Globus hystericus--a somatic symptom of depression? The role of electroconvulsive therapy and antidepressants

Psychological Distress in a Sample of Adult Italian Patients Affected by Vocal Nodules and Muscle-Tension Dysphonia: Preliminary Results

OBJECTIVES

To evaluate the correlation between voice disorders and psychological distress, in terms of anxiety, stress, and depression, in a sample of adult Italian patients and to compare our results with those obtained in a group of adult healthy controls matched by age, sex, geographic distribution, and occupation.

METHODS

This prospective-controlled study included 100 adults with Vocal nodules (VN) and Muscle Tension Dysphonia (MTD1), aged between 18 and 65 years, as Experimental Group (EG) and 100 age-matched subjects without any voice disorders as a Control Group (CG). All patients in the EG underwent a phoniatric evaluation, including the administration of the Voice Handicap Index (VHI) and laryngeal examination. Both patients of EG and CG underwent a Psychological evaluation by means of standardized tests; Beck's Depression Inventory, State Anxiety Inventory (STAI 1-State Anxiety), Trait Anxiety Inventory (STAI 2- Trait Anxiety), and Perceived Stress Scale (PSS-10) were completed by patients. Fisher's exact test and chi-squared test were used to compare all categorical variables, whereas numerical variables were compared either with the nonparametric Mann-Whitney-Wilcoxon or with Kruskal Wallis test. General linear models were used to study continuous variables between patients and controls and between different groups within the sample.

RESULTS

In the study group, the Physical domain (P score) of the VHI was more affected than the Emotional (E score) and Functional ones (F score) both in patients with MTD1 and VN; patients with VN presented a significant difference in P score, E score and VHI total score than patients with isolated MTD 1 (P < 0.005). Psychological assessment showed a significant difference (P < 0.005) between VN and MTD 1 regarding PSS-10 and STAI-1 scores. Low Beck's Depression Inventory scores were present in our sample without significant differences between patients with VN and those with MTD 1. Scores related to psychological distress in the EG were far superior to those obtained by the healthy CG, with markedly significant values especially for PSS-10 (P < 0.0001) and STAI 2 (P < 0.01). Finally, younger patients (18-35 years) with VN showed a highest risk of psychosocial distress.

CONCLUSION

the present study identified a high prevalence of psychological distress among patients with vocal disorders without any prior specific psychiatric diagnosis, especially in terms of anxiety and perceived stress. For this reason both these symptoms should be taken into consideration in the diagnostic, therapeutic, and follow-up process of patients with MTD1 and VN.

Subjective Changes of Taste and Smell in Conjunction With Anxiety and Depression Are Associated With Symptoms in Globus Patients Without Evidence of Pathologic Acid Reflux

BACKGROUND/AIM

Patients suffering from globus often report decreased enjoyment when eating as well as a psychological abnormality. Some patients exhibit taste and smell changes (TSCs) when compared with the period before the diagnosis. The main aim of this study was to explore if TSCs and psychological abnormality are present in patients with globus, whether they are associated with the severity of throat symptoms, and the potential risk factors for globus.

PATIENTS AND METHODS

A total of 116 included patients who met the Rome IV diagnostic criteria for globus had been performed 24-hour pH monitoring, and the results shown no evidence of pathologic acid reflux. Meanwhile, 125 healthy controls were enrolled in this prospective study. All subjects completed several questionnaires including the Taste and Smell Survey, the Glasgow Edinburgh Throat Scale, the Hamilton Anxiety Scale (HAMA), and the Hamilton Depression Scale (HAMD). Multiple logistic regression was performed to explore the potential risk factors for globus. The study protocol was registered on the Chinese Clinical Trial Registry (No. ChiCTR-2100044972).

