Age-related changes in brain perfusion of normal subjects detected by 99mTc-HMPAO SPECT

Previous functional imaging data generally show impairment in global cerebral blood flow (CBF) with age. Conflicting data, however, concerning age-related changes in regional CBF (rCBF) have been reported. We examined the relative rCBF in a sample of healthy subjects of various ages, to define and localize any age-related CBF reduction. Twenty-seven healthy subjects (17 male, 10 female; mean age 49 +/- 15, range 26-71, median 47 years) were studied by 99mTc-HMPAO brain SPECT. The younger age group consisted of subjects below, the older group above 47 years of age, respectively. Analysis was performed by applying three preformed templates, each containing delineated regions of interest (ROIs), to three transaxial brain slices at approximately 4, 6, and 7 cm above the orbitomeatal line (OML). The average number of counts for each ROI was normalized to mean uptake of the cerebellum and of the whole brain slice. Globally, 99mTc-HMPAO uptake ratio normalized to cerebellum was significantly decreased in older subjects, affecting both hemispheres. A slight left-to-right asymmetry was observed in HMPAO uptake of the whole study group. It did not, however, change with age. Regionally, both cortical and subcortical structures of older subjects were involved: uptake ratio to cerebellum was significantly lower (after correction for multiple testing) in the left basal ganglia and in the left superior temporal, right frontal and bilateral occipital cortices at 4 cm above the OML. At 6 cm above the OML, reduced uptake ratios were identified in the left frontal and bilateral parietal areas. At 7 cm, reduced uptake was detected in the right frontal and left occipital cortices. Most of these differences were reduced when uptake was normalized to whole slice, whereas an increase in uptake ratios was observed in the cingulate cortex of the elderly. An inverse correlation between age and HMPAO uptake ratios normalized to cerebellum was observed in a number of brain regions. These findings suggest that advancing age has a differential effect on cerebral perfusion reflected in brain 99mTc-HMPAO uptake.

Influence of socioeconomic status on behavioral, emotional and cognitive effects of rubella vaccination: a prospective, double blind study

A double-blind prospective design was used to investigate the immediate and prolonged psychological effects of a specific viral infection, and the role of immune activation in mediating these effects. Subjects were 240 female teenager girls who were vaccinated with rubella vaccine. Based on analysis of levels of antibodies to rubella, subjects were divided into two groups. An experimental group (n = 60), which included subjects who were initially seronegative and were infected following vaccination, and a control group (n = 180), which included subjects who were already immune to rubella before vaccination. Compared with the control group and to their own baseline, low socioeconomic status (SES) subjects within the experimental group showed a significant increase in the severity of depressed mood, social and attention problems, and delinquent behavior. Ten weeks post-vaccination there were no differences between the experimental and control groups in serum levels of interleukin-1 beta, interferon-gamma, soluble interleukin-2 receptors (sIL-2r), and cortisol. However, a significant negative correlation was found between fatigue-related symptoms and sIL-2r levels in the experimental (r = -0.325), but not the control group (r = -0.046). These findings suggest that viral infection can produce prolonged behavioral, emotional and cognitive problems mainly in subjects belonging to the low SES.

No evidence for significant linkage between bipolar affective disorder and chromosome 18 pericentromeric markers in a large series of multiplex extended pedigrees

Bipolar affective disorder (BP) is a major neuropsychiatric disorder with high heritability and complex inheritance. Previously reported linkage between BP and DNA markers in the pericentromeric region of chromosome 18, with a parent-of-origin effect (linkage was present in pedigrees with paternal transmission and absent in pedigrees with exclusive maternal inheritance), has been a focus of interest in human genetics. We reexamined the evidence in one of the largest samples reported to date (1,013 genotyped individuals in 53 unilineal multiplex pedigrees), using 10 highly polymorphic markers and a range of parametric and nonparametric analyses. There was no evidence for significant linkage between BP and chromosome 18 pericentromeric markers in the sample as a whole, nor was there evidence for significant parent-of-origin effect (pedigrees with paternal transmission were not differentially linked to the implicated chromosomal region). Two-point LOD scores and single-locus sib-pair results gave some support for suggestive linkage, but this was not substantiated by multilocus analysis, and the results were further tempered by multiple test effects. We conclude that there is no compelling evidence for linkage between BP and chromosome 18 pericentromeric markers in this sample.

