One of the partial solved issues in the treatment of depression is somatic pain. Most antidepressants can reduce the intensity of affective symptoms, but somatic pain, if present, is unfortunately, the last which disappears.

to estimate the clinical efficacy of SSRI (paroxetine) compared to venlafaxine XR, a dual action antidepressant, in patients with Major Depressive Disorder (MDD) and somatic pain.

Clinical open study including 48 patients (28-56 years), both sexes, with MDD (DSM-IV), mean scores MADRS=28 and somatic pains at baseline (at least 1 symptom moderate-severe)

MADRS, Depression Checklist (developed by University of Michigan Depression Center), CGI-Severity, CGI-Improvement, side effects, somatic conditions and relapse (follow-up: 6 month).

The patients were divided in 2 groups: Group A: paroxetine (40mg/day), 23 patients; Group B: venlafaxine XR (225mg/day), 25 patients. After 8 weeks: responders in Group A=56%, in Group B= 59%; partial responders: Group A=21% and Group B=15%, non-responsive: Group A=12% and Group B=11%. Drop-outs: Group A=11% and Group B= 15%. Somatic symptoms: 36% of the Group A patients and 28% of the Group B presented at least 1 somatic symptom with moderate to severe intensity. The 6 month follow-up period we evaluated the relapses in all groups and the outcome of the somatic symptoms.

1. 1. In MDD patients both paroxetine and venlafaxine XR demonstrated a good therapeutic effect.

2. 2. The somatic symptoms were less influenced by both antidepressants, till the end of the study.

3. 3. The group B was more responsive to these important aspects.

It has been suggested that mECT reduce relapse rates in chronic/recurrent depression. We aimed to study its efficacy in this group.

A retrospective analysis of 19 patients who received mECT following a successful course of acute ECT. We compared admission rates and bed occupancy during the mECT period with periods of 2-4 years before and after mECT. Information was gathered from case-notes and hospital records. This group was then compared with a similarly matched group, who received a successful index aECT followed by other non-ECT maintenance therapies to compare for secular trends.

19 patients - average age 70.6 (44-88) received mECT (ave. 37 (12-89) applications, mean interval-2.5 weeks). Admission rate fell from 1.02 admission/year to 0.316 (p < 0.001) and acute in-patient stay from 15.24 weeks/year pre-mECT to 7.05 during mECT, p = 0.055 . This was maintained once mECT was stopped. This compared well with comparison group who went on to receive other mentainance therapy (for the same period to control for secular changes), where both admission rates and bed occupancy went up. The change in duration of hospital stay between the two groups were statistically very significant (p<0.001) in favour of the mECT group.

The findings suggest that mECT may have a role in reducing the rate and duration of hospital stay of patients with major depressive disorder. The main weaknesses are the small sample size. This may translate in to socio-economic benefits both for the patients and the health services.

a 69 year old man with drug resistant catatonic schizophrenic disorder was treated at the psychiatric clinic of a general hospital with courses of ECT. In the past he had also responded positively to the same treatment.

Course of the treatment: patient was admitted because of catatonic symptoms such as immobility, mutism and negativism. During his two hospitalizations, a total of 48 ECT sessions was given with encouraging results. Namely after the first hospitalization the patient left the hospital in excellent condition, where as in the second occasion results were fair.

ECT is one of the first somatic therapies in the history of psychiatry. In 1938 Cerletti and Bini administered the first successful treatment of schizophrenia inducing epileptic seizures via electricity. Today ECT is given under general anaesthesia including muscles relaxation, in organized hospital units and thus it is a safe and well tolerated therapy.

our case report confirms the fact that in elderly ECT seems to have good results and few side effects.

This study is a retrospective analysis of the clinical use of ECT at a county hospital in Norway. Our aim was to determine the ECT- parameters, effect and side effects of patients that received ECT and compare standards of ECT practice with similar studies conducted elsewhere.

The study is based on data collected from specific ECT journals and the patients’ hospital journals. We investigated treatment characteristics, side effects (headache, memory problems and others), and effect which was measured as either present or not present. The number of necessary sessions before effect was achieved was also registered.

210 patients received ECT in the study period. The mean number of ECT treatments was 7.9. Bilateral electrode placement was used for 63.3%. The analyses suggest that a unilateral placing of electrodes tended to increase the average number of treatments compared to the bilateral placing of electrodes. The level of energy compared to the placement of electrodes seemed to indicate that unilateral treated received higher energy than those who had the bilateral placing of electrodes. We found that high stimulus dosage required shorter cramps. Common side effects included headache (N=86), retrograde amnesia (N=31) and others (N=17), no side effects (N=28), missing data (N=65).

