Response of depression to electroconvulsive therapy: a meta-analysis of clinical predictors.

OBJECTIVE: Roughly one-third of individuals with depression do not respond to electroconvulsive therapy (ECT). Reliable predictors of ECT response would be useful for patient selection, but have not been demonstrated definitively. We used meta-analysis to measure effect sizes for a series of clinical predictors of ECT response in depression. DATA SOURCES: PubMed was searched systematically to identify studies published after 1980 that tested at least 1 clinical predictor of response to ECT. STUDY SELECTION: Of 51 studies identified, 32 were compatible with meta-analysis. DATA EXTRACTION: The weighted mean odds ratio (OR) or standardized mean difference (SMD) was computed for each of 10 clinical predictors, based on dichotomous outcomes (responder vs nonresponder). Statistical analyses examined robustness, bias, and heterogeneity. RESULTS: Shorter depressive episode duration predicted higher ECT response rate (SMD = -0.37, 7 studies, 702 subjects, P = 4 × 10(-6)). History of medication failure in the current episode was also a robust predictor: response rates were 58% and 70%, respectively, for those with and without medication failure (OR = 0.56, 11 studies, 1,175 subjects, P = 1 × 10(-5)). Greater age and psychotic features were weakly associated with higher ECT response rates, but heterogeneity was notable. Bipolar diagnosis, sex, age at onset, and number of previous episodes were not significant predictors. Analyses of symptom severity and melancholic features were inconclusive due to study heterogeneity. CONCLUSIONS: Longer depressive episodes and medication failure at baseline are robust predictors of poor response to ECT, with effect sizes that are modest but clinically relevant. Patient characteristics used traditionally such as age, psychosis, and melancholic features are less likely to be clinically useful. More robust clinical and biological predictors are needed for management of depressed patients considering ECT.

A case of cerebellar psychopathology.

BACKGROUND: Pathology of the cerebellum has traditionally been associated with motor symptoms, vertigo, and nystagmus. Patients with cerebellar disorders do not usually receive psychiatric evaluations. OBJECTIVE: The authors seek to alert clinicians to the association between cerebellar disease and psychiatric symptoms. METHOD: The authors describe a patient with uncommon psychiatric morbidity associated with cerebellar dysfunction, and provide a brief review of previous research on this phenomenon. RESULTS: Neurology consultants suggested that physical exam findings and behavioral changes could be accounted for by cerebellar cognitive affective syndrome. This syndrome involves dysfunction of the cerebellum, including classic cerebellar findings, in addition to cognitive difficulties and affective/personality changes. CONCLUSION: The suspected etiology was post-infectious cerebellitis from Epstein-Barr virus infection.

Clinical equivalence of generic clozapine.

OBJECTIVE: To determine if mental health service utilization increases when patients are converted to generic clozapine. METHOD: About 125 patients taking clozapine in a community mental health clinic were switched from Novartis Clozaril to generic clozapine (Mylan Pharmaceuticals). Serum clozapine levels were obtained 2 weeks before, and 2 weeks after, the switch to generic clozapine. The number of outpatient visits, emergency room visits, and hospitalizations in the year prior to the switch were compared to those in the year following the switch, to determine service utilization. RESULTS: Psychiatric emergency room visits decreased, but clozapine serum levels, inpatient hospital days, partial hospital admissions, and outpatient psychiatrist visits did not change after the switch to generic clozapine. CONCLUSIONS: There were no significant increases in mental health service utilization after the conversion to Mylan generic clozapine. The switch to Mylan generic clozapine was cost effective, as the reduction in pharmacy costs was not offset by increased utilization costs.

A survey of psychiatrists' attitudes toward treatment guidelines.

We developed a survey to look at psychiatrists' attitudes toward psychotropic prescribing guidelines, specifically the Texas Medication Algorithm Project (TMAP) algorithms. The 22-page survey was distributed to 24 psychiatrists working in 4 CMHC's; 13 completed the survey. 90% agreed that guidelines should be general and flexible. The majority also agreed that guidelines should define how to measure response to a specific agent; fewer agreed guidelines should specify dosage, side effect management, or augmentation strategies. Psychiatrists were familiar with TMAP; none referred to it in their practice. In spite of this, psychiatrists' medication preferences were similar to those suggested by guidelines.

Assessing conformance to medication treatment guidelines for schizophrenia in a community mental health center (CMHC).

The feasibility of implementing current medication treatment guidelines in a community mental health clinic was examined in this cross-sectional and retrospective study. Specifically, two issues were addressed: 1) could we identify a set of clinical guidelines whose utilization could be monitored with a routine medical chart review; and 2) were the requisite data for such a review available in the medical records. An examination of three sets of published guidelines revealed 5 specific guidelines that could be operationalized and monitored. Records were reviewed for a random sample of two-thirds of all patients currently diagnosed with schizophrenia and schizoaffective disorder (n = 309). Information was collected from the medical record on patient demographics, diagnosis, duration of illness, symptoms and side effects, and medication information. Rates of conformance to the 5 guidelines ranged from a high of 97% to a low of 43%. The use of current guidelines to improve treatment in community clinics appears to be limited by the deficiencies in the medical record and the structure of the guidelines themselves. Standardized progress notes and computerized prescribing programs will improve conformance, and permit the rapid and accurate assessment of conformance to guidelines in community clinics.