Chronic electroconvulsive shock and 5-HT autoreceptor activity in rat brain: an in vivo microdialysis study

In vivo microdialysis was used to determine the effects of chronic electroconvulsive shock (ECS), given daily for 10 days, on basal 5-HT levels in rat frontal cortex and hippocampus and on the effect of systemic administration of the 5-HT-la receptor agonist, 8-OH-DPAT (0.2 mg/kg), to reduce 5-HT levels in these areas by activation of somatodendritic autoreceptors. Neither basal 5-HT levels nor the effects of 8-OH-DPAT on 5-HT levels were altered after chronic ECS. The effect of systemic administration of the 5-HT1A and 5-HT1B antagonist, (+/-)-pindolol (10 mg/kg), to increase 5-HT levels in hippocampus, was also not affected by chronic ECS.

Effect of clinical doses of fluoxetine on psychological variables in healthy volunteers

OBJECTIVE

The authors sought to determine the effect of clinically equivalent doses of fluoxetine on mood and other psychological variables in normal subjects.

METHOD

Fifteen healthy volunteers received placebo for 2 weeks; fluoxetine, 10 mg/day, for 1 week; fluoxetine, 20 mg/day, for 5 weeks; and then an additional 2 weeks of placebo in the context of a single-blind study. The subjects were evaluated with a series of self- and observer-rated instruments.

RESULTS

No significant effects attributable to fluoxetine were observed on any of the psychological variables examined. Minimal adverse effects were reported.

CONCLUSIONS

Significant mood-elevating and other psychological effects of fluoxetine would appear to be induced only when symptomatic targets exist.

Cost and benefit in the choice of ECT schedule. Twice versus three times weekly ECT

BACKGROUND

We compared the antidepressant and cognitive effects of up to eight sessions of bilateral, brief pulse electroconvulsive therapy (ECT) administered twice (ECT x 2) or three times weekly (ECT x 3), to confirm that ECT x 3 acts more rapidly although the two schedules are equivalent in antidepressant outcome, and to establish whether ECT x 3 is indeed associated with more severe memory impairment.

METHOD

Patients with major depression, endogenous subtype were randomly assigned to ECT x 3 or ECT x 2 plus one simulated ECT per week, both up to a maximum of eight real ECT. Depression was evaluated by the Hamilton Depression Scale the day after each treatment and cognitive function by a test battery administered before and after the ECT series and at one month follow-up.

RESULTS

Assessed categorically or parametrically, there was no significant difference in antidepressant outcome between the two schedules. Rate of response was significantly more rapid with ECT x 3 but was associated with more severe memory impairment.

CONCLUSIONS

Twice weekly administration is an optimum schedule for bilateral ECT unless clinical indications require the more rapid antidepressant effect of three times weekly treatment.

Serum neuroleptic levels during reduced dose fluphenazine decanoate maintenance therapy

Forty-one remitted and chronically psychotic schizophrenic out-patients completed a two-year clinical trial during which they were assigned, on the basis of their clinically determined maintenance dosages, to one of two reduced, fixed-dose fluphenazine decanoate (FD) regimens: 35 mg/4 wks (19 patients) or 10 mg/4 wks (22 patients). Eighty-one percent of chronically psychotic patients, who represented 74% of the high dose group, relapsed, in comparison with only 38% of remitted patients (p < .001), who represented 86% of the low dose group. During this study serum neuroleptic levels were assessed, using the radioreceptor assay, before the administration of each FD injection and whenever a patient relapsed. Overall, 334 serum neuroleptic activity measurements were performed. Serum neuroleptic levels were detectable in all patients and were higher, although not significantly, in the 35 mg/4 wks group. The dichotomous clinical outcome of chronically psychotic and remitted patients occurred within the framework of essentially similar serum neuroleptic levels. These findings suggest that: 1) serum neuroleptic levels can be monitored during low dose FD treatment, 2) the poor maintenance therapy outcome of chronically psychotic patients cannot be accounted for by inadequate neuroleptic bioavailability, 3) a majority of remitted FD maintained patients retain their clinical response at serum neuroleptic levels lower than those initially attained at steady state.

