Brattleboro Retreat Psychiatric Review
June 1996
Sarah K. Lentz - Dartmouth Medical School - Class of 1997

Introduction

Psychiatric illness during pregnancy often presents a clinical dilemma. Pharmacologic interventions that are usually effective for these disorders have teratogenic potential and are therefore contraindicated during pregnancy. However, for depression, mania, catatonia, and schizophrenia, an alternative treatment exists: electroconvulsive therapy (ECT), the induction of a series of generalized seizures.

Psychiatric Treatment during Pregnancy

Pharmacologic therapies pose risks to the fetus in pregnant patients. Antipsychotics, particularly phenothiazines, have been noted to cause congenital anomalies in babies born to women treated with these medications during pregnancy (Rumeau-Rouquette 1977). Congenital defects have also been associated with the use of lithium, especially when administered during the first trimester (Weinstein 1977). However, in a recent study by Jacobson et al. (1992), no association between lithium and congenital anomalies was found. Tricyclic antidepressants have been associated with limb reduction deformities (McBride 1972) and, moreover, take four to six weeks to affect depression. During this time, risk to the fetus and woman may be substantial, depending on the mental and psychologic condition of the mother, her ability to care for herself, and possible suicidality. In a crisis situation in which the risks of untreated symptoms are extreme, the patient is known to be refractory to medications, or the medication represents a substantial risk to the fetus, ECT represents a valuable alternative in the pregnant patient. When administered by trained staff, and when precautions germane to pregnancy are taken into account, ECT is a relatively safe and effective treatment during pregnancy.

ECT: The History

Electroconvulsive therapy was first introduced as an effective treatment option for psychiatric illness in 1938 by Cerletti and Bini (Endler 1988). Several years earlier in 1934, Ladislas Meduna introduced the induction of generalized seizures with the pharmacological agents camphor and then pentylenetetrazol as effective treatment in a number of psychiatric illnesses. Prior to this time, no effective biological treatment for psychiatric illness was in use. The work of Meduna therefore, opened a new era of psychiatric practice and was quickly accepted throughout the world (M. Fink, personal communication). With the discovery that more predictable and effective seizures could be induced by ECT, the pharmacological method fell into disuse. ECT persisted as a mainstay of therapy until the 1950s and 1960s, when effective antipsychotic, antidepressant, and antimanic drugs were discovered (Weiner 1994). ECT was largely replaced by medications from this point until the early 1980s, when its usage level stabilized. However, a renewed interest in ECT in the medical community, prompted by failures of pharmacotherapy, has led to an increase in its judicious use in treatment-refractory patients with several psychiatric illnesses, including depression, mania, catatonia, and schizophrenia and also in circumstances in which psychopharmacological treatment is contraindicated, such as during pregnancy (Fink 1987 and personal communication).

ECT: The Procedure

Standard procedure. During the procedure, the patient is administered a short-acting barbiturate, typically methohexital or thiopental, which puts the patient to sleep, and succinylcholine, which induces paralysis. Paralysis suppresses the peripheral manifestations of the seizure, protecting the patient from fractures caused by muscular contractions and other injuries induced by the seizure. The patient is ventilated with 100% oxygen through a bag and hyperventilated before the electrical stimulus is administered. An EEG should be monitored. The stimulus is applied either unilaterally or bilaterally, inducing a seizure that should last at least 35 seconds by EEG. The patient is asleep for 2 to 3 minutes and awakens gradually. Vital signs are monitored throughout (American Psychiatric Association 1990).

Systemic changes that may occur during ECT include a brief episode of hypotension and bradycardia, followed by sinus tachycardia and sympathetic hyperactivity with an increase in blood pressure. These changes are transient and typically resolve over the course of minutes. The patient may experience some confusion, headache, nausea, myalgia, and anterograde amnesia following the treatment. These side effects generally clear over the course of several weeks following completion of the treatment series but can take up to six months to resolve. In addition, the incidence of side effects has been decreasing over the years as ECT technique has improved (American Psychiatric Association 1990). Finally, the mortality rate associated with ECT is approximately only 4 per 100,000 treatments and is generally cardiac in origin (Fink 1979).

During pregnancy. ECT has been found safe during all trimesters of pregnancy by the American Psychiatric Association. However, all ECT on pregnant women should occur in a hospital with facilities to manage a fetal emergency (Miller 1994). During pregnancy, several recommendations are added to the standard procedure to decrease potential risks. An obstetric consultation should be considered in high-risk patients. Vaginal exam is not obligatory, though, since it is relatively contraindicated during pregnancy. Furthermore, nothing about the vaginal exam would affect ECT. In the past, external fetal cardiac monitoring during the procedure was recommended. However, no alteration in fetal heart rate has been observed. Therefore, fetal monitoring as a routine part of the procedure is not warranted given its expense and lack of utility (M. Fink, personal communication). In high-risk cases, the presence of an obstetrician during the procedure is recommended.

If the patient is in the second half of pregnancy, intubation is the standard of anesthetic care to reduce the risk of pulmonary aspiration and resultant aspiration pneumonitis. During pregnancy, gastric emptying is prolonged, increasing the risk of aspiration of regurgitated gastric contents during ECT. Pneumonitis may result following aspiration of particulate matter or acidic fluid from the stomach. Standard procedure requires the patient to take nothing by mouth after midnight the night preceding ECT. However, in the pregnant patient this is often insufficient to prevent regurgitation. In the second half of pregnancy, intubation is performed routinely to isolate the airway and reduce the risk of aspiration. In addition, administering a nonparticulate antacid, such as sodium citrate, to raise gastric pH, may be considered as optional adjuvant therapy, but its usefulness is debated (Miller 1994, M. Fink, personal communication).

Later in pregnancy, risk of aortocaval compression becomes a concern. As the uterus increases in size and weight, it may compress the inferior vena cava and lower aorta when the patient is in the supine position, as she is during ECT treatment. With compression of these major vessels, increased heart rate and peripheral resistance compensate but perhaps insufficiently to maintain placental perfusion. This can be prevented, however, by elevating the patient's right hip during the ECT treatment, which displaces the uterus to the left, relieving pressure on the major vessels. Assuring hydration with adequate fluid intake or intravenous hydration with Ringer's lactate or normal saline before ECT treatment will also reduce this risk of reduced placental perfusion (Miller 1994).

ECT During Pregnancy:

Risks and Complications

Reported complications. In a retrospective study of ECT use during pregnancy by Miller (1994), 28 of 300 cases (9.3%) reviewed from the literature from 1942 to 1991 reported complications associated with ECT. The most common complication found by this study is fetal cardiac arrhythmia. Noted in five cases (1.6%), disturbances in fetal cardiac rhythm included irregular fetal heart rate up to 15 minutes postictally, fetal bradycardia, and reduced variability in fetal heart rate. The latter is hypothesized to have been in response to barbiturate anesthetic. The disturbances were transient and self-limited, and a healthy baby was born in each case.

Five cases (1.6%) also reported known or suspected vaginal bleeding related to ECT. Mild abruptio placentae was the cause of bleeding in one case and recurred after each of a weekly series of seven ECT treatments. No source of bleeding was identified in the remaining cases. However, in one of these cases, the patient had experienced similar bleeding in a previous pregnancy during which she received no ECT. In all these cases, the baby was again born healthy.

Two cases (0.6%) reported uterine contraction following shortly after ECT treatment. Neither resulted in any noticeable adverse consequences. Three cases (1.0%) reported severe abdominal pain directly following ECT treatment. The etiology of the pain, which resolved following the treatment, was unknown. In all cases, healthy babies were born.

