Melancholia and Multiple Chemical Sensitivity-A Case Report.

Randomized comparison of ultra-brief bifrontal and unilateral electroconvulsive therapy for major depression: Clinical efficacy

We compared the MMPI-2 profiles of adults with multiple chemical sensitivity (MCS), epileptic seizures (ES), and nonepileptic seizures (NES). Both NES and MCS are medically unexplained conditions. In previous studies profiles associated with NES were elevated on scales Hs and Hy, compared with profiles associated with ES. We predicted that profiles associated with MCS would be elevated on Hs and Hy compared with the ES group. Patients with ES and NES were diagnosed after intensive EEG monitoring using published criteria. MCS was diagnosed if there was a complaint of illness in response to multiple common odors at levels that are not noxious to most people. All the MCS cases had legal claims for injury related to chemical exposures. The results showed that on MMPI-2 scales Hs, D, and Hy the MCS group had means significantly higher than both the ES and NES groups. Fake Bad Scale scores were elevated in 11 MCS cases, and regression-based estimates of Fake Bad Scale scores showed elevation in the MCS group compared with both seizure groups. We conclude that MMPI-2 data, obtained from people seeking financial compensation, indicate that there is a strong psychological component to MCS symptoms.

Efficacy of ultrabrief pulse electroconvulsive therapy for depression: A systematic review

Preliminary data suggest that focal electrically administered seizure therapy (FEAST) has antidepressant effects and less adverse cognitive effects than traditional forms of electroconvulsive therapy (ECT). This study compared the impact of FEAST and ultrabrief pulse, right unilateral (UB-RUL) ECT on suicidal ideation. At 2 sites, patients in a major depressive episode were treated openly with FEAST or UB-RUL ECT, depending on their preference. The primary outcome measure was scores on the Beck Scale for Suicide Ideation (SSI). Scores on the suicide item of the Hamilton Rating Scale for Depression (HRSD-SI) provided a secondary outcome measure. Thirty-nine patients were included in the intent-to-treat sample (FEAST, n = 20; UB-RUL ECT, n = 19). Scores on both the SSI and HRSD-SI were equivalently reduced with both interventions. Both responders and nonresponders to the interventions showed substantial reductions in SSI and HRSD-SI scores, although the magnitude of improvement was greater among treatment responders. Although limited by the open-label, nonrandomized design, FEAST showed comparable effects on suicidal ideation when compared with routine use of UB-RUL ECT. These results are encouraging and support the need for further research and a noninferiority trial.

Electroconvulsive therapy (ECT) is highly effective and rapid in treating depression, but it carries a risk of significant cognitive adverse effects. Magnetic seizure therapy (MST), an investigational antidepressant treatment, may maintain the robust antidepressant efficacy of ECT while substantially reducing adverse effects due to its enhanced focality and weaker stimulation strength; however, previous clinical trials of MST were limited by small sample sizes. To compare the antidepressant efficacy of MST vs ultrabrief pulse right unilateral (RUL) ECT. A between-participants, double-blinded, randomized clinical trial was conducted at 3 academic hospitals from June 2007 to August 2012. Adults aged 18 to 90 years who were referred for treatment with ECT, had a major depressive episode in the context of major depressive disorder or bipolar disorder, and had a baseline 24-item Hamilton Depression Rating Scale (HDRS-24) total score of 18 or higher were included. Participants were randomly assigned 1:1 to treatment with MST or ultrabrief pulse RUL ECT. After the treatment course, patients were naturalistically followed up for up to 6 months to examine the durability of clinical effects. Treatment with MST, applied at 100 Hz at 100% of the maximum device power for 10 seconds, or ultrabrief pulse RUL ECT, applied at 6 times seizure threshold. The primary outcome was change from baseline in HDRS-24 total score, with patients followed up for up to 6 months. A reduction of at least 50% in the HDRS-24 score indicated response, and at least a 60% decrease in the HDRS-24 score and a total score of 8 or less indicated remission. Of the 73 participants (41 [56.2%] female; mean [SD] age, 48 [14.1] years), 35 were randomized to MST and 38 to ECT. Among them, 53 (72.6%) were classified as completers (29 in the MST group and 24 in the ECT group). Both MST and ECT demonstrated clinically meaningful antidepressant effects. In the intent-to-treat sample, 18 participants (51.4%) in the MST group and 16 (42.1%) in the ECT group met response criteria; 13 (37.1%) in the MST group and 10 (26.3%) in the ECT group met remission criteria. Among completers, 17 of 29 (58.6%) in the MST group and 15 of 24 (62.5%) in the ECT group met response criteria; 13 of 29 (44.8%) in the MST group and 10 of 24 (41.7%) in the ECT group met remission criteria. There was no significant difference between MST and ECT for either response or remission rates. However, the mean (SD) number of treatments needed to achieve remission was 9.0 (3.1) with MST and 6.7 (3.3) with ECT, a difference of 2.3 treatments (t71.0 = 3.1; P = .003). Both MST and ECT showed a sustained benefit over a 6-month follow-up period, again with no significant difference between them. Compared with MST, ECT had significantly longer time to orientation after treatment (threshold level: F1,56 = 10.0; P = .003) and greater severity of subjective adverse effects, particularly in the physical and cognitive domains. This randomized clinical trial found that the efficacy of MST was indistinguishable from that of ultrabrief pulse RUL ECT, the safest form of ECT currently available. These results support the continued development of MST and provide evidence for advantages relative to state-of-the-art ECT. ClinicalTrials.gov Identifier: NCT00488748.

