Lithium Remains Extremely Effective in Preventing Suicide, Study Finds - Everyday Health

By Jeffrey Kopman, Everyday Health Staff Writer

THURSDAY, June 27, 2013 — People living with a mood disorder face a 30 times greater risk of suicide than the general population, but scientists hope that lithium can reduce that risk by more than 60 percent, according to a study from the University of Oxford published in the British Medical Journal.
Lithium is a commonly used medication for psychiatric disorders, specifically bipolar disorder and depression.  Previous studies found that lithium might play a role in reducing suicide rates associated with these conditions, but larger samples were recommended for future studies.
The University of Oxford study examined 48 trials from 1968 to 2013 involving 6,674 participants. The study was 70 percent larger than any previous studies to examine the benefits of lithium.
In addition to lithium, trial participants were tested on the effects of several other drugs relative to a placebo. These drugs included: amitriptyline, carbamazepine, valproate (including divalproex), fluoxetine, fluvoxamine, imipramine, lamotrigine, mianserin, maprotiline, nortriptyline, olanzapine, phenelzine, quetiapine, and thyroid hormone.
When compared with a placebo, lithium treatment resulted in fewer suicides and fewer deaths from any other cause. Lithium also showed some benefit for preventing cases of self-harm, although the correlation was not as strong.
“Lithium has been used for suicide prevention for 30 years,” said Edward Shorter, PhD FRSC, professor of psychiatry at University of Toronto, who was not affiliated with the study. “All studies, except for one in 2005, have shown that it can prevent suicide. Lithium, if taken regularly, can keep you illness free. Preventing suicide is important, but it’s not the only benefit of lithium.”
However, the updated analysis further confirms that lithium is one of the most effective treatment options for suicide prevention, and clearly showed a reduced risk of suicide and death of more than 60 percent compared to a placebo.
While the benefits of lithium versus other active drugs were not considered to be statistically significant, study authors did note that lithium performed better than carbamazepine in reducing episodes of self-harm.
Researchers attributed the reduced suicide risk to lithium’s ability to reduce mood disorder relapses, and suggested the drug might also decrease aggression and impulsivity.
“This updated systematic review reinforces lithium as an effective agent to reduce the risk of suicide in people with mood disorders," said the study authors. "Understanding the mechanism by which lithium acts to decrease suicidal behavior could lead to a better understanding of the neurobiology of suicide."
Despite adverse effects, lithium therapy should be considered as part of the clinical decision making process that weighs the pros and cons of treatment, the study concluded.
Some patients might not want to take on the added side effects associated with lithium treatment, which include nausea, headache, tremor of hands, dehydration, and lithium toxicity through overdose.
“The benefits of lithium are considerable, and the adverse effects only affect a small minority,” said Dr. Shorter. “They can include loss of renal function, but this is uncommon. Many patients stay on lithium for decades without any side effects.”
Alternative options include other mood stabilizing drugs, and electroconvulsive therapy.
“Mood stabilizers also have some effect in suicide prevention, and some don’t have the side effects of lithium,” explained Shorter. “But the main alternative is electroconvulsive therapy (ECT), which is super effective to prevent suicide, and has unjustly received negative reputation.”
ECT, commonly known as electroshock therapy, induces seizures in patients to treat psychiatric disorders. First used in 1938, ECT remains one of the more controversial and heavily opposed treatment options, due to the graphic nature of the treatment. The therapy requires patients to be placed under general anesthesia and muscle relaxers before receiving electric pulses to the head.
Side effects can include severe short-term memory loss, causing the FDA to claim it is a high risk option — an opinion Dr. Shorter and the American Psychiatric Association disagree with.
“I would recommend ECT over lithium. If your patient is suicidal, ECT is the best treatment," concluded Shorter.

ect therapy

Virginia Interventional Psychiatry offers innovative depression treatment - RichmondBizSense

Dr. William Sauvé leads Richmond’s first outpatient transcranial magnetic stimulation therapy center, treating depression without the need for medications

Virginia Interventional Psychiatry began treating patients this spring in their Glen Allen clinic, just north of the Innsbrook Corporate Center. VIP is the first outpatient clinic in the Richmond area specializing exclusively in Transcranial Magnetic Stimulation (TMS) Therapy. TMS Therapy is an FDA-cleared treatment for patients with depression who have not found relief from antidepressants or other therapies, who are unable to use certain psychotropic medications, or who desire a treatment program that does not require antidepressant medication.

TMS Therapy is quickly gaining popularity among patients who are unable to achieve symptom relief, as it is a unique, non-invasive, non-sedative form of outpatient depression treatment. And unlike electroconvulsive therapy, which requires anesthesia and a longer treatment regimen, TMS Therapy has very few side effects and allows the patient to remain awake and cognizant of the entire procedure. Patients are able to come in for 45-minute treatment sessions and resume normal activity immediately afterwards.

The clinic’s founders began their work with TMS Therapy at a local inpatient hospital, utilizing this approach in their work with our nation’s veterans, many of whom had been suffering from mood disorders. They were impressed by the results that were achieved and the efficacy of TMS Therapy in treating depression, already solidly supported by numerous research studies. In February of this year, they opened Virginia Interventional Psychiatry to begin caring for Richmond residents with treatment-resistant depression and those not wishing to use antidepressants.

Founding psychiatrist, Dr. William M. Sauvé, MD, says “Transcranial Magnetic Stimulation (TMS) Therapy provides a new hope in the treatment of depression that creates the potential for remission, not just management. Depression can be a devastating illness, and TMS Therapy represents a real, concrete strategy for sufferers to get well. After the FDA recognized its efficacy, and with insurance companies now covering a majority of the treatment cost, patients have an option beyond antidepressants and electroconvulsive therapy (ECT). ”

Virginia Interventional Psychiatry is located at 5231-C Hickory Park Drive in Glen Allen. For more information, please visit www.viptms.com or call 804-464-8471.

