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Shrink Life in General
Electroconvulsive Therapy Consensus Development Conference Statement. This information is presented by National Institutes of Health in conjunction with the National Institute of Mental Health on a Consensus Development Conference on Electroconvulsive Therapy on June 10-12, 1985.
A consensus panel representing psychiatry, psychology, neurology, psychopharmacology, epidemiology, law, and the general public considered the scientific evidence and agreed on answers to the important questions about this treatment.
More recent and up to date is information about Electroconvulsive Therapy (ECT) by Dr. Raymond Crowe, MD Professor of Psychiatry University of Iowa Department of Psychiatry Peer Review Status: Internally Peer Reviewed
First Published: March 2000
Last Revised: December 2004
Previous articles about Electroconvulsive therapy (ECT) on this blog:
Genes, enzymes and neurotransmitters
Genes are located on DNA in the nucleus of the cells in your body. You usually have two genes on each arm of a chromosome ( one from dad and one from mum). If the two genes are identical it’s called that they are homozygote, if they are different it is heterozygote. Genes are read by other cell nucleus material (RNA) which starts a sequence to produce proteins. The most important proteins being enzymes. Enzymes are needed for the metabolism of neurotransmitters among others. Neurotransmitters are chemicals that are used to relay, amplify and modulate electrical signals between a neuron and another cell in the brain.
Catechol-O-MethylTransferase (COMT) is a major enzyme in the brain for the metabolism of dopamine, a neurotransmitter. A polymorphism in the gene coding for COMT results in substantial effects, with a homozygote allele variant leading to a three to fourfold reduction in enzymatic activity compared to the other homozygote variant.
In general, polymorphism describes multiple possible states for a single property. This single property being a single amino-acid sequence in the allele for COMT. The presence of Met/Met and Met/Val or Val/Met results in a much lower activity of COMT than Val/Val (high activity).
Low Dopamine concentration in Prefrontal Cortex
The high genotype of COMT was associated with better treatment response to ECT than low allele containing genotypes. Since high genotype results in a high activity of COMT and a low dopamine concentration in the prefrontal cortex we can assume that low dopaminergic activity in the prefrontal cortex is associated with a better response to ECT.
This was shown in 119 treatment-refractory depressed patients admitted consecutively for electroconvulsive therapy (ECT). The effect of clinical variables also related to a better response to ECT were studied using univariate analysis of variance. These covariates: higher illness severity, age, age at onset, sex and the number of ECT treatment did not affect the treatment response.
Not all studies with COMT polymorphism and response to antidepressants found an association between this polymorphism and response. COMT also plays a role in the metabolism of norepinephrine, another important neurotransmitter in the brain. Other limitations of this study are a small patient sample and the concomitant use of psychotropic drugs during ECT. ECT itself was properly performed.
Biological variables predicting response
A very nice publication in a new field of research. Important topic predicting response in a patient with biological variables.
Catechol-O-methyltransferase(COMT) polymorphisms predict treatment response in electroconvulsivetherapy
The Pharmacogenomics Journal (2007),1–4.
Sami Anttila et al.
Dr S Anttila,Department of Psychiatry,
Tampere University Hospital,Pitkaniemi
In 1860, Elizabeth Packard, who differed with the theology of her clergyman husband, was forcibly placed in an Illinois state hospital. She remained there for 3 years. At that time, Illinois law stated that “married” women could be hospitalized at a husband’s request without the evidence required in other cases. Want to know how this ended?
The Question of Patient Restraint in 1900?
Women were not welcomed into the medical profession during the first half of the 19th century. Many arguments against women becoming physicians were physiological and neurological: would the education and training required make a woman unfit for her “primary duty,” childbirth? And was rest (physical and mental) necessary during menstruation? Want to know when this was abolished?
American asylums were influenced by visits of their superintendents and others to European hospitals. Want to know about these developments?
Have a look at 19th-Century Psychiatric Debates.