Four cases (1.3%) reported premature labor after the patient received ECT during pregnancy; however, labor did not immediately follow ECT treatment, and it appears ECT was not related to the premature labors. Similarly, five cases (1.6%) reported miscarriage in pregnant patients who received ECT during their pregnancy. One case appeared to be due to an accident. However, as Miller (1994) points out, even including this latter case, a miscarriage rate of 1.6 percent is still not significantly higher than that of the general population, suggesting that ECT does not increase the risk of miscarriage. Three cases (1.0%) of stillbirth or neonatal death in patients undergoing ECT during pregnancy were reported, but these appear to be due to medical complications unrelated to the ECT treatment.

Medication risks

Succinylcholine, the muscle relaxant most commonly used to induce paralysis for ECT, has undergone limited study in pregnant women. It does not cross the placenta in detectable amounts (Moya and Kvisselgaard 1961). Succinylcholine is inactivated by the enzyme pseudocholinesterase. Approximately four percent of the population is deficient in this enzyme and could, consequently, have a prolonged response to succinylcholine. In addition, during pregnancy, pseudocholinesterase levels are low, so this prolonged response is not infrequent and could occur in any patient (Ferrill 1992). In the Collaborative Perinatal Project (Heinonen et al. 1977), 26 births to women exposed to succinylcholine during the first trimester of pregnancy were assessed after birth. No abnormalities were noted. However, several case reports noted complications in the use of succinylcholine during the third trimester of pregnancy. The most notable complication studied in women undergoing caesarian section was development of prolonged apnea that required continuous ventilation and lasted several hours to days. In nearly all the infants, respiratory depression and low Apgar scores were seen after birth (Cherala 1989).

Pharyngeal secretions and excessive vagal bradycardia can also occur during ECT treatments. To prevent these effects during the procedure, anticholinergic agents are often administered prior to ECT. The two anticholinergics of choice are atropine and glycopyrrolate. In the Collaborative Perinatal Project (Heinonen et al. 1977), 401 women received atropine, and four women received glycopyrrolate during their first trimester of pregnancy. In the women who received atropine, 17 infants (4%) with malformations were born, while in the glycopyrrolate group, no malformations were seen. The incidence of malformations in the atropine group was not greater than would be expected in the general population. Likewise, studies of these two anticholinergics used in the third trimester of pregnancy or during labor did not reveal any adverse effects (Ferrill 1992).

To induce sedation and amnesia prior to the treatment, a short-acting barbiturate is typically used. The agents of choice, methohexital, thiopental, and thiamylal, have no known adverse effects associated with pregnancy (Ferrill 1992). The only known exception is that administration of a barbiturate to a pregnant woman with acute porphyria may trigger an attack. Elliot et al. (1982) conclude that the recommended dose of methohexital in nonpregnant adults appears to be safe for use during the third trimester of pregnancy.

Teratogenicity. In the retrospective study by Miller (1994), five cases (1.6%) of congenital abnormalities were reported in children of patients who underwent ECT during pregnancy. The cases with noted abnormalities include an infant with hypertelorism and optic atrophy, an anencephalic infant, another infant with clubfoot, and two infants demonstrating pulmonary cysts. In the case of the infant with hypertelorism and optic atrophy, the mother received only two ECT treatments during the course of her pregnancy; however, she had received 35 insulin coma therapy treatments, which are suspected of teratogenic potential. As Miller notes, no information on other potential teratogenic exposures was included in these studies. Based on the number and pattern of congenital anomalies in these cases, she concludes that ECT does not appear to have an associated teratogenic risk.

Long-term effects in children. Literature examining the long-term effects of ECT treatment during pregnancy is limited. Smith (1956) examined 15 children between the ages of 11 months and five years whose mothers had undergone ECT during pregnancy. None of the children demonstrated intellectual or physical abnormalities. Sixteen children, aged 16 months to six years, whose mothers had received ECT during the first or second trimester of pregnancy, were examined by Forssman (1955). None of the children was found to have a defined physical or mental defect. Impastato et al. (1964) describes follow-up on eight children whose mothers had received ECT during pregnancy. The children ranged in age from two weeks to 19 years at the time of examination. No physical deficits were noted; however, mental deficiencies were noted in two and neurotic traits in four. Whether ECT contributed to the mental deficits is questionable. The mothers of the two mentally deficient children had received ECT after the first trimester, and one received insulin coma treatment during the first trimester, which could have contributed to the mental deficit.

Summary

ECT offers a valuable alternative for treating the pregnant patient suffering from depression, mania, catatonia, or schizophrenia. Pharmacological therapy for these psychiatric illnesses carries inherent risks of side effects and adverse consequences to the unborn child. Medications often require a long time to take effect, or the patient may be refractory to them. Additionally, these psychiatric conditions themselves are a risk to the mother and fetus. An effective, expeditious, and relatively safe alternative for pregnant patients requiring psychiatric treatment is ECT. The risk of the procedure can be minimized by modifying the technique. Medications used during the procedure are reportedly safe to use during pregnancy. In addition, complications reported in pregnant patients who received ECT during pregnancy have not been conclusively associated with the treatment. Research conducted to date suggests that ECT is a useful resource in psychiatric treatment of the pregnant patient.

Bibliography
References
* American Psychiatric Association. 1990. The practice of electroconvulsive therapy: recommendations for treatment, training, and privileging. Convulsive Therapy. 6:85-120.
* Cherala SR, Eddie DN, Sechzer PH. 1989. Placental transfer of succinylcholine causing transient respiratory depression in the newborn. Anaesth Intens Care. 17:202-4.
* Elliot DL, Linz DH, Kane JA. 1982. Electroconvulsive therapy: pretreatment medical evaluation. Arch Intern Med. 142:979-81.
* Endler NS. 1988. The origins of electroconvulsive therapy (ECT). Convulsive Therapy. 4:5-23.
* Ferrill MJ, Kehoe WA, Jacisin JJ. 1992. ECT during pregnancy. Convulsive Therapy. 8(3):186-200.
* Fink M. 1987. Is ECT usage decreasing? Convulsive Therapy. 3:171-3.
* Fink M. 1979. Convulsive Therapy: Theory and Practice. New York: Raven.
* Forssman H. 1955. Follow-up study of sixteen children whose mothers were given electric convulsive therapy during gestation. Acta Psychiatr Neurol Scand. 30:437-41.
* Heinonen OP, Slone D, Shapiro S. 1977. Birth defects and drugs in pregnancy. Littleton, MA: Publishing Sciences Group.
* Impastato DJ, Gabriel AR, Lardaro HH. 1964. Electric and insulin shock therapy during pregnancy. Dis Nerv Syst. 25:542-6.
* Jacobson SJ, Jones K, Johnson K, et al. 1992. Prospective multicentre study of pregnancy outcome after lithium exposure during first trimester. Lancet. 339:530-3.
* McBride WG. 1972. Limb deformities associated with iminobenzyl hydrochloride. Med J Aust. 1:492.
* Miller LJ. 1994. Use of electroconvulsive therapy during pregnancy. Hosp Community Psychiatry. 45(5):444-450.
* Moya F, Kvisselgaard N. 1961. The placental transmission of succinylcholine. J Amer Society Anesthesiology. 22:1-6. * Nurnberg HG. 1989. An overview of somatic treatment of psychosis during pregnancy and postpartum. Gen Hosp Psychiatry. 11:328-338.
* Rumeau-Rouquette C, Goujard J, Huel G. 1977. Possible teratogenic effect of phenothiazines in human beings. Teratology. 15:57-64.
* Smith S. 1956. The use of electroplexy (ECT) in psychiatric syndromes complicating pregnancy. J Ment Sci. 102:796-800.
* Walker R, Swartz CD. 1994. Electroconvulsive therapy during high-risk pregnancy. Gen Hosp Psychiatry. 16:348-353.
* Weiner RD, Krystal AD. 1994. The present use of electroconvulsive therapy. Annu Rev Med 45:273-81.
* Weinstein MR. 1977. Recent advances in clinical psycopharmacology. I. Lithium carbonate. Hosp Formul. 12:759-62.

