Complications of concurrent lithium and electroconvulsive therapy: a review of clinical material and theoretical considerations

Delirium with Concurrent Use of Lithium and ECT and the Safety Implications: Case Reports and Review of the Literature

Using electroconvulsive treatment and lithium together to treat acute manic episodes is common, but the effects of combining these therapies vary according to the literature. Some studies have found severe adverse side effects, while others have found the combination of both medications safe and helpful. To investigate potential adverse side effects, this study reports on two cases where bipolar affective disorder patients developed delirium after receiving electroconvulsive therapy and lithium concurrently. The delirium was attributed only to the combined administration of these medicines after ruling out other potential causes. Additionally, alterations in blood-brain barrier permeability, such as those caused by electroconvulsive therapy and age, increased the likelihood of delirium. As a result, caution should be taken when using this combination of medicines, especially in those predisposed to delirium. This study established links between these medications and adverse effects, such as delirium. Further research is necessary to determine the efficacy and risks of combining these medications, establish causality, and develop prevention strategies.

Absence of Longer Reorientation Times in Patients Undergoing Electroconvulsive Therapy and Concomitant Treatment with Lithium

Objective

Lithium is a drug of choice in the treatment of bipolar disorder and refractory depressive disorders. However, previous research suggests lithium has a negative cognitive impact in recovery from electroconvulsive therapy (ECT) and a higher risk of delirium, so patients are often required to stop taking lithium before ECT, despite risk of relapse. We studied the cognitive impact of serum lithium levels in patients undergoing ECT.

Methods

This was an observational prospective study. Serum lithium levels, thyroid and biochemical parameters were measured prior to each ECT session. Time elapsed from the anesthetic induction to the electrical stimulus and then to the patients’ reorientation was recorded, as well as the motor seizure duration and electroencephalogram (EEG) seizure duration. A statistical analysis using a linear mixed model was run while adjusting for confounding factors.

Results

Ten participants underwent a total of 86 ECT sessions (41% right unilateral ultrabrief pulse, and 59% bilateral brief pulse). A negative interaction between lithium levels and reorientation time was found among those doing bilateral brief pulse ECT. No association was observed in patients doing unilateral ultrabrief pulse ECT. No significant relationship was observed between lithium and both motor and EEG-assessed seizure duration.

Conclusion

This study suggests that low to moderate serum lithium levels (< 0.7 mmol/L) might have no harmful cognitive effects in patients under right unilateral ultrabrief pulse and bilateral brief pulse ECT.

Electroconvulsive Therapy (ECT) in Bipolar Disorder Patients with Ultra-Rapid Cycling and Unstable Mixed States

Background and Objectives: Unstable mixed episodes or rapid switching between opposite affective poles within the scope of short cycles was first characterized in 1967 by S. Mentzos as complex polymorphous states with chaotic overlap of manic and depressive symptoms. Well-known examples include antidepressant-induced mania/hypomania and rapid/ultra-rapid/ultradian cycling, when clinicians observe an almost continuous mixed state with a constant change of preponderance of manic or depressive symptoms. Achieving stable remission in these cases is challenging with almost no data on evidence-based treatment. When mood stabilizers are ineffective, electroconvulsive therapy (ECT) has been suggested. Objectives: After reviewing the evidence from available literature, this article presents our own clinical experience of ECT efficacy and tolerability in patients with ultra-rapid cycling bipolar disorder (BD) and unstable mixed states. Materials and Methods: We conducted an open, one-year observational prospective study with a "mirror image" design, including 30 patients with rapid and ultra-rapid cycling BD on long-term mood stabilizer treatment (18 received lithium carbonate, 6 on valproate and 6 on carbamazepine) with limited effectiveness. A bilateral ECT course (5-10 sessions) was prescribed for regaining mood stability. Results: ECT was very effective in 12 patients (40%) with a history of ineffective mood stabilizer treatment who achieved and maintained remission; all of them received lithium except for 1 patient who received carbamazepine and 2 with valproate. Nine patients (30%) showed partial response (one on carbamazepine and two on valproate) and nine patients (30%) had no improvement at all (four on carbamazepine and two on valproate). For the whole sample, the duration of affective episodes was significantly reduced from 36.05 ± 4.32 weeks in the year prior to ECT to 21.74 ± 12.14 weeks in the year post-ECT (p < 0.001). Depressive episodes with mixed and/or catatonic features according to DSM-5 specifiers were associated with a better acute ECT response and/or long-term mood stabilizer treatment outcome after ECT. Conclusions: ECT could be considered as a useful option for getting mood instability under control in rapid and ultra-rapid cycling bipolar patients. Further randomized trials are needed to confirm these results.

