Preliminary Assessment of Pre-Electroconvulsive Therapy Evaluation Practices in European Countries: The Need for Guidelines

OBJECTIVES

Pre-electroconvulsive therapy (ECT) evaluation is an essential part of ECT preparation, a standard treatment in the psychiatric field. However, no routine pre-ECT evaluation has been published so far. This preliminary study aimed to explore different practices in pre-ECT evaluation across European countries.

METHODS

The data were collected as a snowball sample approach using an online survey from September 2019 to April 2020. The final analysis included data from 18 clinics placed in 16 European countries.

RESULTS

Regulations on the pre-ECT evaluation were found in 9 countries. All clinics reported doing complete blood count, serum electrolytes, and renal function analysis as a part of regular laboratory testing, alongside with a cardiovascular assessment. Ten clinics reported using psychiatric scales. Six clinics reported doing a cognitive assessment, of which all had regulations on the pre-ECT evaluation. Not one evaluation had the same sets of procedures and diagnostics.

CONCLUSIONS

The differences in assessment approaches mirror high variability of the pre-ECT evaluation practice across Europe. Cognitive assessment and objectification of psychiatric symptoms should be a regular part of the pre-ECT evaluation because of the monitoring of the most common adverse effect and observing the clinical response to ECT. Standardization of the pre-ECT evaluation and ECT in general would remove criticisms and opposition to the treatment, make it based on the best of our knowledge, and provide a method respectful of patients' best interests and rights.

Weekly patterns of suicide and the influence of alcohol consumption in an urban sample

BACKGROUND AND PURPOSE

The weekly fluctuation in suicide rates is influenced by several factors including sex, psychiatric illness and alcohol dependence. The purpose of this study is to explore the impact of current alcohol use on suicid.

METHODS

Data on sex, date of death, results of blood and/or urine alcohol tests and history of alcohol dependence in suicide victims over the 1997-2002 period were retrieved from a forensic database in two cities in Chuvash Republic.

RESULTS

Over the six-year study period, 1,379 suicides were committed, 59% of them under the influence of alcohol. The peak incidence for men and women regardless of previous alcohol consumption was on Wednesdays and Mondays, respectively. The overall suicide rate was highest on Mondays and lowest on Thursdays. Both sexes were less likely to commit suicide during holidays than on weekends or workdays while intoxicated with alcohol.

CONCLUSION

In this urban sample, the distribution of suicide across weekdays only partly followed the international pattern. The peak incidence of suicide showed sex difference, with the highest incidence for women on Mondays and for men on Wednesdays. The higher suicide rate on workdays might be accounted for by work-related stress, while the lower rate on weekends could be explained that people usually drink alcohol in the comforting company of family or friends, which reduces psychological tension and suicidal ideation. The majority of men consumed alcohol before committing suicide, regardless of the day of the week, while this observation was true for women only on Fridays and Sundays. Alcohol consumption greatly contributes to suicidal behavior in Chuvash Republic.

Prevalence and correlates of aggressive behavior in psychiatric inpatient populations

Aggressive behavior in patients with psychiatric disorders is attracting increasing research interest. One reason for this is that psychiatric patients are generally considered more likely to be aggressive, which raises a related question of whether diagnoses of psychiatric disorders predict the prevalence of aggressive behavior. Predicting aggression in psychiatric wards is crucial, because aggressive behavior not only endangers the safety of both patients and staff, but it also extends the hospitalization times. Predictions of aggressive behavior also need careful attention to ensure effective treatment planning. This literature review explores the relationship between aggressive behavior and psychiatric disorders and syndromes (dementia, psychoactive substance use, acute psychotic disorder, schizophrenia, bipolar affective disorder, major depressive disorder, obsessive-compulsive disorder, personality disorders and intellectual disability). The prevalence of aggressive behavior and its underlying risk factors, such as sex, age, comorbid psychiatric disorders, socioeconomic status, and history of aggressive behavior are discussed as these are the components that mostly contribute to the increased risk of aggressive behavior. Measurement tools commonly used to predict and detect aggressive behavior and to differentiate between different forms of aggressive behavior in both research and clinical practice are also reviewed. Successful aggression prevention programs can be developed based on the current findings of the correlates of aggressive behavior in psychiatric patients.