Brattleboro Retreat Psychiatry Review
Volume 5 - Number 1 - June 1996
Publisher Percy Ballantine, MD
Editor Susan Scown
Invited Editor Max Fink, MD

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Electroconvulsive Therapy/ECT: Ontario - 1995-2001 (Partial and Approximate) Compiled by Don Weitz [5]

[5]Note: PPHs=provincial psychiatric hospitals. ECTs at Penetanguishene & Hamilton mental health centres are administered at local general hospitals as of 1999. GCPHs=general hospitals/community psychiatric hospitals, include Centre for Addiction & Mental Health. Since the Ministry of Health publishes no figures for number of patients in GCPHs, these figures must be approximate. Sincere thanks to the Ministry of Health for providing me with the raw data from which I calculated the above numbers and per cents. All data are based on the fiscal year April 1-March 31. Some ECT statistics are available under Freedom of Information requests. There is no government rule or regulation requiring hospitals to report ECT statistics to the Ministry of Health.

For survivor-produced electroshock information, see these urls:
Shocked! ECT Resources
Mind Freedom

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Before you go any further, I want to remind you, I am not a doctor and the information below is not medical advice. For diagnosis and treatment, please see a licensed doctor or therapist.

Books and Tapes

I highly recommend Healing Anxiety with Herbs by Dr. Harold Bloomfield, Hope And Help For Your Nerves and Peace From Nervous Suffering by Dr. Claire Weekes, and Taking Back The Power, an audio package by Bronwyn Fox.

Meditation and Relaxation Tapes

I try to meditate at least once a day. It helps control negative thoughts which provoke anxiety and is a very powerful and useful tool which you can incorporate in your every day routine to help eliminate negative thoughts. Meditation works on relaxing your mind. Once your mind relaxes, your body follows. Relaxation techniques work on relaxing the muscles in your body. Once you have learned these techniques you can apply them in any situation.

Emotional Freedom Technique

This technique is used by tapping on certain meridian points to help alleviate symptoms of anxiety. It works extremely well on phobias.

Herbs and Vitamins

Passion flower: Passion flower is a very effective herb for many nerve conditions. It sedates, soothes and relaxes, helps relieve muscular spasms, and tends to relieve pain. Passion flower assists in insomnia, with no associated side effects such as stupor, depression, and confusion; as often occurs with various drugs used to treat insomnia.

Nervous tensions, nervous agitation, anxiety, hysterical behaviour, hyper-activity in children, poor mental concentration, Parkinson's disease, epilepsy, neuralgia, shingles, high blood pressure, spasmodic asthma and nervous conditions associated with menstrual periods, child birth and menopause may all be relieved by this wonderful, safe, gentle nervine herb.

Passion flower is often available combined with valerian in nerve relaxer formulas, or in herbal formulas for insomnia in combination with valerian and other herbs and minerals.

Chamomile: For centuries Chamomile has been a highly respected herb. In the garden, it's thought of as the doctor plant because it helps to strengthen and revive weak herbs nearby. Chamomile's action and influence is rapid upon the circulation, stomach and uterus, and also relaxes nerves. It promotes normal monthly periods and relieves muscular pain and spasms, including colic.

It's soothing to babies, but is also beneficial as a general tonic, assisting the appetite, digestion, and relieving some cases of lumbago, neuralgia, insomnia and rheumatic problems.

As a strong tea, this herb is anti-inflammatory, antibiotic and anti-spasmodic, being useful for menstrual cramps and mild internal infection. The Germans state that the curative powers of Chamomile are immense and call it alles zutraut, which means capable of anything.

Bach's Rescue Remedy: Consists of five remedies which are combined together. It consists of STAR OF BETHLEHEM for shock. ROCK ROSE for great fear and panic. IMPATIENTS for mental and physical tension, when the sufferer cannot relax and the mind is agitated and irritable. CHERRY PLUM for loss of emotional control, when the sufferer screams, shouts or becomes hysterical; and CLEMATIS, the remedy for the bemused, distant feeling, which often precedes a faint.

Kava Kava: The botanical has been used in parts of the Pacific at traditional social gatherings as a relaxant and in cultural and religious ceremonies to achieve a higher level of consciousness. The roots can be made into a mildly narcotic beverage that's comparable to popular cocktails in our culture. In Germany, Kava Kava is used as a nonprescription drug to reduce anxiety. Kava was first mentioned in scientific records in 1886, and it is gaining popularity in the U.S. for its relaxing effects.

More recently, Kava Kava has also gained popularity with the natives of Hawaii, Australia and New Guinea where it is used medicinally, as well as recreationally. Kava also is effective as a pain reliever and can be used instead of aspirin, acetaminophen and ibuprofen.

Recent clinical studies have shown that the herb kava is a safe, nonaddictive, anti-anxiety medicine, and is as effective as prescription anxiety agents containing benzodiazepines such as valium. While benzodiazepines tend to promote lethargy and mental impairment, kava has been shown to improve concentration, memory, and reaction time for people suffering from anxiety. Kava has been clinically demonstrated as a means of achieving a state of relaxation without the adverse side effects.

B Complex: Nourishes nerve and brain tissue for healthy mental function. Provides dietary support for proper metabolic function of the body's immune system. Helps the body effectively manage fatigue and tension. Provides essential vitamins that support a healthy cardiovascular system.

B5: Pantothenic acid (vitamin B5)s' most important function is as an essential component in the production of coenzyme A, a vital catalyst that is required for the conversion of carbohydrates, fats, and protein into energy. Pantothenic acid (vitamin B5) is also referred to as an antistress vitamin due to its vital role in the formation of various adrenal hormones, steroids, and cortisone, as well as contributing to the production of important brain neuro-transmitters such as acetylcholine. In addition to helping to fight depression Pantothenic acid (vitamin B5) also supports the normal functioning of the gastrointestinal tract and is required for the production of cholesterol, bile, vitamin D, red blood cells, and antibodies.

Ginseng: A small perennial plant, the most potent species are found in Siberia and Korea, taking six years to mature. Gingseng is a general tonic especially valuable for feverish and inflammatory disease. It is reputed to promote the hormone-producing glands, preventing tiredness and the debilitating effects of old age, often to maintain sexual potency and as an aphrodisiac. It is recommended for hemorrhage and blood diseases, and women can take ginseng for everything from normalizing menstruation to easing childbirth.

Ginseng is apparently taken by Russian astronauts for resistance to disease and stress, in strengthening the immune system. It is also used in the treatment of anaemia, atherosclerosis, depression, diabetes, oedema, hypertension and ulcers. Alleviates coughs, chest problems and fever at the same time. It can promote both mental and physical vigour and good digestion.

The Chinese have held ginseng root in almost religious esteem as a panacea for many ailments, for thousands of years.

Gingko: Probably the world's oldest living tree species having survived over 200 million years, Ginkgo Biloba is extremely resistant to pollution and disease. The active ingredients, flavoglycosides play an important role in promoting better circulation. Clinical trials in the trials in the aged have shown improvement in short term memory, headache, vertigo, ringing in the ears, lack of energy and depression. Relieves chillblains and pains in legs after exercise. Increases alertness and general feeling of well being. Furthermore, Ginkgo Biloba has an antioxidant effect and protects against stroke by its anti-aggregatory effect on blood platelets. Can be used as an inhalation for sinus congestion, coughs, colds and asthma.