Hypoperfusion of parts of the brain in depressive disorder largely normalizes after response to antidepressants. Perfusion changes after response to electroconvulsive therapy (ECT) follows a different course. This interesting conclusion is recently published in the Journal of Nuclear Medicine. The design of this study delivers interesting results besides those already mentioned.
First they compared healthy controls with depressed patients without medication for at least 2 weeks before undergoing SPECT. Single photon emission computed tomography (SPECT) is a nuclear medicine tomographic imaging technique using gamma rays. It is very similar to conventional nuclear medicine planar imaging using a gamma camera. However, it is able to provide true 3D information. Usually the gamma-emitting tracer used in functional brain imaging is 99mTc-HMPAO (hexamethylpropylene amine oxime). 99mTc is a metastable nuclear isomer which emits gamma rays which can be detected by a gamma camera. When it is attached to HMPAO, this allows 99mTc to be taken up by brain tissue in a manner proportial to brain blood flow, in turn allowing brain blood flow to be assessed with the nuclear gamma camera. Because blood flow in the brain is tightly coupled to local brain metabolism and energy use, the 99mTc-HMPAO tracer (as well as the similar 99mTc-EC tracer) is used to assess brain metabolism regionally.
Compared with healthy controls depressed patients had a significant lower regional cerebral blood flow (rCBF) before treatment over the frontal lobes and the subcortical nuclei (amygdala, caudate, thalamus and hypothalamus).
The effect of antidepressants and ECT were compared with these baseline measures after treatment. Another SPECT was performed after 6 weeks of medication or completion of the ECT course.
For those patients who responded to antidepressants, a significant increase in rCBF was found in the right parietal lobe of depressed patients. No perfusion changes were found in non-responders. No perfusion differences were found between medication responders and controls. In other words, responders on antidepressants had regained normal cerebral blood flow comparable to normal controls.
In contrast, rCBF was still lower in ECT responders than in controls, in the same region as before treatment as well as in the occipital and cerebellar regions. Especially this last finding is of interest since previous studies used the cerebellum as reference region for data analysis assuming the cerebellum had nothing to do with depression. The cerebellum was not traditionally considered a major contributor to the neurocircuitry of mood regulation. This assumption has to be refuted, cerebellar dysfunction is known to have an impact on cognition and affect.
The fact that further reduction in rCBF in posterior brain regions occur after response to ECT could be a state phenomenon or a trait phenomenon. Long term studies are needed to document the course of rCBF changes.
This is the Talairach under-surface view showing the Prefrontal Inferior Orbital area at the top of the picture and the Temporal lobes in the middle of the picture. With Major Depression we see significant decreased blood flow to both of these areas of the Brain as is shown here.
Reduced perfusion to the frontotemporal cortex bilaterally.
99mTc-HMPAO SPECT Study of Cerebral Perfusion After Treatment with Medication and Electroconvulsive Therapy in Major Depression
Yoav Kohn,Nanette Freedman,Hava Lester,Yodphat Krausz,Roland Chisin,Bernard Lerer,and Omer Bonne.
J Nucl Med 2007;48:1273–1278.
Electroconvulsive therapy during pregnancy should be performed with caution. In a case report a woman with a first time pregnancy received ECT during pregnancy. She was on maintenance ECT, every 2 weeks during her pregnancy she received ECT. She had a bipolar depression and was only partially responsive to conventional medical therapy.
Fetal heart rates were recorded after each treatment but it was unclear how soon after the treatments and at what gestational age this testing began.
At 36 weeks she had an elevated blood pressure and elevated protein on a 24-hour analysis. Labor was inducted because of preeclampsia. The newborn unexpectedly had severe neurological deficits associated with multiple brain infarcts.