Factors associated with post-electroconvulsive therapy delirium: A retrospective chart review study

Although electroconvulsive therapy (ECT) is generally a safe therapeutic method, unexpected adverse effects, such as post-ECT delirium, may occur. Despite its harmful consequences, there has been little discussion about the predictors of post-ECT delirium. Thus, the current study aimed to clarify the factors associated with post-ECT delirium by reviewing electronic medical records of 268 bitemporal ECT sessions from December 2006 to July 2018 in a university hospital.Demographic and clinical characteristics of sessions involving patients with or without post-ECT delirium were compared. Multiple logistic regression analysis was applied to analyze the correlation between variables and post-ECT delirium.Post-ECT delirium developed in 23 sessions (8.6%). Of all the demographic and clinical variables measured, only etomidate use was significantly different between delirium-positive and delirium-negative groups after Bonferroni correction. The regression model also indicated that etomidate use to be significantly associated with post-ECT delirium.In this study, etomidate was associated with a higher risk of developing post-ECT delirium, an association that appeared unrelated to other possible measured variables. Practitioners should take into account the risk of post-ECT delirium while choosing anesthetics, so as to prevent early discontinuation before sufficient therapeutic gain is achieved.

A Pilot Study of Cognitive Impairment in Longstanding Electroconvulsive Therapy-treated Schizophrenia Patients Versus Controls

BACKGROUND

Electroconvulsive therapy (ECT), though reliable and effective, is controversial due to its media portrayal as a treatment with severe side effects. Electroconvulsive therapy is mainly given to patients suffering from affective disorders and treatment-resistant schizophrenia. Although past research assessed the amount and duration of memory loss due to ECT, little is known about its influence on cognition for patients suffering from schizophrenia, whose cognitive decline is an inherent part of their illness. We aimed to test whether maintenance ECT causes cognitive decline among elderly schizophrenia patients.

METHODS

Twenty elderly (age >65 years) patients suffering from schizophrenia and schizoaffective disorder who received maintenance ECT were matched with 20 controls suffering from the same illnesses that have never been treated with ECT. The match was based on age, sex, and illness duration. The participants were evaluated using the Montreal Cognitive Assessment for cognitive decline and a Positive and Negative Syndrome Scale (PANSS) for illness severity.

RESULTS

A lower score in the abstraction subscale was found in the maintenance ECT population (P = 0.002), without significant differences in the total Montreal Cognitive Assessment and the delayed-recall subscale scores. In the treatment group, a correlation was found between an impairment in naming and positive symptoms in the PANSS score (r = -0.45) and between abstraction impairment and negative symptoms (r = -0.56) and total PANSS score (r = -0.497).

CONCLUSIONS

Maintenance ECT does not worsen existing global cognitive deficits or delayed recall in elderly schizophrenia patients. The abstraction impairment was possibly due to the higher disease burden of the patients referred to ECT.

Prevalence and Predictors of Postictal Confusion After Electroconvulsive Therapy

OBJECTIVE

To investigate the prevalence and predictors of postictal confusion (PIC) in patients who received electroconvulsive therapy (ECT).

METHODS

We conducted chart reviews for 79 patients who were receiving inpatient ECT. Subjects with PIC were identified. PIC was defined by confusion, disorientation, motor restlessness, purposeless movement, and nonresponse to verbal commands following ECT within an hour, intravenous benzodiazepine was necessary to manage disturbed behavior. Multivariable logistic regression analysis was used to examine the association of PIC with demographic and clinical variables.

RESULTS

Prevalence of PIC was 36.7%. In 912 ECT sessions, the occurrence of PIC was 86 times. Patients with PIC (n = 29) had significant higher body mass index (BMI) (27 ± 6.6 kg/m² vs 24.1 ± 5.2 kg/m², t = -2.22, df = 77, p = 0.029) than patients without PIC (n = 50). PIC associated with BMI (Pearson correlation = 0.25, p = 0.029). BMI was significant predictor of PIC after adjusting for other covariates (odds ratio = 0.91, 95% CI= 0.83-0.99, p < 0.035).

CONCLUSION

PIC was not uncommon in patients receiving ECT. BMI was an independent predictor of PIC. Psychiatrists should be aware of the risks of PIC in patients with high BMI receiving ECT.

