Nicholas J. Delva

Therapeutic advantage of bifrontal electrode placement in ECT

Fifty-nine patients suffering from a major depressive episode, for whom electroconvulsive therapy (ECT) was clinically indicated, were randomly assigned to one of three electrode placement groups for treatment with brief pulse, threshold-level ECT: bitemporal (BT), right unilateral (RU) or bifrontal (BF). Comparison of these groups in terms of number of treatments, duration of treatment, or incidence of treatment failure, showed that the bilateral placements were superior to the unilateral; comparison of Hamilton, Montgomery-Asberg, and visual analogue scale scores showed that the bifrontal placement was superior to both bitemporal and unilateral treatment. Bitemporal treatment showed therapeutic results intermediate between BF and RU. Because BF ECT causes fewer cognitive side effects than either RU or BT, and is independently more effective, it should be considered as the first choice of electrode position in ECT.

Electrode placement in ECT : cognitive effects

Forty patients suffering from a major depressive disorder, for whom electroconvulsive therapy (ECT) was clinically indicated, were assigned to one of three electrode placement groups: bitemporal (BT), right unilateral (RU) or bifrontal (BF). Comparisons of these groups in terms of cognitive status showed that the BF placement, which avoided both temporal regions, spared both verbal and nonverbal functions. These differential effects, which were independent of the degree of clinical depression, were not, however, evident three months after the last ECT.

Clozapine-Induced Seizures: Recognition and Treatment

Objectives: To inform clinicians about the types of seizures that can be induced by clozapine and to provide recommendations for treatment. Methods: We identified articles on clozapine-induced seizures from a MEDLINE search of the English-language literature from 1978 to July 2006. The frequency of each type of seizure and the dosages of clozapine associated with seizures were compiled. In addition to this review, we report a new case illustrating the challenge of diagnosing subtle seizure activity. Results: The tonic-clonic variety is the most frequently described clozapine-induced seizure. Myoclonic and atonic seizures together constitute about one-quarter of the reported seizures. The mean dosage of clozapine associated with seizures is not high (less than 600 mg daily). Conclusions: It may be difficult for clinicians to recognize subtle types of clozapine-induced seizures, such as myoclonic, atonic, or partial seizures. Clinicians should not place excessive reliance on the plasma level of clozapine or electroencephalogram findings to predict the occurrence of seizures. When a first seizure occurs, it is recommended that the dosage of clozapine be reduced or an alternative antipsychotic agent be employed. If a second seizure occurs, an anticonvulsant drug should be started. Special attention should be paid when commencing or discontinuing concurrent medication that may affect the plasma level of clozapine.

Osteopenia, pathological fractures, and increased urinary calcium excretion in schizophrenic patients with polydipsia

Ten male chronic schizophrenic patients with polydipsia and 10 nonpolydipsic controls, matched for gender, diagnosis, duration of illness, age, and race, were studied by dual- and single-photon absorptiometry to estimate bone density of the lumbar spine and radius and by 24-hr urine collections to estimate urinary electrolyte excretion. Bone density was normal in the control group, but was abnormally low in the polydipsic group, which had a markedly increased incidence of fractures. Electrolyte excretion was normal in the control group and in the polydipsic group when water intake was restricted to normal amounts; increased urinary sodium and calcium excretion occurred in proportion to polydipsia. As polydipsia is associated with a number of physiological changes, the cause of the osteopenia is unclear; we suggest that a negative calcium balance caused by increased urinary calcium excretion induced by extracellular space expansion may play an important role in the causation of the skeletal changes.

The sleep of remitted bipolar depressives: comparison with sex and age-matched controls.

The sleep of 10 bipolar patients was recorded for five consecutive nights following their recovery from a depressive episode. In all respects except the number of arousals, their sleep did not differ reliably from that of 10 sex and age-matched control subjects. We conclude that sleep measures are unlikely to be useful as trait markers of a depressive diathesis in bipolar disorder.

The role of nocturnal penile tumescence in differentiating between organic and psychogenic impotence: the first stage of validation.