Preeclampsia is a disorder that occurs only during pregnancy and the postpartum period and affects both the mother and the unborn baby. Affecting at least 5-8% of all pregnancies, it is a rapidly progressive condition characterized by high blood pressure and the presence of protein in the urine. Preeclampsia and other hypertensive disorders of pregnancy are a leading global cause of maternal and infant illness and death.
A cause and effect relationship between ECT and the inter hemispheric infarcts cannot be established. Whether ECT in this case led to tetanic uterine contractions causing a fetal bradycardia or possibly induced a fetal arrhythmia, resulting in fetal brain injury, is purely speculative. This chain of events does not seem likely because uterine contractions of sufficient strength to severely limit placental blood flow probably would have been noticed by the patient. Other possible explanations for this complication could be the preeclampsia, and medication use is not mentioned in this case report.
There are no prospective or controlled studies exploring the effects of ECT on pregnancy and the foetus. Many case reports have been written but these data do not provide evidence for definitive conclusions. According to the editorial in the same issue of this case report:
How likely is it that a study could be done to show a statistically significant association between ECT and fetal brain injury? If the rate of neurological impairment in an unexposed control group was in the range of 1 in 1,000 births and the rate of injury in infants of ECT-exposed women was 10 times higher, a prospective cohort study would have to enroll over 1,000 women in both the treated and control groups to demonstrate this difference with statistical significance. Given the rarity of ECT use in pregnancy, such a study would obviously not be feasible.
Nevertheless the American Psychiatric Association has published guidelines for management of a pregnant patient undergoing ECT.
These guidelines are aimed at minimizing potential complications including aspiration and altered uteroplacental blood flow. Specific recommendations include
1. Consultation with an obstetrician before initiation of treatment.
2. Treatments performed in a facility with immediate access to obstetric care for emergencies.
3. Monitoring of fetal heart rate before and after treatments. Increase in monitoring at viability to include a non stress test with tocometry after treatments. Perform a Level 2 ultrasonography between 18 weeks and 22 weeks gestational age.
4. Routine anesthetic measures (leftward tilt of trunk, adequate oxygenation, hydration, and muscle relaxation, nonparticulate antacid, consider intubation in the third trimester).
But above all ECT in pregnancy should only be used in cases of emergency in which any delay is life threatening or when medication has failed. Given the risks of non treatment of major depression and the undefined risk of ECT in pregnancy, we must, as the authors of this case report suggest, use drug therapy as our first-line approach to treatment. The neonatal risks with pharmacotherapy are real, but adverse effects generally do not have long-term consequences. Most importantly, in contrast to ECT, large-scale studies on drug therapy have been performed, allowing the risks to be quantified.
In our next post will be talking about postpartum tubal ligation after pregnancy complicated by preeclampsia or gestational hypertension. This is to determine the anesthetic and surgical morbidity associated with postpartum tubal ligation after pregnancy complicated by pregnancy induced hypertension. About the tubal surgeries you can look for Tubal Reversal Surgeon Birmingham AL which has the most advanced methods for tubal reversal or tubal sterilization reversal or tubal ligation reversal, this surgical procedure can restore fertility to women after a tubal ligation, and can give women the chance to become pregnant again, not with the matter of recent issues or diseases.
Let’s be careful out there. Sgt. Phil Esterhaus, Hill Street Blues.
Pinette MG, Santarpio C, Wax JR, Blackstone J. Electroconvulsive therapy in pregnancy. Obstet Gynecol 2007;110:465–6.
Is Electroconvulsive Therapy in Pregnancy Safe?[Editorial]
Obstetrics & Gynecology. 110(2, Part 2) (Supplement):451-452, August 2007.