Rich Wire is a paid news release service offered by Richmond BizSense. To share and promote your organization's news, click here.

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Hard to Treat Depression Patients Recover Completely With Magnetic Therapy - PR Newswire (press release)

LONDON, July 2, 2013 /PRNewswire/ --

Leading  London Centre  presents first 'real world' UK data, supporting effectiveness of  repetitive Transcranial Magnetic Stimulation  for the treatment of major depression

Data from the first 'real-world' treatment audit presented today at The Royal College of Psychiatrists' International Congress 2013 in Edinburgh show that 60% of patients with treatment-resistant depression achieved complete remission (patients report and show no symptoms) when treated with repetitive Transcranial Magnetic Stimulation (rTMS).[1] These data are in-line with results reported in major treatment centres in the US and Canada.

Results from the 'real-world' audit of the first ten UK patients to be treated with rTMS at The London Psychiatry Centre, showed that six of the ten patients assessed achieved no anxiety or depression symptoms at the end of the treatment. Furthermore, one other patient responded to treatment as indicated by a 50% reduction in their depression score. All patients tolerated the treatments well with no significant side effects, with two subjects reporting an occasional mild headache, responding to paracetaomol.[1]  

Dr Rafael Euba, Consultant Psychiatrist at the Centre said, "These data reinforce the body of existing worldwide evidence for rTMS and its proven ability to treat depressed patients who have not responded to drug treatment and/or therapy."

rTMS is a painless and non-invasive method of brain stimulation that relies on electromagnetic induction using an insulated coil placed over the scalp, focused on an area of the brain thought to play a role in mood regulation.[2] Treatment with rTMS is licenced in the UK for adults with depression who have failed to achieve satisfactory improvement from two prior antidepressant medications, at or above the minimal effective dose and duration in the current episode. For these patients, rTMS provides an effective and pain-free alternative to experience relief from depression, without the side-effects that may be associated with more extreme or chemical alternatives.[3],[4],[5],[6],[7] Offered widely at high profile hospitals and centres in the US, including John Hopkins and Harvard's McLean Hospital, The London Psychiatry Centre is the first and only clinic to offer rTMS treatment in the UK.

One of the patients who recently completed the four week treatment said, "The treatment shifted the way I approach problems and almost blocks my negative way of thinking. I feel like the person I used to be 30 years ago! I've got my brain back!" After two weeks of treatment, not only had the patient stopped taking her medication completely, she no longer felt the dread she woke up with every day and decided to start doing new things, feeling optimistic about her future.

Around one in ten people in the UK suffer from depression at some point in their lifetime, which is over six million people, a number equivalent to the entire population of Scotland. More frequently prescribed treatments don't always work or are not suitable, plus their side-effects can cause weight gain, low sex drive and even heart problems. Up to 70% of people with depression will continue to experience symptoms despite taking medication and/or receiving psychotherapy. This is known as treatment-resistant depression, which is very common.

According to larger international clinical studies, one in two patients who were unresponsive to antidepressant medication experience a significant improvement in their depressive symptoms when treated with rTMS, while 1 in 3 experiences recovery.[6] Patients with resistant depression treated with rTMS also benefited from a shorter recovery time of around 4 weeks. This compares to those trying alternative medications that would typically experience improvements in around 6-9 months, if recognised treatment protocols are followed.

A further 13 patients have been treated with rTMS since the audit presented today, with all of them achieving complete remission within 4 weeks.  An audit of all 23 patients treated showed that 78% of the patients treated at The London Psychiatry Centre with rTMS achieved complete remission, a further 9% improved but did not achieve remission and 13% did not improve.[8]

If you or a person you know would like to find out more information about treatment with rTMS visit The London Psychiatry website at http://www.psychiatrycentre.co.uk.

Notes to Editors

About depression

Around one in ten people in the UK suffer needlessly from depression at some point in their lifetime and it is thought that a large number of people are still undiagnosed. The condition can impact every aspect of a person's life including their ability to work, establish and maintain relationships and their overall quality of life. Depression has also been associated with an increased risk of cardiovascular disease, such as heart attack and stroke.[9],[10],[11],[12]

About rTMS

rTMS is a non-invasive method of brain stimulation that relies on electromagnetic induction using an insulated coil placed over the scalp, focused on an area of the brain thought to play a role in mood regulation.[13] The coil generates brief magnetic pulses, which pass easily and painlessly through the skull and into the brain. The pulses generated are comparable to those generated by magnetic resonance imaging (MRI) machines. When these pulses are administered in rapid succession, it is referred to as "repetitive TMS " or "rTMS", which can produce longer lasting changes in brain activity.[4]Clinical studies have consistently shown that rTMS is effective in treatment-resistant depression,[6],[14],[15],[16],[17],[18],[19],[20].rTMS has been licensed in the UK to treat patients with depression who have not seen a satisfactory response to 2 antidepressants.

In comparison to more extreme alternatives such as electroconvulsive therapy (ECT), rTMS is considerably less invasive, has minimal side effects,[21] and has proven to offer equivalent health benefits.[22] rTMS is therefore seen as a safe middle step in people who do not respond to antidepressants, before considering ECT. In the US, rTMS is offered as a standard therapy in a number of high profile health clinics including John Hopkins and the Mayo Clinic.  

rTMS treatment is well tolerated and non-invasive, requiring only five sessions per week for between two to  six weeks, sometimes followed by maintenance or top-up treatment 6 -12 months later.[19],[20] Patients also recover faster in around 4 weeks, compared to those who tried different forms of medication, who took between 6-9 months to see significant improvements. Patients don't need to go to hospital to receive treatment with rTMS; the simple procedure is performed in an outpatient clinic.