Psychosocial aspects of hematopoietic stem cell transplantation

Hematopoietic stem cell transplantation (HSCT) has become a conventional and potentially curative treatment for various hematological diseases. As more sophisticated procedures have been developed and mortality rates have decreased, attention has shifted to the psychosocial challenges associated with transplantation. The psychosocial difficulties accompanying transplantation are addressed in the context of both quality of life (QOL) and psychopathological research. Among the psychiatric comorbidities of HSCT, anxiety, depression, sleep and sexual disorders, delirium and post-traumatic stress disorder are the most studied conditions. Recently, more attention has been focused on the psychosocial burden of caregivers. Devising recommendations for the management of psychiatric symptoms and psychosocial interventions in HSCT sufferers and close relatives is a major concern to consultation–liaison psychiatrists and transplant teams. This review synthesizes and critically evaluates the current literature on the psychosocial aspects of HSCT and appraises the clinical significance of these outcomes. Issues of QOL assessment; psychosocial functioning and QOL in the course of HSCT; impact of graft-versus-host disease and other predictors of QOL and psychosocial functioning; comorbid psychiatric disorders; and interventions to maintain or improve QOL and reduce psychopathology and psychosocial burden on family members are presented.

Hungarian Psychiatrists' Recognition, Knowledge, and Treatment of Catatonia

DSM-5 introduced a number of modifications to the catatonic syndrome, which is now closer to Kahlbaum's original concept. The aim of the present study was to assess residents' and qualified psychiatrists' knowledge, experience and views about the treatment of catatonia in acute psychiatric care in Budapest, Hungary. Authors approached all psychiatric units that provide acute psychiatric care (N = 11) in Budapest and invited all psychiatrists and residents, who consented, to participate in the survey, completing a 13 items questionnaire. Ninety-eight fully qualified and trainee psychiatrists completed the questionnaire. Although 84.7% of the participants rated their knowledge of catatonia as moderate or significant, there were a number of obvious mistakes in their answers. Most catatonic signs and symptoms were not identified by almost 50% of the respondents and the frequency of catatonia was also underestimated. The views of the majority of the participants reflected the Kraepelinian concept, in which catatonia is primarily associated with schizophrenia. Although benzodiazepines are widely recommended as a first line treatment for catatonia, only 69.4% of participants chose them as a treatment option. In view of its clinical importance, catatonia deserves more attention in the education and training of medical students and psychiatric residents.

Changes in the Practice of Electroconvulsive Therapy in Poland: A Nationwide Survey Comparing Data Between 2005 and 2020

BACKGROUND

The use and the characteristics of the practice of electroconvulsive therapy (ECT) in Poland have not been evaluated since 2005, when a nationwide survey revealed its rare utilization (0.11 patients/10,000 inhabitants/year). The aims of this study were to determine the current use of ECT and to compare the findings with those of the previous survey.

METHODS

Two questionnaires were sent to all 48 inpatient psychiatric centers in Poland. The first one - to units providing ECT to explore its practice, and the second - to units not performing ECT to explore the reasons for not using this treatment.

RESULTS

Nineteen (39.6%) of all psychiatric inpatient centers confirmed the use of ECT. The utilization rate was 0.13 patients/10,000 inhabitants. Similar to the findings from 2005, the main indications were affective disorders, and bitemporal electrode placement was the dominant method used for the delivery of ECT. Age-based and titration-based methods were applied exclusively in 50% and 25% of the centers, respectively (compared with 15% and 35% in 2005, respectively), while both methods were used in the remaining 25%. Improvements in safety were reflected by the use of comprehensive pre-ECT evaluation and treatment monitoring. None of the centers used sine-wave devices; this contrasts with their use by 29% of the centers in 2005. The main reasons for not using ECT were insufficient funding and a lack of experienced staff.

