Geriatric psychiatry in the psychiatry clerkship: a survey of current education practices.

OBJECTIVE: The aging of the US population and shortage of geriatric psychiatrists mean that all medical students must be prepared to evaluate psychiatric symptoms in older patients. The authors sought to describe current geriatric psychiatry teaching practices during the psychiatry clerkship. METHODS: Psychiatry clerkship directors at 110 American medical schools were surveyed about didactic and clinical experiences of geriatric psychiatry. RESULTS: Sixty-two (56 %) of programs responded. One fifth of programs lacked specific instruction in geriatric psychiatry. Programs were more likely to include instruction on dementia than late-life depression. Increased geriatric psychiatry educational offerings were associated with the following: number of geriatric psychiatrists on faculty, presence of a geriatric psychiatrist on the medical education committee, and inclusion of geriatric psychiatry specific items in clerkship learning objectives. CONCLUSIONS: Current practices in some clerkships are inadequate to prepare medical students to care for older patients with psychiatric symptoms.

Automatic implantable cardioverter defibrillator in electroconvulsive therapy.

As the number of patients with implantable cardiac devices increases so too does the frequency with which these individuals present for electroconvulsive therapy (ECT). The rationale for deactivating an automatic implantable cardioverter defibrillator before ECT has been made based on the concern that artifacts generated during treatment could be interpreted as a treatable rhythm by the internal device, resulting in a discharge. We believe that the risk of inappropriate discharge during ECT is very low and outweighed by the considerable benefit of an active device being able to more quickly treat a malignant dysrhythmia.

Depression severity in electroconvulsive therapy (ECT) versus pharmacotherapy trials.

OBJECTIVE: We sought to compare the level of severity of depressive symptoms on entry into electroconvulsive therapy (ECT) clinical trials versus pharmacotherapy clinical trials. DATA SOURCES: English-language MEDLINE/PubMed publication databases were searched for ECT literature (search terms: ECT, electroconvulsive therapy, depression, and Hamilton) for clinical trials in which depressed patients had baseline Hamilton Rating Scale for Depression (HRSD) scores. For comparison, we used a convenience sample of 7 large pharmacotherapy trials in major depression (N = 3677). The search included articles from 1960 to 2011. STUDY SELECTION: We included 100 studies that met the following criteria: ECT trial for depression, patients adequately characterized by diagnosis at baseline, and patients rated at baseline by 15-item HRSD (HRSD15), HRSD17, HRSD21, HRSD24, or HRSD28, with mean (SD) and sample size (n) reported. For the comparator pharmacotherapy trials, we chose to use a subset of the studies (excluding one study of minor depression) in the widely publicized meta-analysis of Fournier et al, as well as the STAR*D study and one additional study by Shelton et al. This provided 7 studies of major depression using HRSD17 (total N = 3677). DATA EXTRACTION: Data extracted included number of subjects and baseline and final HRSD scores, with mean (SD) values. RESULTS: Of 100 ECT studies, 56 studies (N = 2243) used the HRSD17 version. The mean baseline HRSD17 score in the ECT trials was 27.6, the mean in the pharmacotherapy trials was 21.94, a statistically, and clinically, significant difference. In a subanalysis of the 16 ECT studies that used the HRSD24 version, the mean baseline score was 32.2. CONCLUSIONS: This selective literature review confirms that patients who entered ECT clinical trials were more severely ill than those who entered the selected comparator pharmacotherapy trials. Such data highlight the critical role of ECT in the treatment of severe and treatment-resistant mood disorders.

Low-dose right unilateral electroconvulsive therapy (ECT): effectiveness of the first treatment.