St John's Wort: One of the best herbs for mood elevation is St. John's wort. Several controlled studies have shown positive results in treating patients with mild to moderate depression. Improvement was shown with symptoms of sadness, helplessness, hopelessness, anxiety, headache and exhaustion with no reported side effects.

Its action is based on the ability of the active ingredient, hypericin to inhibit the breakdown of neurotransmitters in the brain. The herb also inhibits monoamine oxidase (MAO) and works as a serotonin reuptake inhibitor (SRI); both are actions similar to drugs prescribed for depression. In Germany, nearly half of depression, anxiety, and sleep disorders are treated with hypericin. St. John's wort should not be taken with any other antidepressants, it is not effective for severe depression, and no one should stop taking any prescribed medications for depression without proper medical care.

St. John's wort has been administered in the treatment of many illnesses. The most well known action of St. John's wort is in repairing nerve damage and reducing pain and inflammation. The herb has been used to relieve menstrual cramping, sciatica, and arthritis. It has a favorable action on the secretion of bile and thus soothes the digestive system.

The active constituents in the herb (there are over 50) include hypericin and pseudohypericin, flavonoids, tannins and procyanidins. The tannins are responsible for the astringent effect for wound healing. Hypericin increases capillary blood flow and is a MAO inhibitor.

There are many studies documenting the clinical effects of hypericum as an antidepressant treatment similar to several synthetic antidepressants, but with a minimum of side effects. Hypericin has been demonstrated to increase theta waves in the brain. Theta waves normally occur during sleep and have been associated with deep meditation, serene pleasure and heightened creative activity. St. John's wort effectually may improve perception and clarify thinking processes.

Common Use: St. John's wort has been used traditionally as an herbal treatment for anxiety and depression. It is an effective astringent that promotes wound healing and has antiviral properties that can counter herpes simplex, flu viruses and is being investigated as a treatment for acquired immunodeficiency syndrome (AIDS).

Note: If you are pregnant or lactating or taking anti-depressants like Prozac, check with your physician before taking St. John's wort.

Kali phos 6x: A nerve tonic. Useful for rundown nervous system due to worry or excitement.

Mag phos 6x: Beneficial for relief of muscular cramps and spasms, flatulence, colic and occasional minor pains.

This is a complete list of the herbs and vitamins that I use and have found beneficial in their calming and soothing properties and to help my body maintain a healthy balance.

Warning: Please get advice from your Doctor before using any vitamins or herbs or any anxiety treatment as some may not be suitable for you and others can be very harmful when mixed with medications.

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Medication can play a useful role in treating anxiety disorders and may be used in conjunction with other forms of therapy. Anti-depressant and anti-anxiety medications are often used to ease symptoms so that other therapy can go forward.

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Medication is most effective when combined with psychological therapies. The chance of recurrence is reduced when medication and psychological therapies are used together.

Finding the right medication and dosage for each individual may require some detective work on the part of the physician. Diagnosing the specific disorder will narrow the field of appropriate medications, and the doctor will make the final selection based on individual circumstances and the patient's health history.

Side Effects and Other Reactions

Knowing what to expect prevents unnecessary concern and also alerts the patient to the kinds of reactions that should be reported right away. Most people can take medications commonly used to treat anxiety disorders without difficulty, but sometimes there are side effects. Side effects vary with the drug, but they can range from minor annoyances like dry mouth or drowsiness to more troubling reactions like an irregular heartbeat. Fortunately, most side effects disappear in the first week or two of treatment.

If the side effects persist, or if they interfere with normal activities, ask the doctor if he or she would change dosages or try a different medication.

Using medication is more complicated for some groups of people. The doctor should be informed if a woman is pregnant or attempting pregnancy.

Young children and the elderly also need special attention. Treatment of elderly patients may be complicated by other health problems and/or other medication regimens.

People with high blood pressure, kidney and liver ailments, or other chronic conditions may need to avoid certain medications.

Patients should not deviate from the prescribed medication dosages unless instructed by their doctor. Getting the right results from medication depends on taking the right amount at the right time. Dosages and their frequency are determined by the desire to assure a consistent and steady amount of medication in the blood system and by the length of time the drug remains active. A drug regimen is likely to last several months, but some patients may only require short-term therapy. Others may need medication for a year or longer.

Terminating medication requires as much care as initiating it. Drugs used in the treatment of anxiety disorders should be phased out gradually under direct supervision of a physician.

What Medications Are Used to Treat Anxiety Disorders?

Azaspirones

Azaspirones is a class of drug effective in the treatment of GAD. It works gradually over 2-4 weeks to relieve symptoms of GAD. It does not cause sedation, impair memory or balance, nor does it potentiate the effects of alcohol. It is not habit forming and can be discontinued without causing withdrawal symptoms. The drug is generally well tolerated and the side effects are not usually serious enough to make most people stop taking it.

Benzodiazepines

Most of the benzodiazepines are effective against generalized anxiety disorder (GAD). Some drugs in this group are also used to treat panic disorder and social phobia.

Benzodiazepines are relatively fast-acting drugs. Their principal side effect is drowsiness, but they have the potential for dependency. Individuals taking benzodiazepines can experience a return of their anxiety symptoms when the drug is discontinued. They may also experience temporary withdrawal symptoms. These problems can be minimized if the patient and doctor work together.

Beta blockers

These drugs are used mainly to reduce certain anxiety symptoms like palpitations, sweating and tremors, and to control anxiety in public situations. They often are prescribed for individuals with social phobia. Beta blockers reduce blood pressure and slow the heartbeat.

Tricyclics (TCAs)

These drugs were first used for treating depression, but some are also effective in blocking panic attacks. Most tricyclics may also reduce symptoms of post- traumatic stress disorder (PTSD) and some are effective against obsessive-compulsive disorder (OCD)

Tricyclics generally take two or three weeks to take effect. Some individuals feel the drugs' most annoying side effect is weight gain. Other side effects include drowsiness, dry mouth, dizziness and impaired sexual function.

Monoamine Oxidase Inhibitors (MAOIs)

These drugs are used in the treatment of panic disorder, social phobia, PTSD and sometimes OCD, but they require dietary restrictions and some doctors prefer to try other treatments first. Anyone taking a MAO inhibitor must avoid other medications, wine and beer, and food such as cheeses that contain tyramine.

Selective Serotonin Reuptake Inhibitors (SSRIs)

These are the newest medicines available for treating anxiety disorders. SRIs may be considered a first-line of treatment for panic disorder, and they often are effective against obsessive-compulsive disorder (OCD). Traditionally used to treat depression, the safety and convenience of SRIs (they require once-a-day dosing) have made them among the most widely-used drugs in the world. The most common side effect, which tends to resolve over time, is mild nausea. Sexual dysfunction, primarily ejaculatory delay, also has been reported.

New medications

New medications are being developed and tested constantly. Your doctor can advise you if one of these newer drugs is appropriate.

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The impression I am left with after reviewing this article is "why the fuss?" I realize it's a big deal for the ECT industry to get an article published in JAMA, but I'm not blown away by anything reported here, except by the fact that the high relapse rate is well-acknowledged. That's an area that has been ignored in contemporary ECT research for a long time in favor of studies giving it almost unconditional praise.

The use of lithium as an augmentation agent with antidepressants has been known for about a decade, and studies have shown it to be fairly successful. I realize that the scope of this study was to examine methods to lower the unacceptably high relapse rate in ECT, but at the very least, there should have been an additional group that had no ECT and took the lithium/nortriptyline combination. I strongly suspect that over a six-month period, a similar rate of remission from depression would have resulted. Since the researchers didn't bother, however, it's only a supposition.

