ECT in bipolar and unipolar depression: differences in speed of response.

OBJECTIVES: There is sparse evidence for differences in response to electroconvulsive therapy (ECT) between patients with bipolar or unipolar major depression, with virtually no information on speed of response. We contrasted a large sample of bipolar (BP) and unipolar (UP) depressed patients in likelihood and rapidity of clinical improvement with ECT. METHODS: Over three double-blind treatment protocols, 228 patients met Research Diagnostic Criteria for UP (n = 162) or BP depression (n = 66). Other than lorazepam PRN (3 mg/day), patients were withdrawn from psychotropics prior to the ECT course and until after post-ECT assessments. Patients were randomized to ECT conditions that differed in electrode placement and stimulus intensity. Symptomatic change was evaluated at least twice weekly by a blinded evaluation team, which also determined treatment length. RESULTS: Patients with BP and UP depression did not differ in rates of response or remission following the ECT course, or in response to unilateral or bilateral ECT. Degree of improvement in Hamilton Rating Scale for Depression scores following completion of ECT was also comparable. However, BP patients received significantly fewer ECT treatments than UP patients, and this effect was especially marked among bipolar ECT responders. Both BP I and BP II patients showed especially rapid response to ECT. CONCLUSIONS: The BP/UP distinction had no predictive value in determining ECT outcome. In contrast, there was a large effect for BP patients to show more rapid clinical improvement and require fewer treatments than unipolar patients. The reasons for this difference are unknown, but could reflect a more rapid build up of anticonvulsant effects in BP patients.

Personality disorders in elderly patients with dysthymic disorder.

The authors evaluated personality disorders in elderly patients with DSM-IV dysthymic disorder (DD) to identify prevalent personality disorders and their clinical correlates. Outpatients (>/=60 years; N=76) with DD were evaluated; most were male (65.8%) and had late age at onset (>50 years: 60.5%). Axis II disorders were present in 31.2% of patients, with obsessive-compulsive personality disorder (OCD; 17.1%) and avoidant personality disorder (11.8%) being the most common. Personality disorders were associated with an earlier age at onset of depressive illness, greater lifetime history of comorbid Axis I disorders, greater severity of depressive symptoms, and lower socioeconomic status. Personality disorders occurred in a minority of elderly patients with DD and mainly comprised the obsessive-compulsive and avoidant subtypes, similar to reports of personality disorders in elderly patients with major depression. In contrast, young adults with DD have been shown consistently to have personality disorders at high frequency. Together with the predominance of late onset and the lack of psychiatric comorbidity, the current findings on personality disorders reinforce our view that DD in elderly patients is typically a different disorder from DD in young adults.

Subjective memory complaints: a review of patient self-assessment of memory after electroconvulsive therapy.

Interest in patients' subjective complaints about the adverse cognitive effects of electroconvulsive therapy (ECT) spans several decades. This article reviews the major areas that have been examined in relation to patients' subjective assessment of memory function: 1) technical aspects in the administration of ECT; 2) objective tests of cognitive function; and 3) clinical state. For the most part, subjective assessments of memory following ECT have relied on a single instrument, the Squire Subjective Memory Questionnaire (SSMQ). While older reports of the impact of the technical aspects of ECT on subjective memory assessment following ECT suggest a detectable negative influence with certain forms of treatment, most recent studies indicate that subjective memory improves following ECT. This shift in findings may be due to the change in practice from sine wave to brief-pulse ECT. While the impact of ECT on objective tests of memory is clear and reproducible, the relationship of objective findings to subjective memory assessment appears to be weak. Instead, subjective reports of cognitive function are strongly influenced by mood state. Current batteries of objective tests of memory may not include components that are most affected in reports about subjective memory. In addition, the literature mainly reports group effects, and sample sizes have been small. We lack data on the number of individuals who believe ECT has had a markedly negative effect on memory functioning, and on the characteristics of memory function in this subgroup of patients who complain of severe impairment. Furthermore, there is a paucity of information relating patient characteristics to subjective memory outcomes with ECT.