[Electroconvulsive therapy in combination with psychotropic and non-psychotropic pharmacological treatments: Review of the literature and practical recommendations]

CONTEXT

Electro-convulsive therapy (ECT) is the most effective treatment for treatment resistant mood disorders and catatonia. ECT also appears to be an effective treatment in combination with clozapine in the context of treatment resistant schizophrenia spectrum disorders. Although increasingly codified (guidelines on indications, contraindications, methods of implementation), the practice of ECT still lacks consensual protocols. The concomitant use of psychotropic and/or non-psychotropic medication is a common situation when ECT treatment is considered. To our knowledge, there is to date no summary of studies or case reports in France, nor any proposal for guidelines concerning the management of medication of the patient to whom ECT sessions are offered. Indeed, several particularities must be considered. This article proposes to specify for each pharmacological class the possible interaction between ECT and medication. A first section of this article will be devoted to non-psychotropic treatments, and a second section to psychotropic treatments. A practical summary table is also provided.

METHOD

A review of the literature was conducted including all articles published prior to January 2019 referenced in Pub Med database, combining research with Medical Subject Headings "Electroconvulsive Therapy" and each following pharmacological class: "Cardiovascular Agents" "Bronchodilator Agents" "Bronchoconstrictor Agents" "Theophylline" "Anticoagulants" "Hypoglycemic Agents" "Insulin" "Potassium" "Benzodiazepines" "Valproic Acid" "Carbamazepine" "Lamotrigine" "Lithium" "Antidepressive Agents" "Antipsychotic Agents".

RESULTS

After reading the titles, abstracts and whole articles, then searching for additional articles in the references, 50 articles were selected. A summary table summarizing the main risks and proposing a course of action has been produced.

DISCUSSION

It is essential to take into account the specificity and the different physiological mechanisms involved in the ECT treatment in order to adjust the associated pharmacological treatments. The prescription for each molecule should be reviewed when ECT treatment is initiated.

The incidence of prolonged post-electroconvulsive therapy delirium: A retrospective study

OBJECTIVE

The objective of the study was to assess the incidence and determinants of electroconvulsive therapy (ECT)-induced delirium.

MATERIALS AND METHODS

Using a retrospective study design, data of 488 patients undergoing modified ECT were evaluated for the development of new-onset prolonged delirium. Demographic and clinical parameters of patients who developed delirium and those who did not develop delirium were compared.

RESULTS

5.7% of the patients developed prolonged post-ECT delirium. The use of quetiapine in higher doses and the lack of use of antidepressants while receiving ECT were associated with the development of prolonged post-ECT delirium. None of the other clinical and ECT-related parameters emerged as a significant factor associated with the development of prolonged post-ECT delirium.

CONCLUSIONS

A small proportion of patients undergoing ECT develop post-ECT prolonged delirium.

Treating electroconvulsive therapy-induced mania with more electroconvulsive therapy: Evidence for electroconvulsive therapy as the ultra-mood stabilizer

Electroconvulsive therapy has been described as a mood stabilizer, as it is effective in all stages of bipolar disorder. Electroconvulsive therapy-induced mania is a known and potentially dangerous risk of treating bipolar depression with electroconvulsive therapy and there are no established guidelines for the management of electroconvulsive therapy-induced mania. We report a case of electroconvulsive therapy-induced mania where electroconvulsive therapy was continued as the sole, effective antimanic agent, which is the first described case in literature.

When All Else Fails: The Use of Electroconvulsive Therapy for Conditions Other than Major Depressive Episode

The use of electroconvulsive therapy (ECT) for those suffering from major depressive disorder is well-evidenced, time-honored, and recognized by most treatment guidelines. However, since its inception ECT has been used by practitioners for a broader range of neuropsychiatric conditions. This article reviews the highly variable evidence supporting the use of ECT in conditions other than depression, such as schizophrenia, bipolar manic states, catatonia, Parkinson disease, and post-traumatic stress disorder.

The PRIDE Study and the Conduct of Electroconvulsive Therapy: Questions Answered and Unanswered

The recently published PRIDE study (prolonging remission in the depressed elderly) constitutes an important contribution to electroconvulsive therapy (ECT) technique, from the standpoint of both the index course to treat depressive symptoms and the post-remission continuation period to prevent relapse. This study was probably the last large, National Institute of Mental Health-funded, multisite ECT technical study for some time to come, so extracting clinically relevant recommendations is worthwhile. In this commentary, the author discusses evidence from this trial relevant to several important clinical index and continuation ECT technical issues and elaborates several unanswered questions deserving further consideration.

