Lauren S. Liebman

Electroconvulsive therapy (ECT) in Parkinson's disease: ECS and dopamine enhancement.

Introduction In addition to its effects in major psychiatric illness, electroconvulsive therapy (ECT) is known to have a beneficial effect on the core motor symptoms of Parkinson’s disease (PD). This effect is believed to be mediated via dopamine in the striatum. Electroconvulsive shock (ECS), the animal analogue of ECT, is the model in which investigators have sought to elucidate the specific dopaminergic mechanisms by which ECT exerts its therapeutic effect in PD. Electroconvulsive shock has been given to intact animals as well as to animals with neurotoxic lesions that create parkinsonism. Methods In this paper, we selectively review the electroconvulsive shock literature on dopamine in the striatum. Results Electroconvulsive shock, and by extension, ECT, is associated with increased dopamine release and modulation of dopamine receptors. Conclusion Better understanding of how ECT works to enhance dopaminergic systems in the brain could help to make it a more accepted treatment for PD.

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.

Electroconvulsive Therapy is a Standard Treatment; Ketamine is Not (Yet)

To The Editor: Alan Schatzberg’s commentary in the March issue, “A Word to the Wise About Ketamine” (1), urges caution in the clinical use of ketamine pending further research and data collection. We agree with this position and would like to share our clinical experience with seriously depressed patients who have received ketamine infusions prior to electroconvulsive therapy (ECT) referral. In the last year, we have seen at least half a dozen patients who, when they presented for ECT consultation, gave histories of having had either single or repeated ketamine infusions at a private anesthesiologist’s office in New York City. These patients had either no, or very transient, antidepressant benefit from the ketamine or unpleasant adverse effects (mainly dissociative); they were subsequently referred by their psychiatrists for consideration of ECT. Most of these patients were profoundly depressed, and some were suicidal. If a ketamine challenge is to become a standard step in the treatment algorithm for treatmentresistant depression, the risks of not just the ketamine itself, but the delay in definitive treatment, must be taken into account. Seriously depressed patients who have failed to respond to one or more antidepressant medication trials should be referred for ECT consultation, sooner rather than later, to ensure optimal outcomes. Suicide risk in this population is elevated, as is the potential for ongoing medical morbidity, not to mention the continued suffering from the depressive episode itself. A recent study (2) comparing three ketamine infusions with three ECT treatments in 1 week touted ketamine as a superior treatment and received considerable media attention (3). A reasonable interpretation of that research is that it replicated the finding of a signal of early antidepressant responsewith ketamine.However, ketamine remains completely unproven as a definitive treatment for a major depressive episode. Seriously ill psychiatric patients are often desperate for dramatic cures; their health care providers, acknowledging that our current treatments are often lacking, are also eager for the newest breakthroughs. Such desperation and enthusiasm should not cloud our clinical judgment; proven, evidence-based treatments, including ECT for seriously depressed patients, should be offered before unproven, experimental approaches, nomatter how “in vogue” those approaches may be.

Electroconvulsive therapy (ECT) for catatonia in a patient with schizophrenia and synthetic cannabinoid abuse: a case report.

Abstract We present the case of a young man with a long-standing history of schizophrenia who presented with severe and life-threatening catatonia in the setting of synthetic cannabis use who was successfully treated with electroconvulsive therapy. To our knowledge, this is the first reported case of severe and persistent catatonia in the setting of synthetic cannabis use and the first documented successful treatment.

Asystole during electroconvulsive therapy.

In electroconvulsive therapy (ECT) short sinus pauses immediately following the stimulus are common; asystole (the absence of cardiac electrical activity for >6 seconds) during this period occasionally occurs. Asystole in the postictal period is a much rarer event. This Clinical Image in ECT demonstrates such an event. A 62-year-old, 98-kg man with major depressive disorder had previously responded well to acute ECT. His medical history included essential hypertension, gastroesophageal reflux disease, and glaucoma. He had been receiving maintenance ECT every 10 days with bilateral electrode placement at 150 mC (pulsewidth, 0.5 millisecond) using a Thymatron System IV device (Somatics, LLC, Lake Bluff, IL) for several months without complications. General anesthesia was induced with 80 mg of methohexital and muscle relaxation with 70mg of succinylcholine. Given his propensity to develop peritreatment hypertension, the patient was regularly pretreated with 30 mg of labetalol, 1 to 2 minutes before stimulus application. Ketorolac (30 mg) for posttreatment headache and midazolam (2 mg) for posttreatment agitation were also regularly administered. On this day, pretreatment vital signs were as follows: heart rate of 59 and blood pressure of 145/70. Pretreatment electrocardiogram (ECG) showed sinus bradycardia at 56 but was otherwise normal. Thirty milligrams of labetalol was given, followed by his usual methohexital and succinylcholine doses. A stimulus of 150 mC was applied, resulting in an electromyogram seizure of 35 seconds and an EEG seizure of 63 seconds. Upon cessation of the EEG seizure, both the ECG and pulse oximeter were noted to be flatline. While confirming that all ECG leads and the pulse oximeter were still attached to the patient, an attempt was made to palpate a carotid pulse. It was quickly ascertained that all monitors remained appropriately attached to the patient and that he did

Dosing and effectiveness of ketamine anesthesia for electroconvulsive therapy (ECT): a case series

