Antidepressant Discontinuation Syndrome / 신경정신의학

Since selective serotonin reuptake inhibitors were introduced in clinical practice in the 1990s, antidepressant prescriptions have steadily increased. In addition to the prescriptions by psychiatrists, antidepressant prescriptions by non-specialists have also increased. An advanced understanding of the pharmacological and clinical characteristics of antidepressants is essential to improving the treatment response of depressive disorders and the quality of life of patients. Antidepressant withdrawal or discontinuation syndrome can frequently occur if antidepressant maintenance is discontinued without a pre-planned clinical strategy. Nevertheless, it is often unrecognized or mistaken for other clinical situations. This causes patient distress and ultimately reduces long-term treatment compliance. Inappropriate therapeutic decisions can be made if clinicians do not recognize antidepressant discontinuation syndrome. Antidepressant withdrawal is common and preventable. This issue must be recognized because it can be adjusted through appropriate clinical management. This article systematically reviews the clinical features, biological mechanisms, coping strategies, and antidepressant discontinuation strategies related to antidepressant discontinuation syndrome.

The Mediating Role of Anxiety/Depression Between Auditory Verbal Hallucinations and the Level of Insight in Schizophrenia

Objective@#Auditory verbal hallucination (AVH) is a prominent symptom of schizophrenia causing profound distress. The influence of AVHs on insight appears to be intricate and contingent on other accompanying symptoms. This study investigated the relationship and possible mediators between AVHs and the degree of insight. @*Methods@#One hundred patients with schizophrenia participated in the study. Scales were used to evaluate the hallucinatory experience, the level of insight and other psychopathology. Complex relationships between variables were envisaged as a path model, whose initial structure was constructed via Gaussian Graphical Model. The validity of the final model was verified by Structural Equation Modeling. Separate analyses were performed for self-reported and clinician-rated data to enhance the model’s robustness. @*Results@#The greater the severity of the physical aspects of AVHs, the lower the level of insight observed. Conversely, higher emotional distress was associated with increased insight. These relationships were only evident in the self-reported results and were not reflected in the clinician-rated results. The path model suggested that the Positive and Negative Syndrome Scale (PANSS) anxiety/depression factor was an important mediator that linked the found association. Notably, the PANSS negative symptom had the opposite effect on the PANSS anxiety/depression factor and insight, making it difficult to define its overall effect. @*Conclusion@#The findings of this study provided one possible route for the positive influence of AVH experience in gaining insight. The mediating role of anxiety/depression modified by negative symptoms emerged as a valuable concept for clarifying this intricate relationship.

Diagnosis and Treatment of GastroEsophageal Reflux Disease at the Primary Health Care Clinics in Korea / 대한소화기학회지

Background/Aims@#The prevalence of GERD and treatment costs are continuously rising in Korea, and the importance of primary health care clinics where the most treatment of actual patients is conducted is increasing. In this study, the diagnosis of GERD, selection of therapeutic drugs, and treatment methods in primary health care clininics were investigated through a large-scale multi-dimensional surveys. @*Methods@#From January 2015 to December 2018, the study data of 18,010 patients with GERD were retrospectively investigated based on eletronic medical record at 542 primary health care clinics in Korea. @*Results@#Among all GERD patients, endoscopy was used for diagnosis in 16.11% of cases, and the most frequently performed in gastroenterology department (28.85%). The average BMI and the proportion of patients in stages 1 to 3 of obesity were highest in the ERD group, and the majority of the severity of ERD group was mild. Symptoms of the patients with GERD were mainly heartburn, gastric acid reflux, and chest pain. Drug treatment was performed in most of the patients with GERD, and PPI was the main drug, and Esomeprazol was prescribed the most among the main ingredients, and the ratio of PPI alone was high. The rate of symptom improvement after GERD treatment was slightly higher in the ERD group (75.91%) and the NERD group (74.36%) than in the GERD diagnosed without endoscopy group (63.89%). @*Conclusions@#In domestic primary health care clinics, the majority were diagnosed with GERD without endoscopy on the basis of symptoms. The most preferred treatment for GERD was PPI, which was prescribed alone in the majority.

