Time to abandon electroconvulsion as a treatment in modern psychiatry.

This review examines the evidence for the current use of electroconvulsive therapy (ECT) in psychiatry. The history of ECT is discussed because ECT emerged with no scientific evidence, and the absence of other suitable therapy for psychiatric illness was decisive in its adoption as a treatment. Evidence for the current recommendation of ECT in psychiatry is reconsidered. We suggest that ECT is an unscientific treatment and a symbol of authority of the old psychiatry. ECT is not necessary as a treatment modality in the modern practice of psychiatry.

Geographical variation in rate of schizophrenia in rural Ireland by place at birth vs place at onset.

This study examined geographical variation in rate of occurrence of schizophrenia by place at birth vs place at onset, among a rural Irish catchment area population of unusual stability and socioeconomic homogeneity. Within a catchment area of 21,520 persons, all cases of schizophrenia were sought using current inpatient and outpatient records and key informants active in the community. Suspected cases were interviewed personally and diagnosed using DSM-III-R criteria. Place at birth and place at onset of psychosis were specified among the 32 District Electoral Divisions constituting the study region. For the 72 cases ascertained, an unremarkable overall prevalence rate/morbid risk obscured substantial and significant geographical variations therein between District Electoral Divisions. Particularly after controlling for high-density families, men demonstrated prominent geographical variation both by place at birth and by place at onset, with most men remaining unmarried and becoming ill at their place of birth; conversely, women demonstrated prominent variation by place at birth but more limited variation by place at onset, despite more frequent transitions from the parental home to the marital home before onset. Even when cases changed their location before the onset of psychosis, geographical variation in rate of occurrence of schizophrenia remained associated more strongly with factors related to the place of their birth.

Mortality in schizophrenia. Antipsychotic polypharmacy and absence of adjunctive anticholinergics over the course of a 10-year prospective study.

BACKGROUND: Although increased mortality is one of the most consistent and accepted epidemiological findings in schizophrenia, a high rate of suicide appears unable to account fully for this burden which remains poorly understood. METHOD: A cohort of 88 in-patients was followed prospectively over a 10-year period and predictors of survival sought among demographic, clinical and treatment variables. RESULTS: Over the decade, 39 of the 88 patients (44%) died, with no instances of suicide. Reduced survival was predicted by increasing age, male gender, edentulousness and time since pre-terminal withdrawal of antipsychotics; additionally, two indices of polypharmacy predicted reduced survival: maximum number of antipsychotics given concurrently (relative risk 2.46, 95% CI 1.10-5.47; P = 0.03) and absence of co-treatment with an anticholinergic (relative risk 3.33, 95% CI 0.99-11.11; P = 0.05). CONCLUSIONS: Receiving more than one antipsychotic concurrently was associated with reduced survival, in the face of little or no systematic evidence to justify the widespread use of antipsychotic polypharmacy. Conversely, over-cautious attitudes to the use of adjunctive anticholinergics may require re-evaluation.

Developmental trajectory and disease progression in schizophrenia: the conundrum, and insights from a 12-year prospective study in the Monaghan 101.

Though conceptualised originally as a deteriorating disorder, some contemporary studies have been interpreted as challenging these foundations; more radically, it has been proposed that schizophrenia may be a 'static encephalopathy' of neurodevelopmental origin. The argument offered here is that schizophrenia is indeed a neurodevelopmental disorder, but that this is not in itself antithetical to later disease progression. Rather, the onset of psychosis may reflect the maturationally-mediated triggering of an active disease process that is associated with progressive deterioration unless attenuated by antipsychotic drugs. A developmental trajectory is proposed to link first or early second trimester dysplasia to the chronic course of the illness; from this, it is argued that schizophrenia is inherently a progressive disorder but that antipsychotic drugs may act to ameliorate this progressive component and thus confer on the disease course some of the characteristics of a 'static encephalopathy'. The 'true' natural history of an illness cannot be determined from studies in treated populations.

Cognitive dysfunction in chronic schizophrenia followed prospectively over 10 years and its longitudinal relationship to the emergence of tardive dyskinesia.

Basic cognitive function was assessed at initial and at 5- and 10-year follow-up assessments among 41 primarily middle-aged in-patients manifesting the severest form of schizophrenia; additionally, the presence and severity of tardive dyskinesia was evaluated on each occasion. Overall, there was a modest but significant deterioration in cognitive function over the decade, particularly among older men. Longitudinally, patients with persistent tardive (orofacial) dyskinesia continued to show poorer cognitive function than those consistently without such movement disorder, though within neither group did cognitive function change over the decade. Those patients demonstrating prospectively the emergence of orofacial dyskinesia showed a marked deterioration in their cognitive function over the same time-frame within which their movement disorder emerged, but this decline did not progress further thereafter. There appears to exist some modes, progressive deterioration in cognitive function even late in the chronic phase of severe schizophrenic illness which appears to derive primarily from patients showing de novo emergence of tardive orofacial dyskinesia.

Evidence for the existence of schizophrenia in medieval Islamic society.