Aims and MethodA postal questionnaire was sent to Scottish consultant psychiatrists asking about their attitudes towards unilateral and bilateral electroconvulsive therapy (ECT), and the difference in effectiveness between the two ECT types that they considered clinically significant.ResultsThe response rate was 61%. of those that responded, 62% were prescribers of ECT and most (79%) favoured bilateral ECT over unilateral ECT. the outcome that they were most concerned with was remission rate: 97% believe that an absolute difference of more than 5% in remission rate would make the difference in effectiveness between the two types of ECT clinically important.Clinical ImplicationsFuture investigators should focus on comparative remission rates of bilateral and unilateral ECT.

Randomized comparison of ultra-brief bifrontal and unilateral electroconvulsive therapy for major depression: cognitive side-effects

Sick house syndrome (SHS) is a Japanese concept derived from sick building syndrome (SBS), however SHS includes a broader scope of sickness than does SBS. Symptoms of SHS/SBS disappear after leaving the sick house/building, while symptoms of multiple chemical sensitivity (MCS) are elicited by the chance of chemical exposure after leaving the sick house/building. To establish the concept of SHS, we propose to introduce a new classification for SHS. A total of 214 patients complaining of SHS and/or MCS were independently classified using a new classification by clinical ecologists who are experienced physicians with expert knowledge of clinical ecology and general physicians according to disease pathogenesis from clinical records. The classification is as follows: type 1 (symptoms of chemical intoxication), type 2 (symptoms developed possibly due to chemical exposure), type 3 (symptoms developed not because of chemical exposure but rather because of psychological or mental factors), and type 4 (symptoms developed due to allergies or other diseases). The agreements on the classification made by clinical ecologists and general physicians reached 77.1% (Cohen's kappa=0.631), suggesting that this new classification was both apt and accurate. Relations between SHS and allergy/MCS were also studied. The cases classified as SHS type 4 more frequently had allergic past histories than did other types. The proportion of possible MCS cases was higher in the chemical induced SHS group (types 1 and 2) than in other types among male patients. For the universal use in clinical practice, it is necessary to prepare helpful diagnostic criteria of this SHS classification based on pathogenesis and carry our study forward all over the country.

Memory deficits and electrical stimulus intensity with unilateral ECT

This study aims to investigate the clinical effects of benzodiazepines or anticonvulsant use during a course of electroconvulsive therapy (ECT). A case report study of a patient who received ECT with and without concomitant flurazepam and pregabalin is presented. The literature on the use of benzodiazepines and anticonvulsants during ECT is reviewed. A woman with treatment resistant depression received a course of ECT while taking flurazepam and pregabalin, but seizures were of short duration and symptomatic improvement was minimal. After discontinuation of flurazepam and pregabalin, a course of right unilateral ultrabrief ECT was associated with adequate seizures and remission of depression and suicidal ideation. Our literature review suggests that benzodiazepines decrease seizure duration, but most evidence shows no association with increased seizure threshold. One prospective RCT and 3 large retrospective studies found that benzodiazepines compromise the efficacy of unilateral but not bilateral ECT. Regarding anticonvulsants, several studies had varied and contradictory results on their effect on seizure duration and seizure threshold. Of the 2 large retrospective studies and 3 RCTs, only 1 retrospective study showed that anticonvulsants decrease the efficacy of ECT. Judicious assessment of all medications used in combination with ECT is recommended. Overall, published studies suggest that benzodiazepines and anticonvulsants impact the clinical outcomes of ECT less than what would be expected given their pharmacologic effects. However, there are significant gaps in the literature, including a lack of study on suprathreshold stimulation of right unilateral ECT and the possibility of a greater effect with higher medication doses.