Practical Issues With Clonazepam Use / 신경정신의학

Clonazepam, a 7-nitrobenzodiazepine, has been used for the treatment of various neuropsychiatric disorders such as seizures, sleep disorders, panic disorders, anxiety, and movement disorders. However, clonazepam is officially approved as a therapeutic drug only for epilepsy and panic disorders in Korea. This raises ethical issues in clinical practice, as clonazepam is prescribed off-label for most neuropsychiatric disorders in many other countries as well. The misuse and abuse of clonazepam as a recreational drug have also been commonly reported in global literature. In this review, as a therapeutic drug as the authors aim to highlight the pharmacological aspects, clinical effects, and potential addictive risks of clonazepam use, by reviewing the current literature on clonazepam to increase its clinical use by accurately understanding and identifying its psychopharmacological benefits and characteristics. However, establishing the risk/benefit ratio of clonazepam for use in specific clinical situations is difficult because of the lack of adequate updated data. Therefore, the use of clonazepam needs to be approached from the point of view of personalized drug treatment rather than following fixed guidelines which would not reflect the current real-world clinical practices.

Benzodiazepines: Pharmacology Up-to-Date and Practical Issues / 신경정신의학

Benzodiazepines have been widely used as anxiolytics, sedatives, hypnotics, anticonvulsants, or central muscle relaxants since the 1960s despite significant adverse effects, the potential for misuse, and consequent overdose. Benzodiazepines exert their pharmacological action by binding to gamma-aminobutyric acid type A (GABA-A) receptors in the brain and facilitateing the inhibitory actions of the neurotransmitter GABA. Recent findings have also elucidated the effects of benzodiazepines on the allosteric modulation of GABA-A receptors, including receptor subtypes and transmembrane proteins, which is a significant step in our understanding of GABA pharmacology. In clinical practice, the use of benzodiazepines to treat psychiatric disorders has been limited due to the challenges associated with the long-term use, namely the risks of abuse, misuse, and overdose, as well as withdrawal effects. Furthermore, the approval of selective serotonin reuptake inhibitors for anxiety disorders has led to their extensive use as a first-line pharmacological option and they have also been promoted in various practice guidelines for the treatment of anxiety disorders. However, although recent systematic reviews and meta-analyses have shown that benzodiazepines are useful and effective drugs for the treatment of various neuropsychiatric disorders, including anxiety, debates over the clinical use of benzodiazepines continue. More than 60 years after the introduction of benzodiazepines in clinical practice, it is necessary to revisit the controversies associated with benzodiazepine use and to update the discussion current approach to practice with thethrough an understanding of the new data on their pharmacological actions and to identify appropriate indications according to the new diagnostic systems of psychiatric disorders through an extensive literature review.

Electroconvulsive Seizure Normalizes Motor Deficits and Induces Autophagy Signaling in the MPTP-Induced Parkinson Disease Mouse Model

Objective@#Electroconvulsive seizure (ECS) is a potent treatment modality for various neuropsychiatric diseases, including Parkinson disease (PD). Recent animal studies showed that repeated ECS activates autophagy signaling, the impairment of which is known to be involved in PD. However, the effectiveness of ECS on PD and its therapeutic mechanisms have not yet been investigated in detail. @*Methods@#Systemic injection of a neurotoxin 1-Methyl-4-phenyl-1,2,3,6-tetrahydropyridine hydrochloride (MPTP), which destroys dopaminergic neurons in the substantia nigra compacta (SNc), in mice was utilized to induce an animal model of PD. Mice were treated with ECS 3 times per week for 2 weeks. Behavioral changes were measured with a rotarod test. Molecular changes related to autophagy signaling in midbrain including SNc, striatum, and prefrontal cortex were analyzed with immunohistochemistry and immunoblot analyses. @*Results@#Repeated ECS treatments normalized the motor deficits and the loss of dopamiergic neurons in SNc of the MPTP PD mouse model. In the mouse model, LC3-II, an autophagy marker, was increased in midbrain while decreased in prefrontal cortex, both of which were reversed by repeated ECS treatments. In the prefrontal cortex, ECS-induced LC3-II increase was accompanied with AMP-activated protein kinase (AMPK)-Unc-51-like kinase 1-Beclin1 pathway activation and inhibition of mamalian target of rapamycin signaling which promotes autophagy initiation. @*Conclusion@#The findings revealed the therapeutic effects of repeated ECS treatments on PD, which could be attributed to the neuroprotective effect of ECS mediated by AMPK-autophagy signaling.