It has been claimed that descriptions of schizophrenia-like disorders were rare before 1800 in the Western world. Historical evidence from medieval Islamic society shows that madness was common in that society. Despite the limitations of the evidence, we propose that medieval Islamic physicians probably diagnosed and treated many cases of schizophrenia.

Familial-genetic and reproductive epidemiology of schizophrenia in rural Ireland: age at onset, familial morbid risk and parental fertility.

Among all ascertainable cases of DSM IIIR schizophrenia within an unusually homogeneous region of rural Ireland, family history information was sought from multiple sources. Morbid risk for schizophrenia among probands' first degree relatives was 6.1% and did not differ between male (6.5%) and female (5.5%) probands; risk among probands' siblings (8.3%) exceeded that among their parents (1.4%), with only 2% of male and 31% of female probands being themselves married. Both age at onset <25 and having >7 siblings were associated with elevated morbid risk, particularly among relatives of male probands (11.9% vs. 2.2% and 11.8% vs. 3.7%, respectively). Increased fertility particularly among parents of male patients with high familial-genetic loading may contribute to perpetuation of the disorder in the face of those patients' own extremely low fecundity.

Initial 'schizophrenia-like' psychosis in Pick's disease: case study with neuroimaging and neuropathology, and implications for frontotemporal dysfunction in schizophrenia.

'Schizophrenia-like' psychosis has not been reported previously as a prodrome of Pick's disease, a dementia of frontotemporal pathology. A woman having a consistent clinical diagnosis of typical schizophrenia who developed increasing affectivity and cognitive deficits was examined by computed tomography and brain biopsy. This presentation was found to be associated with left frontotemporal atrophy, left sylvian fissure abnormalities and enlargement of the anterior and temporal horns of the left lateral ventricle. On biopsy, all the neuropathological hallmarks of Pick's disease were present. Unusually, some specific aspect of Pick's disease in this patient appears initially to have disturbed brain function in a manner reproducing some fundamental aspect(s) of schizophrenia itself; left frontotemporal dysfunction would appear to be a relevant common denominator.

Sequential cross-sectional and 10-year prospective study of severe negative symptoms in relation to duration of initially untreated psychosis in chronic schizophrenia.

Current clinical correlates of duration of initially untreated psychotic symptoms were investigated in a cross-sectional analysis followed by a 10-year prospective study among 88 in-patients with a long-standing schizophrenic illness, many of whom had experienced prolonged periods of untreated psychosis due to illness onset and hospital admission in the pre-neuroleptic era. After controlling for the effects of age, and duration and continuity of subsequent neuroleptic treatment, the primary clinical correlate of duration of initially untreated psychosis was muteness. Over the subsequent 10-year-period, no new cases of muteness emerged and some existing cases of muteness partially resolved, though the speech that emerged remained very sparse and revealed generally gross cognitive debility. The pathophysiology underlying active, unchecked psychosis may also constitute an active morbid process that is associated with the further progression of severe negative symptoms and cognitive dysfunction in the long-term.

Evidence for a gender-specific decline in the rate of schizophrenia in rural Ireland over a 50-year period.

The issue of whether the incidence rate of schizophrenia may have declined over recent decades has generated considerable controversy. This study sought to ascertain and interview all patients who satisfied contemporary diagnostic criteria for schizophrenia within a defined and unusually homogeneous region of rural Ireland having a total population of 25,178 people; morbid risk for schizophrenia was then examined by quinquennia of birth from 1920-24 to 1965-69. Morbid risk appeared essentially constant for persons born between 1920 and 1939 but fell by 37% for those born between 1940 and 1969, the fall being considerably more prominent in females (-56%) than in males (-19%). Attention is focused on sexual dimorphism in cerebral development and on temporal changes in endogenous or exogenous factors that influence the rate of occurrence of schizophrenia in females.

Effects of two different inhibitors of the arachidonic acid metabolism on platelet sequestration in endotoxic shock.

Metabolites of arachidonic acid are known to play an important part in the pathogenesis of organ injury in endotoxic shock. We compared the effects of the classical cyclooxygenase inhibitor aspirin with that of the dual cyclooxygenase and lipoxygenase inhibitor ketoprofen on the behavior of platelets tagged with 111In-labeled oxine in multiple organs during endotoxin shock. Three groups of sheep (n = 7 in each) were anesthetized before being subjected to endotoxin shock. Group E had no drug treatment (shock controls), group KET received ketoprofen and group ASP received aspirin treatment. In the lungs and in the liver of group E there was a marked sequestration of platelets, which started in both organs immediately after administration of endotoxin and continued throughout the study. In the treated groups, however, the response to endotoxin was both delayed and reduced compared with the untreated shock controls. The first changes in platelet activity were noted after more than 1 h in the treated groups. Four hours after administration of endotoxin, platelet activity (sequestration) had increased in the lungs by 102 +/- 14% in group E, 53 +/- 11% in group ASP and 20 +/- 13% in group KET (P < 0.01, P < 0.01 and P < 0.05 respectively compared to baseline). Corresponding values for the liver were 52 +/- 16% in group E, 22 +/- 19% in group ASP and -2 +/- 12% in group KET (P < 0.01, P < 0.01 and P > 0.05 respectively compared with baseline).(ABSTRACT TRUNCATED AT 250 WORDS)

Gender specificity of geographical variation in morbid risk for schizophrenia in rural Ireland.