About  The London Psychiatry Centre

The London Psychiatry Centre offers an integrated and complete service addressing every need associated with mental health. This includes psychiatric, psychological, therapeutic and social aspects of a patient. Consultant Psychiatrists, Psychologists and Psychotherapists along with nutritionists, coaches, personal trainers and therapists are on site to help.

To find out more information about The London Psychiatry, visit the website - http://www.psychiatrycentre.co.uk.

References

1. Euba R, Poster presented at The Royal College of Psychiatrists' International Congress 2013

2. George M, Taylor J, Baron Short E, The expanding evidence base for rTMS treatment of depression, Current Opinion Psychiatry, 2013,26:13-18

3. O'Reardon JP, Solvason HB, Janicak PG, et al.Efficacy and safety of transcranial magnetic stimulation in the acute treatment of major depression: a multisite randomized controlled trial. Biol Psychiatry 2007; 62:1208-1216.

4. Demitrack MA, Thase ME. Clinical significance of transcranial magnetic stimulation (TMS) in the treatment of pharmacoresistant depression: synthesis of recent data. Psychopharmacol Bull 2009; 42:5-38.

5. George MS, Lisanby SH, Avery D, et al. Daily left prefrontal transcranial magnetic stimulation therapy for major depressive disorder: a sham-controlled randomized trial. Arch Gen Psychiatry 2010; 67:507-516.

6. McDonald WM, Durkalski V, Ball ER, et al.Improving the antidepressant efficacy of transcranial magnetic stimulation: maximizing the number of stimulations and treatment location in treatment-resistant depression. Depress Anxiety 2011; 28:973-980

7. Mantovani A, Pavlicova M, Avery D, et al.Long-term efficacy of repeated daily prefrontal transcranial magnetic stimulation (TMS) in treatment-resistant depression. Depress Anxiety 2012; 29:883-890

8. The London Psychiatry Centre data on file

9. Ludescher B, Machann J, Eschweiler GW, Thamer C, Maenz C, Hipp A, Claussen CD, & Schick F (2011). Active depression is associated with regional adiposity in the upper abdomen and the neck. International journal of psychiatry in medicine, 41 (3), 271-80 PMID: 22073766 [http://www.ncbi.nlm.nih.gov/pubmed/22073766 ]

10. Rubin RR, Gaussoin SA, Peyrot M, DiLillo V, Miller K, Wadden TA, West DS, Wing RR, Knowler WC, & Look AHEAD Research Group (2010). Cardiovascular disease risk factors, depression symptoms and antidepressant medicine use in the Look AHEAD (Action for Health in Diabetes) clinical trial of weight loss in diabetes. Diabetologia, 53 (8), 1581-9 PMID: 20422396 [http://www.ncbi.nlm.nih.gov/pubmed/20422396 ]

11. Rutledge T, Linke SE, Krantz DS, Johnson BD, Bittner V, Eastwood JA, Eteiba W, Pepine CJ, Vaccarino V, Francis J, Vido DA, & Merz CN (2009). Comorbid depression and anxiety symptoms as predictors of cardiovascular events: results from the NHLBI-sponsored Women's Ischemia Syndrome Evaluation (WISE) study. Psychosomatic medicine, 71 (9), 958-64 PMID: 19834049 [http://www.ncbi.nlm.nih.gov/pubmed/19834049 ]

12. Shah AJ, Veledar E, Hong Y, Bremner JD, & Vaccarino V (2011). Depression and history of attempted suicide as risk factors for heart disease mortality in young individuals. Archives of general psychiatry, 68 (11), 1135-42 PMID: 22065529 [http://www.ncbi.nlm.nih.gov/pubmed/22065529 ]

13. George M, Taylor J, Baron Short E, The expanding evidence base for rTMS treatment of depression, Current Opinion Psychiatry, 2013,26:13-18

14. Li CT, Wang SJ, Hirvonen J, et al. Antidepressant mechanism of add-on repetitive transcranial magnetic stimulation in medication-resistant depression using cerebral glucose metabolism. J Affect Disord. 2010, 127(1-3):219-29

15. Blumberger DM, Mulsant BH, Fitzgerald PB, et al. A randomized double-blind sham-controlled comparison of unilateral and bilateral repetitive transcranial magnetic stimulation for treatment-resistant major depression. World J Biol Psychiatry. 2012;13(6):423-35

16. Fitzgerald PB, Hoy K, Gunewardene R, et al. A randomized trial of unilateral and bilateral prefrontal cortex transcranial magnetic stimulation in treatment-resistant major depression. Psychol Med. 2010;41:1187-1196

17. Galletly C, Gill S, Clarke P, Burton C, Fitzgerald PB. A randomized trial comparing repetitive transcranial magnetic stimulation given 3 days/week and 5 days/week for the treatment of major depression: is efficacy related to the duration of treatment or the number of treatments? Psychol Med. Sep 13 2011:1-8.

18. Holtzheimer PE, 3rd, McDonald WM, Mufti M, et al. Accelerated repetitive transcranial magnetic stimulation for treatment-resistant depression. Depress Anxiety. Oct 2010;27(10):960-963.

19. Carpenter LL, Janicak PG, Aaronson ST, Boyadjis T, Brock DG, Cook IA, Dunner DL, Lanocha K, Solvason HB, Demitrack MA. Transcranial magnetic stimulation (TMS) for major depression: a multisite, naturalistic, observational study of acute treatment outcomes in clinical practice. Depress Anxiety. 2012;29(7):587-96.