ECT and lithium in old age depression - cause or treatment of rapid cycling?

OBJECTIVE

This article presents the case of an elderly woman experiencing a depressive phase of Bipolar Affective Disorder 1 (BPAD1), who required electroconvulsive therapy (ECT), prior to which her lithium was ceased, and who developed ultra-ultra-rapid cycling (UURC) and ultra-rapid cycling (URC). This resolved with the recommencement of lithium and continuation of ECT.

METHOD

Case report and review of the relevant literature.

RESULTS

The patient's mood stabilized with recommencement of lithium and continuation of ECT.

CONCLUSIONS

Ceasing lithium prior to ECT may carry a risk of URC or UURC in BPAD1.

Delayed Onset and Prolonged ECT-Related Delirium

Electroconvulsive therapy (ECT) is effective in the treatment of depression. Delayed post-ECT delirium is rare but can occur in a small subset of patients with risk factors and in most cases resolves with the use of psychotropic medications. We report a unique presentation of a patient who developed a delayed post-ECT delirium with fecal incontinence that commenced 24 hours after the administration of ECT. The condition resolved spontaneously after 48 hours without the use of psychotropic medications.

Physical treatments for bipolar disorder: a review of electroconvulsive therapy, stereotactic surgery and other brain stimulation techniques

BACKGROUND

Despite pharmacological advances, bipolar disorder continues to be difficult to treat. This article reviews the evidence base for the use of electroconvulsive therapy (ECT) and other brain stimulation therapies in bipolar disorder.

METHODS

The evidence base for the efficacy of ECT and transcranial magnetic stimulation in the treatment of mania, bipolar depression and mixed affective states was reviewed. Reports on the use of vagus nerve stimulation, stereotaxic surgery, deep brain stimulation, magnetic seizure therapy and transcranial direct current stimulation in treating depression, as well as bipolar disorder were also reviewed. Studies were identified from Medline and Embase database searches.

RESULTS

There are a few randomized controlled trials of ECT in mania and bipolar depression, and none in mixed affective states. Nevertheless, such studies consistently reported clinically meaningful efficacy, with a majority of pharmacotherapy resistant patients responding to ECT. Evidence for the use of other brain stimulation therapies in treating bipolar mood states is preliminary and limited.

CONCLUSIONS

ECT is an effective treatment for acute mania, bipolar depression and mixed affective states and has useful efficacy even in pharmacotherapy-resistant patients. Other brain stimulation techniques may have potential for the treatment of bipolar disorder and should be further researched.

A prospective comparative study of interaction between lithium and modified electroconvulsive therapy

OBJECTIVES

To compare patients on lithium and those not on lithium with regard to adverse effects while receiving ECT.

METHODS

Inpatients with schizophrenia, non-organic psychosis, mania and depression, who were prescribed ECTs either on (n=27) or not (n=28) on lithium were studied. Clinicians blind to lithium-status recorded seizure parameters, interaction with succinyl choline, cardiovascular response, recovery from ECT and immediate post-ECT complications.

RESULTS

The lithium group showed no significant difference in terms of seizure variables, apnea time, and recovery from anaesthesia when compared to the non-lithium group. Average maximum heart rate, average maximum systolic blood pressure and average maximum rate pressure product were significantly lower in patients who had combined lithium and ECT. In lithium patients the average time to post-ECT recovery was directly correlated with serum lithium level.

CONCLUSIONS

Though concurrent lithium is by and large safe during ECT, it benefits to maintain serum lithium level at lower end of therapeutic range. However, the findings can be applied to relatively young patients with no risk factors for ECT-complications.

Electroconvulsive Therapy: A Review of History, Patient Selection, Technique, and Medication Management

Electroconvulsive therapy (ECT) is a safe and effective treatment for severe and persistent depression, bipolar disorder and schizophrenia. Though ECT is now over 60 years old, it remains an underutilized treatment today. History, patient selection, safety, and characteristics of the treatment stimulus, technique, and medications used in ECT are reviewed. Dosing strategies, as pertaining to seizure threshold, will be considered. Mechanisms of action, especially with regard to serotonin, norepinephrine, and dopamine receptor expression will be discussed.