Optimizing the Efficacy of Electroconvulsive Therapy / 신경정신의학

Modern electroconvulsive therapy (ECT) is a non-pharmacological and biological treatment that is clinically effective and safe. ECT is used in the treatment of many psychiatric disorders, some neurological diseases, and psychiatric emergencies requiring a rapid and life-saving clinical response. Generalized seizures of the central nervous system induced by the electrical stimulation of ECT are an essential component of the therapeutic effects, which are attributed to the various neuronal responses of the brain. Modern ECT is conducted under general anesthesia, given to the extent of loss of consciousness, followed by administration of a muscle relaxant, and ECT with minimally appropriate electrical stimulation. ECT optimization has the main objective of ensuring maximum clinical efficacy and safety with minimal adverse events through adequate generalized seizures. Since its first introduction in clinical practice in 1938, many studies have been carried out and advances made to enhance the therapeutic effects of ECT and address the adverse events associated with it. As a result, there have been developments such as the use of a square wave instead of a sine wave, various electrode placements, dose titration methods, seizure thresholds, general anesthesia with muscle relaxation, session scheduling, monitoring of electroencephalograms (EEG) and electromyograms, etc. and these have been applied to actual clinical practice. Research on the clinical characteristics and the optimal ECT parameters to increase the efficacy of seizures is still ongoing. In this review, various factors associated with ECT such as EEG monitoring, motor seizures, electrode placements, stimulation dose and titration, seizure evaluation and adequacy, and the ECT algorithms are discussed to improve the efficacy of modern ECT as a useful treatment for psychiatric disorders.

Breakthrough Psychosis and Long-Acting Injectable Antipsychotics / 대한정신분열병학회지

“Breakthrough” of psychosis despite good compliance of antipsychotics medication for a long time is a major obstacle to the treatment of schizophrenia, whether the mechanism is caused by dopamine hypersensitivity or insufficient dose of antipsychotics. Researchers advocating “Dopamine Supersensitivity Psychosis” (DSP) emphasize to avoid excessive inhibition of dopamine 2 receptors from the beginning of treatment. On the other hand, researchers advocating “Breakthrough psychosis on Antipsychotic Maintenance Medication” (BAMM) in which psychosis recurs due to insufficient medication despite continuous administration of antipsychotics without non-adherence argue that dose of antipsychotics should be increased to enhance therapeutic effect. In patients using long-acting antipsychotics injection (LAI), non-compliance can be ruled out. We believe that in treating non-affective psychosis, it is necessary to continuously maintain the lowest dose possible using the optimal dose considering the side effects of second-generation antipsychotics and the cycle and stage of psychosis, and the optimal formulation such as LAI.

An International Adult Guideline for Making Clozapine Titration Safer by Using Ancestry-Based Personalized Dosing Titrations, C-Reactive Protein and Serum Clozapine Levels: Korean Translation and Its Clinical Application Cases / 대한정신분열병학회지

Objectives@#During the initial clozapine titration, it is crucial to monitor for inflammatory reactions to ensure safe and effective administration. Clozapine metabolism varies by ancestry, particularly among Asians, warranting lower dosage. Recently, Dr. De Leon introduced guidelines based on ancestral differences. We aimed to provide a Korean translation, focusing on illustrating the necessity through clinical cases. @*Methods@#The Korean translation of the guidelines, approved by Dr. De Leon, involved two psychiatrists who reviewed and revised each other’s work. An additional board-certified psychiatrist conducted an independent review. We examined two clinical cases from our institution’s database, where clozapine titration faced challenges due to fever and pneumonia, assessing guideline applicability. @*Results@#The guidelines recommend a target clozapine dose of 175-300 mg/day for Asians with average metabolism and a slower titration rate compared to other ancestries. In both cases, CRP elevation was detected either before or simultaneously with the onset of fever, with a concentration-to-dose ratio ranging from 3.06 to 6.97. @*Conclusion@#The initial clozapine titration process should consider metabolic differences by ancestry and monitor for inflammation. Further research is needed to optimize the titration process for Koreans, considering metabolic rates, usage patterns, and side effects.