82.2% of patients improved with treatment, 51.1% experienced improvement between treatment 4 and 7, 17.8% patients did not respond to the treatment, missing data 35.7%.

Our findings are mainly in concordance with previous reports of ECT use in public funded hospitals.

It was repeatedly reported that low frequency rTMS diminishes treatment-resistant auditory hallucinations. The main drawback to rTMS in general, so far has been the impossibility of precise targeting of the rTMS coil at the given cortical area. Stereotactic neuronavigation is a unique technology utilising the ability of aiming the coil with a high degree of anatomic accuracy based on an evaluation of the structural or functional neuroimaging of the brain.

To prove the clinical effect of using rTMS neuronavigation in the therapy of treatment-resistant auditory hallucinations

Seventeen schizophrenic patients with predominantly symptoms of treatment-resistant auditory hallucinations were treated.

Using double-blind sham-controlled parallel design, we evaluated the effect rTMS neuronavigation focused over the left temporo-parietal area, direct to the place with the highest metabolic activity (SPM II analysed PET contrast).

Parameter settings were: 0.9Hz, MT 100%, 1080 puses/session, 10 sessions, duration: 20 minutes per session.

Clinical effect was assessed using PANNS, AHRS and HCS.

We found a significant improvement in the total on scales of HCS and AHRS, representing more than 30% reduction of the symptoms after neuronavigated rTMS. Sham rTMS did not showed a trend for improvement over time. No side effects during rTMS were observed.

Our study shows the acute effect of rTMS neuronavigation in the therapy of auditory hallucinations in schizophrenia. We believe that using neuronavigation and respecting an individual brain parameters and metabolic changes, we can evaluate higher efficiency of the rTMS method.

Supported by CNS, MZČR MZ0PCP2005 and MŠMT 1M0517

An 83-year old female patient was first admitted to our department at the age of 72 years, after a suicide attempt. She was diagnosed as having psychotic depression and received antidepressive medication with moderate effect. Relapses were multiple despite continuation medication. The failure of administered antidepressive medication to prevent relapse, necessitated the use of index, continuation and eventually maintenance ECT. The additional parallel use of mood stabilisers (lithium and lamotrigine) allowed us to lower the frequency of M-ECT. Attempts to discontinue M-ECT led to relapse and M-ECT is now seen as a life-long treatment for that patient. To date (2007) our patient has received 450 treatments. Her depression remains in remission over the last years. Despite the unusual large number of administered ECT, her memory function appears to be unimpaired and repeated assessments with the MMSE test have not revealed cognitive deterioration.

For some patients long-term M-ECT is the only effective treatment to prevent relapse in depression. The risks of long-term M-ECT, especially regarding its possible adverse effects on cognition, are still under research.

Our case-report provides support for the safety of expanded M-ECT which, in some cases, can be seen as a life-long treatment.

Number of previous studies reported that low-frequency repetitive transcranial magnetic stimulation (rTMS) diminishes treatment-resistant auditory hallucinations. However, little is known about the electrophysiological effect on regional functional activity subsequent to the rTMS treatment.

Eighteen schizophrenic patients with antipsychotic-resistant auditory hallucinations were randomized to either active (n=9) or sham (n=9) rTMS. Low-frequency rTMS (0,9Hz, 100% MP, 1200 stimuli per session) was administered over the left temporo-parietal region for ten days. In case of sham rTMS a coil was tilted at 90°. EEG data were recorded within tree days before and after rTMS treatment. The localization of the differences in electrical activity (current density) was assessed by voxel-by-voxel paired t-tests of the LORETA (low resolution brain electromagnetic tomography) images. The clinical effect was assessed by the Positive and Negative Syndrome Scale (PANSS), Hallucination Change Scale (HCS) and the Auditory Hallucination Rating Scale (AHRS) by a rater blind to the treatment condition.

After two weeks of treatment, both HCS and AHRS scores were significantly improved for patients receiving active rTMS compared to the sham group. LORETA analysis revealed a decrease of current densities in high-frequency bands (alpha 2, beta 1 and beta 2) in the left frontal, temporal and parietal lobes in case of active group. No significant differences in electrical activity were observed in sham group.

Real rTMS but not sham stimulation attenuated an auditory hallucinations and was associated with a decrease of activity in high-frequency bands on the left hemisphere.