In vivo cyclic AMP responses in rat brain are not modified by chronic electroconvulsive shock

In vivo microdialysis was used to determine the effects of chronic electroconvulsive shock (ECS), given daily for 10 days, on the cyclic AMP (cAMP) responses to noradrenaline (NA) and to forskolin in the cortex of freely-moving conscious rats. Microdialysis probes were inserted on the final day of ECS administration, and cAMP responses measured the following day. Chronic ECS did not modify the responses to either NA or forskolin. These results differ markedly from those previously obtained with incubated slices of rat brain. It is concluded that care is needed in interpreting results obtained by either ex vivo or in vitro methods.

Schizophrenia, chronic hospitalization and the 5-HT2C receptor gene

Frequency of a polymorphism in the coding region of the 5-hydroxytryptamine2C (5-HT2C) receptor gene (HTR2C Xq24) was not significantly different in 122 unrelated Israeli schizophrenia patients compared with 180 control subjects matched for gender and ethnicity. However, proportion of time spent in hospital since the first admission was significantly greater in patients hemi- of homozygous for the 5-HT2Cser allele than in patients carrying other genotypes (p = 0.006). The 5-HT2Cser genotype conferred a 3.3-fold increased risk for lifetime hospitalization exceeding 10 years. Genetically determined variation in the 5-HT2C receptor may influence the clinical course and phenotypic expression of schizophrenia.

Excess dopamine D4 receptor (D4DR) exon III seven repeat allele in opioid-dependent subjects

Only in the past decade has a role of heredity in substance abuse been established as a result of extensive twin and family studies. More recently, several candidate genes have been investigated for their possible role in alcoholism and cocaine abuse. Specific genetic factors in opioid substance abuse have not been investigated in man, although animal studies suggest that quantitative trait loci (QTLs) can be identified that predispose mice both to morphine and alcohol preference. Central dopaminergic pathways figure prominently in drug-mediated reinforcement suggesting that dopamine receptors are likely candiadates for association with substance abuse in man. In addition, we recently reported an association between a human personality trait, Novelty Seeking and the long alleles (represented chiefly by the 7-repeat) of the D4 dopamine receptor (D4DR) exon III polymorphism. The personality trait of Novelty Seeking is also more pronounced in substance abusers, who score higher in this dimension than control subjects. The twin role of dopamine receptors in mediating Novelty Seeking and drugreinforcement prompted us to examine a group of Israeli heroin addicts for prevalence of the D4DR repeat polymorphism. We now show that the 7-repeat allele is significantly over-represented in the opioid-dependent cohort and confers a relative risk of 2.46. To our knowledge this is the first report of an association between a specific genetic polymorphism and opioid addiction.

Post-traumatic stress disorder and depression. An analysis of comorbidity

BACKGROUND

We examined psychiatric morbidity following war-related psychic trauma, with a special focus on the depressive comorbidity of post-traumatic stress disorder (PTSD).

METHOD

Subjects consisted of 60 Israeli veterans who sought psychiatric treatment 4-6 years after having been exposed to war trauma. PTSD and psychiatric comorbidity were diagnosed using the Structured Interview for PTSD and the Schedule for Affective Disorders and Schizophrenia.

RESULTS

Both lifetime (100%) and current (87%) PTSD were the most prevalent disorders. Comorbidity was extensive, with major depressive disorder (MDD) most prevalent (95% lifetime, 50% current), followed by anxiety disorders, minor affective disorders, and alcoholism or drug misuse.

CONCLUSIONS

Within post-traumatic psychiatric and MDD are the most prevalent disorders. In addition it appears that PTSD, although related to post-traumatic MDD beyond a mere sharing of common symptoms, is at the same time differentiated from it as an independent diagnostic category.

Evidence suggestive of a locus on chromosome 5q31 contributing to susceptibility for schizophrenia in German and Israeli families by multipoint affected sib-pair linkage analysis

Suggestive evidence for a potential susceptibility locus for schizophrenia at 5q31 was obtained in two family samples. Sample I consisted of 14 families with schizophrenia and revealed for the marker IL9 a lod score of 1.8 by two point lod score analysis. Sample II comprised 44 families including four from sample I and was ascertained in order to employ affected sib-pair analysis by identity by descent. A lod score of 1.8 around the marker D5S399 was obtained by multipoint analysis. The lod score remained positive, but decreased to 1.27 when the four families from sample I were excluded in order to use sample II as a statistically independent replication sample. We propose a susceptibility locus for schizophrenia with probably minor contribution in the pedigrees under investigation.