Resolution of Persistent Auditory Verbal Hallucinations after Long-term Electroconvulsive Therapy Maintenance: A Case Report of a Patient with Clozapine-resistant Schizophrenia

A 32-year-old woman with schizophrenia and persistent auditory verbal hallucinations (AVHs), which caused continuous suicidal thoughts and depression, was treated with electroconvulsive therapy (ECT) of an acute course followed by maintenance ECT (M-ECT) augmented onto clozapine for 7 years. Although the general psychopathology and AVHs initially reduced slightly with ECT and clozapine, her AVHs and suicidal thoughts did not decrease subjectively. When 3 years of M-ECT, her voices declined sharply, and improvement was maintained for 2 years thereafter. A total 91 ECT sessions were performed. The daily clozapine dose was decreased from 325 to 200 mg and plasma levels remained higher than 350 ng/ml; there were no noticeable cognitive side effects. In summary, we report a case showing a sudden sharp reduction in persistent AVHs after 3 years of long-term M-ECT.

Challenges in Prescribing Clozapine in the Era of COVID-19:A Review Focused on Immunological Implications

The global COVID-19 pandemic has disrupted every aspect of the healthcare system. Apart from the issues surrounding COVID-19 itself, care for existing patients has met many challenges. One such challenge is caring for patients who are on clozapine treatment and have been confirmed positive for COVID-19. Schizophrenia has been considered to have a deep connection with the immune system, and clozapine can induce further changes in this system. COVID-19 can ravage the compromised immune system and aggravate tissue damage. The intricate relations between schizophrenia, clozapine, and COVID-19 make it difficult to predict the clinical course of COVID-19 in clozapine-treated patients. However, the rigid prohibition on using clozapine if COVID-19 is confirmed may harm patients. Patients who have to use clozapine are often refractory cases with no alternatives. Therefore, the decision to maintain or stop clozapine must be made after a comprehensive review of the patient’s unique situation. To do this, theoretical and practical issues surrounding the use of clozapine in COVID-19 should be reviewed and discussed. In this review, we gather useful information surrounding this issue and present an overview. Focusing on the immune system, various theoretical possibilities that could arise from schizophrenia, clozapine, and COVID-19 were carefully examined, and practical checklists for the care of these patients were explored. It is hoped that this review will convince many clinicians to pay attention to this momentous issue and facilitate more active sharing of clinical experiences.

Satisfaction Survey of Patients Toward Electroconvulsive Therapy / 신경정신의학

Objectives@#This study examined the satisfaction of patients who had undergone electroconvulsive therapy to provide important information for improving the social misunderstanding about electroconvulsive therapy, to increase the effectiveness of treatment, and make a decision of effective treatment. @*Methods@#A questionnaire survey was conducted to determine the satisfaction, adverse effects, attitudes, and experiences toward electroconvulsive therapy in patients at 2 to 4 weeks after finishing an acute course of electroconvulsive therapy in three psychiatric hospitals. @*Results@#There were 85 respondents (38 males), whose average age was 42.0±13.6 years and average illness duration was 12.8±8.9 years. Fifty-two patients (61.2%), 19 (22.4%), 8 (9.4%), and 6 (7.1%) were diagnosed with schizophrenia, major depressive disorder, bipolar disorder, and other mental disorders, respectively. The average session number for acute electroconvulsive therapy was 12.6±6.0 sessions, and 61 patients (71.8%) had received maintenance electroconvulsive therapy. Among the respondents, 60.0% reported that they were satisfied with the electroconvulsive therapy. Satisfaction was similar according to sex, age, diagnosis, electrode placement, and use of anesthetic agents. Forty-three (53.8%) patients experienced memory impairment during acute electroconvulsive therapy. @*Conclusion@#This study showed that patients who received electroconvulsive therapy were generally satisfied with the treatment and that memory impairment should be detected early and managed promptly. Follow-up studies with a large number of subjects and variables will be needed to determine the predictive factors affecting satisfaction toward electroconvulsive therapy.