How does the fact that the ECT used was double the legal limit of electricity factor into the success rate? This is something that has troubled me for quite some time, in that this amount of electricity isn't what is used in practice. I do wonder how this study would have turned out if the researchers had stayed within the electrical limits. (There are numerous other studies that compare results using varying amounts of electricity, and it's generally acknowledged that the more electricity, the higher response rate.)

Unfortunately, these issues are not addressed at all in this study.

I picked up on some things that were entirely ignored by Dr. Sackeim and his colleagues. He cites a relapse rate of greater than 50 percent, and he says that researchers assume a relapse rate of 50 percent with placebo. Yet their own relapse rate in the placebo group, even using double the maximal charge output, is 84 percent? Why is this? Second, of the 290 patients who received this high dose ECT, 114 - almost 40 percent - didn't respond, according to Figure 1.

So you've got 40 percent in the study not even responding to the high dose ECT, then of those who responded, you've got relapse rates of 84, 60 and 39 percent.

This isn't very encouraging, is it?

Look at the actual numbers and draw your own conclusions. Of 290 people who completed ECT, six months later only 28 were considered not to have relapsed!

This kind of number is completely unacceptable, yet it is packaged as something new and innovative.

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Contents:

• Aromatherapy
• Acupuncture
• Bach's Flower Remedies
• Reiki
• Herbalism
• Homeopathy
• Massage
• Shiatsu
• Yoga
• Meditation

Aromatherapy for Treatment of Anxiety and Stress:

Chronic anxiety can contribute to many health problems, but aromatherapy has a quick and simple method for reducing it, according to aromatherapist Valerie Ann Worwood in her new guide, The Fragrant Mind. Aromatherapy works with the essential oils of plants, prepared in any of the following ways, says Worwood: blend with 1 ounce of base oil to make a massage oil; add to bath water; gently heat in a room diffuser; or inhale from a tissue.

• Tense Anxiety—Symptoms include bodily tension, muscle pains, aches, and a generalized soreness. Mix clary sage (10 drops), lavender (15 drops), and Roman chamomile (5 drops).
• Restless Anxiety—Here one feels dizzy, sweaty, overactive, with palpitations, the sense of a lump in the throat, frequent urination, diarrhea, or upset stomach. Worwood recommends vetiver (5 drops), juniper (10 drops), and cedarwood (15 drops).
• Apprehensive Anxiety—Symptoms generally include worrying, brooding, unease, a sense of foreboding, even paranoia. For relief of this emotional state, try mixing bergamot (15 drops), lavender (5 drops), and geranium (10 drops).
• Repressed Anxiety—This variant of anxiety involves feeling on edge, concentration difficulties, irritability, insomnia, or a sense of chronic exhaustion. Worwood advises a blend of neroli (10 drops), rose otto (10 drops), and bergamot (10 drops).

Acupuncture for Treatment of Stress:

Acupuncture is primarily concerned with regulating the individual's life force, the body energy or 'Qi'. It has a number of beneficial physiological effects -- Acupuncture has a relaxation response with decreased heart rate, lowered BP, stress reduction and increased energy and tissue regeneration. It has been shown to produce a calming or tranquilizing action that is of particular interest to people in states of stress. Acupuncture can relieve feelings of anxiety and depression, which may be serious handicaps for people trying to cope with difficult domestic, social and work problems. It can give a person a feeling of well-being and self-confidence. It is an effective substitute for sleeping pill, tranquilizers, and antidepressant drugs. Acupuncture can be used in many cases not only as an alternative to these drugs but also to treat side effects and dependence. In fact a number of patients have come for acupuncture treatment specifically to come off their antidepressants. There is considerable evidence that acupuncture could substantially reduce the consumption of drugs such as Prozac.

Acupuncture can provide a safe and effective tool for stress. It will not, of course, change the circumstances of a person's life, but it will usually produce a feeling of well-being. The practitioner can help restore balance and thus protect health by identifying each individual's unique energy profile to see where the weak spots are and where support is needed to restore balance. Acupuncture can open a window of opportunity. As the heavy feelings of stress are relieved, a person feels more confidence in his ability to cope with unpleasant aspects of his life situation and make necessary changes

Bach's Flower Remedies for Treatment of Anxiety and Stress:

"There is no true healing unless there is a change in outlook, peace of mind, and inner happiness." - Dr. Edward Bach, 1934

Edward Bach, medical doctor, bacteriologist, and homeopathic physician, dedicated his life to discovering a system of healing which would go beyond the diagnosis and treatment of physical symptoms to address the emotional and mental roots of disease. He came to realize that when people were treated on the basis of distinctive personality characteristics, rather than according to their disease, true healing could occur. Convinced that he would discover what he sought in nature, he began to explore the fields and forests of England in search of remedies which would be effective, pure, and inexpensive.

One day, the sight of dewdrops glistening on flower petals inspired him with the idea that the heat of the sun, acting through the dew, must draw out the healing essence of each flower Through the development of a method for extracting this essence and self-experimentation with the resulting essences he isolated flowers which addressed a broad range of psychological conditions. These became known as the Bach Flower Remedies.

Reiki Healing:

Reiki (pronounced "Ray-kee") is Japanese for "universal life-force energy". Reiki is a method of natural healing using the universal life force energy to promote healing.

When the energy in our body becomes imbalanced or depleted, due to stress or illness, our body can no longer heal itself. It needs help.

Reiki is a powerful hands-on healing technique in which this energy is drawn through the practitioner's body and then transferred to the client. Physical, mental, emotional and spiritual blocks are released during a healing to bring clients greater health, well-being and harmony.

Reiki supports the body's natural ability to heal itself. It vitalizes body, soul and mind.

Benefits of Reiki for Spiritual and Emotional Balance:

Reiki functions on all levels. Mental, spiritual, physically and emotionally. It balances the body's energies. It loosens up blocked energy and promotes a state of relaxation. It cleans the body of poisons and enhances deeper detoxification.

Herbalism for Treatment of Anxiety and Stress:

Herbs are used to relieve stress and tension. Herb relaxants include :

1. Black Cohosh,
2. Black Haw
3. California Poppy
4. Chamomile
5. Cramp Bark
6. Hops
7. Hyssop
8. Jamaican Dogwood
9. Lady's Slipper
10. Lavender
11. Lime Blossom
12. Misletoe
13. Motherwort
14. Pasque Flower
15. Passion Flower
16. Rosemary
17. St.John's Wort
18. Skullcap
19. Valerian.

In addition to the herbs that work directly on the nervous system, the anti-spasmodic herbs - which affect the peripheral nerves and the muscle tissue - can have an indirect relaxing effect on the whole system. Remember the connection - if you can calm the nervous system, you'll calm the physical system.

Homeopathy for Treatment of Anxiety:

Homeopathy treats the patient as one integral unit of mind and body.
Homeopathic medicines for anxiety are selected on the basis of presenting symptoms, the site of manifestation and the personality of the patient. After taking homeopathic medicines, the patient can himself judge the response. He develops a general feeling of well-being and looks at life with a positive attitude. The associated symptoms like loss of appetite, insomnia, headaches also are greatly relieved.

Massage for Treatment of Anxiety and Stress:

The benefits of massage are :

Shiatsu for Spiritual and Emotional Balance:

Shiatsu is a form of physical therapy developed first in Japan based on traditional Chinese medical theory and various Japanese massage techniques. In a shiatsu treatment the practitioner uses direct pressure with hands and fingers on the client's body.
The practitioner works along energy channels (meridians) and on points along those channels (acu-points or tsubo) to stimulate the flow of energy (ki).

