Asunto(s)

Asunto(s)

Asunto(s)

RESUMEN

This issue includes the findings from the largest randomised controlled trial ever conducted with bilateral, unilateral and bifrontal electroconvulsive therapy (ECT). The background to the study and its findings are discussed.

Asunto(s)

Asunto(s)

RESUMEN

BACKGROUND: Magnetic seizure therapy, in which seizures are elicited with a high-frequency magnetic field, is under development as a new treatment for major depressive disorder. Its use may be justified if it produces the antidepressant effects of electroconvulsive therapy (ECT), coupled with limited cognitive side-effects. AIMS: To evaluate the usefulness of a new 100 Hz magnetic seizure therapy device. METHOD: We induced seizures with 100 Hz magnetic transcranial stimulation in 11 patients with major depressive disorder during one session of a regular course of ECT. Recovery times after seizures induced by magnetic seizure therapy and ECT were compared. RESULTS: Seizures could be elicited in 10 of the 11 patients. Stimulation over the vertex produced tonic-clonic activity on 9 out of 11 occasions. Stimulation over the prefrontal midpoint elicited seizures on 3 out of 7 occasions. The mean duration of magnetically induced seizures was 31.3 s, ranging from 10 to 86 s. All patients had an exceptionally quick recovery of orientation: mean of 7 min 12 s (s.d.=2 min 7 s, range 4 min 20 s to 9 min 41 s). The recovery times were on average 15 min 35 s shorter with magnetic seizure therapy than with ECT in the same patients (paired-samples t-test: P<0.0001). Patients reported feeling less confused after magnetic seizure therapy. Side-effects were confined to myoclonic movements, associated with the use of etomidate. CONCLUSIONS: The new 100 Hz magnetic stimulator elicits seizures in the majority of patients when administered over the vertex. Magnetic seizure therapy was associated with shorter recovery times and less confusion following treatment. Subsequent work will be required to assess the safety and effectiveness of magnetic seizure therapy in the treatment of depression.

Asunto(s)

RESUMEN

BACKGROUND: In May 2003, the National Institute for Clinical Excellence published controversial clinical guidelines that intended to restrict the indications for the use of electroconvulsive therapy (ECT) in the United Kingdom. OBJECTIVE: We investigated whether the guideline had affected the rate of usage of ECT in the City of Edinburgh and set this in the context of ECT usage in the City since 1993. METHOD: We calculated the annual rate of ECT usage using a case register and contemporaneous and coterminous population data, reporting separately rates for young people (younger than 18 years), the general adult population, and older adults (aged 65 years of age and older). RESULTS: No young person was treated after 1998. There were similar significant falls in the rates of usage in both the general adult and older age population (-60%). There was no suggestion that the fall had accelerated after May 2003. CONCLUSIONS: No early effect of the guidance was found in the rate of ECT usage in the City of Edinburgh, but the passage of time will be required to assess any longer term effect.

Asunto(s)

RESUMEN

OBJECTIVES: Resistance to antidepressant medication is the commonest stated indication for electroconvulsive therapy (ECT) by psychiatrists, but what this means in practice has not been described. Our aims were to survey what antidepressant drug treatment had been prescribed to patients before they underwent ECT and to what extent this treatment would satisfy operational criteria for adequate antidepressant drug treatment used in ECT research. METHODS: The survey was conducted prospectively among 37 depressed patients referred for a new course of bilateral ECT and where antidepressant medication resistant was identified as the indication for ECT. RESULTS: Only half the sample had been prescribed more than one antidepressant drug, and only 38% had been prescribed any augmentation compound. Although the majority of patients were resistant to medication when rated by the older operational criteria, only half the sample met contemporary criteria for medication resistance. CONCLUSIONS: The findings suggest a lack of agreement between clinicians and researchers in what constitutes medication resistance as a possible indication for ECT. It will take some time to establish if the revised UK Royal College of Psychiatrists ECT Handbook will encourage more intensive medical treatment of depressive illness before the use of ECT.

Asunto(s)

Asunto(s)

RESUMEN

BACKGROUND: Antidepressant medication resistance is the commonest indication for electroconvulsive therapy (ECT) in Scotland. Evidence from the USA suggests that clinical response is reduced for medication resistant patients. The aim of the present study was to establish if the American results were generalisable to routine clinical practice in Edinburgh. METHOD: Fifty eligible depressed patients consecutively referred for a new course of bilateral ECT at the Royal Edinburgh Hospital were prospectively assessed as part of the National Audit of ECT in Scotland. The patients were categorised into those who had received adequate drug treatment pre-ECT (and could therefore be classed as medication resistant) and those who had not, using five operational definitions. The clinical response of the ECT was then compared between groups, using the Montgomery-Asberg Rating Scale for Depression (MADRS) and Clinical Global Impression Scale (CGI). RESULTS: Patients defined as medication resistant had an identical response to patients who were not defined as medication resistant (in both groups 60% met the predetermined criterion for clinical response), and this was consistent across the five operational definitions. CONCLUSIONS: The hypothesis that medication resistance is associated with a reduced probability of clinical response to ECT was not supported. LIMITATIONS: Some patients who were inadequately drug treated might have proven eventually to be medication resistant, which would have obscured a potential difference in clinical response. It is not known how generalisable the results are to clinical practice in the rest of the UK.

Asunto(s)

Asunto(s)

RESUMEN

Pituitary hormone release after electroconvulsive therapy (ECT) may provide important information about certain of the effects of ECT on neurotransmitter function. Previously we quantified pituitary hormone release by the increase in the area under the hormone concentration/time curve. Swartz has rightly pointed out that this method ignores the rate of elimination of hormone and cannot be a measure of total hormone released. Swartz has proposed a kinetic model of hormone release, and in this paper we assess the reliability of parameters derived from it when applied to our own data on the effects of ECT on the release of prolactin and oestrogen-stimulated neurophysin. The deviations between observed and predicted values were small when only five post-ECT samples were used. Contrary to expectations, the goodness of fit did not improve when the number of sampling points was increased to nine after ECT. It was possible to fit a unique curve to the observed data in only 28 of 54 data sets. The reasons for these findings are discussed.