Concurrent treatment of nonresistant major depression with desipramine and lithium: a double-blind, placebo-controlled study

The objective of this study was to compare the onset, rate of antidepressant (AD) response, and treatment outcome of depressed patients treated for 5 weeks with either the concomitant administration of the tricyclic AD desipramine (DMI) and lithium carbonate (Li) or with DMI alone. In this double-blind, placebo-controlled study, 31 nonpsychotic, mild to moderately depressed outpatients (DSM-III-R unipolar or bipolar major depression) were randomly assigned to 5 weeks of treatment with DMI plus Li (N = 16) or DMI plus placebo (N = 15). Drug dosages were adjusted to achieve therapeutic plasma levels. Clinical state was rated weekly by the Hamilton Rating Scale for Depression, the Clinical Global Impression Scale, a Visual Analogue Self-Report Scale, and an adverse-effect form. Twenty-seven patients completed the study, 12 in the DMI-Li group and 15 in the DMI-placebo group. Four patients dropped out due to adverse events, all from the DMI-Li group. Both groups responded well to treatment, without a significant difference between them in the rate of response of final outcome. Sixty-seven percent (10/15) of the patients taking DMI only and 75% (9/12) of the patients taking DMI plus Li met our response criteria. The combination of DMI and Li was associated with significantly more adverse effects than DMI alone. Concurrent treatment with Li did not demonstrate an enhancement of either DMI's efficacy or its onset of action in these patients, suggesting that this strategy may not confer any additional benefit compared with DMI alone in mild to moderately depressed patients who are not preselected for nonresponse to an AD during their current depressive episode.

Dopamine D4 receptor gene polymorphisms: relation to ethnicity, no association with schizophrenia and response to clozapine in Israeli subjects

The dopamine D4 receptor (DRD4) is a candidate gene in the search for a genetic etiology of schizophrenia and for pharmacogenetic factors in the response to antipsychotic treatment. Previous work has not found linkage or association of a polymorphism in exon 3 of this gene with diagnosis of schizophrenia or response to clozapine. In this study we examined this association in Israeli schizophrenic subjects treated with clozapine, compared to ethnically matched controls. Another polymorphism of this gene, in exon 1, was also studied. Both polymorphisms showed no association with schizophrenia or treatment response. A significant difference in allelic distribution of DRD/ exon 3 polymorphism was found between Ashkenazi and non-Ashkenazi control subjects.

Evidence for an association between the dopamine D3 receptor gene DRD3 and schizophrenia

Association of the dopamine D3 receptor gene (DRD3) and schizophrenia was examined in unrelated Israeli and Italian schizophrenic patients and ethnically matched normal control subjects. In the combined sample, there was a significant excess of DRD3 allele 2 among the schizophrenic patients (chi2 = 4.70, d.f. 1, p = 0.03). Comparison of genotype frequencies revealed an excess of the 2-2 genotype in the combined schizophrenic sample (chi2 = 8.30, d.f. 1, p = 0.01) and in the non-Ashkenazi Israeli schizophrenics alone (chi2 = 5.70, d.f. 2, p = 0.05). DRD3 2-2 genotype conferred a significantly increased risk of schizophrenia (chi2 = 8.21, d.f. 1, p = 0.004; OR = 2.87, CI 95% = 1.36-5.76) in the combined sample and in the non-Ashkenazi Israeli schizophrenics (chi2 = 7.22, d.f. 1, p = 0.04; OR = 7.22, CI 95% = 1.04-24.83). In the combined and Italian samples, allele 2 was associated with early age of onset as was the 2-2 genotype in the combined sample and non-Ashkenazi group. The 2-2 genotype was associated with poor response to neuroleptics, particularly in the non-Ashkenazi, Israeli schizophrenics. The possibility that DRD3 or a locus in linkage disequilibrium with it may play a role in the transmission of schizophrenia, is considered in relation to previous positive and negative reports.

"Failure to thrive" in elderly depressed patients: a new concept or a different name for an old problem?