Combined use of lamotrigine and electroconvulsive therapy in bipolar depression: a case series

OBJECTIVE

Lamotrigine and electroconvulsive therapy (ECT) are both safe and effective treatments for bipolar depression. Concerns exist that anticonvulsants may interfere with seizure expression during ECT or may exacerbate cognitive side effects, potentially affecting clinical response. This report examines the clinical use of concurrent ECT and lamotrigine for acute bipolar depression and the transition to maintenance therapy.

METHODS

Nine patients with acute bipolar depression were simultaneously treated with a course of ECT while titrating lamotrigine for maintenance therapy. We compared mean stimulus intensity, mean seizure duration, and mean time to orientation after treatment for each patient during treatment with their highest and lowest lamotrigine dose.

RESULTS

All 9 patients were treated to remission. From the lowest daily dose to the highest daily dose, mean increase in lamotrigine was 102.8 mg. Clinically adequate seizures were obtained in each patient. Lamotrigine had minimal effect on each measured ECT parameter. The interval between ECT treatments was spaced to a mean of 15.2 days. The treatment combination was well tolerated, with no serious adverse events, no rashes, and no worsening of cognitive side effects.

CONCLUSIONS

Concurrent use of lamotrigine with ECT in bipolar depression seems safe, did not interfere with routine ECT practice, and allowed for transition to maintenance pharmacotherapy.

Lithium and ECT--concurrent use still demands attention: three case reports

Bipolar disorders as well as recurrent major depressive episodes can be most effectively treated with electroconvulsive therapy (ECT). Since continuation/maintenance ECT is not well established, prophylactic therapy in recurrent illnesses is more commonly carried out using antidepressive medication alone or more often in combination with lithium. In case of relapse the clinically important question of discontinuation of lithium versus the concurrent use of ECT and lithium may arise. The safety of concurrent use has also to be balanced when lithium treatment is started within an ECT course. Since recent studies have reported no negative interactions with concurrent use, we here report three cases (one case of a prolonged seizure, a serotonin syndrome and a focal seizure) of severe lithium-induced side effects while patients underwent ECT without complications and lithium serum levels were still subtherapeutic. Clinical consequences are discussed and disturbances of the blood brain barrier system as a speculative cause are hypothesized taking previous studies, animal studies and an additional reported clinical case into account.

The safety of electroconvulsive therapy and lithium in combination: a case series and review of the literature

Early reports cautioned against the combination of lithium and electroconvulsive therapy (ECT), citing risk of excessive cognitive disturbance, prolonged apnea, and spontaneous seizures. However, recent case series with larger numbers of patients indicate that the combination may be used safely and with optimal efficacy in certain clinical circumstances. In this report, we describe 12 patients in whom the combination of lithium and ECT was deemed safe. We also provide a comprehensive review of published literature and provide detailed recommendations for clinical practice.

Naturalistic evaluation of inpatient treatment of mania in a private Brazilian psychiatric hospital

OBJECTIVE

To describe the clinical practices on the treatment of mania in a Brazilian hospital, and to compare them to other international similar reports and practice guidelines.

METHODS

Chart revision of 425 consecutive admissions (269 patients) for the treatment of manic or mixed episodes (ICD-10 criteria) in a private psychiatric hospital of Belo Horizonte, Brazil, from 1996 to 2000. The rates of utilization of each antimanic medication and ECT were compared to those reported in similar international observational studies (X2, bicaudate, alpha =0.05).

RESULTS

The observed frequencies of use of each treatment modality were: lithium (71.5%); carbamazepine (34.8%); valproate (9.4%); antipsychotics (83.3%); benzodiazepines (62.4%); antidepressants (7.5%) and ECT (33.2%). The differences detected between local practice and international guidelines were: lower rate of valproate and higher rate of carbamazepine prescription; the use of sine wave devices for ECT; frequent concomitant use of ECT with lithium (72.3%), benzodiazepines (46.8%) and/or carbamazepine (31.2%).

CONCLUSIONS

These results suggest the need to develop national practice guidelines for the treatment of mania and for the use of ECT, and to promote their propagation through specific medical educational programs, aiming at the standardization of practices based on the available scientific evidence.