20. Connolly KR, Helmer A, Cristancho MA, Cristancho P, O'Reardon JP. Effectiveness of transcranial magnetic stimulation in clinical practice post-FDA approval in the United States: results observed with the first 100 consecutive cases of depression at an academic medical center. J Clin Psychiatry. 2012;73(4):e567-73.

21. Eranti S, Mogg, et al. [http://www.ncbi.nlm.nih.gov/pubmed/17202547 ] A Randomized, Controlled Trial with 6-Month Follow-Up of Repetitive Transcranial Magnetic Stimulation and Electroconvulsive Therapy for Severe Depression". American Journal of Psychiatry, 2007164 (1): 73-81

22. Coverage Policy Analysis: Repetitive Transcranial Magnetic Stimulation (rTMS), The New England Comparative Effectiveness Public Advisory Council, completed by: The Institute for Clinical and Economic Review. June 2012

SOURCE The London Psychiatry Centre

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ECT in Kids: Safe, Effective, Robust and… Underutilized - Medscape

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A zap to the brain makes you think people are more attractive - NBCNews.com (blog)

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A zap to the brain makes you think people are more attractive NBCNews.com (blog) Electroconvulsive therapy, (ECT) what most know as shock therapy, treats depression with a strong jolt, but remains stigmatized. And transcranial magnetic stimulation (TMS) has been known to work the same way as tDCS, but relies on magnets instead of ... and more »

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Lithium and Electroconvulsive Therapy: A Case Report - Healio

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Lithium and Electroconvulsive Therapy: A Case Report Healio Major depression is a very common illness encountered in psychiatric practice. A difficult challenge in the treatment of major depression / bipolar depression is the management of treatment resistance. We frequently see patients who are treatment ...

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Lithium Remains Extremely Effective in Preventing Suicide, Study Finds - Everyday Health

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Lithium Remains Extremely Effective in Preventing Suicide, Study Finds Everyday Health “But the main alternative is electroconvulsive therapy (ECT), which is super effective to prevent suicide, and has unjustly received negative reputation.” ECT, commonly known as electroshock therapy, induces seizures in patients to treat psychiatric ... and more »

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Lithium and Electroconvulsive Therapy: A Case Report - Healio

Lithium and Electroconvulsive Therapy: A Case Report | Psychiatric Annals #wrap:before, #wrap:after { content: " "; display: table; } #wrap:after { clear: both; } Tell us what you think about Healio

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Lithium and Electroconvulsive Therapy: A Case ReportDiana P. Sabagh, MD; Inci Bijan, MD; Carrol T. Longshore, MD

Read Full Text ArticleHTML IconPsychiatric AnnalsJune 2013 - Volume 43 · Issue 6: 248-251DOI: 10.3928/00485713-20130605-02

Major depression is a very common illness encountered in psychiatric practice. A difficult challenge in the treatment of major depression / bipolar depression is the management of treatment resistance. We frequently see patients who are treatment-resistant being prescribed various mood stabilizers, including anticonvulsants, second-generation antipsychotics, as well as lithium. Lithium has a major role in the maintenance treatment of bipolar illness and adjunctively in recurrent unipolar depression.1  Patients who do not respond completely to psychopharmacological approaches may require somatic treatment, including electroconvulsive therapy (ECT). ECT performed with concomitant anticonvulsants, antidepressants, and lithium remains controversial. There is no clear consensus in the literature as to whether performing ECT on a patient who is being prescribed lithium is safe. One issue with the data on concomitant use of lithium and ECT is that all of the studies are retrospective in nature. Therefore, it is difficult for the treating psychiatrist to have the necessary data to make the best decision with regard to combining ECT and lithium. Because lithium is known to have antisuicidal properties, the discontinuation can have significant implications while ECT is being performed.

As stated, there is still some controversy regarding combining lithium and ECT. A review article by Dolenc and Rasmussen2  described 12 patients in whom the combination of lithium and ECT did not result in any adverse events. Dolnec and Rasmussen2  reviewed virtually all of the literature on ECT and lithium and found most to be anecdotal and retrospective. A case report by Sartorius et al3  described three cases of severe lithium-induced side effects with patients undergoing ECT. These specific side effects consisted of prolonged seizures, serotonin syndrome, and a focal seizure. Case reports by Conway and Nelson4  describe a prolonged seizure when ECT was performed while the patient was taking a combination of buproprion, venlafaxine, and lithium. A similar article written by Rucker and Cook5  described a prolonged seizure with ECT and concomitant clomipramine, lithium, l-tryptophan, quetiapine, and thyroxine. The complexity of polypharmacy in these cases raises the question about the role of lithium toxicity in the pathogenesis of prolonged seizures.

There were several concerns raised in the review by Dolenc and Rasmussen2  regarding the safety of ECT and lithium. First was the theoretical basis that the neuromuscular blockade by succinylcholine would prolong the time to spontaneous respiration in conjunction with lithium. Succinylcholine is routinely administered during ECT as a safety measure to prevent complications such as fractures. The data appear to be inconclusive; however, this does not seem to be a major cause for concern. It is a fact that a side effect of lithium can be delirium and cognitive dysfunction, even in patients not being treated simultaneously with ECT. The second concern was that lithium combined with ECT would increase the risk of delirium. A small sample reported by Milstein and Small6  reported more memory impairment in ECT with concomitant lithium combination patients compared with ECT controls; however, there was no cognitive impairment noted on neuropsychological testing in this sample. The other major concern was the possibility of prolonged seizures in a patient treated with lithium and ECT. There is evidence that lithium may have a tendency to lower seizure threshold, resulting in the possibility of prolonged seizure activity. There are several postulated mechanisms, including synergistic ECT and lithium convulsive susceptibility, as well as the combined effect of lithium and ECT on the noradrenergic system. This can be a potentially serious complication if not recognized. Despite all of the current literature, there is no real agreement regarding the safety of the combination of lithium or other mood stabilizers and ECT.