CONCLUSION

The frequency of ECT use in Poland remains very low. In view of the improvement in the quality of health services in the past decade, such a markedly rare use of an effective treatment was unexpected. There is an urgent need of education to create more positive attitude towards ECT among health professionals and among public, and to increase the training of mental health professionals in ECT.

Attitudes Towards ECT: A Survey of Polish Mental Health Professionals

BACKGROUND

Although the efficacy of electroconvulsive therapy (ECT) has been well established, the utilization rate of ECT has decreased in Poland in recent years. One of the main reasons could be the negative attitude towards ECT in the community and by mental health professionals. The aim of this study was to assess the knowledge about and attitudes toward ECT in Polish mental health professionals including psychiatrists and non-physicians: nurses, psychologists, social workers.

SUBJECTS AND METHODS

Psychiatrists and other mental health professionals in two large Polish hospitals were approached to participate in the survey by completing a 28-item questionnaire. The specific hospitals have been selected due to the fact that they were located in the same province of Poland (Mazowsze), had similar catchment area and profile, provided similar mental health services with only one exception; one offered ECT while the other did not. Of the 185 questionnaires that had been distributed, 165 were completed yielding a response rate of 89.19%. The study population consists of 85 psychiatrists and trainees and 80 non-physicians.

RESULTS

Psychiatrists did not differ from other mental health professionals with respect to the knowledge and attitudes toward ECT. However, there were significant differences in the attitude (9.1±3.8 vs 7.1±3.3; p<0.001) and knowledge (5.9±3.8 vs 2.8±4.1; p<0.001) scores between those professionals, who have ever worked in a psychiatric ward where they could observe ECT sessions and those who have not had such an opportunity.

CONCLUSIONS

Frequent witnessing of ECT sessions seems to be the most effective educational intervention to change negative attitudes towards ECT.

[Ethical questions in the clinical use and research of electroconvulsive therapy]

Electroconvulsive therapy (ECT) is one of psychiatry's most long-standing and criticized treatments. Some of the criticisms come from the ethical aspect of ECT. The authors review the ethical issues of clinical application and research of ECT. ECT in the treatment of psychiatric patients is considered ethical, if it is conducted according to the four main principles of bioethics (beneficence, non-maleficence, autonomy and justice). ECT research should also comply with other international guidelines and research ethics codes. In recent decades, the principle of informed consent has become widespread in psychiatry, which requires objective information from the attending doctor according to the most reliable scientific information. The UN Convention on the Rights of Persons with Disabilities considers psychiatric disorders to be part of the concept of disability. For disabled psychiatric patients, assisted decision-making is a desirable way of self-determination. In doing so, it is important to use decision support instead of decision-substituting mechanisms, although for patients lacking insight, decisionsubstituting mechanisms are unavoidable.

[The public's attitudes towards electroconvulsive therapy in Hungary]

BACKGROUND AND PURPOSE

This research focused on the knowledge and attitude toward to electroconvulsive therapy (ECT) in the general population of Hungary. There are only a few studies in the international literature focusing on the public's attitude towards ECT, and no such study has been published from Hungary.

METHODS

Participants were reached through social media and asked to fill out a semi-structured questionnaire on internet that comprised seventeen questions. Participation in the survey was entirely voluntary and anonymous. Participants of the survey were not working in health care; their answers to the questionnaire were compared to those of health-care workers.

RESULTS

The result showed a significant difference between healthcare workers' and lay people's knowledge and attitude towards ECT. Two third of lay participants have never heard about ECT. Those familiar with ECT were relatively well-informed about its certain aspects yet rejection of ECT was significantly higher in the group of lay participants than in health-care workers.

CONCLUSION

Lay people's incomplete knowledge and negative attitude towards ECT was confirmed by this survey. The dissemination of reliable information - which should be the shared responsibility of mental health professionals and the media - would be vitally important to disperse the prejudices and doubts about ECT.