The morbid risk for schizophrenia was determined separately for men and women within each of 36 contiguous district electoral divisions of a rural Irish county in which all cases of schizophrenia satisfying DSM-III-R criteria had been sought. The distribution of morbid risk values for men (0.0-19.2 per 1000) was in accordance with a statistical model for random occurrences in space, while for women (0.0-38.3 per 1000) it deviated markedly from such a model; thus, morbid risk for schizophrenia showed very prominent geographical variations in women, but not in men. These findings may have a basis in factors that can show both spatial inhomogeneity and gender specificity in their consequences for schizophrenia.

Effects of ketoprofen on respiratory and circulatory changes in endotoxic shock.

OBJECTIVE: To study the effects of ketoprofen, a dual inhibitor of the arachidonic acid metabolism, on hemodynamic and respiratory changes during endotoxic shock. DESIGN: Prospective, randomised, controlled study using an established intact animal model of endotoxic shock in sheep. SETTING: An animal laboratory in a university hospital. INTERVENTIONS: 4 groups were studied (n = 7 in each). Group K received ketoprofen and group A received aspirin 30 min before start of endotoxin infusion. Group E received endotoxin, but no drug treatment. Group C received neither endotoxin nor drug treatment. All the animals were anaesthetised with ketamine, had controlled ventilation with FiO2 = 0.5 and received Ringer's lactate at an infusion rate that would keep the pulmonary capillary wedge pressure constant. RESULTS: Both ketoprofen and aspirin prevented the early rise in pulmonary arterial pressure that occurred in group E a few minutes after start of i.v. infusion of endotoxin. Furthermore, ketoprofen prevented any significant changes in arterial blood pressure, arterial oxygen tension, oxygen delivery index, oxygen extraction ratio, respiratory compliance, intrapulmonary shunt fraction, and platelet counts that occurred in group E. Aspirin, on the other hand, provided only partial and time limited (1-2 h) protection against these changes. Wet-to-dry weight ratios of the lungs were significantly lower in the ketoprofen treated than in the untreated shock controls and the aspirin treated animals. CONCLUSION: Ketoprofen completely prevented the changes in hemodynamics and respiratory function observed in control-endotoxin-treated animals.

Multiple organ platelet sequestration, hemodynamics, and gas exchange in endotoxin shock and the effects of aspirin-terbutaline treatment.

We studied the effects of two different drugs on multiple organ platelet sequestration, hemodynamics, and respiratory function during endotoxin shock. Twenty-eight sheep (four groups) were anesthetized and ventilated. Group AT-E received aspirin and terbutaline 30 min before and group E-AT 30 min after Escherichia coli endotoxin. Group E also received endotoxin but no drug treatment (shock controls), and group C received neither endotoxin nor drug treatment. There was a marked platelet trapping in the lungs and in the liver immediately after administration of endotoxin in groups E and E-AT, but after 4 hr it was less pronounced in group E-AT than in the endotoxin controls (P < 0.05). In the pretreated animals (group AT-E) there was no increase in platelet sequestration until almost 2 hr after endotoxin both in the lungs and the liver, but at the end of the study (240 min) there was no difference between the pre- and posttreated groups. No significant changes occurred in the kidneys and spleen in any of the groups. In groups E and E-AT the endotoxin infusion resulted in 200% rise in pulmonary artery pressure (PAP) and a sharp decrease in mean arterial pressure (MAP; 25-30%), respiratory compliance (CT; 50%), arterial oxygen tension (PaO2; 70%) as well as in oxygen delivery index (DO2; 30-40%) within 30 min. After 4 hr the PAP had decreased significantly in group E-AT, but remained high in group E (> 100% higher than in group C). Also MAP, PaO2, DO2 and CT improved slightly in group E-AT, while they remained low in group E.(ABSTRACT TRUNCATED AT 250 WORDS)

Evidence for geographical variations in the prevalence of schizophrenia in rural Ireland.

Geographical variations in the rate of occurrence of schizophrenia have been the subject of much speculation and controversy, but it has proved extremely difficult to establish the existence of the phenomenon within a given study area. Using current inpatient and outpatient records and information from key informants active in the community, this study sought to identify all cases of schizophrenia in 36 District Electoral Divisions, constituting a clinical catchment area of 25,178 persons in a rural Irish county. Though the overall prevalence rate (3.3 per 1000) was unremarkable, this obscured a substantial and significant variation in prevalence rates (from 0.0 to 14.3 per 1000) between District Electoral Divisions. Prevalence rates in five District Electoral Divisions made particular contributions to the overall deviation from a statistical model for random occurrences in space. The results indicate spatial inhomogeneity in the prevalence of schizophrenia in rural Ireland and imply geographical variation in environmental or genetic factor(s) of etiologic relevance.