Joseph Peuskens

Randomized comparison of ultra-brief bifrontal and unilateral electroconvulsive therapy for major depression: cognitive side-effects.

OBJECTIVEnThe cognitive side-effects of bifrontal (BF) and right unilateral (UL) ultra-brief pulse (0.3 ms) electroconvulsive therapy (ECT) were compared, in the treatment of patients with a depressive episode.nnnMETHODnNeuropsychological functioning in patients with a medication refractory depressive episode, that were treated with a course of BF ultra-brief ECT at 1.5 times seizure threshold (ST) or UL ultra-brief ECT at 6 times ST, by random assignment, was assessed before treatment, and 1 and 6 weeks after the treatment course, by a blinded rater.nnnRESULTSnOf the 64 patients that were included, 32 (50%) received BF ECT, and 32 (50%) received UL ECT, by random assignment. Neuropsychological testing 1 and 6 weeks after treatment was performed by 30 (93.75%) and 19 (59.37%) patients, respectively, in the BF-group and 29 (90.62%) and 20 (62.50%), respectively, in the UL-group. There was no deterioration in any of the neuropsychological measures. Patients rated their memory as clearly improved after treatment. There were no significant differences between the patients given BF ECT and those given UL ECT.nnnCONCLUSIONSnUltrabrief pulse ECT, used either in combination with a UL electrode position and a stimulus of 6 times ST, or a BF electrode position with a stimulus of 1.5 times ST, are effective antidepressant techniques, that do not have a deleterious effect on cognitive function.

Ultra-brief pulse ECT in bipolar and unipolar depressive disorder: differences in speed of response

OBJECTIVESnThere is little evidence for differences in response and speed of response to electroconvulsive therapy (ECT) between patients with bipolar and patients with unipolar depressive disorder. In the only prospective study to date, Daly et al. (Bipolar Disord 2001; 3: 95-104) found patients with bipolar depression to show more rapid clinical improvement and require fewer treatments than unipolar patients. In this study, response and speed of response of patients with unipolar and bipolar depression treated with ultra-brief pulse ECT were compared.nnnMETHODSnAll patients (n = 64) participated in a randomized trial comparing ultra-brief pulse bifrontal ECT at 1.5 times seizure threshold and unilateral ECT at 6 times seizure threshold. Thirteen patients (20.3%) had DSM-IV-defined bipolar depression. The Hamilton Rating Scale for Depression and Clinical Global Impression scale were administered at baseline and repeated weekly during and after the course of treatment by a blinded rater. At the same time point, the Beck Depression Inventory and the Patient Global Impression scale were administered. Speed of response was analyzed using survival analyses.nnnRESULTSnPatients with bipolar and unipolar depression did not differ in rates of response or remission following the ECT course, nor in response to unilateral or bifrontal ECT. Patients with bipolar depression, however, showed a more rapid response than patients with unipolar depression.nnnCONCLUSIONSnPatients with bipolar depression tend to show more rapid clinical improvement with ECT than patients with unipolar depression.

Randomized comparison of ultra-brief bifrontal and unilateral electroconvulsive therapy for major depression: clinical efficacy.

BACKGROUNDnIt has been suggested that electroconvulsive therapy (ECT) with an ultra-brief pulse width in combination with a bilateral electrode placement has diminished antidepressive efficacy, as compared to unilateral ultra-brief pulse ECT.nnnOBJECTIVEnThe antidepressive efficacy of bifrontal and right unilateral ultra-brief pulse (0.3 ms) ECT were compared.nnnMETHODnEighty-one patients with a medication refractory depressive episode were treated with a course of bifrontal ultra-brief pulse ECT at 1.5 times seizure threshold or unilateral ultra-brief pulse ECT at 6 times seizure threshold by random assignment. The 17 item-Hamilton Rating Scale for Depression (HRSD), Beck Depression Inventory, Clinical Global Impression and Patient Global Impression were administered at baseline and repeated weekly during and 1 and 6 weeks after the course, by a blinded rater.nnnRESULTSn64/81 patients (79%) completed the study, half of which were treated with bifrontal ECT. At the end of the course, 78.1% of the BF group and 78.1% of the UL group responded, whereas, 34.38% (N=11) of the BF group and 43.75% (N=14) of the UL group achieved strict remission criteria (HRSD-score < or = 7). There were no significant differences between the patients given bifrontal ECT and those given unilateral ECT, although patients receiving unilateral ECT achieved response/remission-criteria after a smaller number of treatments.nnnLIMITATIONSnRelatively small number of subjects.nnnCONCLUSIONSnUsing an ultra-brief pulse width, both BF and UL-ECT are efficacious, although patients receiving UL-ECT achieve response/remission-criteria after a smaller number of treatments.nnnTRIAL REGISTRYnhttp://www.controlled-trials.com/nnnREGISTRATION NUMBERnISRCTN56570426.