We present two cases of patients treated with lithium and ECT, one of whom had an extreme adverse event of prolonged seizure.

Case 1

A 33-year-old Mexican man who was single, unemployed, and living with his cousin was referred to Elmhurst Hospital Center for ECT from Queens Hospital Center inpatient services. At Queens Hospital Center, medication treatment, partial hospitalization program, and inpatient hospitalization failed to relieve symptoms of depression and suicidal ideations. The patient had a history of a suicide attempt in December 2008 that consisted of overdosing on acetaminophen on the day following his 33rd birthday. He reported two prior psychiatric hospitalizations within the past 6 months secondary to suicidal ideations and depressed mood. At the time of his admission to our service, the patient was on the following medication regimen: venlafaxine 150 mg twice daily, aripiprazole 20 mg in the morning, clonazepam 2 mg at bedtime, and lithium 300 mg twice daily, with lithium level of 0.47 mEq/L on admission.

During the initial interview, the patient reported feelings of loneliness and emptiness since his childhood. Additionally, he stated that at age 12 he made a promise to kill himself at age 33 years. He chose that age because it was the age of Jesus Christ’s when he was crucified. Prior to his suicide attempt, he left his job and spent most of his days alone at home searching the Internet for different methods of suicide. Family members reported the patient’s behavior became increasingly strange (eg, telling his family members that he did not need food to survive).

On admission, the patient was fairly groomed and appeared to be his stated age. He was cooperative, with normal psychomotor activity and normal speech. His mood was depressed and sad with constricted and congruent affect. His thought process was linear and goal directed, and his thought content was remarkable for anhedonia. He expressed suicidal ideations with an ambivalent plan but denied homicidal ideations or intent. The patient denied any perceptual disturbances, and delusions were not elicited. He was awake, alert, and oriented to person, place, and time. His intelligence was estimated to be average. His insight and judgment were poor.

His medication regimen was slightly modified upon admission: venlafaxine was decreased from 150 mg twice daily to 75 mg in the morning and 150 mg at bedtime. The patient’s lab results and electrocardiogram were within normal limits. He had no known medical problems. Initially, the patient stated feeling depressed with flat and sad affect. He denied active suicidal and homicidal ideations but reported passive suicidal ideations, stating “if nothing works out, I will stay out for 1 month and then I will kill myself by stabbing my chest with a knife.” The patient remained helpless and hopeless and continued to voice significantly worrisome suicidal ideation.

Due to the severity of the symptoms and lack of response to previous treatment, a decision was made to proceed with ECT. Prior to ECT, the following workup was performed: cervical spine X-ray, medical clearance, and anesthesiology clearance. The patient was also given appropriate education regarding ECT treatment and agreed to informed consent.

ECT treatment was initiated on May 13, 2009. ECT parameters were as follows: charge 317 mC, energy 55.8 joules, dynamic impedance 220 Ohms, frequency 60 Hertz, duration 3 seconds, pulse width .6 msec, and current 800 mA with bilateral electrode placement. The patient experienced tonic clonic seizure activity, but the seizure duration became extremely prolonged. After 3 minutes of uninhibited seizure activity, the determination was quickly made that pharmacological intervention was required to treat the prolonged seizure activity. The anesthesiologist treated the patient in succession with midazolam 2 mg intravenously at 2-minute intervals followed by propofol 100 mg intravenously. Ultimately, the patient responded following 2 mg of intravenous lorezapam. The prolonged seizure duration was 10 minutes. The patient suffered no deleterious effect.

Due to the extremely serious nature of the prolonged seizure, a decision was made to discontinue lithium for the remainder of the ECT treatment protocol. Lithium was reinitiated at 900 mg/day on June 12, 2009, following successful course of 12 ECT treatments. The patient did not respond fully to psychopharmacology and the ECT cycle, so psychological testing was performed. The testing confirmed evidence of depression; however, there was a strong correlation with schizoid personality disorder. This personality disorder probably played a role in his treatment response.

Case 2

The patient is a 31-year-old man with a long history of psychiatric illness and numerous hospitalizations who has been followed at Mount Sinai School of Medicine. He was transferred from Mount Sinai to Elmhurst Hospital Center.

Upon admission to the Comprehensive Psychiatric Emergency Program the patient was complaining of what he initially described as racing and disorganized thoughts. As per patient report, he had been treated with a variety of antidepressants and adjunctive agents. He also described being involved in experimental protocols with non–US Food and Drug Administration-approved antidepressants as well as ketamine at Mount Sinai School of Medicine, with only marginal clinical improvement. After discussion with the patient and in consultation with his treating psychiatrist, the patient agreed to a trial of ECT. The first treatment was done on October 28, 2009. The patient had been started on lithium on September 8, 2009, which he willingly agreed to take. His blood levels of lithium ranged from 0.42 meq/L to 0.45 meq/L during the course of ECT therapy. After the first session of ECT, the patient had no adverse effects secondary to his being treated with lithium. The patient had a series of eight treatments, with the last one being performed at maximum energy (charge 576 mC, energy 117 joules, frequency 60 Hertz, duration 6 seconds, pulse width 1.0 msec, and current 800 mA with bilateral electrode placement). The patient had an excellent response to ECT with a remission of his depressive symptoms.

Discussion

Lithium is a very useful medication in psychiatry, but it is a medication that must be carefully monitored. Above therapeutic levels, the patient may suffer confusional states, and this can happen even at normal lithium levels. There is a paucity of clinical studies to guide the clinician in how to proceed when considering the combination of lithium and ECT. The American Psychiatric Association guidelines recommend that lithium and ECT not be used in conjunction, but these guidelines were last updated 11 years ago. The British guidelines from 2006 embrace the use of lithium and anticonvulsants combined with ECT.