Electroconvulsive therapy (ECT) is a safe and effective treatment for severe and persistent depression, bipolar disorder and schizophrenia. The authors pretend to describe their experience and evaluate the efficacy of the technique on clinical practice.

We present our experience of ECT use at a University Hospital in Lisbon, Portugal, over the course of 5 years, thought a naturalistic review.

During the study period, 81 patients received ECT. ECT was conducted under the supervision of consultant psychiatrist and anaesthetist with continuous monitoring during and after the procedure. Bitemporal electrode placement was used twice or thrice weekly. Most commonly used sleep induction agents were thiopental and propofol. The average number of ECTs administered per patient was 8. Patients who received ECT were diagnosed unipolar major depression (49.4%), bipolar disorder (29.6%), schizophrenia (19.8%) and schizoaffective disorder (1.2%). Mean age of patients who received ECT were 44 years, in a great range between 16 and 81 years-old. The majority was female (65.4%). Almost all patients showed improvement in their clinical condition (90%). The most frequent complication was bradycardia followed by hypertension. No major complication was observed in any of the patients. Thirty-three percent of patients repeat the ECT along those 5 years. When support ECT started to be realized, recurrence decreased.

Our study demonstrates the effectiveness of ECT. We strongly recommend following guidelines to ensure patient safety and minimizing side effects. This will ensure better patient acceptability and compliance.

Major depression is one of the most prevalent diagnoses in the elderly and represents an important cause of morbidity and mortality in this group. There exists evidence that electroconvulsive therapy (ECT) is particularly efficient and safe in the elderly patient.

Bibliographic review on Pubmed, Medline and Textbooks of Psychiatry

The use of ECT in the psychogeriatric patient has indication in episodes of major depression, mania, schizophrenia and other psychotic disorders, and also when there exists concomitant neurological (affective disorders in dementia, Parkinson´s disease, and post stroke depression). or other mental syndromes (catatonia or delirium secondary to various medical conditions).

Because the geriatric population suffers multiple organic comorbidities, the following risk factors require evaluation: history of head trauma, focal or general neurological complaints (recent stroke, intracranial tumour, hypertension or aneurysm), angina, congestive heart failure, bone fractures, osteoporosis, spinal disease and oesophageal reflux.

The following adverse effects have been described: cardiac ischemia, arrhythmia (tachycardia and bradycardia), hypertension, pneumonia secondary to aspiration of gastric contents, musculoskeletal and dental injury, increase of intraocular pressure, post ictal confusion and disorientation, impaired retrograde and anterograde memory.

The indication, risks factors and possible adverse effects of ECT should be carefully evaluated in the elderly patient.

Cognitive side-effects are the most troublesome side-effects after electroconvulsive therapy (ECT). Efforts to reduce side-effects, maintaining a high efficacy are ongoing. Cognitive effects of bifrontal and unilateral ultra-brief pulse ECT were compared, in the treatment of patients with a depressive episode.

Sixty four patients with a depressive episode that was highly medication refractory, and with a high degree of comorbidity completed a course of bifrontal ECT at 1.5 times seizure threshold (ST) or unilateral ECT at 6 times ST, with a pulse width of 0.3 msec by random assignment. An extensive cognitive battery was performed at baseline and at 1 and 6 weeks post-treatment, by a blinded rater.

At the end of the treatment course, 78.1% of patients responded (≥ 50% decrease HDRS-scores). There was a significant increase in global cognitive function (MMSE), verbal memory (RAVLT), attention (CPT), executive function (WCST) and autobiographical memory (AMI). Patients reported a significant increase of their subjective memory function both during and after the ECT-course. There were no significant differences between the patients given bifrontal ECT and those given unilateral ECT.

Bifrontal and unilateral ultra-brief pulse ECT are effective treatment techniques that do not cause measurable cognitive side-effects or cognitive complaints.

Electroconvulsive therapy (ECT) involves the administration of a variable frequency electrical stimulus shock via electrodes applied to the scalp to induce a seizure for therapeutic purposes. In 2001, the American Psychiatric Association (APA) task force on ECT concluded that convincing data exists to support use for major depression, bipolar depression and mania, schizophrenia, and schizoaffective and schizophreniform disorders. However, the National Institute for Clinical Excellence in the UK (NICE 2003) does not recommend that ECT be used as a long-term treatment to prevent recurrence of depressive illness, and that it recommends that ECT should not be used in the general management of schizophrenia.

