Tsunami and mental health in Thailand.

Over 5000 people lost their lives when the Asian tsunami hit the Andaman coast of southern Thailand. The delivery of services was complicated because a large number of tourists were in the area. The setting up of the Mental Health Centre for the Thai Tsunami disaster within the Department of Mental Health produced prompt mental health response. Regular contact using a variety of means provided supervision and mentoring. The Thai response built on the existing volunteer network. A Mobile Mental Health Team provided on the spot needs assessment and help. Thai experience provides a culturally acceptable way of delivering mental health services and normalization was the most appropriate response.

Combined ECT and neuroleptic therapy in treatment-refractory schizophrenia: prediction of outcome.

There have been scanty reports of the clinical features of schizophrenic patients treated with electroconvulsive therapy (ECT). This prospective study examined clinical characteristics and predictive factors associated with therapeutic outcome. Two hundred and ninety-three patients with refractory schizophrenia were treated with a combination of ECT and flupenthixol. Outcome assessments included the Brief Psychiatric Rating Scale (BPRS), the Global Assessment of Functioning (GAF), and the Mini-Mental State Examination (MMSE). One hundred and sixty patients (54.6%) met a response criterion. The responders were younger, had shorter durations of illness and current episode, more admissions, and less family history of schizophrenia. The duration of current episode (t=5.0, P<0.0001), followed by baseline GAF score (t=3.1, P=0.002), duration of illness (t=3.1, P=0.002), baseline MMSE score (t=3.0, P=0.003), duration of the previously failed neuroleptic trials (t=3.0, P=0.003), family history of schizophrenia (t=2.1, P=0.03), and paranoid type (t=2.1, P=0.04), could predict the therapeutic outcome. Treatment resulted in marked improvement in positive symptoms but had a minimal effect or led to a worsening of negative symptoms.

Factors influencing treatment frequency of continuation ECT in schizophrenia.

Although continuation and maintenance electroconvulsive therapy (C-ECT and M-ECT) have been used since 1943, no studies reported data that might help guide the selection of C-ECT frequency. This two-phase study was conducted in 32 chronic schizophrenic patients, with history of prior responsiveness to ECT to determine clinical variables associated with treatment frequency of C-ECT. After acute combination treatment with ECT and neuroleptics (Phase I), all patients received weekly ECT during the first 4 weeks of C-ECT (Phase II). They were then assigned to receive either weekly (n = 8) or biweekly (n = 24) ECT, depending on the history of their prior responsiveness to C-/M-ECT and their Brief Psychiatric Rating Scale (BPRS) scores. At the third month, patients with biweekly ECT were assigned to receive either biweekly (n = 17) or triweekly ECT (n = 7) following the same criteria. The duration of Phase II was 6 months. Onset of illness, numbers of admission, educational level, duration of trials of the previously failed neuroleptics, BPRS scores, and percentage of reductions in BPRS scores at the end of Phase I, Global Assessment of Functioning (GAF) scores at the end of Phase I, Mini-Mental State Exam (MMSE) scores at Phase I entry and Phase I end, and GAF and MMSE scores during the first month of Phase II showed a differentiation between patients having weekly treatment versus biweekly treatment. Whereas a history of previously failed flupenthixol treatment, dosage of flupenthixol used in this study, and MMSE scores at the end of Phase I and during the first month of Phase II showed a differentiation between patients having biweekly C-ECT versus triweekly C-ECT. Our results suggest that the better the prognostic factors for each patient, the longer the frequency of C-ECT.

Seizure threshold rise during electroconvulsive therapy in schizophrenic patients.

A rise in seizure threshold during a course of electroconvulsive therapy (ECT) has been demonstrated in patients with depression and mania, but no information has been available as to whether the same result occurs in schizophrenia. Ninety-three patients with schizophrenia underwent estimation of the seizure threshold by the dose-titration method, at the first and second, seventh, fourteenth, and twentieth treatments over an index ECT course. The 3-week stabilization period was used as a response criterion. Eighty-six patients (92%) showed a rise in threshold. The magnitude of increment was 269+/-244%. The rise in seizure threshold could be predicted by the number of treatments, initial seizure threshold and EEG seizure duration, and these factors explained 42% of the variance.

