Ventricular tachycardia with ECT.

A case is presented in which a patient with ischemic heart disease developed episodic, nonsustained ventricular tachycardia (VT) during electroconvulsive therapy for major depression. The VT had a frequency of 200 beats/min and ceased spontaneously after 17 s. Altered autonomic discharge in the presence of ischemia is the probable cause. Predisposing factors, as well as management considerations, are discussed.

ECT in acute delirium and related clinical states.

A retrospective investigation of electroconvulsive therapy (ECT)-treated patients in 1992-94 at the Psychiatric Hospital in Aarhus, Denmark showed that en bloc treatment had been given in 39 cases of 420 patient series. The basic diagnoses (according to ICD-10) were severe depressive disorder, bipolar affective disorder mixed state, manic disorder, acute transient psychotic disorder, schizoaffective disorder, and schizophrenia; all patients were in a severely psychotic condition. Eight patients were diagnosed with acute delirium. Delirious symptoms disappeared completely after the first few ECT treatments. Patients were subsequently given supplementary treatment for the underlying disease. ECT is an effective treatment for psychoses complicated by acute delirium.

Electroconvulsive therapy in the Nordic countries, 1977-1987.

In 1977 a questionnaire was sent to all psychiatric departments in the Nordic countries: Sweden, Norway, Denmark, Finland and Iceland, concerning indications for electroconvulsive therapy (ECT) and the use of unilateral and bilateral treatment, respectively. The inquiry was repeated in 1987 and the answers compared with those obtained in 1977. In addition, the answers from Denmark were compared with previously performed inquiries. The use of exclusively unilateral treatment (U) and of both unilateral and bilateral treatment (UB) has increased in most of the countries and exclusively bilateral treatment (B) has decreased drastically. In Denmark the situation has not changed for ECT in endogenous depression and acute delirium, and the use in reactive psychosis, mania and schizophrenia decreased somewhat during the 1970s and then again stabilized or increased during the 1980s. Nearly all departments in the Nordic countries used ECT in endogenous depression in 1977 and were still doing it in 1987. In mania, about 50% of all departments have found ECT indicated occasionally or exceptionally both in 1977 and 1987. Manic-depressive mixed states have been regarded as an indication in somewhat more than two thirds of departments, increasing during the period. The use of ECT in schizophrenia has been rare and somewhat decreasing, but still about half of the departments apply it once in a while. In reactive psychosis the use of ECT decreased slightly, but in 1987 it was still in use for this indication in about 50% of all departments. In acute delirium there has been an overall increase in the use of ECT.(ABSTRACT TRUNCATED AT 250 WORDS)

The combination of lithium and carbamazepine in treatment and prevention of manic-depressive disorder: a review and a case report.

The action of carbamazepine (CZP) is similar to that of lithium with regard to therapeutic effect towards mania; in addition, it has a certain effect towards endogenous depression. Furthermore, CZP has a prophylactic effect towards manic-depressive mood swings, although probably not as expressed as that of lithium. In some cases, especially in rapid-cyclers, neither CZP nor lithium have this effect when applied separately, whereas the combination of the two drugs is effective in some cases. A review of the relevant literature, as well as an illustrative case history, is presented.

Zuclopenthixol and perphenazine in patients with acute psychotic states. A double-blind multicentre study.

Fifty-four patients with acute psychotic states were included in a double-blind multicentre study of zuclopenthixol and perphenazine given orally. Fourteen patients had not received test preparations for a minimum of 3 weeks as stated in the protocol, and were excluded. The remaining 40 patients received the test preparations for 3 to 12 weeks, with an average of 49 days for patients receiving zuclopenthixol and 45 days for patients receiving perphenazine. Clinical evaluations were done at baseline and at weeks 1, 2, 4, 6, 8, and 12 including the CGI, a CPRS subscale for schizophrenia, and the UKU Side Effects Rating Scale. The patients received on average 37 mg zuclopenthixol or 30 mg perphenazine daily. Statistically, significant reductions on the CGI, severity of illness, and on the CPRS (total score) were found for both drugs when comparing baseline with later scores. No significant differences between the drugs were found. It was also impossible to demonstrate a difference in clinical profile between the two drugs on the basis of the single items on the CPRS. Although small differences between the two drugs were found, as regards number and type of side effects, it is concluded that the pattern of side effects was almost identical in the two treatment groups.