Penney et al7  reviewed the concurrent and simultaneous administration of ECT and lithium and concluded that those patients treated in combination had a greater chance of suffering confusion and some complications, but the length of stay was not prolonged. They conclude by stating that guidelines should be taken into consideration but there is no absolute contraindication to using the combined modality.7 

Milstein and Small6  also reviewed the subject and concluded that lithium can interact with anesthesia and with ECT, resulting in organic brain syndromes. They recommend that the combination of lithium and ECT be avoided.6 

Stewart8  wrote about a case report of maintenance ECT and lithium that was described as safe and effective without any evidence of adverse effects. The occurrence of adverse events in two articles9,10  explored the question of negative interaction between lithium and ECT. This study reviewed 31 cases of patients who received lithium and ECT concurrently compared with a control group of 135 who received ECT only. In this study, there was no difference in groups. Consequently, in patients who can benefit from the combination, there should be no concern in using the modality.

Rudorfer et al11  looked at the pharmacokinetic and pharmacodynamic interactions. As the significant information on combined lithium and ECT largely consists of case reports and prospective controlled trials, it is difficult to postulate the mechanism of possible toxicity. In this study, the major considerations were the drug-drug interactions between lithium and ECT premedications. In addition, changes in lithium concentration and the possibility for potentiating the effects of anesthetic agents and neuromuscular blockade agents were examined. There is little evidence that lithium prolongs the action of succinylcholine; reduced serum cholinesterase activity is most likely responsible.

Martin and Kramer12  reviewed a series of 17 patients treated with ECT and lithium and they found no abnormal parameters and indicated no concerns regarding the simultaneous administration of ECT and lithium.

Lippmann and Tao13  reviewed the literature and presented a case report as well. The case described a patient who received 14 inpatient and more than 70 outpatient ECT treatments over 4 years while concurrent lithium was being administered. Consequently, the authors indicate that concurrent lithium and ECT may be utilized in appropriate cases.

Mukherjee14  reviewed the subject of ECT and lithium from the perspective of a therapeutic advantage or possible adverse affects. He concentrated on a discussion of the central nervous system effects of lithium and ECT with concerns about confusion and incoherent speech.

Gupta et al15  described a case as well as conducting a brief review of the literature. In the patient’s treatment, lithium was withheld during the active phase of treatment but was then restarted during the maintenance phase. The patient suffered no adverse events such as prolonged seizures or delirium or memory loss. Gupta15  concluded that there are many conflicting opinions regarding the use of lithium and ECT but that it might be considered an alternative strategy.

Naguib and Koorn16  reviewed psychotropics, anaesthetics, and ECT and came to the conclusion that there is a good deal of data that raises questions about the safety of lithium and ECT; however, there does not seem to be an absolute contraindication.

Conclusion

Patients who are treated with ECT are quite ill and often are taking a number of adjunctive medications to treat their mood symptoms. There is certainly a significant database to consider in making the decision to combine lithium and ECT. Ultimately, one must decide based upon the severity of the patient’s symptoms and the expected risk of continuing or withholding lithium and other mood stabilizers. Both ECT and lithium can be life-saving alone and sometimes together.

As the British and American data are often contradictory, the decision to continue lithium is indeed complicated and the decision as to how to proceed may be based upon clinical decisions and judgment. We feel that ECT and lithium is not contraindicated but the concomitant use must be carefully considered.

References  George MS, Nahas ZH, Borckardt JJ, Anderson B, Foust MJ. Nonpharmacological somatic treatments. In: Hales RE, Yudofsky SC, Gabbard GO, eds. The American Psychiatric Publishing Textbook of Psychiatry. 5th ed. Arlington, VA: American Psychiatric Publishing; 2008.   Dolenc TJ, Rasmussen KG. The safety of electroconvulsive therapy and lithium in combination: a case series and review of the literature. J ECT. 2005;21(3):165–170 doi:10.1097/01.yct.0000174383.96517.77 [CrossRef] .   Sartorius A, Wolf J, Henn FA. Lithium and ECT — concurrent use still demands attention: three case reports. World J Biol Psychiatry. 2005;6(2):121–124 doi:10.1080/15622970510029948 [CrossRef] .   Conway CR, Nelson LA. The combined use of bupropion, lithium, and venlafaxine during ECT: a case of prolonged seizure activity. J ECT. 2001;17(3):216–218 doi:10.1097/00124509-200109000-00014 [CrossRef] .   Rucker J, Cook M. A case of prolonged seizure after ECT in a patient treated with clomipramine, lithium, L-tryptophan, quetiapine, and thyroxine for major depression. J ECT. 2008;24(4):272–274. doi:10.1097/YCT.0b013e31815bd768 [CrossRef] .   Milstein V, Small JG. Problems with lithium combined with ECT. Am J Psychiatry. 1988;145(9):1178.   Penney JF, Dinwiddie SH, Zorumski CF, Wetzel RD. Concurrent and close temporal administration of lithium and ECT. Convuls Ther. 1990;6(2):139–145.   Stewart JT. Lithium and maintenance ECT. J ECT. 2000;16(3):300–301 doi:10.1097/00124509-200009000-00013 [CrossRef] .   Jha AK, Stein GS, Fenwick P. Negative interaction between lithium and electroconvulsive therapy — a case-control study. Br J Psychiatry. 1996;168(2):241–243 doi:10.1192/bjp.168.2.241 [CrossRef] .   Gangadhar BN, Janakiramaiah N. Lithium and ECT in combination. Br J Psychiatry. 1996;169(6):794 doi:10.1192/bjp.169.6.794a [CrossRef] .   Rudorfer MV, Linnoila M, Potter WZ. Combined lithium and electroconvulsive therapy: pharmacokinetic and pharmacodynamic interactions. Convuls Ther. 1987;3(1):40–45.   Martin BA, Kramer PM. Clinical significance of the interaction between lithium and a neuromuscular blocker. Am J Psychiatry. 1982;139(10):1326–1328.   Lippmann SB, Tao CA. Electroconvulsive therapy and lithium: safe and effective treatment. Convuls Ther. 1993;9(1):54–57.   Mukherjee S. Combined ECT and lithium therapy. Convuls Ther. 1993;9(4):274–284.   Gupta S, Austin R, Cali LA, Bhatara V. Nightmares treated with cyproheptadine. J Am Acad Child Adolesc Psychiatry. 1998;37(6):570–572. doi:10.1097/00004583-199806000-00003 [CrossRef] .   Naguib M, Koorn R. Interactions between psychotropics, anaesthetics and electroconvulsive therapy: implications for drug choice and patient management. CNS Drugs. 2002;16(4):229–247 doi:10.2165/00023210-200216040-00003 [CrossRef] .AUTHORS

