Factors Associated With Postictal Agitation After Electroconvulsive Therapy.

OBJECTIVE: This study investigated the occurrence of postictal agitation (PA) in patients undergoing an acute series of electroconvulsive therapy (ECT) and further explored patient and treatment variables associated with PA. METHODS: Charts were retrospectively searched for patients undergoing an acute series of ECT. Postictal agitation was identified by the administration of a sedative after ECT. Demographic, diagnostic, medication, and ECT variables that could also be associated with PA were collected and accounted for in statistical analysis. RESULTS: In this population, 22 of 156 patients experienced PA. Associations that reached statistical significance included sex, weight, active substance use disorder, seizure duration (as observed by motor movements), and waking time. Only seizure duration and waking time maintained significance after multivariable analysis. CONCLUSIONS: These data identify clinical factors that could help predict PA. Patients with greater weight, male sex, or an active substance use disorder ought to be carefully monitored for PA, and staff in the recovery suite should be especially vigilant about such patients with longer seizures and waking times.

Effectiveness of Electroconvulsive Therapy in Patients With Major Depressive Disorder and Comorbid Borderline Personality Disorder.

OBJECTIVE: Previous research suggests that electroconvulsive therapy (ECT)-the criterion standard for the treatment of severe depression-is not as effective when the patient has comorbid borderline personality disorder (BPD). The ECT outcomes of patients with and without BPD were compared in a retrospective chart review to test this claim. METHODS: We enrolled 137 patients with a diagnosis of major depressive disorder who completed the McLean Screening Instrument for Borderline Personality Disorder. Twenty-nine patients had positive screening scores for BPD. The difference in Patient Health Questionnaire (PHQ-9) scores before and after ECT was compared between patients with and without BPD. Follow-up PHQ-9 scores determined after treatment were collected and analyzed. RESULTS: Electroconvulsive therapy equally improved symptoms of depression as measured by PHQ-9 score in both patients who screened positive and patients who screened negative for BPD. No difference in the increase in PHQ-9 scores between these 2 groups was noted 1 month after treatment (P = 0.19). CONCLUSIONS: These data showed that a positive BPD screen does not necessarily predict a poorer response to ECT, nor does it predict greater symptom recurrence after ECT. This does not suggest that ECT is necessarily an appropriate treatment for major depressive disorder in patients with a comorbid BPD, given the limitations of screening instruments.

Decreasing Treatment Duration of Electroconvulsive Therapy (ECT) Using Daily Right Unilateral Ultrabrief Instead of Bitemporal ECT.

OBJECTIVE: Electroconvulsive therapy (ECT) is an effective treatment for depression, but the standard 2 to 3 times weekly treatment course results in a total treatment duration of >2 weeks. We explored the viability of decreasing treatment duration by using daily right unilateral ultrabrief (RULUB) ECT instead of standard bitemporal (BT) ECT. METHODS: This study involved a retrospective review of records of inpatients 18 to 64 years of age who were treated between 2012 and 2017 at a large tertiary ECT center. Lead placement/technique, treatment duration (days from first to last ECT), number of ECT treatments, and scores on the Patient Health Questionnaire-9 (PHQ-9), and the Hamilton Depression Rating Scale (HamD-24) were collected. Statistical analysis was performed using 1-way analysis of variance and t tests. RESULTS: Of 214 patients, 112 started daily RULUB ECT (86 were completers and 26 were eventually switched to BT), and 83 started and completed BT ECT. Daily RULUB completers finished their course of ECT 6.5 days faster than those who received BT ECT (11.7 vs. 18.2 d, P<0.0001), while the number of ECT treatments did not significantly differ between the 2 groups (daily RULUB 8.6 treatments vs. BT 8.3 treatments, P=0.4402). There were no significant differences in the final PHQ-9 or HamD-24 depression scores between the 2 groups. One case of significant cognitive impairment was observed in the daily RULUB group. CONCLUSIONS: Daily RULUB ECT compared with BT ECT allowed depression to be treated faster and with similar efficacy. Randomized controlled trials, which include the use of formal cognitive and physical side effect measures, are needed to further explore the viability of daily RULUB ECT.

Petitioning for Involuntary Commitment for Chemical Dependency by Medical Services.