Formula methods of estimating seizure threshold in bilateral electroconvulsive therapy (ECT) have been successful in 75% (at the first ECT) and 80% (at the sixth ECT) of treatments (Gangadhar et al., 1998). This study showed the same results for unilateral (UL) ECT patients. Its aim was to compare formula and titration methods for threshold determination. The seizure threshold (dependent variable) was determined by the titration method used at the first ECT in consecutive consenting patients (n = 80) prescribed UL ECT under general anesthesia. The independent variables were age, gender, diagnosis, illness severity, concurrent drugs, head circumference, and inion-nasion distance. Forward, step-wise, linear regression analysis showed age as the only significant predictor of seizure threshold (15% of variance). A formula based on regression analysis was prospectively applied in an independent sample (n = 30) of patients receiving UL ECT using the titration method for threshold determination. The results calculated a higher threshold than the actual threshold used in 14 patients, a threshold level in 8 patients, and below threshold in 8 patients. Formula-based estimates would have been successful in 22 (73%) patients, but the majority of them would have received higher than the recommended stimulus dose. Titration is the method preferred for clinical use. However, if a patient's doctor wishes to use the formula-based method, he or she should do so with specific considerations.

This Doctor of Medicine thesis is based on a series of seven published papers examining aspects of electroconvulsive therapy (ECT) that are of interest to old age psychiatrists. Review Papers. Two review papers are included. The first is a systematic review and meta-analysis of bifrontal ECT for depression. Bifrontal electrode placement was developed as a potentially cognitive-sparing alternative to more conventional electrode placements. Our findings suggested that the advantage of bifrontal ECT may lie in a more favourable benefit to cognitive risk profile than both bitemporal and high-dose right unilateral ECT, rather than in its absolute efficacy. Our in-depth review of the role of ictal electroencephalographic (EEG) indices in ECT practice addressed the objective of optimising ECT treatment technique as a means of improving its risk-benefit profile. Our findings suggested that measures of seizure intensity, consistency of EEG pattern over time and postictal suppression can be appraised alongside clinical findings to guide ECT administration. Epidemiological Studies. Our two original epidemiological studies examined ECT use in Victoria, Australia, from 1998 to 2007 based on analysis of statutory data from the Office of the Chief Psychiatrist of Victoria. There first provided an overview of ECT use in young (25-44 years), middle-aged (45-64 years) and older adults (65+ years) and graphically presented ten-year population-adjusted ECT utilisation rates. A higher utilisation rate among older adults was one key finding. The second paper reanalysed this data according to a ‘young-old’ (65-79 years) and ‘old-old’ (80+ years) age division to determine if this pattern was accentuated with increasing age. Age-adjustment of data revealed that old-old adults (women especially) had the highest rate of ECT use overall as well as for depression and public sector treatment. Our findings have clinical and service delivery implications, given the higher medical comorbidity and personal care needs of this population. Clinical Studies. The first of three original clinical research studies examined the rise in the stimulus dose required across a course of moderate-dose right unilateral ECT, as an indirect marker of treatment adequacy among older adults. Our finding that required treatment doses generally did not increase quickly, despite rising seizure thresholds across a treatment course, suggested that moderate-dose ECT cannot be dismissed as a treatment option simply because of the rate of change in electrical stimulation. The second paper examined the impact of ECT on tests of balance and gait, to increase understanding of the potential factors contributing to ECT-related falls in older adults. The absence of any deleterious effect of ECT on balance and gait led us to postulate that post-ECT confusion might actually be a key mediator of ECT-related falls. The final paper compared clinicodemographic characteristics of cognitive test completers and noncompleters from a prior study of the impact of ECT on the cognition of older adults, to determine the likelihood of the results of such studies being widely clinical applicable. Our findings suggested cognitive test nonparticipants to be more severely psychiatrically unwell than test participants, suggesting their exclusion might bias and clinically invalidate study results.