RESULTS

First, globus patients without evidence of pathologic acid reflux exhibited a 58.62% and 31.03% change in taste and smell, respectively, while their levels of anxiety and depression were 51.72% and 44.83%, respectively. Second, there was a significant difference in the taste score (Z=-4.954, P<0.001) and smell score (Z=-4.552, P<0.001) between globus group patients and healthy controls. Similarly, globus group patients had a higher HAMA score (9.52±2.437 vs. 3.12±1.059, t=6.867, P<0.001) and HAMD score (9.79±2.931 vs. 3.16±1.650, t=6.416, P<0.001) when compared with the healthy controls. Third, in globus group patients, the Glasgow Edinburgh Throat Scale was significantly correlated with the taste score (Spearman ρ=0.782; P<0.001), smell score (Spearman ρ=0.582; P=0.001), HAMA (Spearman ρ=0.676; P<0.001), and HAMD (Spearman ρ=0.672; P<0.001). In addition, the taste score was significantly correlated with HAMA (Spearman ρ=0.532; P=0.004) and HAMD (Spearman ρ=0.681; P<0.001), while the smell score was significantly correlated with HAMD (Spearman ρ=0.392; P=0.035). Finally, multivariate logistic regression revealed that TSCs, anxiety, and depression were significant independent risk factors for globus, with depression exhibiting the highest degree of association (odds ratio: 3.244).

CONCLUSIONS

TSCs and psychological comorbidities are prominent in globus patients without evidence of pathologic acid reflux. The obtained results indicated that there is a strong relationship between TSCs, psychological comorbidities, and globus. Therefore, awareness of this high prevalence of TSCs and psychological disorder may help to better understand the severity of throat symptoms.

Major Depressive Disorder in the Older Adult Associated With Globus Pharyngeus and Weight Loss - An Indication for Electroconvulsive Therapy

Aspiration pneumonia and extreme weight loss are risks whenever globus pharyngeus (GP) complicates major depressive disorder (MDD) in the older adult. The timely administration of electroconvulsive therapy (ECT) may reverse GP in this context. We review cases of GP in depressed older adults and describe both successful outcomes, as well as a fatal outcome associated with delays in offering ECT. MDD in the older adult complicated by GP and marked weight loss, or repeated aspiration, should be considered an urgent indication for ECT.

Chronic cough is associated with depressive mood in women regardless of smoking status and lung function

BACKGROUND

Chronic cough is a common respiratory symptom, and, if persistent, the patient's quality of life can worsen and result in a depressive mood, or vice versa. Although previous reports suggest a relationship between chronic cough and depression, we further investigated this relationship according to smoking status and lung function.

METHODS

This observational study used cross-sectional data from the 6^th Korean National Health and Nutrition Examination Survey (2014 and 2016). Propensity score matching using age, sex, smoking status, and lung function was performed for participants with and without chronic cough to reduce the confounding effects associated with depressive mood. Questionnaires recorded coughs persisting for >3 months and the Patient Health Questionnaire-9 (PHQ-9) assessed the severity of depressive mood.

RESULTS

Among 12 494 participants who were >18 years old, 226 with chronic cough were matched with 226 with non-chronic cough. Overall, chronic cough participants showed higher PHQ-9 scores than the non-chronic cough participants (4.29 ± 5.23 vs. 2.63 ± 3.38, P < .001). When stratified by sex, the difference remained significant in women (5.69 ± 5.96 vs. 3.05 ± 3.97, P < .001) but not in men (3.18 ± 4.27 vs. 2.31 ± 3.65, P = .092). When stratified by lung function status, the difference remained significant for those with normal lung function (4.32 ± 5.32 vs. 2.78 ± 3.86, P = .003) and reduced lung function (4.19 ± 4.93 vs. 2.11 ± 3.55, P ≤ 0.001). Multivariate logistic regression analysis revealed that chronic cough was associated with PHQ-9 score (odds ratio [OR], 1.06; 95% confidence interval [CI], 1.014-1.27, P = .014), chronic obstructive pulmonary disease (OR, 4.87; 95% CI, 1.041-22.86, P = .044) and physician-diagnosed bronchial asthma (OR, 2.93; 95% CI, 1.162-7.435, P = .023).

CONCLUSIONS

Depressive mood is significantly correlated with chronic cough in females.

ESNM/ANMS Review. Diagnosis and management of globus sensation: A clinical challenge

Globus is a non-painful sensation of a tightness or a lump/foreign body in the throat that is not associated with dysphagia and may actually improve during meals. While several otorhinolaryngologic, thyroid, and esophageal disorders have been linked to globus, cause-and-effect relationships are difficult to establish. Consequently, though part of the evaluation, objective otorhinolaryngologic and esophageal testing is often negative. The presence of alarm symptoms, particularly pain, weight loss, dysphagia, or odynophagia is indications for objective testing. A diagnosis of idiopathic globus requires exclusion of pharyngeal, laryngeal, and esophageal disorders with laryngoscopy, endoscopy, high-resolution manometry, barium radiography, and/or ambulatory reflux monitoring. A trial of acid-suppressive therapy may be reasonable in the absence of alarm symptoms, especially if concurrent reflux symptoms are identified. Ablation of heterotopic gastric mucosa in the proximal esophagus has been reported to improve globus symptoms. Beyond these specific approaches, further management of idiopathic globus consists of reassurance, neuromodulators, and complementary approaches. Globus has a benign course with no long-term consequences, and the overall prognosis is good as the magnitude of symptoms may decline over time.