Challenges in Prescribing Clozapine in the Era of COVID-19:A Review Focused on Immunological Implications

The global COVID-19 pandemic has disrupted every aspect of the healthcare system. Apart from the issues surrounding COVID-19 itself, care for existing patients has met many challenges. One such challenge is caring for patients who are on clozapine treatment and have been confirmed positive for COVID-19. Schizophrenia has been considered to have a deep connection with the immune system, and clozapine can induce further changes in this system. COVID-19 can ravage the compromised immune system and aggravate tissue damage. The intricate relations between schizophrenia, clozapine, and COVID-19 make it difficult to predict the clinical course of COVID-19 in clozapine-treated patients. However, the rigid prohibition on using clozapine if COVID-19 is confirmed may harm patients. Patients who have to use clozapine are often refractory cases with no alternatives. Therefore, the decision to maintain or stop clozapine must be made after a comprehensive review of the patient’s unique situation. To do this, theoretical and practical issues surrounding the use of clozapine in COVID-19 should be reviewed and discussed. In this review, we gather useful information surrounding this issue and present an overview. Focusing on the immune system, various theoretical possibilities that could arise from schizophrenia, clozapine, and COVID-19 were carefully examined, and practical checklists for the care of these patients were explored. It is hoped that this review will convince many clinicians to pay attention to this momentous issue and facilitate more active sharing of clinical experiences.

Satisfaction Survey of Patients Toward Electroconvulsive Therapy / 신경정신의학

Objectives@#This study examined the satisfaction of patients who had undergone electroconvulsive therapy to provide important information for improving the social misunderstanding about electroconvulsive therapy, to increase the effectiveness of treatment, and make a decision of effective treatment. @*Methods@#A questionnaire survey was conducted to determine the satisfaction, adverse effects, attitudes, and experiences toward electroconvulsive therapy in patients at 2 to 4 weeks after finishing an acute course of electroconvulsive therapy in three psychiatric hospitals. @*Results@#There were 85 respondents (38 males), whose average age was 42.0±13.6 years and average illness duration was 12.8±8.9 years. Fifty-two patients (61.2%), 19 (22.4%), 8 (9.4%), and 6 (7.1%) were diagnosed with schizophrenia, major depressive disorder, bipolar disorder, and other mental disorders, respectively. The average session number for acute electroconvulsive therapy was 12.6±6.0 sessions, and 61 patients (71.8%) had received maintenance electroconvulsive therapy. Among the respondents, 60.0% reported that they were satisfied with the electroconvulsive therapy. Satisfaction was similar according to sex, age, diagnosis, electrode placement, and use of anesthetic agents. Forty-three (53.8%) patients experienced memory impairment during acute electroconvulsive therapy. @*Conclusion@#This study showed that patients who received electroconvulsive therapy were generally satisfied with the treatment and that memory impairment should be detected early and managed promptly. Follow-up studies with a large number of subjects and variables will be needed to determine the predictive factors affecting satisfaction toward electroconvulsive therapy.

Initial Seizure Threshold in Ultra-Brief Pulse Width Right Unilateral Electroconvulsive Therapy / 신경정신의학

Objectives@#The present study investigates the initial seizure threshold (IST) of an ultra-brief pulse width right unilateral electroconvulsive therapy (UBP-RUL ECT) in Korean patients with mental disorders to identify its predictive factors for clinical improvement. @*Methods@#This study includes thirty patients who received 0.3-ms UBP-RUL ECT using upward titration to measure IST after the use of general anesthesia and muscle relaxation between December 2015 and June 2020. During the second session, the amount of charge that ranged between 500% to 600% of IST was applied as the stimulus intensity (SI). Demographic and clinical information was gathered from electronic medical records, and a stepwise variable selection was conducted to identify the relevant predictors of IST. @*Results@#The mean age of study subjects was 49.7±18.3 years, and 12 (40.0%) patients were male. The mean IST and SI were 31.6±17.2 mC and 176.0±98.5 mC, respectively, which did not differ between males and females. The mean scores of the Clinical Global Impression-severity and the Clinical Global Impression-improvement before and after acute ECT were 5.8±0.8 and 2.1±0.7, respectively. The age and anesthetic dose per body weight were significant predictors of IST. However, the IST and SI were not associated with clinical improvement. @*Conclusion@#The present study demonstrated that the IST distribution for UBP-RUL ECT in Korean patients with mental disorders was comparable to those reported in previous literature. The IST was associated with age and anesthetic dose.

