Phenelzine (“Nardil”) in the Treatment of Endogenous Depression

To many minds there can be but little change in the treatment of depression since Johnson prescribed these remedies in 1776. Indeed the place of chemistry is now prominent, although its application is apparently more important to the patient than its study. It is believed that an enzyme, mono-amine oxidase, found in cerebral tissues, plays a part in the genesis of depression. Amphetamine inhibits the destruction of adrenaline by amine oxidase (McIlwain, 6) and amphetamine is of value in the treatment of mild depression (Guttmann and Sargant, 5). Another substance is 5-hydroxytryptamine, or serotonin, which is said to excite cerebral neurones briefly between its liberation and destruction; it is a cerebral vasoconstrictor and is destroyed rapidly by amine oxidase (McIlwain, 6). Iproniazid (Marsilid) is a drug which inhibits amine oxidase and has been used in the treatment of depression (West and Dally, 10). Its central actions are considered to be similar to those of 5-hydroxytryptamine. Recently, Chessin (3) has described yet another amine oxidase inhibitor, phenelzine, which is the study of this paper.

Electroplexy (E.C.T.) Techniques in Current use

At a recent court case (40), the plaintiff, who sustained bilateral acetabular fractures following unmodified electroplexy, maintained that the defendants were guilty of negligence by failing to use relaxant drugs to prevent the risks of injury.

Acute pulmonary edema caused by hypoglycemia due to insulin overdose

We report a very rare case of acute pulmonary edema caused by hypoglycemia from insulin overdose during an attempted suicide. A 16-year-old woman with type 1 diabetes was brought to our hospital because of hypoglycemic coma. She exhibited severe hypoxia; upon intubation, bloody froth poured out of the tube. Chest X-ray revealed bilateral infiltrates. Endocrinological data revealed high concentrations of catecholamines. This case indicates that pulmonary edema remains a potential complication of insulin overdose. The possible mechanisms of pulmonary edema associated with hypoglycemia are discussed.

Hypoglycemia-Induced Neurogenic-Type Pulmonary Edema: An Underrecognized Association

OBJECTIVE

To report a case of hypoglycemia-induced pulmonary edema and to analyze the underlying pathophysiologic processes.

METHODS

A case report with clinical and laboratory data is presented, and related studies from the medical literature are discussed.

RESULTS

A 23-year-old man with type 1 diabetes was brought to the emergency department because he was found unconscious at home. Despite a morning blood glucose level of 30 mg/dL, he had taken his usual dose of Lente insulin (40 U), and a period of unconsciousness of unknown duration ensued. Intravenous administration of dextrose increased his blood glucose level to 118 mg/dL, but x-ray films of the chest disclosed evidence of pulmonary edema. After 48 hours of supportive care, his respiratory signs and symptoms resolved. The pathophysiologic construct for hypoglycemia-induced pulmonary edema is thought to be the same as for neurogenic pulmonary edema, with a massive sympathetic nervous system discharge being the common denominator in both conditions.

CONCLUSION

Clinicians should be aware that severe hypoglycemia can lead to noncardiogenic pulmonary edema as a result of a massive sympathetic nervous system discharge and its associated hemodynamic alterations, in the same manner as occurs in neurogenic pulmonary edema.

The use of electroconvulsive therapy in special patient populations

BACKGROUND

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

METHOD

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

RESULTS

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

CONCLUSIONS

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

ECT in the treatment of patients with neurological and somatic disease

OBJECTIVE

An evaluation of the safety and efficacy of electroconvulsive therapy (ECT), for the treatment of patients with severe medical and neurological illness, was undertaken.

METHOD

The English-language literature reporting the use of ECT in patients with neurological and somatic disease was reviewed. This review included reports describing ECT used for the treatment of affective disturbances and catatonia in patients with concurrent neurological or somatic disease, as well as reports dealing with the efficacy of ECT for the treatment of certain neurological conditions for which it has been reported to have some benefit independent of its psychiatric effect.

