William Vaughn McCall

A multi-site randomized clinical trial to reduce suicidal ideation in suicidal adult outpatients with Major Depressive Disorder: Development of a methodology to enhance safety.

Background/aims: Suicide is a major public health concern, yet there are very few randomized clinical trials that have been conducted to reduce suicidal ideation in patients at risk of suicide. We describe the rationale and refinements of such a trial that is designed to assess the effect of a hypnotic medication on suicidal ideation in adult outpatients currently experiencing suicidal ideation. Methods: “Reducing Suicidal Ideation Through Insomnia Treatment” is a multi-site randomized clinical trial that includes three recruiting sites and one data management site. This 4-year study is in its second year of recruitment. The purpose of the study is to compare hypnotic medication versus placebo as an add-on treatment to a selective serotonin reuptake inhibitor as a means of reducing suicidal ideation in depressed adult outpatients with insomnia and suicidal ideation. The safety features of the study follow the 2001 National Institutes of Health guidelines for studies that include patients at risk of suicide. Results: In total, 584 potential participants have undergone telephone screening; 67% of these failed the phone screen, most often due to an absence of expressed suicidal ideation (26% of the telephone screen fails). A total of 115 people appeared for a face-to-face baseline assessment, and 40 of these had completed a taper off of their ineffective psychotropic medications before the baseline assessments. In all, 64% of those who completed baseline assessments failed to proceed to randomization, most commonly because of no clinically significant suicidal ideation (51% of those excluded at baseline). One participant was offered and accepted voluntary psychiatric hospitalization in lieu of study participation. Thus far, 40 participants have been randomized into the study and 88.7% of scheduled visits have been attended, with 93.8% adherence to the selective serotonin reuptake inhibitor and 91.6% adherence to the randomized hypnotic versus placebo. None of the randomized participants have required hospitalization or had a suicide attempt. Conclusion: By carefully considering the inclusion and exclusion criteria and other safety features, the safe conduct of randomized clinical trials in suicidal adult patients is possible, including the inclusion of participants who have undergone a prescribed tapering off of psychotropic medications prior to baseline assessment.

Representations of ECT in English-Language Film and Television in the New Millennium.

Objective The aim of the study was to survey the media landscape to determine whether visual depictions of electroconvulsive therapy (ECT) are becoming more or less medically accurate in the new millennium. Method English-language film and television shows depicting ECT were analyzed for patient demographics, administrator roles, indication, consent, anesthesia, paralytics, bite block, lead placement, electroencephalogram, and outcome. Results Thirty-nine ECT scenes were viewed, and just 3 included all 5 essential tools of modern ECT: anesthesia, paralytic, electrodes, electroencephalogram, and a bite block. Conclusions Media depictions of ECT do not reflect current practice. Too often, ECT is portrayed as a torture technique rather than an evidenced-based therapy, and even in a therapeutic setting, it is too often shown with outdated techniques.

Paradoxical insomnia and subjective-objective sleep discrepancy: A review

Paradoxical insomnia is characterized by discrepancy between subjective and objective assessments of sleep and is challenging to diagnosis and treat. Typically, polysomnographic (PSG) findings show significantly longer total sleep time than patients report of sleep, and the difference between subjective and PSG sleep is greater than that seen in other insomnia subtypes. Subjective-objective sleep discrepancy may also present in different clinical pictures, as marked discrepancies between patients perception of sleep and objective findings are common in a variety of medical, sleep and psychiatric disorders. However, there is a paucity of literature about the etiology and treatment of sleep discrepancy and paradoxical insomnia. Therefore, the underlying neurophysiological mechanisms of sleep discrepancy and paradoxical insomnia should be further investigated. Additionally, well-controlled clinical trials are needed to establish an evidence based intervention for treatment.

Repetitive transcranial magnetic stimulation for the treatment of major depression in a patient with an intracranial space-occupying lesion: A case report of safety

This is the first case report of the safety of therapeutic repetitive transcranial magnetic stimulation (rTMS) in a patient with an intracranial space-occupying lesion who had recurrent major depression. In this case, the intracranial space-occupying lesion was a mixed cystic and solid enhancing pineal region mass measuring approximately 16.9 × 12.2 × 15.5 mm. The patient remitted from depression with 36 sessions of dorsolateral prefrontal cortex rTMS treatments over a 6-week period. During the rTMS treatment course, patients medication list included bupropion that potentially can increase the risk for a seizure and topiramate that potentially can reduce the risk for seizure associated with the treatment. The patient tolerated the rTMS treatment well, reporting only transient headache and discomfort at the site of stimulation after the treatment. She tolerated the procedure well and had no incidental seizure activity throughout her treatment sessions.