Diana P. Sabagh, MD, is Child Fellow, Mount Sinai Services of Elmhurst Hospital Center. Inci Bijan, MD, is PGY-4 Resident in Psychiatry, Mount Sinai Services of Elmhurst Hospital Center. Carrol T. Longshore, MD, is Residency Training Unit Director, Mount Sinai Services at Elmhurst Hospital Center.

Address correspondence to: Carrol T. Longshore, MD, Mount Sinai Services at Elmhurst Hospital Center; 79-01 Broadway, Elmhurst, NY 11373; email: long-shc@nychhc.org.

Disclosure: The authors have no relevant financial relationships to disclose.

doi: 10.3928/00485713-20130605-02

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ECT in Kids: Safe, Effective, Robust and… Underutilized - Medscape

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ECT in Kids: Safe, Effective, Robust and… Underutilized Medscape ECT is one of the most effective treatments for major depression, said Dr. Puffer, a general psychiatry resident at the Mayo Clinic, with response rates in adults that are higher than those achieved with pharmacotherapy alone, and although somewhat ...

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Clips From Last Night: Jermaine Jackson on Michael's use of sleeping pills ... - CNN (blog)

After deliberating for more than 16 hours, over the course of two days, a six woman jury finds George Zimmerman not guilty Piers Morgan interviewed Jermaine Jackson last night for the hour, and the two talked about Michael Jackson's use of the drug Propofol. "He's lived all this time doing Demerol and sleeping pills and also pain pills," he said. "We didn't know about Propofol...if you look at the past tours, you never heard about these symptoms: Michael Jackson not knowing whether to go right or left when he comes on stage."

He also talked specifically about Dr. Conrad Murray:

Jermaine: "I didn't know who he was, but I said, 'there's something strange about this guy, he's acting strange.'"

-–
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Virginia Interventional Psychiatry offers innovative depression treatment - RichmondBizSense

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Virginia Interventional Psychiatry offers innovative depression treatment RichmondBizSense TMS Therapy is quickly gaining popularity among patients who are unable to achieve symptom relief, as it is a unique, non-invasive, non-sedative form of outpatient depression treatment. And unlike electroconvulsive therapy, which requires anesthesia ...

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'The Impossible Lives of Greta Wells,' by Andrew Sean Greer - New York Times

Illustrations by Michael KirkhamThe clock is always ticking in Andrew Sean Greer’s “Impossible Lives of Greta Wells.” Elegiac in tone, this tale of time travel, loss and compromise is as precisely engineered as a Swiss watch. The premise is deceptively simple. It is 1985, and Greta Wells, a photographer living in Greenwich Village, has just suffered two devastating losses: Her twin brother, Felix, has died of AIDS and her lover, Nathan, has left her for another woman. Thrown into a deep depression, she consults a psychiatrist, who in turn sends her to Dr. Cerletti, an advocate of electroconvulsive therapy. “Will it change me?” Greta asks, before her first session. “Not at all, Miss Wells,” he replies. “What has changed you is your depression. What we’re trying to do is bring you back.”

Instead the treatment takes Greta away. The next day she wakes up in her own room — but not in her own time. “Instead of my white walls, I saw pale lilac wallpaper patterned in ball and thistle. Gold-framed paintings placed along it, and sooty gaslight back plates.” Not only that, she’s a different Greta. “I marveled at the long red hair falling in waves over the delicate yellow nightgown I had never owned before, trimmed with little useless ribbons. I touched my face and wondered: What trick was this? How could this be me?”

The trick — and it’s an ingenious one — is this: The ECT procedure somehow allows Greta to travel across the 20th century to 1918, then to 1941, then back to 1985. In each of these worlds, the people and places are the same. Only the circumstances are different. In 1918, Greta’s twin, Felix, is alive and well, but engaged to Ingrid, a senator’s daughter, and having a secret affair with Alan, his lover of 1985. In 1941, he’s married to Ingrid, has an infant son and is again having an affair with Alan. Greta’s Aunt Ruth, her closest confidante, is almost exactly the same in 1918 as she is in 1985, but in 1941 she’s been killed in a car accident. Most bewilderingly for Greta, she and her lover, Nathan, are married in both 1918 and 1941. They have a young son in 1941, and Nathan has given up the woman for whom he left Greta in 1985. In 1918, it’s Greta who’s having the affair — with a much younger man named Leo.