[Survey of anxiolytic drug dependence in patients treated in psychiatric and addiction rehabilitation wards]

Introduction: Anxiolytic drug dependence is a cause for growing concern worldwide including Hungary. Psychiatric patients and patients with other drug addictions are at increased risk for anxiolytic drug dependence. Yet, there is only limited scientific information about the real extent of this issue. Aim: To examine the frequency of use of benzodiazepine-containing drugs and comparing the consumption habits of patients treated in psychiatric and addiction rehabilitation wards in a hospital in Budapest. Method: The survey was based on an anonymously and voluntarily completed questionnaire during a face-to-face interview of 103 patients in two wards. The 19-item questionnaire targeted anxiolytic drug use and related behavioral patterns. Statistical analysis: Socio-demographic data were given with means and standard deviations or with percentages as appropriate. For the comparison between the two groups of patients, t-test, Mann–Whitney U-test or chi-square test were used in accordance with the distribution of the sample. Results: Symptoms indicating anxiolytic dependence, use of multiple anxiolytics, and combination of anxiolytic drugs with alcohol were very frequent in both wards. However, there were some significant differences between the two samples. Anxiolytic drug abuse and illicit drug use were significantly more frequent in patients at the addiction ward. Indicators of social status, particularly the place of residence, significantly influenced non-prescription misuse of anxiolytic drugs. Conclusions: The results draw attention to the high frequency of anxiolytic drug misuse and dependence in psychiatric and addiction patients warranting urgent action to confront this challenge. Orv Hetil. 2020; 161(15): 594–600.

Neurocognitive functions in patients with hepatitis C infection

BACKGROUND AND PURPOSE

With improving treatment options, more attention is being paid to the neurocognitive symptoms related to hepatitis C infection (HCI). While HCI-related neurocognitive impairments are frequently subclinical, they can influence patients' quality of life and fitness to work. Objective - The aim of this study was to assess HCI patients' neurocognitive functions and explore the correlations between disease variables and neurocognitive symptoms.

METHODS

The study was conducted between January 1, 2013 and December 31, 2015. All patients with HCI were included in the study who were registered at the Hepatology Outpatient Clinic of Szent István and Szent László Hospitals, met inclusion criteria and volunteered to participate. Patients' sociodemographic data and medical history were recorded in a questionnaire designed for the study. The 21-item Beck Depression Inventory was used to detect depressive symptoms. Six computerized tests were used to evaluate patients' neuropsychological functions.

RESULTS

Sixty patients participated in the study. In comparison with general population standards, patients demonstrated poorer performance in several neurocognitive tests. Neuropsychological performance was correlated with age, sex, length of time since HCI diagnosis, Fibroscan score and the number of previous antiviral treatments.

CONCLUSION

The study's main finding is that compared to general population standards, patients with hepatitis C virus-related disease exhibit impaired neuropsychological functioning in visuomotor and visuospatial functions, working memory, executive functions, and reaction time. Executive functions and reaction time were the most sensitive indicators for the length and severity of the disease. Deterioration in these functions has a major negative effect on work performance particularly in certain occupations.

Electroconvulsive Therapy in the Shadow of the Gas Chambers: Medical Innovation and Human Experimentation in Auschwitz

Six years after it was first introduced into psychiatry in 1938, electroconvulsive therapy (ECT) became the subject of criminal human experiments in Nazi Germany. In 1944, at the Auschwitz III / Monowitz camp hospital, the Polish Jewish prisoner psychiatrist Zenon Drohocki started experimental treatments on prisoners with an ECT device that he had constructed himself. According to eyewitnesses, Drohocki's intention to treat mentally unstable prisoners was soon turned into something much more nefarious by SS doctors (including Josef Mengele), who used the device for deadly experiments. This article provides an account of this important and little-known aspect of the early history of ECT, drawing on an extensive array of historical literature, testimonies, and newly accessible documents. The adoption of ECT in Auschwitz is a prime example of the "grey zone" in which prisoner doctors had to operate-they could only survive as long as the SS considered their work useful for their own destructive purposes.