With increasing frequency one may encounter the term "failure to thrive (FTT)" as applied to elderly patients. FTT in elderly patients is characterized by an insidious deterioration in their self-care abilities, loss of weight, loss of interest in social activities, a gradual decline in physical and/or cognitive function, and increased dependency on family members. The deterioration is beyond the expected, age-associated, "normal" decline. Depression is considered to be only one of the possible causes of FTT in the elderly. However, we suggest that the term, "FTT," as applied to elderly, depressed patients, does not appear to have intrinsic clinical value in that it describes a situation which represents an extreme form of the depressed syndrome rather than a separate clinical entity. It seems that early recognition of FTT would lead to appropriate supportive treatment being instituted before an advanced level of deterioration is reached. However, early diagnosis of the depression should have the same result and should lead to appropriate antidepressant treatment combined with vigorous nutritional intervention as well. The clinical problem which may lead to a delay in treatment of "FTT" affected elderly depressed patients is not a failure to diagnose "FTT" but a failure to diagnose depression.

Cerebral hypoperfusion in medication resistant, depressed patients assessed by Tc99m HMPAO SPECT

Functional imaging studies generally show decreased cerebral metabolism and perfusion in depressed patients relative to normal controls, although the location of the deficits varies. We used Tc99m HMPAO SPECT to compare cerebral blood flow in medication resistant, depressed patients and a normal control group. HMPAO uptake ratios (adjusted for age) were significantly lower in the depressed patients in the transaxial slices 4 cm and 6 cm above the orbitomeatal line (OML) on the left side. Examining individual regions of interest (corrected for age and multiple testing), we found significantly lower perfusion in the left superior temporal, right parietal and bilateral occipital regions in the patient group. These findings are in limited agreement with previous HMPAO SPECT studies. Methodological differences between studies, particularly variability in adjusting data for age, lead to a divergence in findings. Future research should seek to standardize protocols and data analysis in order to generate comparable results.

Increased cerebral blood flow in depressed patients responding to electroconvulsive therapy

Considerable data support the existence of impaired regional cerebral blood flow (rCBF) in major depression. We compare rCBF in depressed patients before and after electroconvulsive therapy (ECT) to define whether the impairment is a "state"-related property or a trait phenomenon.

METHODS

Twenty patients with a major depressive disorder were studied by 99mTc-HMPAO brain SPECT, 2-4 days before and 5-8 days after a course of ECT. Three transaxial brain slices delineating anatomically defined regions of interest at approximately 4, 6 and 7 cm above the orbitomeatal line were used, with the average number of counts for each region of interest normalized to the area of maximal cerebellar uptake.

RESULTS

Technetium-99m-HMPAO uptake significantly increased in patients who responded to ECT but remained unchanged in patients who did not respond to the treatment (response defined as a reduction of at least 60% on the Hamilton Depression Rating Scale). An inverse correlation was observed between severity of depression and HMPAO uptake, and clinical improvement was positively correlated with the increase in tracer uptake.

CONCLUSIONS

These findings imply that reduced rCBF in depression, as reflected in brain 99mTc-HMPAO uptake, is a "state"-related property and is reversible by successful treatment. Technetium-99m-HMPAO uptake may serve as an objective state marker for depression, an an indicator of the severity of depression and as an objective means of evaluating response to treatment.

Genetic relationship between dopamine transporter gene and schizophrenia: linkage and association

This study explores the genetic relationship between schizophrenia and the dopamine transporter gene (DAT) by a variety of methods. In a sample of 48 families--each family containing at least one nuclear family with a pair of affected siblings--we performed linkage analysis using the maximum likelihood (LOD score) method as well as sibpair analysis (identity by descent). In addition, we investigated a sample of 108 nuclear families--index case affected with schizophrenia/chronic schizoaffective disorder--for association using the haplotype relative risk method. Linkage between schizophrenia and DAT using two- and three-point linkage analysis was excluded with all disease models employed. No evidence for association between haplotypes of the VNTR-probe of the DAT and schizophrenia has been detected. Thus, a contribution of the DAT gene to the genetic diathesis of schizophrenia is unlikely in the families studied.

Brain SPECT imaging of neuropsychiatric disorders

Brain imaging has become an integral part of the evaluation of neurological and psychiatric disorders. Functional imaging techniques, SPECT and PET, together with structural modalities, CT and MRI, are widely employed. Functional imaging studies are routinely used in the diagnostic workup of patients with well-characterized neurological disorders, such as epilepsy and brain tumors, and have a growing role in research on psychiatric disorders without known mechanisms such as depression and schizophrenia. Furthermore, many well-defined neurological disorders manifest prominent psychiatric symptomatology which may pose difficulties in differential diagnosis. This review addresses the current knowledge of SPECT findings in patients who present with psychiatric phenomena, associated with disorders at the interface of neurology and psychiatry.