Defining “good” and “poor” outcomes in patients with schizophrenia or schizoaffective disorder: A multidimensional data-driven approach

The studys goal was to characterize the typology of patient outcomes based on social and occupational functioning and psychiatric symptoms following antipsychotic drug treatment, and to explore predictors of group membership representing the best/worst outcomes. A hierarchical cluster analysis was used to define groups of patients (n=1449) based on endpoint values for psychiatric symptoms, social functioning, and useful work measured up to 30 weeks of treatment. Stepwise logistic regression was used to construct predictive models of cluster membership for baseline predictors, and with 2/4/8 weeks of treatment. Five distinct clusters of patients were identified at endpoint (Clusters A-E). Patients in Cluster A (25.6%, best outcome) had minimal psychiatric symptoms and mild functional impairment, while patients in Cluster D (14.3%) and E (14.8%) (worst outcome) had moderate-to-severe symptoms and severe functional impairment. Occupational functioning, disorganized thinking, and positive symptoms were sufficient to describe the clusters. Membership in the best/worst clusters was predicted by baseline scores for functioning and symptom severity, and by early changes in symptoms with treatment. Psychiatric symptoms and functioning provided complementary information to describe treatment outcomes. Early symptom response significantly improved the prediction of outcome, suggesting that early monitoring of treatment response may be useful in clinical practice.

Switching to amisulpride.

SUMMARY The introduction of atypical antipsychotics represents an important advance in the treatment of schizophrenia. As their therapeutic efficacy, tolerability and safety profiles are clearly superior to classical neuroleptics, atypical antipsychotic agents are considered to be the treatment of choice in first episode patients. In addition, an increasing number of patients are being switched from classical to atypical antipsychotic agents. Switching is especially relevant in patients with a poor therapeutic response to classical neuroleptics and persistent symptoms (positive symptoms, negative symptoms, depressive syndromes, cognitive deficit); in patients with a psychotic relapse despite compliance; in patients with important side-effects (not only acute and tardive extrapyramidal symptoms [EPS] and general side-effects, but also dysphoria or neuroleptic-induced deficit syndrome [NIDS]); and in patients who are non-compliant due to side-effects. Switching to atypical antipsychotics should be performed with extreme care in stabilised patients; or in patients who present a danger to themselves or others at relapse; or in patients who are on depot neuroleptics who were non-compliant to previous oral treatment. Switching requires careful planning to reduce the risk of withdrawal effects (neuroleptic withdrawal syndrome, cholinergic rebound, exacerbation of symptoms or relapse, rebound of parkinsonism, dystonia, akathisia, dyskinesia), which may mask the beneficial effects and lead to early discontinuation of the new treatment. Patients, family and carers should be actively involved at all stages, and educated about the possible benefits and problems associated with switching therapy. Cross-tapering old and new treatment is the preferred method for switching and this involves tapering off the previous antipsychotic agent and any adjunctive treatment (sedatives, anticholinergic medication), while gradually titrating the new atypical antipsychotic agent to the established therapeutic dose. Switching patients to amisulpride treatment offers effective antipsychotic therapy, with a positive effect on negative and depressive symptoms. Amisulpride treatment also results in improved quality of life and social functioning in addition to fewer relapses and days of hospitalisation during long-term follow-up.