[The impact of the COVID-19 epidemic on the content of the delusions]

The COVID-19 epidemic was declared a pandemic by the World Health Organization on 11 March 2020. The outbreak and spread of the disease has caused fear, insecurity and anxiety in people around the world. The pan - de mic has both direct and indirect effects on mental health problems, as fear of the virus can trigger or exacerbate mental illness and influence the onset of symptoms. Case studies suggest that this emergency can affect the content of delusions and hallucinations, as well as contribute to psychotic relapse. In addition to a brief review of the literature, we describe the case of three psychotic patients of the Jahn Ferenc South Pest Hospital, Centre for Psychiatry and Addiction Medicine, whose delusions and hallucinations were affected by the COVID-19 pandemic. In two cases, the symptoms of a reactive, transient psychotic episode presumably provoked by psychosocial stressors were determined, and in one case, the positive symptoms of a patient suffering in a psychotic disorder were determined by COVID-19.

The prevalence of catatonic syndrome in acute psychiatric wards

OBJECTIVES

The aim of this prospective study was to determine the prevalence of the catatonic syndrome in a cohort of patients admitted to acute psychiatric units in Hungary.

METHODS

Patients admitted to the acute inpatient unit of the Center of Psychiatry and Addiction Medicine, SzentIstván and SzentLászló Hospitals in a 4-month period were screened for catatonic signs and symptoms. Catatonic signs/symptoms were scored according to both the DSM-5 diagnostic criteria and the Bush-Francis Catatonia Rating Scale (BFCRS). Clinical diagnoses were established using the Structured Clinical Interview for DSM-IV Disorders (SCID), while cognitive performance was estimated with the Clock Drawing Test and the Mini-Mental State Examination (MMSE).

RESULTS

During the study period, 342 patients were admitted to the above-mentioned acute inpatient units. The prevalence figures for the catatonic syndrome were 8.55% and 5.02% according to the BFCRS and the DSM-5, respectively.

CONCLUSIONS

The prevalence of catatonic syndrome in an acute inpatient setting is within the broad range of figures reported in the literature. The difference between the standardized assessment (BFCRS) and routine clinical judgment (DSM-5) is noteworthy and suggests that a significant minority of catatonic patients might not be identified in clinical practice. As acute catatonia can be effectively treated, and early treatment could prevent potentially lifethreatening complications, recognition of catatonic symptoms is vitally important.

Electroconvulsive therapy: 80 years old and still going strong

Electroconvulsive therapy (ECT), which is among the oldest and most controversial treatments in the field of psychiatry, has its 80^th birthday this year. In this brief historical overview, the discovery of the therapeutic effects of convulsive therapy by Laszló Meduna, and the circumstances that motivated Ugo Cerletti and Lucio Bini to use electricity as a means of seizure induction are described. Meduna’s original theory about the antagonism between epilepsy and schizophrenia has been replaced by hypotheses on the mechanism of action of ECT. The position of ECT in modern psychiatry is also discussed with special attention to its most important clinical indications, including catatonia, and pre- and postpartum affective and psychotic states that are responsive to ECT and in which ECT may even be lifesaving. Adverse effects and comparison of ECT with recently developed brain stimulation methods are also reviewed. The negative media portrayal of ECT and its earlier misuse may have contributed to its negative professional and public perceptions indicated repeatedly in attitude surveys. This negative attitude has played an important role in the decreasing use of ECT in the developed world and a reduction in access to ECT, which constitutes a violation of psychiatric patients’ right to an effective treatment.

Schizophrenia with prominent catatonic features: A selective review

A widely accepted consensus holds that a variety of motor symptoms subsumed under the term 'catatonia' have been an integral part of the symptomatology of schizophrenia since 1896, when Kraepelin proposed the concept of dementia praecox (schizophrenia). Until recently, psychiatric classifications included catatonic schizophrenia mainly through tradition, without compelling evidence of its validity as a schizophrenia subtype. This selective review briefly summarizes the history, psychopathology, demographic and epidemiological data, and treatment options for schizophrenia with prominent catatonic features. Although most catatonic signs and symptoms are easy to observe and measure, the lack of conceptual clarity of catatonia and consensus about the threshold and criteria for its diagnosis have hampered our understanding of how catatonia contributes to the pathophysiology of schizophrenic psychoses. Diverse study samples and methodologies have further hindered research on schizophrenia with prominent catatonic features. A focus on the motor aspects of broadly defined schizophrenia using modern methods of detecting and quantifying catatonic signs and symptoms coupled with sophisticated neuroimaging techniques offers a new approach to research in this long-overlooked field.