Effects of stimulus intensity on the efficacy of bilateral ECT in schizophrenia: a preliminary study.

BACKGROUND: This preliminary study examined the effects of electrical stimulus intensity on the speed of response and efficacy of bilateral electroconvulsive therapy (ECT) in the treatment of schizophrenia. METHODS: Sixty-two patients with schizophrenia received combination treatment with bilateral ECT and flupenthixol. Using a randomized, double-blind design, the effects of three dosages of the ECT electrical stimulus were examined. Patients were treated with a stimulus intensity that was just above seizure threshold, two-times threshold, or four-times threshold. Assessments of outcome used the Brief Psychiatric Rating Scale, Global Assessment of Functioning, and the Mini-Mental State Exam. RESULTS: Thirty-three of sixty-two patients met remitter criteria, including maintaining improvement over a 3-week stabilization period. The dosage groups were equivalent in the number of patients who met remitter criteria. The low-dose remitter group (n = 11) received more ECT treatments and required more days to meet remitter status than both the twofold (n = 11) and fourfold remitter groups (n = 11). There was no difference among the groups in change in global cognitive status as assessed by the Mini-Mental State Exam. CONCLUSIONS: This preliminary study indicates that treatment with high-dosage bilateral ECT speeds clinical response in patients with schizophrenia. There may be a therapeutic window of stimulus intensity in impacting on the efficacy of bilateral ECT, which needs further study. A more sensitive battery of cognitive tests should be used in future research.

Seizure threshold in electroconvulsive therapy: III. A long-term study.

There has been a dearth of long-term studies investigating the seizure-threshold changes in patients receiving electroconvulsive therapy (ECT). This study aimed to determine changes in seizure threshold over acute, continuation, and maintenance ECT (Phases I, II, and III). Twenty schizophrenic patients were estimated to have a seizure threshold by the dose-titration method. All patients had a rise in seizure threshold at the end of Phase I with 185 +/- 196 per cent increments. Ten patients had a further threshold-increase at the sixth month (Phase II, n = 20), and four at the twelfth month (Phase III, n = 14). The overall threshold-increases of Phases II and III were 370 +/- 342 per cent and 416 +/- 427 per cent, respectively. Seizure-threshold increases were robust during acute ECT, and tended to reach a plateau over the continuation and maintenance phases.

Seizure threshold in ECT: I. Initial seizure threshold.

Seizure threshold determination is of crucial importance in optimizing electrical stimulus dosage during administering electroconvulsive therapy (ECT). We measured initial seizure threshold by means of Srinakharinwirot University titration schedule in 150 psychotic patients. Initial seizure threshold was approximately 104 millicoulombs on average, but varied widely (12-fold) across patients. Motor seizure duration was inversely related to initial seizure threshold. Seizure threshold could be strongly predicted by age. The results may have important clinical implications for stimulus dosing strategy in ECT.

Continuation ECT in treatment-resistant schizophrenia: a controlled study.

In patients with treatment-resistant schizophrenia (TRS), this study compared the efficacy of continuation treatment with flupenthixol alone, continuation electroconvulsive therapy (ECT) alone, and combined continuation ECT and flupenthixol. One hundred fourteen TRS patients received acute treatment (Phase I) with bilateral ECT and flupenthixol (12-24 mg/day). Fifty-eight patients met remitter criteria, including clinical stability during a 3-week stabilization period, and were eligible for the continuation treatment study (Phase II). Fifty-one patients enrolled in the single-blind Phase II continuation trial, and were randomized to the three treatment groups. The duration of the Phase II study was 6 months. Assessments of outcome included the Brief Psychiatric Rating Scale, Global Assessment of Functioning, and the Mini-Mental State Examination. Forty-five patients either relapsed or completed the Phase II study, and six patients dropped out. Among completers, 6 of 15 (40%) patients relapsed in the combined continuation ECT and flupenthixol group. In both the group treated with continuation ECT alone and that with flupenthixol alone, 14 of 15 (93%) patients relapsed. Analyses of intent-to-treat and completer samples demonstrated a marked advantage for the combination treatment condition in relapse prevention. Furthermore, all eight patients who received maintenance ECT combined with neuroleptic medication (Phase III study) maintained therapeutic benefits during the follow-up period of 3-17 months after the continuation treatment study. Among TRS patients who respond to acute combination treatment with ECT and neuroleptic therapy, continuation of this combination treatment is more effective in relapse prevention than use of ECT or neuroleptic therapy alone.

