Ronald Schouten

Comparative effects of esmolol and labetalol to attenuate hyperdynamic states after electroconvulsive therapy

We studied 18 patients (age range, 53-90 yr) with at least one cardiovascular risk factor who were treated with electroconvulsive therapy (ECT) and compared effects of five pretreatments: no drug; esmolol, 1.3 or 4.4 mg/kg; or labetalol, 0.13 or 0.44 mg/kg. Each patient received all five treatments, during a series of five ECT sessions. Pretreatment was administered as a bolus within 10 s of induction or anesthesia. Doses of methohexital and succinylcholine were constant for the series of treatments and the assignment to no drug or to drug and dose was determined by randomized block design. Measurements of systolic and diastolic blood pressure (SBP, DBP) and heart rate (HR) were recorded during the awake state and 1, 3, 5, and 10 min after the seizure. The deviation of ST segments from baseline was measured by an electrocardiogram (ECG) monitor equipped with ST-segment analysis software. The results (mean +/- SEM) show that without pretreatment, there were significant (P<0.05) peak increases in SBP and HR (55 +/- 5 mm Hg and 37 +/- 6 bpm, respectively), recorded 1 min after the seizure. Comparable reductions (by approximately 50%) in these peak values were achieved after esmolol (1.3 mg/kg) or labetalol (0.13 mg/kg), and cardiovascular responses were nearly eliminated after the same drugs in doses of 4.4 and 0.44 mg/kg, respectively. The deviation of ST-segment values from baseline in any lead was not measurably influenced by either antihypertensive drug. SBP values were lower after labetalol 10 min after the seizure, but not after esmolol. Asystolic time after the seizure was not significantly longer with either drug. No adverse reactions were observed. Because SBP effects were still present 10 min after the seizure, esmolol may be preferred if administration of a large dose of a beta-adrenergic blocker is contemplated. (Anesth Analg 1995;80:557-61)

Community response to disaster: the role of the workplace

&NA; Disasters, natural and man‐made, have a considerable impact on communities. Most recently, disasters stemming from terrorist attacks have become a leading cause of concern. The importance of work in the lives of employees, coupled with the vulnerability of workplaces as potential targets of terrorist attacks, suggests that workplaces can and should play a role in planning for, and responding to, disasters. This article addresses the role of the workplace in disasters, with an emphasis on the psychological impact of such events, by drawing upon experience and literature related to workplace violence and to other traumatic events in the workplace.

Intracranial haemodynamics during attenuated responses to electroconvulsive therapy in the presence of an intracerebral aneurysm

OBJECTIVES This report describes successful anaesthesia and electroconvulsive therapy (ECT) in a patient with an unruptured basilar artery aneurysm. ECT is associated with a hyperdynamic state characterised by arterial hypertension, tachycardia, and considerably increased cerebral blood flow rate and velocity. These responses pose an increased risk for subarachnoid haemorrhage when an intracranial aneurysm coexists. METHODS A 54 year old woman presented for ECT. She had a 20 year history of major depression which was unresponsive to three different antidepressant drugs. There was also an unruptured 5 mm saccular aneurysm at the basilar tip, which had been documented by cerebral angiography, but its size had remained unchanged for the previous four years. After she declined surgical intervention, she gave informed consent for ECT. During a series of seven ECT sessions middle cerebral artery flow velocity was recorded by a pulsed transcranial Doppler ultrasonography system. She was pretreated with 50 mg oral atenolol daily, continuing up to the day of the last ECT and immediately before each treatment, sodium nitroprusside was infused at a rate of 30 μg/min, to reduce systolic arterial pressure to 90–95 mm Hg. RESULTS Systolic flow velocity during the awake state ranged from 62–75 cm/s, remaining initially unchanged with sodium nitroprusside infusion. After induction of anaesthesia (0.5 mg/kg methohexitone and 0.9 mg/kg succinylcholine), flow velocities decreased to 39–54 cm/s, reaching maximal values of 90 cm/s (only 20% above baseline) after ECT. These flow velocities recorded post-ECT were considerably below the more than twofold increase recorded when no attenuating drugs were used. Systolic arterial blood pressure reached maximal values of 110–140 mm Hg and heart rate did not exceed 66 bpm. Rapid awakening followed each treatment, no focal or global neurological signs were apparent, and the patient was discharged in remission. CONCLUSION In a patient with major depression and a coexisting intracerebral saccular aneurysm who was treated with ECT, the combination of β blockade with atenolol and intravenous infusion of sodium nitroprusside prevented tachycardia and hypertension, and greatly attenuated the expected increase in flow velocity in the middle cerebral artery.

An approach to selected legal issues: confidentiality, mandatory reporting, abuse and neglect, informed consent, capacity decisions, boundary issues, and malpractice claims.

Medical practice occurs within a legal and regulatory context. This article covers several of the legal issues that frequently arise in the general medical setting. While this article provides an overview of approaches to informed consent, boundary issues, and malpractice claims, it is critical for clinicians to be familiar with the specific requirements and standards in the jurisdictions in which they practice. As a general rule, it is most important that physicians recognize that the best way to avoid legal problems is to be aware of legal requirements in the jurisdictions in which they practice, but to think clinically and not legally in the provision of consistent and sound clinical care to their patients.