Risk of seizures associated with psychotropic medications: emphasis on new drugs and new findings

Psychotropic medications in the classes of antidepressants, antipsychotics and mood stabilisers have been recognised in the literature and clinical settings as having high epileptogenic potential. Among these three classes, clozapine, tricyclic antidepressants (TCAs) and lithium are agents that clinicians have historically recognised as precipitants of drug-induced seizures. There are few reports that review the epileptogenic risk of newer psychotropic agents; in this qualitative review, the authors provide an update on the most recently published reports on seizures associated with antidepressants, antipsychotics, mood stabilisers, anxiolytics and sedative-hypnotics. In general, the epileptogenic risks of the newer psychotropic agents appear to be quite low as long as dosing strategies are consistent with recommended guidelines. Whilst newer psychotropic medications appear to be safe in patients with epilepsy, few studies have specifically addressed this population. In addition, the potential for drug interactions between antiepileptic drugs and psychotropics may be substantial with certain agents. For example, many psychotropes are both substrates and inhibitors of cytochrome P450 (CYP450) isoenzymes, whilst many antiepileptic drugs are both substrates and inducers of CYP450 activity. Every attempt should be made to minimise potential interactions when these agents are concomitantly administered.

Clinical approach to agitation after electroconvulsive therapy: a case report and literature review

Agitation is a neurologic complication that may occur after electroconvulsive therapy (ECT). Severe agitation after ECT has been associated with multiple factors, both anesthetic and psychiatric. This case report describes severe postictal agitation after ECT in a patient with bipolar affective disorder. The clinical management of this challenging presentation is discussed, including both the anesthetic and psychiatric approaches.

Do SSRIs prolong seizure duration during ECT?

The effect of selective serotonin re-uptake inhibitors (SSRIs) on seizure duration during a course of electroconvulsive therapy (ECT) was evaluated in a retrospective study. Although numbers in the SSRI group were small (n=13), there was a significantly longer seizure duration with SSRIs, compared with tricyclic antidepressants (TCAs) and monoamine oxidase inhibitors (MAOIs). More studies are needed to see whether this is a general finding or whether it reflects individual variation, and most importantly, what effects, if any, this has on clinical outcome.

Negative interaction between lithium and electroconvulsive therapy--a case-control study

BACKGROUND

Concurrent use of lithium and ECT is suspected to increase neurotoxicity.

METHOD

A retrospective case-control study over an eight-year period was conducted to investigate the adverse effects of a combined lithium/ECT treatment. Thirty-one subjects with combined lithium/ECT treatment were compared with a control group (ECT only) of 135 cases matched for age and sex.

RESULTS

Most cases in both groups had no adverse effects. Three (10%) study group subjects and 15 (11%) controls experienced brief delirium. Three controls and none of the subjects developed a prolonged confusion. There were no significant differences in the profile of other adverse effects between the two groups.

CONCLUSION

Prescription of lithium together with ECT was not associated with higher frequency of adverse effects.

Lithium and electroconvulsive therapy: adversaries, competitors, allies?

As treatments for manic-depressive illness, lithium and electroconvulsive therapy (ECT) share the properties of efficacy, diagnostic specificity, and action on both mania and depression. Therapeutic and prophylactic similarities and dissimilarities are analyzed, as well as the use of lithium continuation treatment following ECT. Possible adverse interaction is discussed, and a strategy is proposed for studying biologic modes of action.

The treatment of late luteal phase dysphoric disorder

This mini-review provides a comprehensive discussion of the management of the late luteal phase dysphoric disorder (LLPDD). The various treatments will be described with particular attention to their efficacy and the nature of side effects. These include: psychoactive drugs (lithium, anxiolytics, antidepressants), nutritional agents (L-tryptophan, Vitamin B6, prostaglandins precursors and inhibitors), dopamine agonists, diuretics, antihypertensives, hormonal interventions (gonadotrophin releasing hormone analogues, oestradiol, tamoxifen, progesterone, danazol, and oral contraceptives). Less attention has been given to non-pharmacologic approaches such as diet, exercise and psychotherapy. The availability of an operational definition of LLPDD in the DSM-III-R and the improvement in research methodology has provided a clearer direction for clinical management and for future investigations.

Is electroconvulsive therapy safe?

Electroconvulsive therapy is controversial and readily arouses the passions of both its supporters and detractors. In this article, Dr Schoen, an internist, discusses various aspects of this 50-year-old technique, including risks, contraindications, and physiologic effects.

New applications of lithium therapy

Several placebo-controlled double-blind studies have indicated that lithium sometimes augments antidepressants, converting nonresponding patients to responders. Lithium therapy has also benefitted some schizoaffective patients and some alcoholics. Side effects are minimal. Mechanisms involved in lithium's effectiveness have not yet been discovered.