Globus: Current Concepts and Dilemmas

Globus is an area of interest for many medical specialists including otorhinolaryngologists, gastroenterologist, allergists, and psychiatrists. It may be caused by an organic disease, but it is not uncommon that an underlying etiology remains unidentified even after a full workup has been performed. Patients who suffer from globus usually visit several physicians from different specialties without finding a solution for their symptoms. Identifying the underlying cause of globus is not always a simple task; therefore, structural or functional abnormalities of the thyroid, larynx, pharynx, and esophagus should be investigated. Gastroesophageal reflux disease is commonly considered to be the underlying cause after being identified in an otorhinolarygeal (ear, nose, and throat) evaluation, which is usually the first diagnostic step. In the last few years, an inlet patch in the proximal esophagus has been shown to be associated with globus, and its elimination has resulted in symptom resolution in some patients. Finally, globus can be associated with psychiatric disorders as well as oropharyngeal hypersensitivity that could be either chemical or mechanical. Treatment is directed toward an identified organic cause; in those with a functional disorder, the mainstay of therapy includes neuromodulators and psychiatric/psychological interventions.

Managing a patient with globus pharyngeus

A woman aged 47 years reported the feeling of a lump in her throat for the past year. The sensation was present intermittently and usually improved when she ate. She noted it was worse with dry swallows when she felt like a tablet was stuck in her throat. The sensation had become more persistent in recent weeks leading her to worry that she had cancer. She had no cough, sore throat or hoarseness. There were no precipitating factors and no symptoms of weight loss, dysphagia, odynophagia or change in her voice. She had smoked previously and rarely had heartburn. She had no other anxieties and was not under any unusual stress. She was initially assessed by an ear, nose and throat surgeon, who found no abnormalities on examination of her neck, throat and oral cavity. Nasolaryngoscopy was normal. An upper gastrointestinal endoscopy was organised and reported a hiatus hernia, but a 3-month trial of a proton pump inhibitor did not have any impact on her symptoms. The benign nature of her symptoms was discussed at her gastroenterology follow-up appointment. She was discharged back to primary care with a final diagnosis of 'globus'. A trial of speech therapy, cognitive behavioural therapy or amitriptyline would be recommended if her symptoms became more troublesome in future.

Relationship between Depression and Laryngopharyngeal Reflux

This study investigated the relationship between depression, somatization, anxiety, personality, and laryngopharyngeal reflux (LPR). We prospectively analyzed 231 patients with symptoms with LPR using the laryngopharyngeal reflux symptom index and the reflux finding score. Seventy nine (34.2%) patients were diagnosed with LPR. A significant correlation was detected between the presence of LPR and total scores on the Patient Health Questionnaire-9 (5.6±5.3 vs. 4.0±4.6, p=0.017) and the 7-item Generalized Anxiety Disorder Scale (4.3±4.9 vs. 3.0±4.5, p=0.041). LPR was significantly more frequent in those with depression than in those without (45.6% vs. 27.0%, p=0.004). A multivariate analysis confirmed a significant association between the presence of LPR and depression (odds ratio, 1.068; 95% confidence interval, 1.011-1.128; p=0.019). Our preliminary results suggest that patients with LPR may need to be carefully evaluated for depression.

Somatic symptom disorder treated with electroconvulsive therapy

Somatic symptom disorder (SSD) is a challenging condition to treat with chronic pain, a common and disabling symptom. We present a patient who received electroconvulsive therapy (ECT) for SSD with significant improvement in pain and gastrointestinal symptoms. We also present a brief literature review of similar cases treated with ECT. Preliminary evidence suggests that ECT should be considered for treatment of SSD comorbid with major depressive disorder, when standard treatments fail. Further research is needed to clarify whether ECT can be used for SSD without associated depression.

Comparison of paroxetine and amitriptyline in the treatment of refractory globus pharyngeus

BACKGROUND

Clinical trials of antidepressants for treatment of globus are generally rare, let alone for refractory globus pharyngeus.

