Nicardipine improves the antidepressant action of ECT but does not improve cognition.

INTRODUCTION: Cognitive impairment, the most important adverse effect of electroconvulsive therapy (ECT), may involve elevated intracellular calcium ion signaling. Animal research suggests that calcium channel-blocking agents, which attenuate excessive intracellular calcium activity, may reduce cognitive dysfunction caused by ECT. METHOD: The lipid-soluble calcium channel-blocking drug nicardipine or matching placebo were randomly assigned to 26 patients with major depressive disorder receiving ECT. A rater blind to the experimental condition administered the Hamilton Depression Rating Scale, the Montgomery-Asberg Depression Rating Scale, the Beck Depression Inventory, the Mini-Mental State Examination and a comprehensive battery of neuropsychological tests prior to ECT, at the completion of ECT, and 6 months after ECT completion. RESULTS: Compared with patients receiving placebo, patients taking nicardipine had significantly lower scores on the Hamilton and Montgomery-Asberg but not the Beck Depression rating scale scores at the completion of ECT. There were no differences between placebo and nicardipine groups in depression scores 6 months after ECT. Cognitive function declined over the course of ECT and improved over the next 6 months in both groups, but changes were statistically significant for only two subtests on the neuropsychological battery. Changes in Mini-Mental State Examination scores were small and were not significant at any point. There were no significant differences between nicardipine and placebo treated groups in any assessment of cognition. DISCUSSION: Standard approaches to ECT in younger patients without preexisting neurological impairment do not produce cognitive side effects of sufficient severity for calcium channel-blocking agents to reduce these side effects demonstrably. Studies of treatments for cognitive impairment should be conducted in patients with risk factors for more severe cognitive impairment such as geriatric patients or patients with a history of interictal delirium during previous treatment with ECT. A possible effect of nicardipine in enhancing the antidepressant action of ECT requires further investigation in a study designed to test this action.

Justifiability, sympathy level, and internal/external locus of the reasons battered women remain in abusive relationships.

Reasons why battered women remain in abusive relationships were rated by college students as to the degree of sympathy the reasons engendered, the degree to which the reasons seemed to justify the woman remaining, and whether the reasons appeared more within the woman's control (internal) or imposed upon her (external). Four clusters of reasons emerged that varied on the sympathy and justifiability ratings: Physical Restraint/Lack of Resources; Maintenance of the Relationship; Personal Deficits; and Loss of Resources. Sympathy for the individual reasons was correlated with viewing these reasons as more justifiable for keeping her in the relationship. Both sympathy and justifiability ratings were higher if the reasons were seen as externally imposed on the woman. The more the participants viewed the battered woman as possessing socially desirable traits, the more they had sympathy for the reasons she stayed and viewed them as justifiable. Gender and ethnicity differences on the ratings were also found. Implications for future research and application of the findings are discussed.

Use of clozapine in 10 mentally retarded adults.

The cost, side effect profile, and required weekly blood draws associated with clozapine may dissuade some clinicians from prescribing this atypical neuroleptic to mentally retarded patients. All publications on clozapine use in mentally retarded patients are reviewed and the treatment of 10 such patients is described, bringing the total number of published cases to 84. Clozapine is efficacious and well tolerated in this population and should be considered for those patients with psychosis or bipolar illness who are intolerant of or unresponsive to other agents.

Novel alternatives and supplements to lithium and anticonvulsants for bipolar affective disorder.

BACKGROUND: Most clinicians are familiar with the traditional anticonvulsants as alternatives to lithium in the treatment of bipolar mood disorders. METHOD: This review of the English, French, German, and Italian language literature on novel treatments, including electroconvulsive therapy, calcium channel blocking agents, antipsychotic drugs, benzodiazepines, thyroid hormone, psychosurgery, and two new antiepileptic drugs, that have not been studied as extensively as lithium, carbamazepine, and valproate but that may have promise as alternatives or supplements to traditional thymoleptics when the standard treatments are not effective or are poorly tolerated. We searched MEDLINE and PSYCHINFO data bases using the keywords bipolar, mood, and/or treatment. We then searched bibliographies of articles retrieved by the first strategy. RESULTS: The theoretical rationale for each treatment is discussed, followed by a critical discussion of the evidence supporting its efficacy. CONCLUSION: The potential risks and benefits of each treatment in actual clinical practice are placed in perspective.

Valproate-associated pancreatitis and cholecystitis in six mentally retarded adults.

BACKGROUND: Pancreatitis is usually considered a rare side effect of valproate. We describe five cases of pancreatitis and one case of cholecystitis associated with the use of valproate. METHOD: Through chart review, we identified all patients in our facility treated with valproate between 1989 and 1994, and all cases of pancreatitis and cholecystitis identified during that same period in our population of 322 mentally retarded patients. We also searched MEDLINE for all published cases of pancreatitis or cholecystitis associated with valproate treatment. RESULTS: Five (7%) of 72 valproate-treated patients experienced pancreatitis, and one experienced cholecystitis; all recovered fully. This brings the total number of reported cases of valproate-associated pancreatitis to 55. CONCLUSION: Pancreatitis may occur more frequently than previously recognized in mentally retarded adults treated with valproate. Developmentally disabled patients should be carefully monitored for this potentially lethal side effect.

Opiate antagonists for recurrent self-injurious behavior in three mentally retarded adults.

Opiate antagonists have shown promise for treating a subset of self injurious patients. The authors report on the use of naltrexone with three mentally retarded adults who had long histories of self-injurious behavior and unsuccessful behavioral and drug treatments; for all three, the self- injurious behavior was substantially decreased. The authors have found a positive response for half the self-injurious patients for whom naltrexone has been tried. Before any drug therapy is initiated, environmental reinforcers of the behavior should be sought out and modified, and any reversible medical and psychiatric disorders should be treated.

The use of opiate antagonists for recurrent self-injurious behavior.

Despite a plethora of studies on the behavioral and pharmacologic treatment of self-injurious behavior, and despite our best efforts, many patients continue to harm themselves. The authors review the literature on the use of opiate antagonists for the treatment of self-injurious behavior.

Suicide: risk factors and therapeutic considerations in the emergency department.

Emergency physicians often encounter covertly and overtly suicidal patients, and can thus play a key role in the prevention of suicide. The epidemiology and diverse presentations of suicidal behavior are reviewed. We then provide a detailed approach to the assessment of suicide risk, and criteria for safe discharge from the emergency department (ED). Finally, management considerations for the ED are discussed.

Suicide: risk factors and prevention in medical practice.

Suicide is a preventable cause of death that increasingly affects younger age groups. We review the epidemiology of suicide in the general population, in psychiatric patients, and in medical/surgical patients. The essential role of the primary care physician in preventing suicide is examined.

Symptoms of insulin-induced hypoglycemia in normal subjects.

In order to better characterize the psychobiology of hypoglycemic symptom production, six normal subjects had physiological/biochemical and symptom ratings at 20, 30 and 40 min after six different doses of intravenous regular insulin (0.0, 0.5, 1.0, 2.0, 3.0 and 4.0 units, in a Latin-square design); subjects also indicated after each dose whether they believed they had received an active or an inactive substance. Choice response switched from inactive to active substance when plasma glucose fell to the mid to high 50s mg/dl (i.e. whole blood glucose of approximately 50), and plasma epinephrine levels rose to between 100 and 200 pg/ml. Adrenergic symptoms and 'weakness' were most strongly associated with choice; other symptom variables had weaker associations. Symptoms were more strongly correlated with epinephrine than glucose levels, but anxiety was not strongly correlated with the epinephrine increases.