A study was conducted to assess the validity of nocturnal penile tumescence (NPT) as a means of distinguishing between psychogenic and organic erectile failure (impotence). On the basis of independent clinical criteria, patients were assigned to one of four diagnostic categories—organic impotence, psychogenic impotence, mixed etiology, and uncertain etiology. The NPT characteristics of the patients in the organic and psychogenic groups were compared and decision rules formulated in order to provide optimal discrimination between the two diagnostic categories. A decision rule based on the maximum erectile response observed for each patient led to the correct diagnosis in 80% of cases. Accuracy was increased to 95% when a decision rule based on the maximum frequency of nocturnal erections was employed. The clinical value and limitations of NPT as a diagnostic procedure are discussed.

Electrical dose and seizure threshold : Relations to clinical outcome and cognitive effects in bifrontal, bitemporal, and right unilateral ECT

In patients allocated blindly and randomly to receive bitemporal, right unilateral, or bifrontal electroconvulsive therapy, seizure length, electrophysiologic characteristics (dynamic impedance, seizure threshold, and changes in threshold), and the degree of suprathreshold stimulation were recorded. The relations of these variables to clinical outcome and cognitive effects were determined. There were no differences in seizure length between groups, and there were no significant correlations between seizure length and any measure of clinical response. There were substantial differences between the groups in mean charge per treatment, with the right unilateral group receiving lower doses than either bilateral group. Convulsion time was inversely related to applied charge and the rate of increase in charge. There were no significant correlations between impedance, charge, energy, or rate of increase in charge on the one hand, and clinical improvement on the other. The increase in threshold during the course of treatment was not related to clinical change. Cognitive impairment was related to electrical dose only in the bifrontal group, which showed the least degree of treatment-induced intellectual dysfunction. Compared with bitemporal or right unilateral treatment, bifrontal electroconvulsive therapy yields the best ratio of benefits to side effects and should be given at threshold level to minimize cognitive loss.

Protocols for the use of cyproterone, medroxyprogesterone, and leuprolide in the treatment of paraphilia.

Objective: To propose a protocol for minimizing medical complications associated with the use of cyproterone, medroxyprogesterone, and depot leuprolide to treat paraphilia. Method Review of the relevant literature. Results Certain patient populations should not be treated with these medications, and medical complications associated with each can be detected early and avoided. Conclusions For each drug, a series of screening tests prior to use and scheduled testing during use can minimize potential medical complications.

Mortality over a 20-year period in patients with primary polydipsia associated with schizophrenia: A retrospective study

Primary polydipsia, excessive fluid intake without medical cause, is present in over 20% of seriously and persistently ill psychiatric inpatients. The long-term effects of primary polydipsia on longevity have not previously been examined. Inpatients in a psychiatric hospital were screened for polydipsia in 1985. Those identified to be polydipsic, the majority of whom suffered from schizophrenia, were re-evaluated in 2005 and compared with a control group of non-polydipsic patients. Chart reviews were conducted and follow-up data were obtained. Of 172 patients at the time of screening, 48 suffering from schizophrenia either had or went on to develop polydipsia; 42 non-polydipsic patients with schizophrenia from the original survey were randomly selected as controls. Primary polydipsia had a significant negative effect on longevity. The median age at death (age at which 50% of cases have died) was 59 years for polydipsic patients and 68 for non-polydipsic control patients. Adjusting for duration of schizophrenia, smoking, and diagnosis, a patient with polydipsia had a 74% greater chance of dying before a non-polydipsic patient (a hazard ratio of 2.84 [95% Confidence Interval (CI): 1.22-6.64]). Outcome was worst in patients with severe polydipsia: the median age at death was 57 years and a patient with severe polydipsia had a 75% greater chance of dying before a non-polydipsic patient (hazard ratio of 3.36 [95% CI: 1.31-8.60]). When polydipsia is associated with schizophrenia, mortality is increased in comparison to that in patients with schizophrenia who do not drink water to excess.

Sleep deprivation in depression: Pattern of relapse and characteristics of preceding sleep

The pattern of relapse following therapeutic response to 40-hr sleep deprivation (SD) was examined in nine depressed patients. On the night ending SD patients were awakened from polygraphically recorded sleep on one or more occasions, in order to assess the clinical state. All subjects were found to demonstrate a precipitous and full relapse over this night, the timing of the relapse varying considerably between individuals. No association was found between deterioration in the clinical state and characteristics of preceding sleep. These results are consistent with the notion that, in predisposed individuals, some process associated with sleep has a depressogenic effect. However, they necessitate revision of theories of SD and depression that emphasize the infrastructure of sleep.