The primary focus in treatment is to establish an harmonious flow of energy through the meridians. The particular insight of eastern medical practice is in its understanding of energy and how energy is a dynamic force in the body. Shiatsu addresses all levels of the person (physical, mental, emotional and spiritual). The treatment is most often experienced as deeply relaxing and practitioners can work with conditions of both acute and chronic natures.

Yoga to Reduce Anxiety and Stress:

Everyone suffers from mild anxiety from time to time, but chronic anxiety takes a tremendous toll on the body, draining energy resources and keeping the body in a constant state of stress. The effects of anxiety are magnified when the body is not exercised: tension in the muscles builds, breathing remains constricted most of the time and the mind has no rest from the whirling thoughts and feelings that feed the anxiety.

Yoga helps you to access an inner strength that allows you to face the sometimes-overwhelming fears, frustrations, and challenges of everyday life. Yoga reduces stress in the body, breath, and mind by building coping skills with a small daily routine of exercise, breathing, and meditation. A few Yoga exercises practiced daily (especially if they are done just prior to meditation) help to regulate the breath and relax the body by gently releasing tension from the large muscle groups, flushing all parts of the body and brain with fresh blood, oxygen, and other nutrients, and increasing feelings of well-being. "Whole body" exercises such as the Sun Poses are particularly helpful because they encourage you to breathe deeply and rhythmically. Many exercises can be adapted so you can do them even in an office chair.

The Complete Breath technique is a must for anyone who often feels "stressed out." Once learned, the Complete Breath can be used anywhere, anytime, to reduce the severity of panic attack, to calm the mind, or to cope with a difficult situation. Learning to concentrate simply on the sound of the breath as you inhale and exhale evenly and smoothly will help you gently but effectively switch your attention from feelings of anxiety to feelings of relaxation.

Daily practice of complete relaxation and meditation are also essential - even a few minutes of meditation during your work day can make a difference. This daily training in focusing the mind on stillness will teach you how to consciously quiet your mind whenever you feel overwhelmed. Meditation puts you in touch with your inner resources; this means less dependence on medications, greater self-awareness, and a fuller happier life.

Meditation for Treatment of Anxiety and Stress:

People with recurring symptoms of anxiety and nervous tension are usually barraged by a constant stream of negative "self-talk." Throughout the day your conscious mind may be inundated with thoughts, feelings, and fantasies that trigger feelings of upset. Many of these thoughts replay unresolved issues of health, finances, or personal and work relationships. This relentless mental replay of unresolved issues can reinforce the anxiety symptoms and be exhausting. It is important to know how to shut off the constant inner dialogue and quiet the mind.

The first two exercises require you to sit quietly and engage in a simple repetitive activity. By emptying your mind, you give yourself a rest. Meditation allows you to create a state of deep relaxation, which is very healing to the entire body. Metabolism slows, as do physiological functions such as heart rate and blood pressure. Muscle tension decreases. Brain wave patterns shift from the fast beta waves that occur during a normal active day to the slower alpha waves, which appear just before falling asleep or in times of deep relaxation. If you practice these exercises regularly, they can help relieve anxiety by resting your mind and turning off upsetting thoughts.

Please remember, I'm not a doctor and all treatments should be discussed with your doctor or therapist before using them.

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Cognitive Behavioral Therapy and Behavioral Therapy

Research has shown that a form of psychotherapy that is effective for several anxiety disorders, particularly panic disorder and social phobia, is cognitive-behavioral therapy (CBT). It has two components. The cognitive component helps people change thinking patterns that keep them from overcoming their fears. For example, a person with panic disorder might be helped to see that his or her panic attacks are not really heart attacks as previously feared; the tendency to put the worst possible interpretation on physical symptoms can be overcome. Similarly, a person with social phobia might be helped to overcome the belief that others are continually watching and harshly judging him or her.

The behavioral component of CBT seeks to change people's reactions to anxiety-provoking situations. A key element of this component is exposure, in which people confront the things they fear. An example would be a treatment approach called exposure and response prevention for people with OCD. If the person has a fear of dirt and germs, the therapist may encourage them to dirty their hands, then go a certain period of time without washing. The therapist helps the patient to cope with the resultant anxiety. Eventually, after this exercise has been repeated a number of times, anxiety will diminish. In another sort of exposure exercise, a person with social phobia may be encouraged to spend time in feared social situations without giving in to the temptation to flee. In some cases the individual with social phobia will be asked to deliberately make what appear to be slight social blunders and observe other people's reactions; if they are not as harsh as expected, the person's social anxiety may begin to fade. For a person with PTSD, exposure might consist of recalling the traumatic event in detail, as if in slow motion, and in effect re-experiencing it in a safe situation. If this is done carefully, with support from the therapist, it may be possible to defuse the anxiety associated with the memories. Another behavioral technique is to teach the patient deep breathing as an aid to relaxation and anxiety management.

Behavioral Therapy and Phobias

Behavioral therapy alone, without a strong cognitive component, has long been used effectively to treat specific phobias. Here also, therapy involves exposure. The person is gradually exposed to the object or situation that is feared. At first, the exposure may be only through pictures or audiotapes. Later, if possible, the person actually confronts the feared object or situation. Often the therapist will accompany him or her to provide support and guidance.

If you undergo CBT or behavioral therapy, exposure will be carried out only when you are ready; it will be done gradually and only with your permission. You will work with the therapist to determine how much you can handle and at what pace you can proceed.

The Goals and Methods of Cognitive Behavioral Therapy

A major aim of CBT and behavioral therapy is to reduce anxiety by eliminating beliefs or behaviors that help to maintain the anxiety disorder. For example, avoidance of a feared object or situation prevents a person from learning that it is harmless. Similarly, performance of compulsive rituals in OCD gives some relief from anxiety and prevents the person from testing rational thoughts about danger, contamination, etc.

To be effective, CBT or behavioral therapy must be directed at the person's specific anxieties. An approach that is effective for a person with a specific phobia about dogs is not going to help a person with OCD who has intrusive thoughts of harming loved ones. Even for a single disorder, such as OCD, it is necessary to tailor the therapy to the person's particular concerns. CBT and behavioral therapy have no adverse side effects other than the temporary discomfort of increased anxiety, but the therapist must be well trained in the techniques of the treatment in order for it to work as desired. During treatment, the therapist probably will assign "homework" -- specific problems that the patient will need to work on between sessions.

CBT or behavioral therapy generally lasts about 12 weeks. It may be conducted in a group, provided the people in the group have sufficiently similar problems. Group therapy is particularly effective for people with social phobia. There is some evidence that, after treatment is terminated, the beneficial effects of CBT last longer than those of medications for people with panic disorder; the same may be true for OCD, PTSD, and social phobia.

Medication may be combined with psychotherapy, and for many people this is the best approach to treatment. As stated earlier, it is important to give any treatment a fair trial. And if one approach doesn't work, the odds are that another one will, so don't give up.

If you have recovered from an anxiety disorder, and at a later date it recurs, don't consider yourself a "treatment failure." Recurrences can be treated effectively, just like an initial episode. In fact, the skills you learned in dealing with the initial episode can be helpful in coping with a setback.

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Give yourself some useful new instructions. You can hypnotize yourself if you put your mind to it. It' s not dangerous - you can't get 'stuck' under hypnosis or give yourself some harmful command. You'll just use the space given by deep relaxation to put some constructive thoughts where they'll do most good.

Start by lying on the floor or sitting in a straight backed chair, hands in your lap. If you have time, go through the foot-to-head relaxation.

If time is short, do some breathing exercises to set the scene and put you in a calm and peaceful frame of mind.