Initial Seizure Threshold in Ultra-Brief Pulse Width Right Unilateral Electroconvulsive Therapy / 신경정신의학

Objectives@#The present study investigates the initial seizure threshold (IST) of an ultra-brief pulse width right unilateral electroconvulsive therapy (UBP-RUL ECT) in Korean patients with mental disorders to identify its predictive factors for clinical improvement. @*Methods@#This study includes thirty patients who received 0.3-ms UBP-RUL ECT using upward titration to measure IST after the use of general anesthesia and muscle relaxation between December 2015 and June 2020. During the second session, the amount of charge that ranged between 500% to 600% of IST was applied as the stimulus intensity (SI). Demographic and clinical information was gathered from electronic medical records, and a stepwise variable selection was conducted to identify the relevant predictors of IST. @*Results@#The mean age of study subjects was 49.7±18.3 years, and 12 (40.0%) patients were male. The mean IST and SI were 31.6±17.2 mC and 176.0±98.5 mC, respectively, which did not differ between males and females. The mean scores of the Clinical Global Impression-severity and the Clinical Global Impression-improvement before and after acute ECT were 5.8±0.8 and 2.1±0.7, respectively. The age and anesthetic dose per body weight were significant predictors of IST. However, the IST and SI were not associated with clinical improvement. @*Conclusion@#The present study demonstrated that the IST distribution for UBP-RUL ECT in Korean patients with mental disorders was comparable to those reported in previous literature. The IST was associated with age and anesthetic dose.

The Determination of the Duration of ElectroconvulsiveTherapy-Induced Seizure Using Local Standard Deviationof the Electroencephalogram Signal and the Changesof the RR Interval of Electrocardiogram

Objectives@#ZZIn electroconvulsive therapy (ECT) research and practice, the precise determination of seizure duration is importantin the evaluation of clinical relevance of the ECT-induced seizure. In this study, we have developed computerized algorithms to assessthe duration of ECT-induced seizure. @*Methods@#ZZSubjects included 5 males and 6 females, with the mean age of 33.1 years. Total 55 ECT sessions were included in theanalysis. We analyzed the standard deviation of a finite block of electroencephalography (EEG) data and the change in the local slope ofRR intervals in electrocardiography (ECG) signals during ECT-induced seizure. And then, we compared the calculated seizure durationsfrom EEG recording (EEG algorithm) and ECG recording (ECG algorithm) with values determined by consensus of clinicians basedon the recorded EEG (EEG consensus), as a gold standard criterion, in order to testify the computational validity of our algorithms. @*Results@#ZZThe mean seizure durations calculated by each method were not significantly different in sessions with abrupt flattenedpostictal suppression and in sessions with non-abrupt flattened postictal suppression. The intraclass correlation coefficients (95% confidenceinterval) of the three methods (EEG algorithm, ECG algorithm, EEG consensus) were significant in the total sessions [0.79(0.70–0.86)], the abrupt flattened postictal suppression sessions [0.84 (0.74–0.91)], and the non-abrupt flattened postictal suppressionsessions [0.67 (0.45–0.84)]. Correlations between three methods were also statistically significant, regardless of abruptness of transition. @*Conclusions@#ZZOur proposed algorithms could reliably measure the duration of ECT-induced seizure, even in sessions with nonabrupttransitions to flat postictal suppression, in which it is typically difficult to determine the seizure duration.