Acute or chronic lithium does not affect agonist-stimulated inositol trisphosphate formation in rat brain in vivo

Rats were given lithium either acutely by s.c. injection (4 m eq kg-1) or chronically by including 0.2% LiCl in their diet for 3 weeks. Microdialysis probes were inserted into the cortex or hippocampus, using re-usable guides, and perfused with artificial CSF. Fractions were collected beginning 18 h after the end of treatment and were analysed for inositol trisphosphate (IP3). Neither acute nor chronic treatment affected basal levels of IP3 or stimulation of IP3 formation by either carbachol or noradrenaline in the hippocampus. Similarly, neither basal nor carbachol-stimulated IP3 levels in rat cortex were affected by acute Li administration. It would appear that the reductions in these parameters previously reported by other workers using brain slices were due to inositol depletion occurring at the stage of brain slice preparation. The inositol depletion hypothesis for the mechanism of action of lithium does not therefore appear to be supported by in vivo evidence.

Interrelationship of age, depression, and central serotonergic function: evidence from fenfluramine challenge studies

The purpose of this study was to examine the relationship between age-associated changes in central serotonergic function and abnormalities associated with major depression. Under randomized double-blind conditions, prolactin and cortisol responses to the serotonin-releasing agent d,l-fenfluramine hydrochloride (60 mg orally) and placebo were examined in 30 normal subjects (15 men, 15 women; age range 21-84 years) and 39 patients with major depressive disorder, endogenous subtype (14 men, 25 women; age range 29-72 years). In the normal subjects, a significant Age x Challenge x Time interaction was observed in the prolactin response (p = .03). This was primarily due to the elevated prolactin responses of the younger healthy women. Peak minus baseline (delta) prolactin responses were negatively correlated with age (women, p = .004; men, p = .06). In the depressed patients there was no age-related decline in prolactin response to fenfluramine. When depressed and healthy younger subjects were compared, delta prolactin responses to fenfluramine were significantly blunted in young patients with depression (p = .003) irrespective of the significant effect of gender (p = .01), but not in older depressed patients. Cortisol responses to fenfluramine did not reveal consistent effects of age, gender, or diagnosis. Age-related decline in central serotonergic function may make older individuals more vulnerable to depression and possibly render depressive episodes more frequent, more severe, and less amenable to treatment.

Electroconvulsive therapy and resistant depression: clinical implications of seizure threshold

BACKGROUND

Patients with major depressive disorder (MDD) were treated with electroconvulsive therapy (ECT) to determine (1) variability of initial seizure threshold, (2) factors that influence seizure threshold, (3) change in seizure threshold during the ECT course, and (4) relationship of seizure threshold to antidepressant effects.

METHOD

Seizure threshold was measured by a stimulus titration technique during the first, eighth, and final ECT of medication-free patients who had MDD, endogenous subtype based on Research Diagnostic Criteria and were randomly assigned to three-times-weekly, bilateral, brief pulse ECT (N = 24) or twice-weekly ECT plus one simulated treatment per week (N = 23). Subsequent to the first ECT, stimulus intensity was 1.3 to 1.8 (median = 1.5) times threshold. The Hamilton Rating Scale for Depression (HAM-D) was the primary clinical outcome measure.

RESULTS

Initial seizure threshold varied by 594%. Gender (p = .03), total strength of pre-ECT pharmacotherapy trials (p = .02), and age (p = .12) accounted for 23.9% of the variance. Threshold increased by 42% +/- 26% (p = .0001) from the first to the final ECT, and seizure duration decreased by 33% +/- 28% (p = .0001). Seizure duration and mean stimulus intensity were negatively associated over all treatments (r = -.49, p = .0003). Change in HAM-D score was related to duration of the current depressive episode (r = -.39, p = .006) and total strength of pre-ECT pharmacotherapy trials (r = -.39, p = .008), but not to seizure threshold or duration.

CONCLUSION

(1) Initial seizure threshold for pulse bilateral ECT is highly variable and not yet amenable to accurate prediction. (2) Stimulus titration allows threshold to be determined on an individual basis and dosage for subsequent treatments to be defined. (3) Seizure duration is of limited value as a sole criterion for the adequacy of treatment when initial threshold is unknown and/or electrical doses that substantially exceed threshold are used. (4) With moderately suprathreshold bilateral ECT, a relationship of seizure threshold to antidepressant response is not demonstrable.