Among women with implants, a statistically significant 3-fold excesses of suicide and deaths from alcohol or drug dependence, as well as an excess of deaths from accidents and injuries consistent with substance abuse or dependence was found . The increased risk of suicide was not apparent until 10 years after implantation, all thought not in every patient this happens, patients from breast lift in la jolla ca do not suffer this. This was found in a study of a nationwide cohort of 3527 Swedish women with cosmetic breast implants. This study had a mean follow-up of 18.7 years (range, 0.1-37.8 years). This number of deaths in this group was compared with the number expected among the age- and calendar-period-matched general female population of Sweden. The abstract of this study from the Annals of Plastic Surgery
The excess of deaths from suicides, drug and alcohol abuse and dependence may be due to an underlying psychiatric condition among these women.
From an article on Anxiety, Addiction and Depression Treatments
It needs to be made clear that the number of women whose causes of death could be linked to mental health concerns was small even within the study. The death rates were much higher than the population at large, but only future research will allow stronger conclusions. What is clear at this juncture is that more thorough pschological screening, both before and after surgery, might be appropriate. Elective cosmetic surgery should not be restricted or at all impeded by these screenings, but it would make sense that since we know there is a connection, that we use it to help improve the lives of those who may unknowingly be dealing with depression, anxiety or any number of mental health conditions.
Continued treatment for 6 to 12 months beyond the acute phase of depression reduces the risk of relapse to 50%. Patients taking antidepressants during the continuation phase are at least 50% less likely to experience a relapse compared to patients with placebo. These continuation studies of antidepressants have used two different designs:
1. Patients are initially treated with an antidepressant, responders are then randomised to continue with the antidepressant or switched to placebo in a double-blind matter, both doctor and patient don’t know what they are on.
2. Patients are treated with an antidepressant or placebo in a double blind fashion, responders to active treatment and placebo are continued on the treatment to which they initially responded.
The authors of this study in the Journal of Clinical Psychopharmacology hypothesised that the design of the study would impact on the likelyhood of relapse (getting a depression again). They speculated that the first design would result in more relapse since there is an obvious change in treatment, patients can be aware that they initially received active medication, and there is now a change that they will will be switched to placebo. Expectation of a positive outcome in this design would be lower.
The authors conducted a meta-analysis of antidepressant continuation studies and compared the relapse rates using these 2 different designs. They identified 16 continuation studies of new-generation antidepressants, 11 using the first design and 5 using the second design.
In the second design the frequency of relapse was lower compared to the studies using the first design. Also the difference between relapse with the antidepressant and placebo was greater with this design.
The design of these studies has a significant impact on the absolute percentage of patients who relapse on both active medication and placebo, as well as an effect on the difference between relapse frequency between antidepressant and placebo.
Other factors such as longer continuation phase, demographic factors, depression severity, broader definition of treatment response during the acute phase, and a broader definition of relapse did not explain the outcome of this meta-analysis. Drug withdrawal did not account for the difference in absolute relapse rates related to study design.
Treatment optimism for patients and raters may explain reduced relapse rates in the second design. Design should be taken into accoun when comparing results of continuation studies.
Impact of Study Design on the Results of Continuation Studies of Antidepressants.
Journal of Clinical Psychopharmacology. 27(2):177-181, April 2007.
Zimmerman, Mark MD; Posternak, Michael A. MD; Ruggero, Camilo J. PhD
Teen depression or depression during adolescence can be hard to discover. Even young good looking kids can suffer from it. In an article called: Depression has many faces, the author Jessica Lopez describes the “faces of depression” in teens and the troubles these teens can experience. Besides mentioning the symptoms of depression there is also a myth versus fact part in this article.
Myth: Telling an adult that a friend might be depressed is betraying a trust. If someone wants help, he or she will get it.
Fact: Depression, which saps energy and self-esteem, interferes with a person’s ability or wish to get help. It is an act of true friendship to share your concerns with an adult who can help.
Reading this nice article I came across an excellent website called KidsHealth.org.
KidsHealth is the largest and most-visited site on the Web providing doctor-approved health information about children from before birth through adolescence. Created by The Nemours Foundation’s Center for Children’s Health Media, the award-winning KidsHealth provides families with accurate, up-to-date, and jargon-free health information they can use.