Carbamazepine in treatment and prophylaxis of manic-depressive disorder.

The review presents 23 studies on the action of carbamazepine (CZP) in manic-depressive disorder, some of these studies being double-blind investigations, others open investigations and some anecdotal reports. Surveys of therapeutic as well as prophylactic effects in manias and depressions are presented. There seems to be a definite antimanic and a less expressed but indubitable antidepressant therapeutic effect of CZP, and a considerable prophylactic effect in mania as well as depression, an effect which is possibly a little less than that of lithium. It must, however, be stressed that this conclusion is based on a number of different and heterogeneous studies which have been combined. In addition 5 cases are presented concerning rapid cycling cases with early onset of the disorder and without response to or bad compliance with lithium. In spite of the clinical similarity of these cases the effect of CZP was good in 3 and poor in 2 of the 5 cases presented.

Is bilateral ECT ever indicated?

To investigate whether it is indicated to make a shift to bilateral technique when the first 6-10 unilateral ECT treatments have produced no improvement in patients with endogenous depression, a retrospective study was made concerning 61 patients 34 of whom (group U) continued with unilateral treatment while in 27 (group UB) a shift was made to bilateral technique. No significant differences were found between the groups with regard to final therapeutic result, only a tendency to better effect in the first mentioned group. This tendency can be explained by the somewhat higher age in this group. The duration of seizures, administration of benzodiazepines, as well as treatment with antidepressive drugs, were equal in the groups, which were thus comparable. It is concluded that since bilateral ECT may severely impair memory for weeks or months the patients should not be stressed by a change to this technique.

Present practice of electroconvulsive therapy in Scandinavia.

We have set up guidelines for the practice of electroconvulsive therapy, based on Scandinavian clinical experience and research. Because the therapeutic effect is a result of the cerebral seizure, and the organic side effects partly consequences of the electrical stimulation, the aim should be to induce maximal seizure activity using minimal electrical energy. Essential features of optimal therapy are (1) absence of therapy with benzodiazepines and other anticonvulsant drugs, (2) superficial narcosis, (3) abundant oxygen supply, (4) threshold stimulation with brief-pulse stimuli, and (5) unilateral, parietotemporal, nondominant application of the electrodes. Seizure duration should always be measured to make sure that maximum seizure activity has taken place.

Influence of unilateral ECT on tryptophan metabolism in endogenous depression.

Thirteen patients with endogenous depression received an oral load of L-tryptophan (100 mg/kg) before and after a series of unilateral ECT. Age-matched and sex-matched controls also received the tryptophan load twice, at intervals corresponding to those used in the patients. After the loads the level of tryptophan in serum was lower in patients than in control subjects. ECT failed to influence either baseline or postload tryptophan levels. The results are consistent with the notion of disturbances in tryptophan metabolism in patients with endogenous depression, but they fail to clarify the mechanism responsible for the antidepressant effect of ECT.

Factors influencing seizure duration and number of seizures applied in unilateral electroconvulsive therapy. Anaesthetics and benzodiazepines.

A certain minimum in the duration of seizures appears to be a condition for a satisfactory therapeutic effect in ECT. The aim of the present investigation is to elucidate the importance of some factors which may influence the seizure duration. In a controlled double-blind investigation with crossover, carried out on 19 patients, thiopentone and methohexitone were compared as anaesthetics for unilateral ECT. No differences were found between the anaesthetics regarding duration of seizures, number of treatments with insufficient seizures duration or amount of energy applied. Blood pressure measured after the seizure was slightly higher with thiopentone than with methohexitone and methohexitone as anaesthetic for ECT. In a retrospective investigation concerning seizure duration in unilateral ECT, patients given benzodiazepines during the treatment period were compared with patients who received no such medication. The benzodiazepine group showed shorter seizure duration, more cases with insufficient seizure duration and a need for a greater number of treatments. Benzodiazepines should be administered with caution during ECT, as they can impair the efficacy of treatments and consequently prolong the treatment period.