To review and describe the practice of ECT in the largest psychiatric hospital in Singapore.

This was a retrospective descriptive study performed on all patients who were administered electroconvulsive therapy at the Institute of Mental Health in Singapore during the 2-year study period of 1st July 2005 – 30th June 2007. Data was collected from existing medical records on the demographics, indications, frequency and the complications of the patients given ECT. The frequency of missed fits was also determined as measuring the number of missed-fits provided one way of assessing an ECT clinic's efficiency.

The main indications for electroconvulsive therapy at the Institute of Mental Health in Singapore were patients with Schizophrenia or Schizoaffective Disorders with poor response to medications, followed by patients with mood disorders. The rate of complications of ECT and the frequency of missed-fits were found to be low.

The previous studies have detected changes of brain electrical activity after the cerebellar hemisphere rTMS and the vermis rTMS. We supposed that right cerebellar 1Hz rTMS evokes changes in the left frontal cortex. The aim of our study was to determine if 1Hz cerebellar hemisphere and 1 Hz vermis rTMS induces different effect in frontal electrical activity.

We used 10 minutes of 1 Hz rTMS (with 600 impulses) in two sessions (first session- application over the right cerebellar hemisphere, second over the vermis). 31-channel EEG was recorded in 5 right-handed healthy volunteers before and after rTMS. The 3D distribution of the current density was revealed by a method of qEEG- Low Resolution Brain Electromagentic Tomography (LORETA, Pascual-Marqui et al. 1994; 1999).

After 1 Hz right cerebellar hemisphere rTMS the current density decreased in the alfa2, beta1, beta2 and beta3 band over the frontal cortex including medial frontal cortex and the anterior cingulate (p<0.01). After 1 Hz vermis rTMS we found no significant changes.

Our results suggest the possibility to influence the frontal cortical activity by means of the cerebellar hemisphere rTMS. No significant changes after 1Hz vermis rTMS may suggest either large distance between the rTMS coil and the vermis or our sample is too small to make definitive conclusions.

Supported by MZ0PCP2005 and 1M0517

This paper reviews electroconvulsive therapy (ECT) in children and adults with autism and concomitant psychopathology, including affective illness, catatonia and self-injury. Case examples are highlighted.

A review of the English-language literature on ECT in pediatric, adult, autistic and mentally retarded populations was conducted, with focus on catatonia, drug-resistant psychiatric illness and self-injury. This was combined with the author's experience with two autistic adolescents in catatonic stupor, and an autistic child and young adult with severe affective disturbance and self-injury. All four patients underwent ECT with excellent symptom resolution.

ECT is an effective and safe treatment modality across the lifespan for a wide range of psychopathology. Current literature supports the appropriateness, safety and efficacy of ECT in autistic and intellectually disabled populations, where patients suffer from an increased incidence of psychiatric and behavioral disturbances. The following cases are presented:

Pt 1: An 18-year-old female with autism, MR and self-injury in classic catatonic stupor.

Pt 2: A 15 year-old male with autism and MR in catatonic stupor confounded by bradycardia and arrhythmias.

Pt 3: A 19-year-old male with autism, MR, profound depression, tics, compulsions and catatonic symptoms accompanied by self-injury.

Pt 4: An 8-year-old boy with autism, MR, cyclical mood disturbance and intractable self-injury confined to full-body protective equipment.

Electroconvulsive therapy affords excellent symptom remission in autistic individuals with affective illnesses and catatonia, which may be complicated by dangerous self-injury. Prompt diagnosis and pursuit of ECT significantly improve clinical outcome in this patient population.

Uncertainty prevailing about the role of lithium for the development of chronic renal failure; and the prevalence of lithium-induced end-stage renal disease (ESRD) being virtually unknown, we decided to clarify these issues.

Using a questionnaire we counted the number of former or present lithium patients among all ESRD patients on renal replacement therapy (RRT, i.e. dialysis or renal transplant) in two defined regions in Sweden, comprising 30 % of 9 million Swedes. We also counted the number of all lithium patients in the areas. A chart review is under way to retrieve clinical data for the assessment of the nephrotoxic effect of the lithium therapy.

There were 2,270 RRT patients (0.08 % of the general population). Twenty-seven of them (1.2 %) acknowledged long-term lithium treatment. Seventeen were on dialysis, ten were transplanted. The concurrent number of lithium patients was 3,567.

Based on our own earlier studies we estimate that 900 (25 %) of the lithium patients in the two regions had been on lithium ≥15 years. Thus, twenty-seven of the long-term lithium patients in this study were subject to RRT.