Effect of hepatitis C infection on the quality of life

PURPOSE

To assess the quality of life (QoL) of patients with hepatitis C infection (HCI) and its correlations with demographic and clinical variables.

DESIGN AND METHODS

QoL and depressive symptoms were evaluated with the validated rating instruments of the 36-item short form (SF-36) generic health survey and the second version of the self-rated Beck depression inventory (BDI-II) in a cross-sectional design and correlated with basic demographic and clinical variables, including the Fibroscan score, which indicates the severity of liver impairment.

FINDINGS

A cohort of 60 HCI patients who participated in the study scored lower than the general population on all domains of the SF-36. In the multivariate correlation analysis, only the physical functioning domain of the SF-36 showed a significant correlation with age, gender, and BD-II and Fibroscan scores.

IMPLICATIONS FOR CLINICAL PRACTICE

QoL is lower for patients who are older, female, and have depressive symptoms. Progression of hepatic cirrhosis is associated with lower QoL in the physical domain.

Memory Impairment Following Electroconvulsive Therapy in Chinese Patients with Schizophrenia: Meta-Analysis of Randomized Controlled Trials

PURPOSE

To evaluate memory impairment associated with electroconvulsive therapy (ECT)-antipsychotic (AP) combination in comparison to AP monotherapy in schizophrenia.

DESIGN AND METHODS

A systematic literature search of randomized controlled trial (RCTs) was performed.

FINDINGS

Eleven RCTs that compared ECT-AP combination (n = 508) with AP monotherapy (n = 510) were analyzed. ECT-AP combination was associated with greater impairment than AP monotherapy in (1) endpoint memory quotient (MQ) of the Wechsler Memory Scale (WMS)-Revised at the end of the ECT course; and (2) picture recall, counting, recognition, and associative learning of the WMS. However, no group difference was found in MQ at 1 and 2 weeks post-ECT.

PRACTICE IMPLICATIONS

The ECT-AP combination was associated with greater transient memory impairment compared to AP monotherapy.

[Accessibility to Electroconvulsive Therapy in Hungary]

INTRODUCTION

In spite of its efficacy, use of electroconvulsive therapy (ECT) has been declined in Hungary over the past decade. This survey explores the circumstances that have obstructed the accessibility to ECT in Hungary.

METHODS

This study was part of a comprehensive survey on the use of ECT in which two semi-structured questionnaires with 25 and 6 questions were sent out to all psychiatric departments in Hungary. The second questionnaire was targeted those departments that did not perform ECT in 2014. Questions were asked about the reasons for not using ECT and the available treatment strategies for patients who needed ECT.

RESULTS

Thirty-one of the 58 Hungarian psychiatric departments did not offer ECT in 2014. Twelve chiefs of service asserted that no patient needed ECT in that year. Due to unavailability of ECT, patients were transferred to other departments for ECT in further 12 departments. Finally, in 7 departments, patients who would have needed ECT were treated with pharmacotherapy instead of transferring them to ECT centers. As for the reasons for the lack of access to ECT, 17 departments had no ECT machine, 12 departments did not have access to anesthesiologists, 6 departments had no budget for ECT, and in 5 departments staff with expertise to deliver ECT was not available.

CONCLUSION

The rate of ECT use in Hungarian psychiatric departments decreased by 20 percent between 2002 and 2014. The most important reasons for this decline were lack of the modern ECT devices or financial sources to buy a modern ECT machine. Further reasons for not using ECT were the availability of anesthesiologists or the lack of finances to employ them. The lack of experience in administering ECT was another reason for not utilizing ECT. These difficulties could be solved with the centralization of ECT provision to a few centres in the country together with defining the pathways for patients to reach these centres.