To his immense credit, Greer — whose other books include “The Confessions of Max Tivoli,” about a man who is born elderly and grows younger by the day — manages the complexities of this temporal round robin with precision and panache. There’s nothing about Greta’s experiences that even suggests they might be delusional. On the contrary, what happens to her is all too real. Thus her beauty in both 1918 and 1941 disarms her: “For it had not occurred to me that I did not merely shift into another self. I shifted into another body.” More disturbingly, she soon discovers that when she is in 1918, her 1918 counterpart is in 1941 and her 1941 counterpart is in 1985.

All three Gretas, it turns out, are undergoing electroconvulsive therapy, just as all three Gretas hope to secure, in the worlds where they have been transported, the things they have lost in their own worlds. “It’s funny,” Aunt Ruth tells her. “You’re all the same, you’re all Greta. You’re all trying to make things better, whatever that means to you. For you, it’s Felix you want to save. For another, it’s Nathan. For this one, it’s Leo she wants to resurrect. I understand. Don’t we all have someone we’d like to save from the wreckage?”

In charting these extraordinary and overlapping journeys, Greer is nothing if not rigorous. What interests him isn’t the why and how of time travel — aside from almost cursory references to quantum physics and the idea of the “transmigration of souls,” the question is hardly pondered at all — but the What If? “They say there are many worlds,” Greta reflects early in the novel. “All around our own, packed tight as the cells of your heart. Each with its own logic, its own physics, moons and stars. We cannot go there — we would not survive in most. But there are some, as I have seen, almost exactly like our own. . . . And in those other worlds, the places you love are there, the people you love are there. Perhaps in one of them, all rights are wronged, and life is as you wish it. So what if you found the door? And what if you had the key?”

David Leavitt teaches at the University of Florida. His new novel, “The Two Hotel Francforts,” set in Lisbon in 1940, will be published in October.

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A zap to the brain makes you think people are more attractive - NBCNews.com (blog)

June 21, 2013 at 4:57 PM ET

Most of us can't actually be as attractive as professional good-looking people like Kate Upton. But new research shows that an electrical shock to the brain can make people perceive other people to be more attractive. The research may one day point toward new treatments for neurological disorders like depression or Parkinson's.

Another workday with your drab, dull-looking coworkers. If only your world was filled with the beautiful people - more Kate Uptons than Katie from accounting, more Jon Hamms than John from HR.

Actually, technology exists that could almost make that possible -- provided you're OK with an electric shock to your brain. But the brain zap isn't some party game. Findings from a new California Institute of Technology study could one day help lead to new, noninvasive ways to study and treat mental disorders.

The Caltech researchers found that people who receive a mild electrical shock deep within the brain ranked people as more attractive than they did before the jolt. It might sound like a silly thing to study, but Vikram Chib, lead author of the paper, explains that rating the attractiveness of faces is one of the hallmark tasks used to diagnose neurological problems like depression, schizophrenia or Parkinson's.

Chib, a postdoctoral scholar at Caltech, wanted to know how an area nestled deep with the brain called the midbrain influenced mood and behavior, and if there were a way to manipulate it noninvasively. The midbrain is believed to be the source of dopamine, a neurotransmitter that plays a role in disorders like depression, schizophrenia, and Parkinson’s disease. While drugs do treat these disorders, Chib and his colleague, Shinsuke Shimojo, hoped that noninvasive deep brain stimulation could change only the midbrain, without influencing the entire body.

The duo used a brain scanner called functional magnetic resonance imaging, or fMRI, to take photos of the 99 study participants' brains as they were asked to rank the attractiveness of faces, both before and after undergoing 15 minutes of electrical stimulation. The stimulation was from something called a transcranial direct-current-stimulation (tDCS) -- it's an inexpensive, noninvasive way to stimulate the brain using electrodes placed on the scalp. The tDCS only uses a 9-volt battery, and the jolt isn't painful -- it feels like a little tingle, or an itch.

Because of the fMRI images, the researchers were able to see what happens in the brain as people examine faces for attractiveness. After the zap, Chib and Shimojo saw increased activity in the brain's prefrontal area and in the midbrain, and they saw a boost of dopamine - something that has already been shown to make people perceive others as more attractive, Chib explains.

Vikram Chib / Translational PsychiatryThese fMRI images from the Translational Psychiatry paper show the region of the brain that was stimulated with the mild electric shock. After the stimulation, the images show increased midbrain activity that is linked with attractiveness ratings.

Dr. Donald Malone, who is chair of psychology and psychiatry at Cleveland Clinic and was not involved in this research, says this research is important: “This article has showed a relatively small stimulation to a certain part of the front of the brain activated a circuit deep within the brain and we can see it on a fMRI. And also resulted in behavioral changes. It is pretty cool.”

But he says this isn’t the first time researchers learned that noninvasive stimulation impacts the midbrain and dopamine. Electroconvulsive therapy, (ECT) what most know as shock therapy, treats depression with a strong jolt, but remains stigmatized. And transcranial magnetic stimulation (TMS) has been known to work the same way as tDCS, but relies on magnets instead of electrical shocks. With ECT and TMS, the treatments are only effective if they are continued indefinitely.

Up next, Chib plans to continue to research brain stimulation, specifically the way it may influence people with neurological or psychiatric disorders like Parkinson's, schizophrenia and depression. The study was published in the journal Translational Psychiatry.

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Hard to Treat Depression Patients Recover Completely With Magnetic Therapy - PR Newswire (press release)

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Hard to Treat Depression Patients Recover Completely With Magnetic Therapy PR Newswire (press release) In comparison to more extreme alternatives such as electroconvulsive therapy (ECT), rTMS is considerably less invasive, has minimal side effects, and has proven to offer equivalent health benefits. rTMS is therefore seen as a safe middle step in people ... and more »

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