall, Hamilton Depression Rating Scale (HAMD) scores were modestly reduced in both groups but with no significant groupxtime interaction (p=0.09) or group main effect (p=0.85); the mean difference in HAMD change scores was -0.3 (95% CI -3.4 to 2.8). At end-of-treatment time-point, 32% of the real group were responders compared with 10% of the sham group (p=0.06); 25% of the real group met the remission criterion compared with 10% of the sham group (p=0.2); the mean difference in HAMD change scores was 2.9 (95% CI -0.7 to 6.5). There were no significant differences between the two groups on any secondary outcome measures. Blinding was difficult to maintain for both patients and raters. CONCLUSIONS Adjunctive rTMS of the left DLPFC could not be shown to be more effective than sham rTMS for treating depression.

Cost-effectiveness of transcranial magnetic stimulation vs. electroconvulsive therapy for severe depression: A multi-centre randomised controlled trial

BACKGROUND Electroconvulsive therapy (ECT) has a long history of use in treating depression. Repetitive transcranial magnetic stimulation (rTMS) has been introduced more recently to the treatment spectrum. Its cost-effectiveness has not been explored. METHOD Forty-six right-handed people with severe depressive episodes referred for ECT were randomised to receive either ECT twice weekly or rTMS on consecutive weekdays. Health and other service use were recorded for retrospective periods of 3 months prior to initiation of treatment and during the 6 months following the end of allocated treatment. Costs were calculated for the treatment period and the subsequent 6 months, and comparisons made between groups after adjustment for any baseline differences. Cost-effectiveness analysis was conducted with incremental change on the 17-item Hamilton Rating Scale for Depression (HRSD) as the primary outcome measure, and quality-adjusted life years (based on SF6D-generated utility scores with societal weights) as secondary outcome, cost-effectiveness acceptability curves plotted. RESULTS Based on the HRSD scores and other outcome measures, rTMS was not as effective as ECT. The cost of a single session of rTMS was lower than the cost of a session of ECT, but overall there were no treatment cost differences. In the treatment and 6-month follow-up periods combined, health and other service costs were not significantly different between the two groups. Informal care costs were higher for the rTMS group. Total treatment, service and informal care costs were also higher for the rTMS group. The cost-effectiveness acceptability curves indicated a very small probability that decision-makers would view rTMS as more cost-effective than ECT. LIMITATIONS Small sample size, some sample attrition and a relatively short follow-up period of 6 months for a chronic illness. Productivity losses could not be calculated. CONCLUSIONS ECT is more cost-effective than rTMS in the treatment of severe depression.

Methohexitone, propofol and etomidate in electroconvulsive therapy for depression: A naturalistic comparison study

BACKGROUND Methohexitone has been the most widely used anaesthetic for electroconvulsive therapy (ECT). However, recent scarcity and erratic availability has led to use of other anaesthetics with differing effects upon ECT. We compared treatment parameters and response to ECT in patients anaesthetised with different anaesthetics in a routine clinical setting. METHODS This was a naturalistic retrospective casenote analysis of 81 consecutive courses of ECT (total 659 treatments) for major depression. RESULTS Three anaesthetics were compared: methohexitone (n=34), propofol (n=13) and etomidate (n=34). Mean seizure duration was lowest (p<0.0001) for propofol. However, mean stimulus charge was highest in the propofol group (p<0.0001) who required a greater increase in stimulus charge during the course of treatment and also experienced a greater proportion of failed seizures (</=15 s on EEG). Despite differing effects upon treatment parameters, choice of anaesthetic did not appear to significantly affect therapeutic response to ECT. Use of propofol may be associated with longer treatment course that could result in extra cost. LIMITATIONS This was a retrospective casenote study, in which patients were not randomised to anaesthetic and standardised outcome measures were not used. The small sample size in the propofol group may have reduced the power of the study to demonstrate other differences between propofol and the other anaesthetic groups. A formal economic analysis was not performed. CONCLUSION Individual anaesthetics differentially influence seizure duration and stimulus charge but final response to ECT appears not to be adversely affected.

Comparison of electroconvulsive therapy practice between London and Bengaluru

Objective To compare electroconvulsive therapy (ECT) practice between London in the United Kingdom and Bengaluru in India. Methods A retrospective case note study was conducted to compare patterns of referrals for ECT in university teaching hospitals in London (n = 46) and Bengaluru (n = 345) during a 1-year period. Further comparison of ECT practice was made for a consecutive series of depressed patients between London (n = 104) and Bengaluru (n = 125). Results The rates of ECT referral were 0.9% of total annual admissions at the London site and 8.2% at the Bengaluru site. At the Bengaluru site, a higher proportion of patients were referred for ECT with a diagnosis of schizophrenia (P < 0.0001). Compared to the Bengaluru sample, depressed patients treated with ECT in London (n = 104) were older with more treatment resistance (P < 0.0001), had longer inpatient stays, and were less responsive to ECT. Conclusions The practice of ECT differed substantially between the London and Bengaluru sites. The relatively limited use of ECT in London reflects local treatment guidelines and may reflect the stigma associated with ECT. Electroconvulsive therapy is more widely used in Bengaluru with good outcomes. Further cross-cultural research is required to study the reasons for such contrasting practices and what constitutes the optimal practice of ECT for health systems in different countries.

Trends in use of electroconvulsive therapy in South London from 1949 to 2006.

Objectives Electroconvulsive therapy (ECT) remains the most acutely effective treatment for severe depression, but its use has declined since its introduction more than 70 years ago. To provide some historical perspective on changes in ECT practice, the objective of the present study was to identify trends in ECT practice in selected teaching hospitals in South London, UK, between 1949 and 2006. Methods Annual rates of ECT for 1949–1970 were estimated from the contemporary hospital reports of the Maudsley and Bethlem Royal hospitals in South London, UK. Case notes were also retrospectively reviewed to calculate annual rates of ECT administration and extract demographic and clinical information for approximately every 5 years between 1987 and 2006. Results The annual rate of ECT peaked at 35% of total admission in 1956 and declined gradually thereafter to 10.8% by 1970 and fell below 2.2% from 1991 onward. Depressed and female patients were more likely to receive ECT. Compared to previous years, patients were more severely ill and treatment resistant in 2006, whereas ethnic minorities made up 30% of patients receiving ECT compared to approximately 14% in the preceding years. Conclusions Currently, ECT seems to be provided increasingly late in more severe illness episodes. The ethnicity of patients receiving ECT in South London may be becoming more representative of the background population, but ECT is being used relatively more frequently for nonaffective disorders in ethnic minorities.