ABSTRACT
BACKGROUND: Electroconvulsive therapy (ECT) is a highly effective, yet still controversial therapy for both the general public and psychiatrists. In this study, we investigated the patients' view regarding effectiveness and tolerability of electroconvulsive therapy under consideration of individual clinical response. MATERIAL AND METHODS: In 31 patients with major depression, subjective effectiveness and tolerability were assessed via a differentiated questionnaire prior to, during, and after ECT. Symptoms were rated using the Montgomery-Åsberg depression rating scale (MADRS) and the Beck depression inventory II (BDIII) RESULTS: Patients assessed ECT to be generally effective both before and after the treatment. This view was independent of their individual treatment success. In contrast, patients' rating of individual effectiveness depended on the objective improvement of their symptoms. Side effects were rated to be generally slight to moderate. CONCLUSION: Against the background of persisting criticism towards ECT, the viewpoint of involved patients provides us with important references for an appropriate judgement of this therapy. The results suggest a good benefit-risk ratio for ECT from the patients' perspective.
ABSTRACT
Background: Electroconvulsive therapy (ECT) is a highly effective, yet still controversial therapy for both the general public and psychiatrists. In this study, we investigated the patients' view regarding effectiveness and tolerability of electroconvulsive therapy under consideration of individual clinical response. Material and Methods: In 31 patients with major depression, subjective effectiveness and tolerability were assessed via a differentiated questionnaire prior to, during, and after ECT. Symptoms were rated using the Montgomery-Åsberg depression rating scale (MADRS) and the Beck depression inventory II (BDI-II). Results: Patients assessed ECT to be generally effective both before and after the treatment. This view was independent of their individual treatment success. In contrast, patients' rating of individual effectiveness depended on the objective improvement of their symptoms. Side effects were rated to be generally slight to moderate. Conclusion: Against the background of persisting criticism towards ECT, the viewpoint of involved patients provides us with important references for an appropriate judgement of this therapy. The results suggest a good benefit-risk ratio for ECT from the patients' perspective.
Subject(s)
Depressive Disorder, Major , Electroconvulsive Therapy , Depressive Disorder, Major/therapy , Electroconvulsive Therapy/standards , Humans , Patient Satisfaction , Psychiatric Status Rating Scales , Surveys and Questionnaires , Treatment OutcomeABSTRACT
BACKGROUND: Severe affective and psychotic disorders may be accompanied by legal incapacity. If in this case the patient refuses treatment and in parallel there is a risk of serious damage to health, treatment can be carried out against the patient's non-autonomous will under defined prerequisites. Due to its good and partly superior effectiveness in the treatment of severe and pharmacotherapy-resistant affective and psychotic disorders, electroconvulsive therapy (ECT) is an important treatment option in such constellations. AIM: Description of the general principles and prerequisites of therapeutic measures against the patient's will. METHODS: Based on a case report, the application of ECT as a medical measure against the patient's will is discussed and assessed in an interdisciplinary approach from clinical, legal, and ethical perspectives. RESULTS AND DISCUSSION: The (empirical) evidence on the general effectiveness of ECT, as well as its application against the will of patients with legal incapacity, clearly shows a positive benefit-risk ratio. When performed against the patient's will, ECT as all compulsory medical interventions, represents a severe encroachment on the individual's fundamental rights of both physical integrity and self-determination. Nevertheless, its application may be medically indicated, legally admissible and ethically appropriate in individual cases to prevent the threat of serious damage to the patient's health. Ethical and legal prerequisites of treatment against the patient's will should be evaluated by a multiprofessional team and the patient's legal guardian should be involved from an early stage.
Subject(s)
Bipolar Disorder/therapy , Depressive Disorder, Treatment-Resistant/therapy , Electroconvulsive Therapy/legislation & jurisprudence , Informed Consent/legislation & jurisprudence , Personal Autonomy , Psychotic Disorders/therapy , Treatment Refusal/legislation & jurisprudence , Bipolar Disorder/psychology , Depressive Disorder, Treatment-Resistant/psychology , Electroconvulsive Therapy/ethics , Electroconvulsive Therapy/psychology , Ethics, Medical , Germany , Humans , Informed Consent/psychology , Interdisciplinary Communication , Intersectoral Collaboration , Legal Guardians/legislation & jurisprudence , Male , Mental Competency/legislation & jurisprudence , Middle Aged , Psychotic Disorders/psychology , Suicide, Attempted/legislation & jurisprudence , Suicide, Attempted/psychology , Third-Party Consent/legislation & jurisprudence , Treatment Refusal/psychologyABSTRACT
BACKGROUND: Electroconvulsive therapy (ECT) is a potent and successful method for the treatment of severe psychiatric disorders. Severe depressive and psychotic disorders may lead to legal incapacity and inability to consent. In Germany, administration of ECT against the patient's will is feasible under certain constellations and is regulated under the terms of the guardianship law. OBJECTIVE: This article outlines the prevalence, effectiveness and tolerability of ECT when applied in nonconsenting patients. MATERIAL AND METHODS: Case report and literature review. RESULTS: The literature on ECT as a treatment in nonconsenting patients is relatively sparse. In 2008 the prevalence in Germany was less than 0.5 % of all patients receiving ECT. Case reports and case series suggest a good and equal level of effectiveness when compared to consenting patients. In the course of treatment the majority of patients consented to receive further ECT and retrospectively judged ECT as helpful. CONCLUSION: The use of ECT is a highly effective treatment in severe psychiatric disorders even when administered as treatment in nonconsenting patients. It can be lifesaving and lead to a rapid improvement of symptoms and relief from severe suffering also from the patients' perspective. Thus, it seems unethical not to consider ECT as a treatment against the nonautonomous will of legally incompetent patients in individual cases. Nevertheless, physicians should always seek to obtain the patients' consent as soon as possible for both legal and ethical reasons.