AIMS

To illustrate the efficacy and side-effects of antidepressants between paroxetine and amitriptyline for refractory globus patients.

METHODS

Refractory globus patients were randomized into paroxetine group; amitriptyline group and lansoprazole group for 6-week treatment. All the subjects were asked to complete the following questionnaires pre- and post-therapy: Glasgow Edinburgh Throat Scale (GETS), Pittsburgh Sleep Quality Index, Hamilton Rating Scale Anxiety/Depression and Medical outcome short-form 36. Treatment response was defined as a >50% reduction in the GETS score.

RESULTS

One hundred and forty-eight patients completed the study. After 6 week treatment, 71.7% of paroxetine group (33/46) were calculated as treatment response, significantly higher than that in amitriptyline group (46.2%, 24/52) and lansoprazole group (14.0%, 7/50). Compared with lansoprazole group or amitriptyline group, a more distinct improvement of emotional well-being, quality of life and quality of sleep were observed in paroxetine group after 6-week treatment.

CONCLUSION

Paroxetine therapy is more efficacious than empirical high-dose antisecretory treatment, or even the low-dose amitriptyline therapy in alleviating globus symptoms, and producing global improvements for refractory globus patients.

Pathophysiology and treatment of patients with globus sensation--from the viewpoint of esophageal motility dysfunction

"Globus sensation" is often described as the sensation of a lump in the throat associated with dry swallowing or the need for dry swallowing, which disappears completely during eating or drinking and for which no organic cause can be established. Due to the uncertain etiology of "globus sensation", it remains difficult to establish standard treatment strategies for affected patients. Lately most attention has been focused on gastroesophageal reflux disease and several reports have indicated that there is a close relationship between esophageal acid reflux and globus sensation. Nowadays, empirical therapy with a high dose of a proton pump inhibitor (PPI) is considered to be indicated for patients with globus sensation, after excluding organic diseases such as pharyngeal cancer, Zenker's diverticulum, or thyroid enlargement. If patients are nonresponsive to PPI therapy, evaluation of esophageal motility should be done. In our recent study, 47.9% had abnormal esophageal motility, with the most common esophageal motility abnormality being an ineffective esophageal motility in PPI-resistant patients with globus sensation. This suggests that prokinetics alone or adding prokinetics to PPI should be the treatment to be considered, although few studies have investigated the efficacy of prokinetics in the treatment of patients with globus sensation. If patients without any esophageal motility dysfunctions are nonresponsive to PPI therapy, either cognitive-behavioral therapy, anti-depressants, or gabapentin could be helpful, although further well-designed, randomized controlled large-scale studies will be necessary to determine the effectiveness of each treatment strategy on patients with globus sensation.

Effects of antidepressants in patients with functional esophageal disorders or gastroesophageal reflux disease: a systematic review

BACKGROUND & AIMS

Patients with functional esophageal disorders present with symptoms of chest pain, heartburn, dysphagia, or globus in the absence of any structural abnormality. Visceral hypersensitivity is a feature of these functional disorders, and might be modulated by antidepressant therapy. We evaluated evidence for the efficacy of antidepressant therapy for symptoms associated with esophageal visceral hypersensitivity in patients with functional esophageal disorders or gastroesophageal reflux disease (GERD).

METHODS

We performed a systematic search of the Cochrane Comprehensive Trial Register, MEDLINE, and EMBASE (through February 2014). We analyzed relevant randomized, placebo-controlled trials reporting the effect of antidepressant therapy on experimentally induced esophageal sensation or intensity, or frequency of heartburn, chest pain, dysphagia, or globus.

RESULTS

The search strategy identified 378 articles; 15 described randomized controlled trials that were eligible for inclusion. In addition, 1 conference abstract and 2 case reports were included, providing the best available evidence on specific symptoms. Esophageal pain thresholds increased by 7% to 37% after antidepressant therapy. Antidepressant therapy reduced functional chest pain over a range from 18% to 67% and reduced heartburn in patients with GERD over a range of 23% to 61%. One study included patients with globus and none of the studies included patients with functional heartburn or functional dysphagia.

CONCLUSIONS

Based on a systematic review, antidepressants modulate esophageal sensation and reduce functional chest pain. There is limited evidence that antidepressants benefit a subgroup of patients with GERD. More controlled trials are needed to investigate the effects of antidepressants on functional esophageal disorders.