Patients who have chemical dependency (CD) are commonly encountered on medical and surgical wards, often for illnesses and injuries sustained as a direct result of their substance abuse. When these patients are repeatedly admitted to the hospital in certain states that provide a legal framework to commit chemically dependent persons to a treatment facility, clinicians often wonder whether they should initiate that process. Should consulting psychiatrists choose to initiate the commitment process, they put into motion a resource-intensive, time-consuming mechanism, with uncertain outcomes, both in the courtroom and at the bedside. Petitioning for involuntary commitment to chemical dependency treatment of a patient from medical and surgical services is poorly understood. In this study, we examined a series of patients for whom petitions for judicial commitment in the state of Minnesota were entered over a 12-month period, and evaluated the likelihood of commitment to treatment, the demographics of patients involved, and the outcomes for this series of patients. Three vignettes are presented to illustrate the severity of these patients' illnesses and potential outcomes of the process. We further describe potential limitations of the commitment system and alternatives to CD commitment that could be explored further.

The PRIDE Study and the Conduct of Electroconvulsive Therapy: Questions Answered and Unanswered.

The recently published PRIDE study (prolonging remission in the depressed elderly) constitutes an important contribution to electroconvulsive therapy (ECT) technique, from the standpoint of both the index course to treat depressive symptoms and the post-remission continuation period to prevent relapse. This study was probably the last large, National Institute of Mental Health-funded, multisite ECT technical study for some time to come, so extracting clinically relevant recommendations is worthwhile. In this commentary, the author discusses evidence from this trial relevant to several important clinical index and continuation ECT technical issues and elaborates several unanswered questions deserving further consideration.

Continuation phase intravenous ketamine in adults with treatment-resistant depression.

BACKGROUND: Little is known about the antidepressive effects of repeated intravenous ketamine infusions beyond the acute phase of treatment in patients with refractory depression. METHODS: Twelve subjects with treatment-resistant non-psychotic unipolar or bipolar major depression and suicidal ideation were given repeated (up to 6) thrice-weekly acute-phase intravenous infusions of ketamine (0.5mg/kg, administered over 100min). Those who remitted during acute-phase treatment received continuation-phase treatment that consisted of 4 weekly ketamine infusions, followed by 4 weeks of post-continuation phase follow-up (during which no further ketamine infusions were administered). Clinical measures were assessed at baseline, at 24h following each infusion, at the last acute-phase observation, and during continuation and post-continuation follow-up (acute phase remitters only). RESULTS: Of the 12 enrollees, 5 (41.7%) remitted and 7 (58.3%) responded to ketamine treatment during the acute-phase. All five subjects who remitted during the acute-phase experienced further depressive symptom improvement during continuation-phase treatment. Four subjects lost remission status during the post-continuation phase, but all were still classified as positive treatment responders at the end of the post-continuation phase. Adverse effects were generally mild and transient during acute- and continuation-phase treatment; however, one subject developed behavioral outbursts and suicide threats during follow-up while hospitalized, and one subject died by suicide several weeks after the end of follow-up. LIMITATIONS: This was an uncontrolled feasibility study with a small sample size. CONCLUSIONS: The continuation-phase administration of ketamine at weekly intervals to patients with treatment-resistant depression who remitted during acute-phase ketamine treatment can extend the duration of depressive symptom remission. The antidepressive effect of ketamine persisted for several weeks after the end of continuation-phase treatment. Our results highlight the need for close monitoring of subjects who are at high baseline risk for suicide but do not respond clinically to ketamine. CLINICALTRIALS. GOV IDENTIFIER: NCT02094898.

Mirtazapine for Symptomatic Relief on a Psychiatric Consultation Service: A Case Series.

BACKGROUND: With a complex pharmacologic profile, mirtazapine may promote sleep, stimulate appetite, improve nausea, and reduce pain. Some practitioners working on the Mayo Clinic inpatient psychiatric consultation/liaison service have recommended mirtazapine in medically ill patients with or without formal psychiatric comorbidity to target these symptoms. OBJECTIVE: To assess the success of this practice, we conducted a retrospective chart review covering a 4.5-year period. METHODS: For patients recommended to start mirtazapine, global improvement in specific symptoms and suspected side effects were recorded. RESULTS: During the study period, 528 medically ill patients started mirtazapine following a recommendation from the psychiatric consultation service. In total, 475 patients were provided mirtazapine to specifically target sleep, nausea, pain, or appetite. There was documented improvement in these symptoms for 37.7%, 37.0%, 36.4%, and 23.5% of the patients, respectively. These rates of improvement are conservative for the 229 patients without documented response, i.e., 48% of the patients who were given the medication for a somatic symptom were counted as having no improvement. Commonly documented adverse effects were daytime sedation (5.3%), worsening mental status (2.3%), and nightmares (1%). CONCLUSIONS: Despite the limitations of this retrospective, qualitative study, these data confirm that mirtazapine is generally well tolerated and can provide at least short-term relief of certain symptoms in medically ill patients. Controlled trials are needed to assess these benefits more systematically, and it is not clear how long mirtazapine should be used for these symptoms.

Has psychiatry tamed the "ketamine tiger?" Considerations on its use for depression and anxiety.