The use of the stabilization period in electroconvulsive therapy research in schizophrenia: II. Implementation.

BACKGROUND: Electroconvulsive therapy (ECT) has been used to treat schizophrenia since its inception in 1938. Nonetheless, there has never been a research study documenting the efficacy of ECT in schizophrenia. All ECT studies suffered unexceptable methodological flaws. The authors hypothesized the 3-week stabilization period as: 1) a screening method for ECT responders, 2) a procedure for obtaining a homogeneous group of patients ideally suitable for the continuation treatment study, and, 3) as a part of our relapse criteria. METHOD: One hundred and fourteen schizophrenic patients received acute Phase I treatment with bilateral ECT and flupenthixol (12-24 mg/d). After the first sign of clinical improvement, all patients had to pass a 3-week stabilization period during which their clinical improvement had to be sustained. The patients had to receive at least 20 ECT treatments before being considered unresponsive to ECT. Fifty one patients enrolled in the continuation (Phase II) treatment study, and were randomized to the 3 treatment groups. RESULTS: In Phase I study, 58 patients were ECT responders by our criteria, 43 were nonresponders, and 13 were drop-outs. Forty five patients either relapsed or completed the Phase II study, while 6 patients dropped out. By our relapse criteria, 6 of 15 relapsed in the combined C-ECT and flupenthixol group, and 14 of 15 relapsed in both the group treated with C-ECT alone or flupenthixol alone. The use of the stabilization period in this study could complete all three objectives previously described. CONCLUSIONS: The use of the stabilization period is very useful in ECT research in schizophrenia.

Effects of twice- versus thrice-weekly electroconvulsive therapy in schizophrenia.

Electroconvulsive therapy (ECT) has been used to treat a variety of psychiatric disorders since 1938. In clinical practice, a schedule of administration varies greatly and definitive guidelines are not available. The disparity of treatment schedules may influence the rate of response and the duration of morbidity and hospital stay, as well as cognitive adverse effects. The authors conducted a retrospective, comparative study of twice-weekly versus thrice-weekly ECT schedules in ECT-responder schizophrenic patients. Forty-three patients received acute treatment with bilateral ECT and flupenthixol (12-24 mg/d). Outcome measures were the Brief Psychiatric Rating Scale, Global Assessment of Functioning, and the Mini-Mental-State Exam. The thrice-weekly ECT patient group (N = 21) had shorter duration of morbidity and more rapid response than the twice-weekly ECT patient group (N = 22). Twice-weekly ECT treatment is as equally effective as thrice-weekly schedule regarding the degree of improvement. There were no significant differences in the degree of improvement and the cognitive impairment at the end of the study.

Short-term effect of combined ECT and neuroleptic therapy in treatment-resistant schizophrenia.

Treatment-resistant schizophrenia (TRS) is a critical public health concern. Short-term treatment with electroconvulsive therapy (ECT), combined with neuroleptics, may increase the response rate in patients with TRS, when compared with either treatment alone. We conducted an open-trial study in 59 patients with TRS with acute exacerbations, by using bilateral ECT combined with flupenthixol (dose range, 12-24 mg/day). After the first sign of clinical improvement, all patients had to pass a 3-week stabilization period during which their clinical improvement had to be sustained. The patients had to receive at least 20 ECT treatments before being considered unresponsive to ECT. Thirty-one patients were ECT responders by our criteria, 19 were non-responders, and nine were dropouts. The responder group had more male patients, paranoid type, of younger age, shorter duration of illness and duration of the current episode, less family history of schizophrenia, and higher pretreatment GAF scores. They received a lesser number of ECT treatments, a less electrical charge used, and lower doses of flupenthixol (p < 0.05). Both positive and negative symptoms improved (p < 0.05), but positive symptoms responded to a greater extent. This study supports the therapeutic efficacy of combined treatment with ECT and neuroleptic drugs. A consensus in the definition of TRS is urgently required.