BACKGROUND: Electroconvulsive therapy (ECT) is a widely used, highly effective antidepressant treatment. Except for the most severely ill patients, right unilateral (RUL) electrode placement is the most frequent initial treatment choice. In current practice, RUL ECT is administered at several multiples of seizure threshold (ST) based on reports that lower stimulus intensity results in lower response/remission rates. Many patients, as part of an initial dose titration to determine ST, will receive a single treatment with low-dose RUL ECT and subsequent treatments with a stimulus at a multiple of ST. OBJECTIVE: To assess response to the first ECT. METHODS: A retrospective analysis of charts from clinical practice at Mount Sinai Medical Center was performed. RESULTS: A single treatment with low-dose (presumably near ST) RUL ECT had a significant and immediate antidepressant effect in our sample of patients with major depression. We determined that this response is similar to that of patients receiving a single initial treatment with high-dose RUL ECT (at a multiple of ST). CONCLUSIONS: These data suggest, contrary to commonly held belief, that RUL ECT may be effective at a low stimulus dose. This argues against restimulating at 6 times ST in the initial session, based on the belief that the near-threshold seizure has no antidepressant efficacy. Our findings suggest a need for further investigation of cases in which low-dose RUL ECT may be an effective antidepressant treatment. Further prospective studies, including larger numbers of patients who receive randomized treatment with low- or high-dose RUL with longer follow-up, are indicated.

Electrocardiographic "bleed through" to the electroencephalogram on an electroconvulsive therapy (ECT) tracing: the return of the tell-tale heart.

Improper recording electrode placement can cause artifacts on electroconvulsive therapy tracings. This shows an example of electrocardiogram artifact in the electroencephalogram.

Methohexital and succinylcholine dosing for electroconvulsive therapy (ECT): actual versus ideal.

This report compares the actual doses of methohexital and succinylcholine used for optimal anesthesia and muscle relaxation in electroconvulsive therapy with written guidelines for dosing. The initial doses of methohexital and succinylcholine in milligrams per kilogram were reviewed and compared with subsequent doses of each agent after adjustments were made for individual patient responses during treatment. The dose of methohexital required to induce general anesthesia for most patients is 1.0 mg/kg. The dose of succinylcholine required to provide adequate muscle relaxation during electroconvulsive therapy is 0.9 mg/kg, although there is considerable variability in patient response to this drug.

Appropriateness for electroconvulsive therapy (ECT) can be assessed on a three-item scale.

Electroconvulsive therapy (ECT) is the most effective and rapid treatment for severe depression; however, it should be prescribed to the limited number of patients with severe mood and psychotic disorders for whom it is clearly appropriate. We present an assessment scale that we hypothesize can be used to predict a patient's appropriateness for ECT, based on the severity, heritability, and episodic nature of their depression. This scale is offered as a tool to help the practitioner and patient gain a sense of how well the patient fits the profile of someone for whom ECT is a reasonable treatment option.

The Telltale Heart or the importance of the "Tap Test" in electroconvulsive therapy (ECT).

The "Tap Test" is a maneuver used to test the functioning of the electroencephalogram and electromyogram leads just prior to electroconvulsive therapy. Here we present a brief case and image that reinforces the importance of this simple test.

Multiple episodes of intraictal cessation during electroconvulsive therapy.

A recent case reported an episode of a "stop-start-stop" phenomenon during an electroconvulsive therapy treatment. We report an example of multiple stop-start-stop episodes during several electroconvulsive therapy treatments of a 16-year-old boy.

Electroconvulsive therapy (ECT) after pulmonary edema.

We report a case of pulmonary edema after electroconvulsive therapy (ECT) in an 88-year-old man with controlled hypertension and treatment-refractory depression. Despite this unexpected episode of pulmonary edema, the patient was able to complete this course of ECT without further complications. Because the pulmonary edema was thought to be due to extremely elevated blood pressures, nitroglycerine and esmolol were used during subsequent treatments, and electrode placement was changed to bilateral to speed recovery.

Left unilateral electroconvulsive therapy (ECT) after oligodendroglioma resection.

A 44-year-old man with a previously resected right parietal oligodendroglioma received left unilateral electroconvulsive therapy (ECT). We present images of his brain magnetic resonance imaging, ECT electrode placement, and the electroencephalogram tracing from his ECT.

Delirium in older adults.

Delirium is a common neuropsychiatric syndrome in the elderly that can occur in several different settings caused by several different processes. It is common and causes increased morbidity and mortality to those affected. This clinical review discusses the prediction, prevention, diagnosis, and treatment of delirium in the elderly population. Several strategies to predict delirium are noted with the discussion of pharmacological and nonpharmacological trials of prevention and treatment. Diagnosis of delirium, specifically with the use of objective instruments, is discussed, as is the evidence for pharmacological and nonpharmacological treatment strategies. Discussion of the neurobiology and genetic markers for delirium may elucidate further areas for future research.