Ketamine has been available for approximately 50 years as an anesthetic agent. It is known to have potent effects on the central nervous system glutamatergic system, in particular blockade of N-methyl-D-aspartate (NMDA) receptors. Based upon pre-clinical evidence of involvement of the glutamatergic system in mood disorders, studies have been undertaken to test the antidepressant properties of ketamine. Several well-controlled studies, along with open-label case series, have established that ketamine can have rapid antidepressant effects. Additionally, data exist showing benefits of ketamine in post-traumatic stress disorder as well as obsessive compulsive disorder. However, improvements in these conditions tend to be short-lived with single infusions of ketamine. Of concern, ketamine has been associated with neurotoxicity in pre-clinical rodent models and is well-known to cause psychotomimetic effects and addiction in humans. While ketamine has been proven safe for use in sub-anesthetic doses administered once or a few times, the safety profile of prolonged use has not been established. Aspects of safety, possible mechanisms of action, and future directions of ketamine research are discussed in addition to the clinical literature on its use in psychiatric conditions.

An Open-Label, Pilot Study of Daily Right Unilateral Ultrabrief Pulse Electroconvulsive Therapy.

Right unilateral ultrabrief (RUL-UB) pulse width electroconvulsive therapy (ECT) has attracted much research attention recently due to its smaller effect on memory than is associated with other forms of ECT, such as bitemporal placement or unilateral standard pulse width. However, RUL-UB has demonstrated slower antidepressant efficacy in comparison to the other techniques. One method to enhance the speed of response to RUL-UB ECT is administration of 5 times a week (termed "daily") treatments as opposed to the more standard twice or thrice weekly schedule. In this open label study, we treated 20 depressed patients with daily RUL-UB treatments for up to 2 weeks (ie, 10 treatments) using standardized assessments of depression and retrograde amnesia. Response and remission rates were commensurate with those reported in other recent studies using this technique with twice or thrice weekly treatment frequencies, and there was no clinically significant effect on retrograde memory function. We conclude that daily administration of RUL-UB ECT may shorten the duration of the course of ECT treatments without compromising cognition. A randomized trial comparing this technique to a thrice weekly schedule of RUL-UB treatments is indicated.

What Type of Cognitive Testing Should Be Part of Routine Electroconvulsive Therapy Practice?

Several decades of research have yielded much information on the cognitive effects of electroconvulsive therapy (ECT) and have informed ECT technical factors such as electrode placement, stimulus dosing, and stimulus parameters. However, the question of what type of cognitive testing should be part of routine ECT practice has not been definitively clarified. The author reviews the recommendations, or lack thereof, in several published ECT guidelines and discusses the purposes that cognitive testing during ECT should serve and difficulties that most ECT services would encounter with intensive testing schedules. Practical utility of formal cognitive testing during and after ECT has not been satisfactorily demonstrated in ECT research. In addition, several key aspects of testing, such as cognitive domain to be tested, specific tests to be used, personnel to do the testing, time points of testing, and exactly how the test results will be interpreted and used have yet to be determined with precision. It is suggested that research efforts be undertaken to address these large gaps in ECT practice.

Clinical Challenges in Maintenance Electroconvulsive Therapy for Older Patients With Medical Comorbidity.

As patients receiving maintenance electroconvulsive therapy (MECT) age, many will acquire medical illnesses that may complicate their course of ECT and the treatment of their underlying psychiatric conditions. In this study, we present 7 cases of patients receiving MECT whose medical illnesses resulted in clinical reassessment of whether or not MECT should be continued. We discuss clinical implications and considerations for treating medically ill patients with MECT.

Thiothixene in the Management of Delirium: A Case Series.

BACKGROUND: Pharmacologic strategies are often required to help manage agitated patients with delirium. First-and second-generation antipsychotic medications (such as haloperidol, quetiapine, and olanzapine) are commonly used. OBJECTIVE: On the psychiatric consultation service in our hospital, thiothixene has been used based on its favorable potency, sedative, and cost profiles. Little has been written about the utility of this drug for management of delirium. METHODS: We reviewed our experience with thiothixene in this setting using pharmacy records to identify patients who received at least 1 dose between July 2011 and March 2014. We scrutinized the relevant medical records (n = 111) and recorded the following data: age, sex, medical diagnoses, signs and symptoms of delirium, dosing of thiothixene, and response to thiothixene in terms of both apparent benefit as well as side effects. RESULTS: Resolution or improvement was documented in 78% of patients and good tolerability in 82% of patients. CONCLUSIONS: Although further data from a randomized, controlled trial would be ideal, our experience suggests that thiothixene could be a safe and effective pharmacologic treatment for agitation and psychosis due to delirium.