Characteristics of thyroid nodules causing globus symptoms

A globus sensation is one of the most common complaints in otolaryngologic clinics, and laryngopharyngeal reflux is the most common cause. However, thyroid nodules also can cause globus symptoms. The purpose of this study was to identify the characteristics of thyroid nodules that cause globus. We selected patients prospectively with a single thyroid nodule on ultrasonograms. Patients with other causes of globus symptoms were excluded using questionnaires, fiber optic laryngoscopic examinations, and a psychiatric screening tool. In total, 175 patients were enrolled. Patients were divided into two groups according to globus symptoms. Ultrasonographic characteristics and clinicopathological parameters were compared between the groups. Among various clinicopathologic and ultrasonographic parameters, size and horizontal location of the thyroid nodule showed significant differences between the groups. Nodules larger than 3 cm and those located anterior to the trachea had a tendency to cause globus symptoms. Regarding horizontal location, nodules that all parts were located anterior to the trachea showed a higher tendency to cause globus symptoms than nodules that only some parts were located anterior to the trachea. In conclusion, thyroid nodules with specific size and location can cause globus symptoms, and this finding can be indicated in patient counseling. Also, conservative treatments or thyroidectomy may be helpful in relieving patients' globus symptoms.

The complexity of globus: a multidisciplinary perspective

Globus is a topic of interest for many specialties including otorhinolaryngology, gastroenterology and psychiatry/psychosomatic medicine, but, although many hypotheses have been suggested, key questions about its aetiology remain. This Review provides an overview of the extensive literature concerning this topic and discusses the quality of the evidence to date. Globus has been associated with oropharyngeal structural lesions, upper oesophageal sphincter disorders, oesophageal disorders, GERD, psychosocial factors and psychiatric comorbidity. However, findings are often contradictory and the literature remains highly inconclusive. Indeed, with the exception of patients with structural-based globus, the Rome III criteria for functional globus only apply to a subgroup of patients with idiopathic globus. In clinical reality, there exists a group of patients who present with idiopathic (nonstructural) globus, but nevertheless have dysphagia, odynophagia or GERD-exclusion criteria for globus diagnosis according to Rome III. The symptomatology of patients with globus might be broader than previously thought. It is therefore crucial to approach globus not from one single perspective, but from a multifactorial point of view, with focus on the coexistence and/or interactions of different mechanisms in globus pathogenesis. This approach could be translated to clinical practice by adopting a multidisciplinary method to patients presenting with globus.

[Paresthesias of the upper respiratory tract]

This review concerns the modern views of etiology, diagnostics, and treatment of the patients presenting with paresthesias of the upper respiratory tract. Various concepts of etiology of this pathology are described along with the relevant diagnostic and therapeutic approaches. Special attention is given to the debatable aspects of diagnostics and treatment of the patients complaining of the feeling of a lump in the throat ("globus sensation"). The opinions of the domestic and foreign authors concerning this problem are considered. The necessity of the search for the new additional therapeutic procedures for the treatment of paresthesias of the upper respiratory tract, including the non-medicamental modalities, is substantiated. It is concluded that the development of the new adequate diagnostic and therapeutic algorithm is indispensable for the enhancement of the effectiveness of the management of the patients with paresthesias of the upper respiratory tract and complaints of "globus sensation".

[Impaired consciousness associated with a hysterical conversion after obstetrical epidural analgesia: a case report with literature review]

The occurrence of impaired consciousness after epidural analgesia is an alarming situation that requires urgent diagnostic and therapeutic approach. Various causes may be responsible for such a state. Hysterical conversion remains an outstanding issue. Through a clinical case of a hysterical conversion and a literature review the authors draw attention to the difficulty of diagnosing this entity after epidural analgesia.

Globus pharyngeus: A review of its etiology, diagnosis and treatment

Globus is a persistent or intermittent non-painful sensation of a lump or foreign body in the throat. It is a commonly encountered clinical condition that is usually long-lasting, difficult to treat, and has a tendency to recur. Furthermore, due to the uncertain etiology of globus, it remains difficult to establish standard investigation and treatment strategies for affected patients. As a first step for managing globus, careful history taking and nasolaryngoscopy are essential. Given the benign nature of the condition and the recent notion that gastroesophageal reflux disease is a major cause of globus, empirical therapy with a high dose of proton pump inhibitors is reasonable for patients with typical globus. If patients are nonresponsive to this therapy, definitive assessments such as endoscopy, multichannel intraluminal impedance/pH monitoring, and manometry should be considered. Speech and language therapy, anti-depressants, and cognitive-behavioral therapy can be helpful in patients whose symptoms persist despite negative investigations.