The Electroconvulsive Therapy in the Prevention of Suicide Risks and Attempts

Suicidality is the most serious complication of mood disorders and psychosis; effective treatment should reduce suicide rates. The Organization for Economic Cooperation and Development age-standardized suicide rate in Korea was 22.6 in 2018, much higher compared to other countries worldwide. As mental and psychiatric problems are the main reasons for suicide attempts, accounting for 31.6% in 2018, targeting such problems should be the focus of efforts to reduce suicide rates. However, the ability of current pharmacotherapeutic and psychotherapeutic interventions to reduce suicide rates is limited due to their delayed effects. Therefore, electroconvulsive therapy (ECT) has been proposed as an alternative treatment. This approach is effective for treating most mental disorders associated with high suicide rates, including severe depression, bipolar disorder, and intractable psychotic disorders; ECT is also effective for Parkinson’s disease, which has the highest suicide rate among all disorders in Korea. The acute, long-term, and prophylactic effects of ECT on suicidality have been reported in the literature, and treatment guidelines outside of Korea recommend that ECT be used at an early stage for rapid reduction of suicide rates, as opposed to being applied as a treatment of last resort. However, only ~0.092 of every 10000 members of the Korean general population received ECT in 2018; this is much lower than the average rate worldwide, of 2.2 per 10000. Elimination of obstacles to the use of ECT, early crisis intervention involving administration of ECT for rapid stabilization, and maintenance ECT to prevent recurrence should reduce suicide rates.

Electroconvulsive Therapy for Psychiatric Disorders in Elderly Adults

Electroconvulsive therapy (ECT) is indicated for various mental disorders (e.g., major depressive disorder, schizophrenia, and bipolar disorder) and the behavioral and psychological symptoms of dementia in elderly patients. Furthermore, ECT is a useful first-line treatment in emergency and crisis situations such as suicide risk, violent behavior, catatonia, and food refusal, which are more frequent in elderly patients. ECT is also effective in the treatment of the motor symptoms of neurological disorders, such as Parkinson’s disease and Huntington’s disease. Due to the high risk of various physical diseases, the comorbid physical conditions of elderly patients should be individually controlled to optimize ECT treatment. Compared to young adults, in elderly patients the seizure threshold is higher, the seizure duration is shorter, and the anesthetic dose is lower. On the contrary, the response rate in the elderly is both faster and higher. Considering potential cognitive decline and the prevention of further deterioration of cognitive function in elderly patients, in the absence of significant comorbidities, twice weekly sessions and right unilateral electrode placement with a lower seizure threshold and less cognitive effect are preferred to bilateral electrode placement, which has a high risk of adverse cognitive effects. After an acute course of ECT, continuation and maintenance of ECT, combined with prescription of therapeutic drugs, may prevent possible relapse or recurrence of mental disorders. In conclusion, ECT can be used to treat mental disorders in elderly adults, with safety and effectiveness comparable to that in young adults.

The Determination of the Duration of ElectroconvulsiveTherapy-Induced Seizure Using Local Standard Deviationof the Electroencephalogram Signal and the Changesof the RR Interval of Electrocardiogram

Objectives@#ZZIn electroconvulsive therapy (ECT) research and practice, the precise determination of seizure duration is importantin the evaluation of clinical relevance of the ECT-induced seizure. In this study, we have developed computerized algorithms to assessthe duration of ECT-induced seizure. @*Methods@#ZZSubjects included 5 males and 6 females, with the mean age of 33.1 years. Total 55 ECT sessions were included in theanalysis. We analyzed the standard deviation of a finite block of electroencephalography (EEG) data and the change in the local slope ofRR intervals in electrocardiography (ECG) signals during ECT-induced seizure. And then, we compared the calculated seizure durationsfrom EEG recording (EEG algorithm) and ECG recording (ECG algorithm) with values determined by consensus of clinicians basedon the recorded EEG (EEG consensus), as a gold standard criterion, in order to testify the computational validity of our algorithms. @*Results@#ZZThe mean seizure durations calculated by each method were not significantly different in sessions with abrupt flattenedpostictal suppression and in sessions with non-abrupt flattened postictal suppression. The intraclass correlation coefficients (95% confidenceinterval) of the three methods (EEG algorithm, ECG algorithm, EEG consensus) were significant in the total sessions [0.79(0.70–0.86)], the abrupt flattened postictal suppression sessions [0.84 (0.74–0.91)], and the non-abrupt flattened postictal suppressionsessions [0.67 (0.45–0.84)]. Correlations between three methods were also statistically significant, regardless of abruptness of transition. @*Conclusions@#ZZOur proposed algorithms could reliably measure the duration of ECT-induced seizure, even in sessions with nonabrupttransitions to flat postictal suppression, in which it is typically difficult to determine the seizure duration.