The prevalence of lithium nephropathy in the RRT population is at least 1 %, 0.8 % in the entire lithium population, and approximately 3 % among long-term lithium patients. The risk of developing ESRD is higher when on lithium therapy compared to the general population. Our results so far underscore the need for adequate safety programs, ascertaining the early detection of lithium nephropathy.

Behçet's Disease(BD) is a primary vasculitis with wide variety of symptoms, in which psychiatric disorders as Bipolar Affective Disorder(BPD) are seen. In such cases; as in all comorbidities, the importance of preferring appropriate treatment is emphasized.

We present a case of hematologic toxicity associated with a valproate level of 116 mg/l in of BPD and BD comorbidity.

The 38 years old male patient, who was diagnosed as BPD 10 years ago and BD 3 years ago, was hospitalized for mixed episode with psychotic features. His routine laboratory parameters were in normal ranges. Olanzapine 10mg/d and valproate 500mg/d were started and Valprote was titrated up to 1000 mg/d. At the 8th day of medication he complained of fatigue and somnolence. By the following 6 days a decrease in the hematologic values as: haemoglobin:15,0/11,4g/dl, hematocrit:%42/32, platelets:334000/202000 microg/ml was noticed. He had no active symptoms of BD. The liver enzymes were moderately high and because of the hepatoxicity with valproate was reported in previous studies, Valprote was stopped and Olanzapine was continued. The hematological and biochemical parameters normalized in two weeks.

The decrease of hematological parameters could not be explained by BD itself or any other organic pathology and normalized after cessation of valproate. Thus a hematotoxicty associated by valproate was considered.

Although the effects of the comorbidity of BPD-BD to hemototoxicity are not clear exactly, this case underlies the importance of careful monitoring the Valprote levels and associated parameters in BPD particularly if comorbidity is present.

Lithium occurs naturally in food and water. While low environmental concentrations in drinking water are associated with mental illnesses and behavioral offences, at therapeutic dosages it is used to treat psychiatric disorders, partly by facilitating serotonergic (5-HT) neurotransmission. However, as little is known about the physiological role of nutritional lithium for neurobiological functioning and emotional processing in the general population, endogenous lithium concentrations were hypothesized to be associated with measurable effects on emotional liability and the loudness dependence (LD) that is proposed one of the most valid indicators of 5-HT neurotransmission.

Auditory evoked potentials (AEP) of healthy volunteers with either high or low lithium serum concentrations were recorded using multi-channel EEG. Emotional liability was assessed using the Brief Symptom Inventory (BSI).

Serum lithium concentrations varied widely, low levels correlating with symptoms of Somatization. While there were no significant correlations between LD and lithium concentrations, LD correlated positively with Paranoid Ideation, and in the high-lithium group inversely with further aspects of emotional liability (Depression, Psychological Distress).

Effects of low levels of endogenous lithium are associated with an increase in emotional liability, and high levels with some protective effects. Findings on the mediating neural correlates point to the 5-HT system, but remain inconclusive regarding LD. Potential benefits of endogenous lithium as a neurobiological trace element on neurobehavioral functioning especially in high-risk individuals would have public health implications.

In the last decades there has been a steady increase in the usage of mood stabilizers (MS); especially for prevention of affective disorders and those illnesses with important loss of impulse control. Our objective was to evaluate trends in the use of MS in our Unit.

113 patients prescribed a MS when admitted, or discharged, from our acute unit, were selected between March 2007 and August 2007. Clinical and demographic relevant variables were taken into consideration. Diagnoses were divided into 10 different categories. Statistical methods were used when appropriated.

40.37% of all the admitted patients were taking MS (100% of all the patients with Borderline Personality Disorders, BPD; 80% of all the patients with Bipolar Disorders, BD). Topiramate (40.71%), Oxcarbamazepine (27.43%) and Lamotrigine (23.89%), were the most used MS. In BD, the use of lithium was common but usually in combination therapy. Topiramate was used for BPD and Lamotrigine for unipolar depression. The largest increase of prescription during admission was observed with oxcarbamazepine.

Nearly a third of the patients admitted received MS, which indicates a high prevalence of use. Lithium remains the first choice MS for the treatment of BD, usually used in association with another MS.

New MS are widely used, especially in disorders which include impulsivity, probably due to a better profile of adverse reactions/interactions than classic MS. However more solid evidence of their efficacy is needed.