The role of psychological distress in laryngopharyngeal reflux patients: a prospective questionnaire study

OBJECTIVES

To determine the role of psychological distress in laryngopharyngeal reflux patients and evaluate the correlation between symptoms, laryngeal signs, pH monitoring results and psychological profile.

DESIGN

Prospective study.

SETTING

Hanyang University Hospital, a university teaching hospital and tertiary referral center.

PARTICIPANTS

One hundred and six patients who were diagnosed with laryngopharyngeal reflux by 24-h ambulatory double probe pH monitoring and 119 healthy controls visiting our health promotion center from January 2006 to June 2007.

MAIN OUTCOME MEASURES

The psychological profile of laryngopharyngeal reflux patients measured by the Symptom Checklist-90-Revised questionnaire were evaluated and compared with those of healthy controls. The correlation between reflux symptom index, reflux finding score, parameters of pH monitoring and the Symptom Checklist-90-Revised profiles were also evaluated.

RESULTS

On the Symptom Checklist-90-Revised questionnaire, the total mean T-scores of the nine symptom dimensions and three global indices of the laryngopharyngeal reflux patients were all below 50. The Global Severity Index, which indicates overall psychological distress, was normal in all of the patients. On comparison with the control group, no statistically significant difference was noted in the psychological profile except on the Somatisation scale where laryngopharyngeal reflux patients showed significantly higher scores. Reflux symptom index showed significant positive correlation with the number of reflux episodes, percentage of time which pH fell below 4 in total positions, and DeMeester score of the upper probe. The nine symptom dimensions and three global indices of Symptom Checklist-90-Revised questionnaire did not show any correlation with reflux symptom index, reflux finding score and the parameters of the 24-h ambulatory double probe pH monitoring.

CONCLUSIONS

Laryngopharyngeal reflux patients did not demonstrate any significant level of psychological distress and their symptom severity showed significant positive correlation with reflux severity.

Marked depression and anxiety in patients with functional dysphonia

The etiology of functional dysphonia is still unclear, but psychological factors are assumed to play an important role . The purpose of this report is to investigate the impact of depression and anxiety in functional dysphonia. Sixty-one patients with functional dysphonia were screened for additional psychiatric disorders (besides 300.11) by a clinical psychiatric interview. They were then compared with healthy controls, matched by age, sex and occupation, with respect to self-reported symptoms of depression, generalized anxiety, and specific anxiety concerning health. The patients had significantly higher scores than the controls in depressive symptoms, in the symptoms of nonspecific and general anxiety, and in the symptoms of specific anxiety concerning health. Fifty-seven percent of the patients also fulfilled DSM-IV criteria for a mood disorder, an anxiety disorder, or an adjustment disorder. Multivariate analysis of covariance, performed to correct for the influence of co-morbid psychiatric diagnoses on self-rated symptoms of depression and anxiety, confirmed significant differences between patients and controls in the symptoms of depression and specific anxiety concerning "somatic complaints." Both symptoms of depression and anxiety should be taken into consideration in the diagnostic as well as the therapeutic process of patients with functional dysphonia.

Globus hystericus: a brief review

Globus hystericus, a form of conversion disorder, is characterized by an uncomfortable sensation of a mass in the esophagus or airway. Evaluation proves no mass exists. Anxiety or psychological conflict is judged to be significantly related to the onset and progression of the sensation. The sensation may lead to difficulty swallowing or breathing and may become severe or life threatening. The disorder is poorly studied and understood. The differential diagnosis is vast. Management of the disorder is similar to that suggested for other conversion disorders. This article reviews the current literature about diagnosis, etiology, treatment, and prognosis of globus hystericus.

The efficacy and safety of ECT in depressed older adults: a literature review

BACKGROUND

Although little doubt exists among practising clinicians in old age psychiatry about the efficacy and safety of ECT in depression, opinions about acceptability differ widely. The objectives of this review were to determine the efficacy and safety of ECT based on both randomised and non-randomised evidence in elderly with a major depressive disorder.

METHODS

Randomised and non-randomised studies on efficacy and safety of ECT in elderly with and without concomitant disorders such as cerebrovascular disorders, Alzheimer's dementia, vascular dementia and Parkinson's disease were selected. Literature was systematically searched in a number of electronic databases.

