The Canadian Journal of Psychiatry

To discuss the effect of electroconvulsive therapy (ECT) on suicide risk in patients with mood disorders.

A review of the available data on the short-term and long-term effects of ECT on suicide mortality among patients with mood disorders.

ECT has an acute but not a long-term beneficial effect on suicidality. Due to the significant limitations of studies in this area, however, the data need to be interpreted with caution.

Despite its well-established efficacy and its increasing use, electroconvulsive therapy (ECT) remains a controversial treatment. Lack of clarity in the issues related to its use in special patient populations (for example, in children, in adolescents, in pregnant women, in the elderly, and in the medically ill) often contributes to the debate about the use of ECT.

The literature on ECT use in special patient populations is reviewed, together with the commonly associated high-risk medical conditions in clinical practice. Specific reference is made in each case to the safety, tolerability, and efficacy of the procedure.

Much of the literature surveyed consists of case studies, although a few controlled trials are available. In general, ECT use in special populations is relatively safe and extremely effective. In small case series, ECT use in children and adolescents is effective but requires further systematic study. In pregnant women, ECT is very effective, and with proper medical care, it is relatively safe in all trimesters of pregnancy, as well as in the postpartum period. The frail elderly are particularly good candidates for ECT because they are often unresponsive to or intolerant of psychotropic medication. Medical conditions that should receive particular attention during a course of ECT are disorders of the central nervous system (CNS), cardiovascular, and respiratory system. With modern anesthesia techniques and careful medical management of each high-risk patient, most can successfully complete a course of ECT. The process of obtaining informed consent also requires special consideration in this group of patients because their capacity to consent to treatment may be compromised.

With careful attention to each patient's medical and anesthesia needs, ECT is an effective and relatively safe procedure in high-risk special patient populations.

To review repetitive transcranial magnetic stimulation (rTMS) as a mode of therapy for depression.

The following aspects of rTMS were reviewed and compared with electroconvulsive therapy (ECT): history, basic principles, technical considerations, possible mode of action, safety, adverse effects, and effects on mood in both healthy individuals and those suffering from bipolar disorder (BD) or depression.

rTMS may selectively increase or decrease neuronal activity over discrete brain regions. As a result of this focused intervention with TMS, the potential for unwanted side effects is substantially reduced, compared with ECT. In open trials, rTMS and ECT are reported to be equally efficacious for patients having depression without psychosis, but the therapeutic benefits reported in double-blind sham-rTMS controlled trials are more modest.

The antidepressant and antimanic effects of rTMS depend on technical considerations such as stimulus frequency, intensity, and magnetic coil placement, which may not yet be optimized. Biological heterogeneity among the patients treated with rTMS may also contribute to differing efficacy across clinical trials. rTMS may possess tremendous potential as a treatment for mood disorder, but this has not yet been realized. rTMS must still be regarded as an experimental intervention requiring further refinement.

To review recent neuroimaging studies of antisocial behaviour, including criminality, psychopathy, sexual offending, aggression, and violence.

Using OVID software, Psycinfo and Medline were searched for studies undertaken in the last 15 years. A brief outline of each technology is followed by a survey of published reports from refereed journals. Where indicated, critical appraisal is offered.

Converging evidence from multiple studies of structure and function indicates that abnormal prefrontal (and probably subcortical) circuitry are very likely involved in antisocial behaviour.

Clinicians should be aware of emerging findings from biological studies of antisociality. Future neuroimaging and other biologically based work, especially when combined with psychosocial initiatives, should yield fruit in attempts to better understand, treat, and prevent such socially devastating and destructive behaviour.

To examine the relation between phobic disorders and alcoholism in a Canadian community sample.

Data came from the Mental Health Supplement of the Ontario Health Survey. The University of Michigan revision of the Composite International Diagnostic Interview (UM-CIDI) was used to diagnose DSM-III-R psychiatric disorders in 8116 Canadian respondents between ages 15 and 64 years. Since the cross-system agreement (ICD-10 and DSM-III-R or DSM-IV) on the diagnosis of alcohol abuse is much lower than that for alcohol dependence, we also examined a WHO category, “hazardous alcohol use.” Logistic regression controlling for age and sex was used to determine odds ratios (ORs) for phobic disorders and alcohol-use diagnoses.

Individuals with lifetime alcohol abuse or dependence had two- to threefold increased odds of having a phobic disorder. Simple phobia and social phobia with multiple fears were significantly associated (ORs 1.5 to 2) with hazardous alcohol use (which had a prevalence of approximately 10%).

Given the early onset of most phobic disorders, the findings suggest that these are a risk factor for hazardous patterns of alcohol use.

Examiner la relation entre les troubles phobiques et l'alcoolisme dans un échantillon communautaire canadien.

To study the usage, efficacy, and side effects patterns of atypical neuroleptics (atypicals) in adolescents and young adults with developmental disabilities (DDs) (mental retardation).

We undertook a chart review of adolescents and young adults (under age 25 years) seen by our specialized mental health team.

Risperidone and olanzapine were by far the most frequently prescribed atypicals. Robust clinical effects were noted for both psychotic and nonpsychotic disorders. Most patients tolerated atypicals well, although a significant minority did experience neuroleptic induced movement disorders (NIMDs), particularly dystonias and dyskinesias. Female patients with DDs appear to be at particular risk of NIMDs.

Atypicals are useful in treating various conditions associated with DDs. This population, however, seems particularly sensitive to NIMDs, hence caution and close monitoring are required.

To compare the social functioning of individuals experiencing their first episode of schizophrenia with those who have experienced multiple episodes and with nonpsychiatrically ill control subjects.

Subjects included 40 patients with first-episode (FE) schizophrenia, 40 patients with multiepisode (ME) schizophrenia, and a control group of 40 nonpsychiatrically ill individuals. Three social-functioning measures were used: the Social Functioning Scale (SFS), the Quality of Life Scale (QOL), and the Assessment of Interpersonal Problem-Solving Skills (AIPSS).

Control subjects significantly outperformed FE and ME participants on all social-functioning measures. FE and ME samples did not differ in their performance on the SFS and the AIPSS. On the QLS, ME participants outperformed FE participants.

This study demonstrated that deficits in social functioning are present near the onset of schizophrenia.

To study the phenomenology, treatment, course, and outcome of patients with comorbid obsessive–compulsive disorder (OCD) and psychotic features.

A retrospective chart analysis was conducted on 15 patients with OCD with psychotic features. Data were collected regarding patient demographics, psychiatric diagnosis, duration of illness, treatment details, and clinically determined outcome over time.

Obsessive doubts, washing, and checking compulsions were the most commonly seen obsessive–compulsive (OC) symptoms. Of the patients, 53% had first-rank symptoms, and 77% showed significant improvement on treatment with a combination of antipsychotic and antiobsessional drugs.

The observed improvement on treatment with a combination of antiobsessional and antipsychotic drugs supports the use of combination treatment in patients who have both OC and psychotic symptoms.