The Script

Say to yourself, 'Everything I am doing makes me healthier, more relaxed, and more in control of my life. I will wake up immediately if I need to. When you feel comfortably relaxed, imagine sitting on a wooden bench in a beautiful garden, full of flowers. Bees are buzzing gently, and the sun warms your skin. At the end of the garden there's a gate. You walk through, noting the rough texture of the weathered wood as you push it open. Beyond it are steps leading down to a secluded beach, with waves gently lapping on the sand. You walk slowly down, feeling the coolness of stone. under your feet as you count the steps - one, two, three... at every step you feel more relaxed... four, five, six... deeply calm and relaxed... seven, eight, nine... your body is relaxed, your mind open to all the good that can come to you here... ten. You are on this beautiful beach, knowing you are perfectly safe and can leave whenever you want. Enjoy the peace and serenity. Nearby you see a wrought-iron seat facing the sea. You sit down and say to yourself, 'I am peaceful, happy and perfectly in control of my life. I easily cope with everything that happens.' Now pinch the fold of skin between thumb and first finger on your right hand (pinch your thumb if you're pregnant). From now on you can relax at will, simply by doing that and remembering this peaceful place. Repeat, 'I am peaceful, happy and perfectly in control of my life. I easily cope with everything that happens. I can relax at will, simply by pinching my right hand and thinking of this place.' When you're ready, return to the steps, knowing you can come back here any time you like. You will return to everyday consciousness as you count down, but will be able to relax at will. Count slowly down from ten, as you walk up the steps, starting to notice the everyday sounds around you. By zero you are back to everyday consciousness, relaxed and alert.

Getting started

You can do this without making a tape, but it's easier to follow spoken .instructions - simply read out the script on this page. Speak in a slow, calm, rather monotonous voice and remember to leave pauses. You can give your self any suggestions you like on your secluded beach, but they must be positive, clear and harm-less. In an emergency, just say to yourself, 'One, two three, ready.' You can snap out of hypnosis instantly, but a brief wake-up formula reduces the jolt. If you find it hard to visualize, just do the counting many people find this equally effective. For deeper relaxation use 30 steps down to the beach instead of 10.

Sleeplessness

When you are wound up about stressful events that have occurred during the day, being unable to go to sleep is the final straw. When nothing seems to work, try this technique of self-hypnosis. It is worth learning it beforehand (read it over to yourself till you know it), then when you come to need it, it will be effortless. Lying down, close your eyes. Imagine a familiar image, say, for example, your bedroom (but keep your eyes shut). Say to your self: 'Nothing but this room exists.' Visualize all the different details that go to make up this room: the ceiling, the walls (are there pictures on them?), the floor (does it have a carpet or rug?), the windows (what are the curtains like?), the furniture dressing table, chest of drawers, wardrobe, the bed on which you are lying. In your mind work systematically from one end of the room to the other, from top to bottom. Then, one by one, wipe the image of each of these details from your mind, until everything has gone. You are left with absolute total emptiness. Concentrate on this void, with you in the middle of it, for a few moments. You will experience a feeling of relaxation coming from it. If you still cannot sleep, repeat the exercise several times. It's usually successful after only a few minutes of 'disconnection'.

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Richard Abrams owns Somatics, Inc., manufacturer of the Thymatron ECT device. At least when he wrote the 'bible' on ECT (Electroconvulsive Therapy, Oxford University Press), his promotion of the Thymatron was subtle. This article is little more than a blatant ad for his company's products.

"The clinical Thymatron© DGx device made by Somatics Inc. provides three quantitative measures of the seizure EEG...In 1997, Somatics introduced a proprietary computer-assisted EEG analysis system for use with their ECT device to obtain the EEG power spectral and coherence analytic measures for routine clinical use."

As if to head off any potential criticism, Abrams does mention the competition, Mecta, but adds, "The clinical significance of these measures has not been prospectively examined..."

In other words, the features of the Thymatron are backed up by research (oddly enough, done by Abrams and friends), but Mecta's are not.

Once again, the King hawks his products...and does it well. He's becoming quite skilled at this. I eagerly await the infomercial and theme song, all from the Don LaPrie of ECT.

by Max Fink, M.D., and Richard Abrams, M.D.
Psychiatric Times, May 1998

For over 50 years we clinicians have administered electroconvulsive therapy with little to guide us in deciding whether or not a particular induced seizure is an effective treatment. At first we thought that piloerection or pupillary dilatation predicted the efficacy of a seizure, but these signs were difficult to assess and were never subjected to controlled experiments.

The duration of the motor seizure was examined next, and in evaluations of the seizures in unilateral and bilateral ECT, it seemed reasonable to opine that a minimum of 25 seconds defined a good seizure (Fink and Johnson, 1982). In studies of unilateral and bilateral ECT with threshold and suprathresh-old energy dosing, motor seizure durations were greater than 25 seconds, yet the threshold-unilateral condition yielded ineffective courses of treatment (Sackeim et al., 1993). Indeed, the new experience finds that longer seizures are not necessarily better for determining efficacy (Nobler et al., 1993; Krystal et al., 1995; McCall et al., 1995; Shapira et al., 1996). The occurrence of a prolonged, poorly developed, low-voltage seizure of indeterminate length and poor postictal suppression is a clear call for restimulation at a higher dose, with the expectation of inducing a shorter, better developed and clinically more effective seizure.

The Seizure EEG

Modern brief pulse ECT devices provide the facility to monitor the seizure by an electroencephalogram, an electrocardiogram, and lately, an electromyogram. For a decade it has been feasible to examine the electrographic characteristics of the EEG seizure as well as its duration. The EEG usually develops patterned sequences consisting of high voltage sharp waves and spikes, followed by rhythmic slow waves that end abruptly in a well-defined endpoint. In some treatments, however, spike activity is poorly defined and the slow waves are irregular and not of particularly high voltage. It is also difficult to define the endpoint, with the record showing a waxing and waning period followed by an imprecise termination. Could these patterns be related to treatment efficacy?

One suggestion was that bilaterally induced seizures were characterized by greater midseizure ictal amplitude in the two to five hertz frequency band than those induced by unilateral ECT (Krystal et al., 1993). Moreover, the seizures in bilateral ECT showed greater interhemispheric symmetry (coherence) during the seizure and more pronounced suppression (flattening) of EEG frequencies in the immediate postictal period. In other words, bilaterally induced seizures were more intense and more widely distributed throughout both hemispheres than seizures induced with unilateral stimulation.

The clinical relevance of these observations derives from the frequently reported therapeutic advantage of bilateral over unilateral ECT in the relief of depression (Abrams, 1986; Sackeim et al., 1993). The apparent validity of these observations led others to specifically examine the clinical predictive value of the described EEG patterns.

The EEG data of Nobler et al. (1993) came from studies of patients receiving either unilateral or bilateral ECT and energy stimulation either at threshold or two and one-half times threshold (Sackeim et al., 1993; 1996). The patients who received threshold unilateral ECT fared poorly compared to those who received bilateral ECT. Regardless of the electrode placement, however, those patients who exhibited greater midictal EEG slow-wave amplitude and greater postictal EEG suppression experienced greater clinical improvement and relief of depression (Nobler et al., 1993), confirming the observations by Krystal et al. (1993). Greater immediate post-stimulus and midictal EEG spectral amplitudes, greater immediate post-stimulus interhemispheric coherence and greater postictal suppression were reported with higher dose stimuli (two and one-half times threshold) compared to barely suprathreshold stimuli (Krystal et al., 1995). In another study, clinical improvement in depression correlated best with evidence for an immediate postictal reduction both in EEG amplitude and coherence (Krystal et al., 1996).