A prospective, randomized, double-blind comparison of bilateral and right unilateral electroconvulsive therapy at different stimulus intensities.

BACKGROUND: Controversy persists about the use of right unilateral (RUL) and bilateral (BL) electroconvulsive therapy (ECT). While RUL ECT results in less severe short-term and long-term cognitive effects, there is concern that it is less efficacious than BL ECT. METHODS: In a double-blind study, 80 depressed patients were randomized to RULECT, with electrical dosages 50%, 150%, or 500% above the seizure threshold, or BL ECT, with an electrical dosage 150% above the threshold. Depression severity and cognitive functioning were assessed before, during, immediately after, and 2 months after ECT. Compared with baseline, responders had at least a 60% reduction in symptom scores 1 week after ECT, and were monitored for relapse for 1 year. RESULTS: High-dosage RUL and BL ECT were equivalent in response rate (65%) and approximately twice as effective as low-dosage (35%) or moderate-dosage (30%) unilateral ECT. During the week after the randomized phase, BL ECT resulted in greater impairment than any dosage of unilateral ECT in several measures of anterograde and retrograde memory. Two months after ECT, retrograde amnestic deficits were greatest among patients treated with BL ECT. Thirty-three (53%) of the 62 patients who responded to ECT relapsed, without treatment group differences. The relapse rate was greater in patients who had not responded to adequate pharmacotherapy prior to ECT and who had more severe depressive symptoms after ECT. CONCLUSION: Right unilateral ECT at high dosage is as effective as a robust form of BL ECT, but produces less severe and persistent cognitive effects.

Learning and memory in bipolar and unipolar major depression: effects of aging.

OBJECTIVE: The goal of this study was to examine the effects of aging on neuropsychological functions in bipolar and unipolar major depression. BACKGROUND: Earlier studies suggested that neurocognitive deficits in mood disorder patients correlate with duration and severity of illness and also that bipolar disorder has a more virulent course than unipolar disorder. We hypothesized that elderly patients with bipolar disorder will demonstrate greater neurocognitive dysfunction than young patients with bipolar disorder and elderly patients with unipolar disorder. METHOD: A battery of tests of general intelligence and learning and memory was administered to 79 inpatients with major depression referred for electroconvulsive therapy. With patients 60 years of age and older defined as elderly, there were 29 young and 24 elderly unipolar patients and 13 young and 13 elderly bipolar patients. RESULTS: Unipolar and bipolar patients did not differ in measures of general intelligence or global cognitive status. Generally, across tests of memory, young bipolar patients exhibited the best performance and elderly bipolar patients exhibited the poorest performance. CONCLUSIONS: The results suggest that over the course of their illness, patients with bipolar disorder experience greater deterioration in memory functions than patients with unipolar disorder. Longitudinal studies are required to support the preliminary findings of this cross-sectional study.

Computerized telephone assessment of the "concrete" needs of chemotherapy outpatients: a feasibility study.

The feasibility of using a computer-automated telephone outreach system to routinely assess the needs of chemotherapy outpatients was evaluated. The automated intervention was designed as a cost-efficient strategy for assessing patients' needs on a periodic basis so that emerging needs could be identified in a timely way. Ninety-seven chemotherapy outpatients were surveyed at least once over the telephone by a computer in a high-quality, digitally stored voice asking 12 questions regarding the patients' "concrete" needs. Early results of this larger ongoing study, in which patients are scheduled to be called every 4 to 6 weeks for approximately four months, indicated that computer-automated surveys had broad-based acceptance among our outpatients and that patients were able to comply accurately with the survey's instructions. Furthermore, the speech recognition system was found to be reliable, and patients' response patterns to the automated surveys valid. Nonparticipation in this study (28.0%) was not substantially higher than in our previous research within this patient population and neither nonparticipation nor attrition appeared significantly attributable to the automation itself. This method offers the potential for cost-efficient, universal, and ongoing assessment of patient needs, facilitating timely intervention, and efficient use of professional staff.