Pitfalls of clinical practice: the treating clinician as expert witness.

&NA; Patients involved in legal proceedings may turn to their psychiatrists for testimony on their behalf. Because the treating psychiatrist has firsthand knowledge of a patients condition, the patient may call the psychiatrist to testify as a fact witness. Fact witnesses testify on the basis of what they have seen or heard; they may not rely on what others have heard (hearsay) or offer expert opinions as evidence. Psychotherapist‐patient privilege generally prevents the psychiatrist from testifying without the patients permission; even in cases where permission is granted (by the patient), such testimony poses substantial hazard to the treatment. Once the privilege is broken, all matters are open to examination. For example, the patient who asks his or her psychiatrist to testify about the emotional harm suffered after an accident cannot then invoke the psychotherapist‐patient privilege to prevent the doctor from discussing the patients previous psychiatric hospitalizations.

Stability and predictive value of self-report personality traits pre- and post-electroconvulsive therapy: A preliminary study

The accuracy and value of personality assessment for depressed patients receiving electroconvulsive therapy (ECT) is an underexplored and controversial area. However, there are data suggesting that personality traits and personality disorders affect the ultimate outcome of depressed patients receiving a variety of somatic treatments including ECT. Despite these data, controversy continues regarding the advisability of evaluating personality functioning in patients with severe depression. This study sought to explore the stability and predictive value of self-reported personality traits in depressed patients undergoing ECT. Sixteen subjects completed a self-report test of personality functioning and the Beck Depression Inventory (BDI) before and after ECT treatment. The results showed that the majority of self-report personality traits were stable pre- and post-ECT treatment. However, major depressive disorder did significantly affect the report of avoidant, histrionic, aggressive-sadistic, and schizotypal personality traits. Treatment did not change the overall personality profile of these subjects. Furthermore, regression analysis controlling for pretreatment depression showed pretreatment borderline personality traits to be significantly related to the posttreatment depression scores (response to treatment). These findings suggest that routine administration of a standard self-report measure of personality may aid in the evaluation of and treatment planning for patients receiving ECT.

Assessment of Occupational Impairment and Disability From Depression

Objective: Examination of the relationship of impairment to disability in the work psychiatry context and identification of practical strategies for occupational physicians to apply to screening, management, and appropriate referral. Methods: Medical literature review. Results: The determination and differentiation of impairment and disability is a complex psychiatric task which requires consideration of the type of employment, assessment of depression-related functional impairments that can create disability for a particular occupation, and individual factors. Conclusions: The authors propose a new and more consistent strategy for identifying impairment severity and its impact on employment, including simple procedures to screen for depression and guidelines to minimize role and boundary confusion.

Legal Concerns in Psychosomatic Medicine

In the practice of psychosomatic medicine, psychiatrists frequently encounter issues of legal concern. This article provides an overview of legal topics frequently encountered by the psychiatric consultant. One such area, discussed first in this article, is confidentiality and the management of private patient information. A second common interface between law and psychiatry is in the area of medical decision making. The psychiatric consultant is often asked to evaluate a patients ability to accept or refuse treatment, and then make a determination of capacity. When the patient cannot give informed consent, an alternate decision maker must be found. Finally, malpractice liability is often a concern for the psychiatric consultant. Overall, psychiatrists should approach the care of patients foremost from a clinical perspective, while understanding the applicable laws and regulations of the jurisdictions in which they practice. In addition, clinicians should be aware of the legal and risk management resources available to them should a complex situation arise.

Terrorism and the behavioral sciences.

&NA; Terrorism has existed for millennia and is a phenomenon well‐known to many parts of the world. Americans were forced to recognize this phenomenon, and our vulnerability to it, by two sets of events in 2001: the attacks on New York City and Washington, DC, and the anthrax mailings that followed shortly thereafter. Psychiatry, psychology, and other behavioral and social sciences have been looked to for assistance in collecting and analyzing intelligence data, understanding terrorism, and developing strategies to combat terrorism. In addition to reviewing areas in which the behavioral sciences have made contributions in addressing this problem, this article discusses the developing roles for behavioral scientists in this field.

Common Pitfalls in Giving Medical-Legal Advice to Trainees and Supervisees

The nineteenth-century American satirist Charles Farrar Browne, writing under the name Artemus Ward, was Abraham Lincoln’s favorite author. An inspiration to Mark Twain, Will Rogers, and other American humorists, Ward is credited with the following observation: “It ain’t so much the things we don’t know that get us into trouble. It’s the things we know that just ain’t so.”1 Long before the advent of medicolegal concerns, fears of malpractice litigation, and the Health Insurance Portability and Accountability Act of 1996 (HIPAA), Ward may have been providing a prescient description of the medicolegal advice that senior clinicians, faculty members, and other supervisors now pass on to trainees. In our experience, some who would ordinarily never presume to offer advice on matters outside their areas of clinical expertise nevertheless freely advise trainees on medicolegal issues, often to the detriment of the junior colleagues and the patients involved. The following three case examples, modified from their original form, demonstrate a few of the ways in which supervisors’ and faculty members’ anxiety, mistaken beliefs, and lack of understanding of the legal system can lead trainees astray, increase their potential difficulties