These analyses of the seizure EEG show promise of defining a clinically effective seizure. The available brief pulse ECT devices allow visual examination of the seizure record so that we can estimate the presence and duration of spike activity and the development of rhythmic high voltage slow wave activity, measure the duration of total seizure activity, and evaluate the endpoint of the fit (precise or imprecise).

In recent research studies, the methods of EEG analysis have been complex. Investigators often use sophisticated multichannel instrumentation recorders and EEG-analytic computer systems that are not usually available in clinical settings, but their elegant findings are consistent with the visual observations of the records provided by clinical ECT devices.

EEG Seizure Measurement

ECT device manufacturers provide some quantification of the EEG changes. The clinical Thymatron? DGx device made by Somatics Inc. provides three quantitative measures of the seizure EEG: seizure energy index (integration of total energy of the seizure), postictal suppression index (degree of suppression at end of the seizure) and endpoint concordance index (a measure of the relation of the endpoints of the EMG and the EEG seizure determinations when simultaneously recorded).

In 1997, Somatics introduced a proprietary computer-assisted EEG analysis system for use with their ECT device to obtain the EEG power spectral and coherence analytic measures for routine clinical use.

In their new Spectrum 5000Q device, the Mecta Corporation makes available the EEG algorithms derived from research by Krystal and Weiner (1994) and licensed from Duke University to assist clinicians in better determining the quality and efficacy of individual seizures. The clinical significance of these measures has not been prospectively examined, yet the measures provide accessible quantitative indices of the seizure EEG which hold the promise of clinical application and provide the means for establishing their validity (Kellner and Fink, 1996).

For immediate application, clinicians can visually examine the available EEG outputs for evidence of good seizure intensity and generalization. The present criteria for an effective seizure include a synchronous, well-developed, symmetrical ictal structure with high amplitude relative to baseline; a distinct spike and slow wave midictal phase; pronounced postictal suppression; and a substantial tachycardia response. These are reasonable criteria based on present experience. Another measure, that of interhemispheric coherence (symmetry), can be roughly estimated visually from a two-channel EEG recording when care is taken to position the recording electrodes symmetrically over both hemispheres.

Examples of inadequate and adequate seizures are shown in Figures 1, 2a and 2b. These samples are derived from an ongoing study involving energy dosing estimates in the first treatment of a 69-year-old man with recurrent major depression. In the first two stimulations, 10% (50 millicoulombs) and 20% (100 millicoulombs) energies were applied. In the third application, 40% (201 millicoulombs) energy was applied. Electrode placement was bilateral.

Interseizure EEG

In patients receiving a course of ECT, EEG recordings made in the days after treatments showed profound and persistent effects. With repeated seizures, the EEG showed a progressive increase in amplitudes, a slowing and greater rhythmicity of frequencies, and the development of burst patterns. These changes in EEG characteristics were related to the number of treatments, their frequency, type of energy and electrical dosage, clinical diagnosis, patient age and clinical outcome (Fink and Kahn, 1957).

The improvement in patient behavior from the Fink and Kahn (1957) study (observed as a decrease in psychosis, lifting of depressed mood and decrease in psychomotor agitation) was associated with the development of high degrees of EEG change. The EEG characteristics predicted which patients had improved and which had not.

The association was quantitative � the greater the degree of slowing of EEG frequencies and the earlier that "high degree" slowing appeared, the earlier and more dramatic was the change in behavior. Elderly patients developed EEG changes early while younger adults were often slow in showing the changes. In some patients the EEG did not slow despite many treatments, except when the treatments were given more frequently during the week.

The association between ECT-induced interictal EEG slowing and improvement in depression was confirmed by Sackeim et al. (1996). EEG records were examined at different times during the treatment course in 62 depressed patients who received either unilateral or bilateral ECT at threshold or high-dose energies. ECT produced a marked short-term increase in delta and theta power, the former of which resulted from effective forms of ECT. The changes in the EEG were no longer present at two-month follow-up. The authors concluded that the induction of EEG slow-wave activity in the prefrontal cortex was tied to the efficacy of ECT.

An important clinical application of EEG methodology is in determining the adequacy of a course of ECT. When a clinical change does not occur in a timely fashion, the interseizure EEG can be examined visually or by computer analysis. Failure of the EEG from the frontal leads to show well-defined delta and theta activity after several treatments suggests that the individual treatments were inadequate. At such times, the treatment technique should be reexamined for adequacy (i.e., sufficient electrical dosage, choice of electrode placement, concurrent drug use), or the frequency of the treatments should be increased. If the patient fails to improve despite apparently sufficient EEG slowing, the diagnosis and treatment plan should be reexamined.

The renewed interest in the seizure EEG as a marker of seizure adequacy, and in the interseizure EEG as a marker of ECT course adequacy is likely to underlie the next phase of research into the physiology of ECT.

Dr. Fink is professor of psychiatry and neurology at the State University of New York at Stony Brook. He is the author of Convulsive Therapy: Theory and Practice (Raven Press), and founder of the quarterly journal, Convulsive Therapy.

Dr. Abrams is professor of psychiatry at the Chicago Medical School. He has conducted basic science and clinical research on ECT for more than 25 years and has written over 70 articles, books and chapters on ECT.

References

Abrams R (1986), Is unilateral electroconvulsive therapy really the treatment of choice in endogenous depression? Ann N Y Acad Sci 462:50-55.

Fink M, Johnson L (1982), Monitoring the duration of electroconvulsive therapy seizures: ™cuff ¹ and EEG methods compared. Arch Gen Psychiatry 39:1189-1191.

Fink M, Kahn RL (1957), Relation of EEG delta activity to behavioral response in electroshock: Quantitative serial studies. Arch Neurol Psychiatry 78:516-525.

Kellner CH, Fink M (1997), Seizure adequacy: does EEG hold the key? Convuls Ther 12:203-206.

Krystal AD, Weiner RD (1994), ECT seizure therapeutic adequacy. Convuls Ther 10:153-164.

Krystal AD, Weiner RD, Coffey CE (1995), The ictal EEG as a marker of adequate stimulus intensity with unilateral ECT. J Neuropsychiatry Clin Neurosci 7:295-303.

Krystal AD, Weiner RD, Gassert D et al. (1996), The relative ability of three ictal EEG frequency bands to differentiate ECT seizures on the basis of electrode placement, stimulus intensity, and therapeutic response. Convuls Ther 12:13-24.

Krystal AD, Weiner RD, McCall WV et al. (1993), The effects of ECT stimulus dose and electrode placement on the ictal electroencephalogram: An intraindividual crossover study. Biol Psychiatry 34:759-767.

McCall WV, Farah BA, Raboussin D, Colenda CC (1995), Comparison of the efficacy of titrated, moderate-dose and fixed, high-dose right unilateral ECT in elderly patients. Amer J Ger Psychiatry 3:317-324.

Nobler MS, Sackeim HA, Solomou M et al. (1993), EEG manifestations during ECT: effects of electrode placement and stimulus intensity. Biol Psychiatry 34:321-330.

Sackeim HA, Luber B, Katzman GP et al. (1996), The effects of electroconvulsive therapy on quantitative electroencephalograms. Relationship to clinical outcome. Arch Gen Psychiatry 53:814-824.

Sackeim HA, Prudic J, Devanand D et al. (1993), Effects of stimulus intensity and electrode placement on the efficacy and cognitive effects of electroconvulsive therapy. N Engl J Med 328:839-846.

Shapira B, Lidsky D, Gorfine M, Lerer B (1996), Electroconvulsive therapy and resistant depression: Clinical implications of seizure threshold. J Clin Psychiatry 57:32-38.

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