Comparison of bifrontal and bitemporal ECT for major depression.

OBJECTIVE: The authors compared the clinical and cognitive effects of bifrontal electrode placement with standard bitemporal electrode placement in the treatment of patients with major depression. METHOD: Forty-eight patients with unipolar or bipolar depression were treated with a course of bifrontal or bitemporal ECT. The Hamilton Rating Scale for Depression and the standardized Mini-Mental State were administered at baseline and repeated during the course of treatment. RESULTS: Forty-seven of the 48 patients who completed the course of treatment met remission criteria by the 12th treatment. There were no differences between the patients given bifrontal ECT and those given bitemporal ECT in the number of treatments required to reach remission criteria. The standardized Mini-Mental State scores of the patients given bitemporal ECT worsened more after treatment than did those of the patients given bifrontal ECT. CONCLUSIONS: Bifrontal electrode placement was as efficacious as bitemporal placement and resulted in less cognitive impairment. A study of the two placements with more cognitive measures is indicated.

Flumazenil reversal of benzodiazepine-induced sedation for a patient with severe pre-ECT anxiety.

We describe various measures to reduce severe anxiety that interfered with much-needed maintenance electroconvulsive therapy in a 32-year-old man. Treatment with ketamine met with moderate success, and then large doses of lorazepam and midazalam were used. The potential anticonvulsant effect of these drugs was successfully reversed by the administration of intravenous flumazenil just prior to the treatments.

Afternoon continuous plasma levels of 3-methoxy-4-hydroxyphenylglycol and age. Distinctive biologic subgroups of endogenous depression?

Afternoon continuous plasma levels of 3-methoxy-4-hydroxyphenylglycol (MHPG) were first shown to be a good representation of the mean 24-hour plasma level of MHPG in 18 normal subjects. Then, after the stability of the procedure was tested and retested, the afternoon continuous test for plasma MHPG levels was performed in 57 normal subjects and 42 endogenously depressed patients. A significant correlation between plasma MHPG levels and age was found in normal subjects and depressive patients. When the variable of age was taken into account, a distinct pattern of increasing plasma MHPG levels with age--the "MHPG per age"--was found in the depressed patients, especially the women, who could be divided into high or low MHPG per age groups. There was almost no association between plasma levels of MHPG or MHPG per age values and clinical symptoms, and the two biologic subgroups did not differ clinically.

Mesoridazine and thioridazine: clinical effects and blood levels in refractory schizophrenics.

Seven schizophrenic (according to DSM-III criteria) inpatients completed a two-phase study; each phase had a 1-week drug-free period followed by 6 weeks of a drug trial. The first phase uniformly involved treatment with chlorpromazine, and in the second phase patients received either mesoridazine (N = 3) or thioridazine (N = 4). Clinical ratings (Brief Psychiatric Rating Scale and Clinical Global Impressions) and neuroleptic blood levels were obtained weekly throughout the study. Whereas patients failed to respond to chlorpromazine 1800 mg/day, response to mesoridazine 400 mg/day and to thioridazine 800 mg/day was established on all Brief Psychiatric Rating Scale factors except for anxiety-depression. A higher neuroleptic blood level was achieved with mesoridazine or thioridazine at less than half the reference chlorpromazine dosage. Correlations between neuroleptic blood level and clinical response were positive for mesoridazine, negative for chlorpromazine, and nonsignificant for thioridazine. These findings are consistent with earlier research. We conclude that drug-resistant schizophrenics seem to improve clinically with mesoridazine or thioridazine, unlike with chlorpromazine, and that for mesoridazine this difference may be a function of selective dopamine receptor blockade.

Sex differences in biological factors putatively related to depression.

Gender differences in the prevalence of affective disorders were suggested by several authorities in the field. Such differences may be attributed to sex-related differences in levels or activity of monoamine transmitters, especially since some of these variables have been shown to be altered by gonadal hormones. The reported association of perimenstrual and postpartum dysphoria, with affective disorders may contribute to further elucidation of pathophysiology of depression in women--in light of the hormonal-behavioral dynamics of these periods. Several factors associated with monoamines biosynthesis, availability, uptake and metabolism were found to be more abnormal in normal and depressed women compared to men. Age-sex differences in some biological markers for depression are reported as well. Their relevance to the underlying pathophysiology of depression is unclear but they may provide clues for further research.

Depression, delusions, and suicide.

A retrospective analysis of all the suicides at the New York State Psychiatric Institute over a 25-year period was carried out. The authors retrospectively assigned diagnoses according to Research Diagnostic Criteria and DSM-III and found that among the patients who committed suicide there were 14 with unipolar endogenous depression. Of those 14 patients, 10 were considered delusional or probably delusional. In comparison, a control group of similarly diagnosed depressed patients taken from the same institution over the same time period included far fewer delusional depressions. Thus, there was a significant association between delusions and suicide: A delusionally depressed patient was five times more likely to commit suicide than a nondelusional one.