RESULTS

Although 121 studies were included in the review process, only four provided randomised evidence. No negative studies with respect to efficacy were found. ECT is effective in the acute treatment of late life depression. ECT is generally safe, although a number of serious complications possibly related to ECT have been described. Most of the objectives of this review could not be answered or refuted with certainty, because firm randomised evidence on the efficacy and safety of ECT in the depressed elderly is missing.

CONCLUSIONS

ECT is effective in the acute treatment of late life depression and is generally safe. Important questions such as the relative efficacy of ECT over antidepressants, the long-term efficacy of ECT, morbidity and mortality related to ECT, cost-effectiveness and the efficacy of ECT in subgroups of patients cannot be answered and need to be studied further.

Electroconvulsive therapy for the depressed elderly

BACKGROUND

Depressive disorder is a common mental disorder in old age, with serious health consequences such as increased morbidity, disability, and mortality. The frailty of elderly may seriously hamper the efficacy and safety of pharmacotherapy in depressed elderly. Electroconvulsive therapy (ECT) in depressed elderly therefore may be an alternative to treatment with antidepressants.

OBJECTIVES

To assess the efficacy and safety of ECT (compared to simulated ECT or antidepressants) in depressed elderly.

SEARCH STRATEGY

We searched the CCDANCTR database, Medline 1966-2000, EMBase 1980-2000, Biological abstracts 1985-2000, Cinahl 1982-2000, Lilacs from 1982 onwards, Psyclit 1887-2000, Sigle 1980-2000. The reference lists of relevant papers were scanned for published reports. Hand searching of the Journal of ECT and the Journal of Geriatric Psychiatry was done. Based on the title of the publication and its abstract, non-eligible citations were excluded.

SELECTION CRITERIA

Data were independently extracted by at least two reviewers. Randomised, controlled trials on depressed elderly (> 60 years) with or without concomitant with conditions like cerebrovascular disease, dementia of the Alzheimer's type, vascular dementia or Parkinson's disease were included.

DATA COLLECTION AND ANALYSIS

Data were independently extracted by at least two reviewers. For continuous data weighted mean differences (WMD) between groups were calculated.

MAIN RESULTS

Randomised evidence is sparse. Only three trials could be included, one on the efficacy of real ECT versus simulated ECT (O'Leary et al 1994), one on the efficacy of unilateral versus bilateral ECT (Fraser 1980) and the other comparing the efficacy of ECT once a week with ECT three times weekly (Kellner 1992). All had major methodological shortcomings; data were mostly lacking essential information to perform a quantitative analysis. Although the O'Leary study concluded that real ECT was superior over simulated ECT, these conclusions need to be interpreted cautiously. Only results from the second trial (unilateral versus bilateral ECT) could be analysed, not convincingly showing efficacy of unilateral ECT over bilateral ECT, WMD 6.06 (CI -5.20,17.32). Randomised evidence on the efficacy and safety of ECT in depressed elderly with concomitant dementia, cerebrovascular disorders or Parkinson's disease is completely lacking. Possible side-effects could not be adequately examined because the lack of randomised evidence and the methodological shortcomings.

REVIEWER'S CONCLUSIONS

None of the objectives of this review could be adequately tested because of the lack of firm, randomised evidence. Given the specific problems in the treatment of depressed elderly, it is of importance to conduct a well designed randomised controlled trial in which the efficacy of ECT is compared to one or more antidepressants.

Current issues in the diagnosis and management of malingering

Malingering is a diagnosis that is frequently avoided by physicians. When there is a claim of symptoms or diseases that either are exaggerated or do not exist, the diagnosis of malingering should be entertained. Malingering is associated with a conscious intent to deceive in order to obtain a known gain. Psychoanalytical, criteria-based (DSM-IV) and 'adaptational' models have been advanced to explain malingering. The differential diagnosis of malingering includes factitious disorder, the somatoform disorders, the dissociative disorders, and specific medical conditions without somatoform disorder. Upon consideration of the differential diagnosis, confirmation of the suspicion of malingering is still required in order to make the diagnosis. Confirmation can be achieved by observation or by inferential methods. Observation can be employed with controlled environment observation or with covert, 'real-world' surveillance; inference may involve primary and/or secondary source information. It may be concluded that a greater attempt should be made to identify this diagnosis, as the cost of malingering to society is considerable.