Changes in Electroconvulsive Therapy Practice in the Last 12 Years in Hungary

BACKGROUND

Electroconvulsive therapy (ECT) was rarely used in Hungary in 2002, and the majority of patients receiving ECT were diagnosed with schizophrenia. This study aimed to explore the use of ECT in Hungary in 2014.

METHODS

Two semi-structured questionnaires were sent to all acute adult psychiatric units in Hungary. The first questionnaire contained items concerning ECT use, and the second explored the reasons for not using ECT.

RESULTS

Fifty-eight acute psychiatric inpatient units were identified, and 54 replied. Although 27 indicated that they used ECT, only 22 actually performed ECT in 2014. Thirty-one units did not offer ECT at all. In 2014, 174 patients received ECT in Hungary, constituting 0.59% of all inpatients treated in the departments where it was offered, equating to 0.176 patients/10,000 population. The indication for ECT shifted from schizophrenia in 2002 (55.6%) to mood disorders in 2014 (58.5%), but the absolute number of ECT-treated patients with mood disorders (110 vs 102) did not change. Reasons for not using ECT included the lack of an ECT machine, unavailability of an anesthesiologist, lack of finances, and lack of experienced staff.

CONCLUSIONS

In view of the high frequency of depression and suicide in Hungary, it is very likely that a significant minority of patients who would benefit from ECT cannot access it, which constitutes a violation of their right to the best possible treatment. The main reasons for the inadequate ECT service are the underfinanced hospital system and a lack of necessary knowledge.

Mass killing under the guise of ECT: the darkest chapter in the history of biological psychiatry

Following its inception, electroconvulsive therapy (ECT), rapidly spread all over the world, including Nazi Germany. Paradoxically, at the same time, the euthanasia programme was started in Germany: the extermination of people with intellectual disabilities and severe psychiatric disorders. In Lower Austria, Dr Emil Gelny, who had been granted a specialist qualification in psychiatry after three months of clinical training, took control of two psychiatric hospitals, in Gugging and Mauer-Öhling. In 1944, he began systematically killing patients with an ECT machine, something that was not practised anywhere else before or after, and remains unprecedented in the history of convulsive therapy. He modified an ECT machine, adding extra electrodes, which he fastened onto a victim's wrists and ankles to administer lethal electric shocks.

Catatonia as a putative nosological entity: A historical sketch

Kahlbaum was the first to propose catatonia as a separate disease following the example of general paresis of the insane, which served as a model for establishing a nosological entity. However, Kahlbaum was uncertain about the nosological position of catatonia and considered it a syndrome, or “a temporary stage or a part of a complex picture of various disease forms”. Until recently, the issue of catatonia as a separate diagnostic category was not entertained, mainly due to a misinterpretation of Kraepelin’s influential views on catatonia as a subtype of schizophrenia. Kraepelin concluded that patients presenting with persistent catatonic symptoms, which he called “genuine catatonic morbid symptoms”, particularly including negativism, bizarre mannerisms, and stereotypes, had a poor prognosis similar to those of paranoid and hebephrenic presentations. Accordingly, catatonia was classified as a subtype of dementia praecox/schizophrenia. Despite Kraepelin’s influence on psychiatric nosology throughout the 20^th century, there have only been isolated attempts to describe and classify catatonia outside of the Kraepelinian system. For example, the Wernicke-Kleist-Leonhard school attempted to comprehensively elucidate the complexities of psychomotor disturbances associated with major psychoses. However, the Leonhardian categories have never been subjected to the scrutiny of modern investigations. The first three editions of the DSM included the narrow and simplified version of Kraepelin’s catatonia concept. Recent developments in catatonia research are reflected in DSM-5, which includes three diagnostic categories: Catatonic Disorder due to Another Medical Condition, Catatonia Associated with another Mental Disorder (Catatonia Specifier), and Unspecified Catatonia. Additionally, the traditional category of catatonic schizophrenia has been deleted. The Unspecified Catatonia category could encourage research exploring catatonia as an independent diagnostic entity.