Purpose Multiple Chemical Sensitivity is a condition principally suffered by women. As with fibromyalgia and chronic fatigue syndrome, Multiple Chemical Sensitivity is usually included among the so called “contested illnesses”, defined as illnesses whose cause, diagnosis, prevalence and even existence are subject to controversy. This article seeks to explore how women with Multiple Chemical Sensitivity experience this contested illness, through their own descriptions of diagnostic processes, search for treatment and encounters with different health professionals. We aim to observe these experiences in detail and to identify aspects that could improve care for Multiple Chemical Sensitivity sufferers. Method Qualitative design. We performed personal in-depth interviews, which were recorded and transcribed to conduct a qualitative content analysis supported by Atlas.ti-7. Subjects/Patients 22 women diagnosed with Multiple Chemical Sensitivity in Spain. Results Two main categories were identified in the interviews: (1) unavoidable barriers: patients’ exposure to chemicals and the absence of treatment, and (2) Skepticism on the part of care providers and lack of recognition in the process of diagnosis. Conclusion Training and above all awareness raising strategies are needed to address health professionals’ prejudices regarding the existence of contested illnesses such as Multiple Chemical Sensitivity. These prejudices hinder diagnosis and medical follow-up, and add negative emotions to the physical limitations already suffered by patients. IMPLICATIONS FOR REHABILITATION Multiple Chemical Sensitivity It is important to promote a compassionate and empathetic attitude among health providers, in order to avoid rejection and delegitimization of the experiences of women with Multiple Chemical Sensitivity. Multiple Chemical Sensitivity protocols should be developed and implemented to give skills to health professionals to assist patients with Multiple Chemical Sensitivity. These protocols should include avoidance of exposure to chemicals present in healthcare facilities. Training programs for health providers should include not only knowledge, but awareness raising about the characteristics and severity of contested illnesses such as Multiple Chemical Sensitivity. Health providers should avoid stigmatizing patients by psychologizing their symptoms and be aware of the existence of stereotypes regarding women suffering from Multiple Chemical Sensitivity.

Bifrontal (BF) electrode placement has been explored to refine the electroconvulsive therapy (ECT) technique. No previous study has compared the cognitive effects of BF versus right unilateral (RUL) ECT by only including the subgroup that is most likely to receive it: elderly patients with major depression. Nondemented patients (n = 65) with major depression, aged 60 to 85 years, were randomly allocated to BF ECT and RUL formula-based ECT. Cognitive function was assessed at baseline (T1), within 1 week after a course of ECT (T2), and 3 months after T2 (T3). Six neuropsychological test measures of memory, 5 of executive function, and 3 of information-processing speed were administered. According to linear mixed models, there were no significant differences between the BF and RUL groups at any time. The retrograde memory score for public facts declined more for the RUL group (P < 0.001) than the BF group (P = 0.005) from baseline to the first retest and remained stable for both groups from T2 to T3. A rapid improvement in selective attention was observed in the RUL group from T1 to T2, but the scores remained stable from T2 to T3 (P < 0.001). This measure remained stable in the BF group from T1 to T3. Our findings indicate that there were negligible differences in the cognitive effects of formula-based BF or RUL ECT. The overall cognitive effects of ECT were equally favorable for each of the groups.

The efficacy of electroconvulsive therapy (ECT) has been recently questioned on the grounds that placebo-controlled (sham ECT) trials are all old and of poor quality; statements have been made that the prescription of ECT should immediately be suspended because its continued use cannot be scientifically justified. These criticisms have come from academicians and have been presented in scientific and news forums with wide readership. A rebuttal is therefore necessary, if only to counter the formation of negative attitudes among patients, health care professionals, and the general public. The quality of sham ECT randomized controlled trials (RCTs) is undoubtedly poor; however, this is so because these RCTs were conducted in an era in which such methodology was par for the field. What critics of ECT have not considered are the large, well-designed, well-conducted, and well-analyzed modern era RCTs that show that bilateral and high dose right unilateral ECT are more effective than low dose right unilateral ECT, or that brief-pulse ECT is more effective than ultrabrief-pulse ECT; in such situations, the inferior form of ECT may be regarded as an active placebo comparison group that represents a scientifically valid substitute for sham ECT. Critics of ECT also do not consider the parachute meta-analysis analogy; just as one does not need a meta-analysis of RCTs to conclude that parachutes work, so too one does not need a meta-analysis of new sham ECT RCTs to conclude that ECT works. ECT is usually recommended to patients who are catatonic, severely ill, or treatment-refractory, and if ECT did not work well in these patients, common sense tells us that it would not continue to be used for such patients more than 80 years after its introduction. Malaria therapy and leucotomy are somatic therapies that were honored with the Nobel Prize, but it is ECT that has survived.