The effects of unilateral brief-interval ECT on memory.

One hundred and three patients treated for endogenous depression with unilateral, non-dominant ECT, half with two, half with four treatments weekly, were examined to determine the effect of the treatment on memory functions. Th first-mentioned group was studied with double-blind technique in connection with an earlier study while the latter group was investigated under open conditions. Tests were made before the first treatment, after the sixth treatment, and after the final treatment (the Wechsler Memory Scale Forms I and II) and at the same times, ratings were made of the depressive state. No significant differences were found between the results of the two groups either with regard to the total results or the sub-test results in WMS. This was true for changes between and the first and the sixth treatment and between the first and the final treatment. On the whole, both groups showed improved results during the course of treatment; a memory reduction to an equal degree in both groups evident before treatment, and thus due to the depression, was eliminated concurrently with the improvement in the depressive condition. With reference to delayed reproduction a comparison made after the sixth treatment showed that the high-frequency treatment group scored significantly higher than the other group. This can only be ascribed to a better therapeutic effect resulting from accelerated treatment. Likewise these improved therapeutic results in the high-frequency treatment group must be responsible for the fact that this group does not show poorer test results than the group treated at the customary frequency-rate in spite of an expected deteriorating effect of accelerated treatment on memory functions and in spite of a larger number of treatments per series in this group. Neither in the higher nor in the lower frequency treatment group were any age-related variations in memory found.

Therapeutic results in brief-interval unilateral ECT.

The study reported comprised 104 patients with endogenous depression who were given unilateral electroconvulsive therapy (ECT). The patients were divided into two equally large groups, one receiving two and the other four treatments per week. The latter group was selected openly, while the former had been collected by a double-blind technique on a previous occasion. The severity of depression was assessed before the first treatment and on the days after the sixth and the last treatment, and at these times memory testing by WMS Forms I and II and EEG were also performed. An analysis is presented of the therapeutic effect obtained, assessed by: (1) the number of treatments applied in the two groups; (2) the reduction in the depression score; and (3) the effect achieved per treatment. In the group with frequent electrostimulation one to two addititional treatments were required, the difference being statistically significant. On the other hand, frequent stimulation tended to be more effective in terms of the reduction in the depression score. The effect per treatment was identical in the two groups. Four treatments per week did not result in a higher frequency of complications. A comparison of the five severest depressions in each of the two groups did not reveal any difference in the therapeutic effect of the two methods of treatment. It is concluded that the technique with four treatments per week instead of two offers the advantage that the duration of the treatment period is reduced by 11-12 days. As the study also revealed that the discomforts, including memory impairment, are not increased by frequent stimulation, it is recommended that unilateral ECT is administered with a frequency of four treatments per week.

EEG in unilateral and bilateral electroconvulsive therapy.

The investigation concerned 100 patients with endogenous depression treated with ECT, 52 unilaterally on the non-dominant hemisphere, and 48 bilaterally. A double-blind investigation of the therapeutic effect and the effect on memory and on EEG was carried out. With unilateral treatment, mainly diffuse and same-sided EEG changes appeared, while with bilateral treatment mainly diffuse and left-sided changes occurred. Bilateral treatment led to significantly more EEG changes than did unilateral treatment. For both groups there was a tendency to greater changes after the last than after the sixth treatment. At termination of treatment, a significantly better therapeutic effect was found in cases where EEG changes appeared, especially severe EEG changes. This applied to the total material but not to the groups of unilaterals and bilaterals taken separately. In the entire material after the first six treatments, the greatest representation of patients with unchanged and impaired memory was found in cases with deteriorated EEG compared to cases with no EEG deterioration. After the entire series of ECT, this correlation no longer was present. After separation of the patients into unilaterals and bilaterals it was not present at any of the stages. In the bilateral group ECT treatment gave more frequent and stronger EEG changes, among the older than among the younger patients. For the unilateral group, there was no comparable difference. The number of weak seizures was significantly greater among the unilaterals than among the bilaterals. The therapeutic effect was not correlated to the number of weak seizures, but the number of weak seizures was positively correlated to the number of treatments applied.