The Practice of Electroconvulsive Therapy in US Correctional Facilities: A Nationwide Survey.

Objectives There are little data regarding the practice of electroconvulsive therapy (ECT) in correctional settings in the United States. A survey was conducted to study the current practice of ECT in US prisons. We hypothesize that ECT is underutilized in the correctional setting. We also review the ethical aspects of using ECT for the treatment of mental illness in the prison population. Methods A 12-question survey via a Survey Monkey link was emailed to chiefs of psychiatry, or the equivalent, of each states department of corrections. We examined the frequency of Likert-type responses, tabulated individual comments for qualitative review, and grouped for comparison. Results Email contacts for chiefs of psychiatry, or the equivalent, for the department of corrections in 45 states (90%) were obtained and a survey link was sent. Thirty-one (68.9%) of 45 responded to the survey. Respondent estimates of the number of inmates with mental illness in 31 prison systems varied from less than 500 to more than 4500. Of these 31, 12 (38.7%) had more than 4500 inmates with mental illness. Four systems reported the use of ECT within the last 5 years. Of those, one reported use in the last 1 to 6 months, and 3 reported use in the last 2 to 5 years. Of these 4 prison systems, all felt that they had up to 10 patients who would benefit if ECT continued to be offered or became available in the future. None of these systems provided ECT within the prison. The inmates were referred to a local state psychiatric facility, a university hospital, or other institutions. The reasons for not using ECT as reported by the respondents are grouped under subheadings of stigma, ethical concerns, logistical concerns, and others. Conclusions Considering the high prevalence of mental illness in prisons, one might expect a high prevalence of ECT responsive mental illness and, hence, provision of ECT to some prisoners with mental illness. However, our survey suggests that the use of ECT in prisons in the United States is low. Stigma, ethical concerns, and logistical concerns were the main hindrances for providing ECT to prisoners with mental illness. Given that ECT is the standard of care in certain clinical scenarios, physicians are obligated to offer such treatment to inmates when necessary. It can be argued that failure of the prison to offer the standard of care is unethical and unconstitutional.

When All Else Fails: The Use of Electroconvulsive Therapy for Conditions Other than Major Depressive Episode

The use of electroconvulsive therapy (ECT) for those suffering from major depressive disorder is well-evidenced, time-honored, and recognized by most treatment guidelines. However, since its inception ECT has been used by practitioners for a broader range of neuropsychiatric conditions. This article reviews the highly variable evidence supporting the use of ECT in conditions other than depression, such as schizophrenia, bipolar manic states, catatonia, Parkinson disease, and post-traumatic stress disorder.

Validating functional data analysis measures from 24-h actigraphy data

ABSTRACT The timing of sleep and wakefulness are under the influence of the circadian pacemaker in the suprachiasmatic nucleus, and the set-point for the circadian pacemaker is revealed by the time of onset of the secretion of melatonin under dim light conditions (DLMO). Measuring DLMO is time intensive and requires biochemical assays; hence it would be desirable to develop simpler alternatives to DLMO measurement that would otherwise provide similar information about health and illness. Continuous, multi-day measurement of actigraphy can be processed to reveal underlying features such as the time of greatest activity (acrophase), or the time of least activity (bathyphase). In this paper, we explore the calculation of the acrophase and bathyphase using a statistical approach called functional data analysis (FDA), and validated the FDA-calculated bathyphase by correlating it with morningness–eveningness self-reports from 47 depressed adults.

Response to Rosenman ‘electroconvulsive therapy stimulus titration: Not all it seems’

Australian & New Zealand Journal of Psychiatry, 52(7) scheme. In the absence of a significant improvement after the sixth treatment, guidelines argue to switch electrode position. There is no evidence to support such a guideline. Nor do we know how to adjust a stimulus dose the best way. The only reasonable answer to the very valid questions raised by Rosenman (2018) is research and replication. Only a small minority of practices we consider to be ‘evidence based’ have been replicated. In psychological sciences, only 1.07% of studies are replication studies (Makel et al., 2012). In psychiatry research, among 83 papers recommending effective interventions, only 16 were replicated. Replication studies showed that effects in the original studies were overestimated (Tajika et al., 2015). Only 36% of replications in psychological research proved to be statistically significant compared to 97% of the original studies (White et al., 2017). White and co-workers (2017) conclude that reproducibility should be one of the core principles of science. Unfor tunately, replication studies have a low priority, for funding agencies and for journal editors alike: research is to be new and innovative. Perhaps, academic institutions should take it as their responsibility to perform and fund replication studies, to guide clinical practice in the scientific direction.