Subject(s)
Electroconvulsive Therapy/legislation & jurisprudence , Electroconvulsive Therapy/methods , Informed Consent/legislation & jurisprudence , Legal Guardians/legislation & jurisprudence , Psychotic Disorders/therapy , Third-Party Consent/legislation & jurisprudence , Adult , Electroconvulsive Therapy/ethics , Evidence-Based Medicine , Female , Germany , Humans , Informed Consent/ethics , Mental Competency , Psychotic Disorders/diagnosis , Risk Factors , Third-Party Consent/ethics , Treatment OutcomeABSTRACT
The profile of brain structural abnormalities in schizophrenia is still not fully understood, despite decades of research using brain scans. To validate a prospective meta-analysis approach to analyzing multicenter neuroimaging data, we analyzed brain MRI scans from 2028 schizophrenia patients and 2540 healthy controls, assessed with standardized methods at 15 centers worldwide. We identified subcortical brain volumes that differentiated patients from controls, and ranked them according to their effect sizes. Compared with healthy controls, patients with schizophrenia had smaller hippocampus (Cohen's d=-0.46), amygdala (d=-0.31), thalamus (d=-0.31), accumbens (d=-0.25) and intracranial volumes (d=-0.12), as well as larger pallidum (d=0.21) and lateral ventricle volumes (d=0.37). Putamen and pallidum volume augmentations were positively associated with duration of illness and hippocampal deficits scaled with the proportion of unmedicated patients. Worldwide cooperative analyses of brain imaging data support a profile of subcortical abnormalities in schizophrenia, which is consistent with that based on traditional meta-analytic approaches. This first ENIGMA Schizophrenia Working Group study validates that collaborative data analyses can readily be used across brain phenotypes and disorders and encourages analysis and data sharing efforts to further our understanding of severe mental illness.
Subject(s)
Brain/pathology , Schizophrenia/pathology , Adult , Brain/diagnostic imaging , Brain Mapping , Case-Control Studies , Female , Functional Laterality , Humans , Image Processing, Computer-Assisted , Longitudinal Studies , Magnetic Resonance Imaging , Male , Middle Aged , Neuroimaging , Prospective Studies , Schizophrenia/geneticsABSTRACT
BACKGROUND: Depressive disorders are common and lead to both individual suffering and high socioeconomic costs. Despite the fact that several effective therapies are available, remission is often not achieved. Electroconvulsive therapy (ECT) can be a therapeutic option in these cases. OBJECTIVES: This review outlines the current evidence for the efficacy, safety and tolerability of ECT for depressive disorders. MATERIAL AND METHODS: A selective literature search was carried out with particular consideration of meta-analyses, systematic reviews, and recommendations of national and international therapy guidelines. RESULTS: For the majority of patients ECT is an effective, safe and well-tolerated therapy for the treatment of depressive disorders. There are relatively high remission rates even in patients with pharmacoresistant depression. There is evidence for a particularly high responsiveness in specific populations. In contrast to the proven effectiveness in the acute treatment of depressive disorders, there is a relative lack of data concerning maintenance therapy. Side effects including cognitive deficits are mostly transient. Modifications in the ECT technique have an impact on effectiveness and tolerability. CONCLUSION: When administered correctly ECT is a highly effective therapy for the treatment of depressive disorders. In the light of the abundance of depressive disorders and lack of remission despite adequate pharmacological treatment, a broader availability and application of ECT would be desirable. The same is true for a more intensive research into the mechanisms of action and response predictors of ECT.
Subject(s)
Cognition Disorders/etiology , Depressive Disorder, Major/therapy , Electroconvulsive Therapy/adverse effects , Electroconvulsive Therapy/methods , Headache/etiology , Cognition Disorders/prevention & control , Depressive Disorder, Major/diagnosis , Evidence-Based Medicine , Headache/prevention & control , Humans , Patient Selection , Treatment OutcomeABSTRACT
The diacylglycerol kinase eta (DGKH) gene, first identified in a genome-wide association study, is one of the few replicated risk genes of bipolar affective disorder (BD). Following initial positive studies, it not only was found to be associated with BD but also implicated in the etiology of other psychiatric disorders featuring affective symptoms, rendering DGKH a cross-disorder risk gene. However, the (patho-)physiological role of the encoded enzyme is still elusive. In the present study, we investigated primarily the influence of a risk haplotype on amygdala volume in patients suffering from schizophrenia or BD as well as healthy controls and four single nucleotide polymorphisms conveying risk. There was a significant association of the DGKH risk haplotype with increased amygdala volume in BD, but not in schizophrenia or healthy controls. These findings add to the notion of a role of DGKH in the pathogenesis of BD.