Objective: To provide additional data about the clinical efficacy and dosing range for ketamine used as the induction agent in electroconvulsive therapy (ECT). Method: We reviewed the clinical data in our academic hospital ECT service over the last four years for patients who had received ketamine as the sole, or adjunctive, anesthesia induction agent. We extracted clinical data about antidepressant response as well as absolute and weight-based dosing for ketamine. Results: We found nine patients who were treated with ketamine as the anesthetic at some point during the course of their treatment (eight as the sole agent, one as adjunctive). The median induction dose for ketamine was 1.1 mg/kg. For most patients, there was demonstrable clinical benefit. Conclusions: Ketamine has a role as an alternative induction anesthetic agent in ECT. Our case series adds to the literature on the concomitant use of ECT and ketamine.

Electroconvulsive therapy (ECT) for catatonia: delay may be risky.

Sir, We read with great interest the superbly presented case ‘‘The use of electroconvulsive therapy in a patient with juvenile systemic lupus erythematosus and catatonia’’. The authors comprehensively document the patient’s complex medical and neuropsychiatric illness. The case highlights how difficult the ultimate diagnosis of catatonia may be in a non-psychiatric patient. Despite appropriate management, recommendation for electroconvulsive therapy (ECT) was delayed for three months as is often the case. Such delay is not without risk; catatonic patients are predisposed to a wide variety of medical complications, many of which may be serious, even lethal. As early as 1977 Regestein et al. described fatal outcomes in two patients with catatonia, warning that catatonic stupor can ‘‘lead to fatal complications, and aggressive medical and psychiatric therapy is indicated’’. As recently as 2012, a death due to the delayed implementation of ECT in a catatonic patient has been reported. Other medical complications that have been reported in association with catatonia include pulmonary emboli, pneumonia, and contractures. The full spectrum of medical complications in catatonic patients has recently been reviewed. ‘‘Malignant catatonia’’ refers to a particularly severe syndrome of catatonic features and autonomic instability that has a high mortality rate if not aggressively treated; ECT may be considered the treatment of choice for this condition. Mon et al. described the use of right unilateral (RUL) ECT in their patient, and this is a helpful addition to the literature about the efficacy of this type of ECT. We continue to believe, however, that in urgently ill patients, for whom transient cognitive impairment is a secondary consideration, bilateral ECT at substantially suprathreshold stimulus dosing remains the technique of choice. While ECT is rarely recommended for children and adolescents, when appropriate indications are present, there is no reason to consider age an impediment to its use. Fortunately for Mon et al.’s patient, a three-month delay did not prevent an excellent outcome; however, we strongly urge early consideration of ECT, when appropriate, to avoid medical complications resulting from prolonged catatonia.

Safe resumption of maintenance electroconvulsive therapy 12 days after surgical repair of hip fracture.

Hip fractures are a common injury affecting older individuals, especially women with osteoporosis. When patients who are at risk for hip fractures or who have had such a fracture that was recently repaired require electroconvulsive therapy, care must be taken to ensure complete muscle relaxation. Adequate muscle relaxation can be achieved using a dose of succinylcholine of approximately 1 mg/kg in most patients, but for patients who are at risk for complications resulting from inadequate muscle relaxation, the dose of succinylcholine may need to be increased by 40% to 50% to ensure complete relaxation.

Case Report: Transient Left Bundle Branch Block Associated with Ect

We present the first reported case of transient left bundle branch block (LBBB) occurring during electroconvulsive therapy (ECT). LBBB is an important clinical finding, as it is associated with a significant increase in mortality. Physicians providing ECT should be aware of the significance of new-onset LBBB; it may occur during treatment.

Somatic treatments for severe bipolar disorder

www.thelancet.com Vol 382 August 10, 2013 505 4 Say L, Souza JP, Pattinson RC, WHO working group on Maternal Mortality and Morbidity classifi cations. Maternal near miss—towards a standard tool for monitoring quality of maternal health care. Best Pract Res Clin Obstet Gynaecol 2009; 23: 287–96. 5 WHO. Evaluating the quality of care for severe pregnancy complications: the WHO near-miss approach for maternal health. http://whqlibdoc. who.int/publications/2011/ 9789241502221_ eng.pdf (accessed July 25, 2013). criteria based on markers of organ dysfunction. Reporting on specific quantitative indicators, derived from the subgroup of women presenting with the strict near-miss criteria, is advised to enable more meaningful comparisons and estimates. Among the indicators, the maternal severity index and the standardised mortality ratio provide standard case-mix adjustment, assessment of health care performance, and estimates of excessive mortality associated with health service constraints. The near-miss concept (prag matically or strictly defi ned) is useful to generate actionable infor mation at the healthservice level. Pragmatic criteria are related to severe maternal morbidity (near miss at large) and useful in qualitative assessments. Strict criteria are related to organ dysfunctions and useful for quantitative assessments and international comparisons. Work is in progress to develop an integrative module that might be particularly useful for poor-resource health facilities. For now, we suggest using context-relevant defi nitions that incorporate as much as possible the strict criteria proposed by WHO. If a real advance in this fi eld is to be made, the diff erent approaches to the nearmiss concept should not compete; they must complement each other in obtaining actionable information to improve maternal health.