CONCLUSIONS

ECT is safe and effective for the treatment of affective and catatonic disorders in patients with most neurological and medical diseases, including elderly and debilitated patients with multiple illnesses, if the specific medical risks are carefully evaluated in each case, and appropriate modifications of technique are used to reduce the risk of potential complications. Apart from its use in psychiatry, ECT has been reported to have therapeutic effects in Parkinson's disease, neuroleptic malignant syndrome, aggressive behavioral disorders following brain injury, certain forms of epilepsy, and some forms of delirium due to toxic or metabolic encephalopathies. The potential for ECT to play an active role in the clinical management of patients with these disorders, many of whom are presently refractory to maximal medical treatment, should be evaluated by systematic studies.

Pre-anaesthetic assessment and the prevention of post-ECT morbidity

The introduction of anaesthesia and muscle relaxation has made ECT relatively safe. In a retrospective study of the case notes of 367 consecutive patients receiving ECT over a two year period, chest X-ray and full blood count added no significant information and were ineffective in predicting morbidity, in contrast to physical examination alone.

Actual practice of ECT in a health region of Britain

A field study of 14 treatment centres found broad agreement between clinical practice and the Royal College of Psychiatrists' Memorandum on the use of ECT. Differences in electrode placement and anaesthetic agents and a poor standard of safety and reliability in the electrical equipment was noted.

Treatment or punishment? A nineteenth-century scandal

In psychiatry the relationship between treatment and punishment is variable and ambiguous. It has always been possible to employ physical methods of treatment for punitive ends, against which the introduction of liberal policies is no complete safeguard. Indulging one's personal animosities towards a difficult or violent patient has always been condemned, but the motives of a psychiatrist may be particularly easily misconstrued. These inherent risks in a psychiatrist's situation are illustrated by a case from the 19th century.

Anaesthesia for electroconvulsive therapy

The results of a prospective study of 3,500 Anaesthetics for electroconvulsive therapy is presented. Minimal differences were observed between thiopentone and methohexitone. Propanidid and Diazepam were found to be unsuitable induction agents. Other findings included minimal serum potassium elevation and a low incidence of post treatment muscle pains. The place of the single-handed operator and the place of unmodified electroconvulsive therapy is questioned as being unacceptable practice.

The effects of electro-convulsive therapy on patients with essential hypertension

There is no doubt that electro-convulsive treatment is a safe treatment, perhaps very safe, yet from time to time reports of a fatality appear in the literature. When death occurs, most authorities agree that it is the cardiovascular system that fails. When there has been no suggestion of respiratory mismanagement, and death has been unrelated to the actual fit, vagal over-activity has received attention as a cause of death. It has been said that almost the only physical contraindication to treatment is a recent coronary thrombosis. Whatever the truth of this may be, uncertainty exists as to the “buffetings” an ischaemic myocardium or a diseased arterial system will tolerate.

A comparison between the results of unmodified and modified electro plexy (E.C.T.)

Since the discovery of the therapeutic value of induced epileptic convulsions in mental illness, there have been efforts to make this form of treatment available to those patients whose psychiatric state would benefit from it but whose physical condition contraindicates its use. Modifications have been sought, particularly since the introduction of electrical methods of inducing the fit. The modification of electroplexy takes three main forms—postural, electrical and chemical (Montagu, 1953) and it is with this third type, the use of anaesthetic and relaxant drugs, that this paper is concerned.

The use of arfonad for the alleviation of cardio-vascular stress following electro-convulsive therapy

The safety of electro-convulsive therapy (E.C.T.) has been greatly increased since muscle relaxants were first introduced for this purpose. Short-acting relaxants such as suxamethonium and suxethonium reduce the usual strong tonic and clonic contractions to faint muscle twitchings, and fractures do not occur. Respiration can be maintained throughout by positive pressure inflation so that cyanosis and stertorous breathing are avoided. This may ensure that material from small pulmonary lesions is not disseminated to other areas. It is disappointing that the cardiovascular commotion is only slightly reduced, and deaths still occur, albeit rarely.

Histological changes in the brain after uncomplicated electro-convulsant treatment

There has been much discussion about the possible occurrence of reversible and irreversible histological changes in the brain following the convulsive treatment of mental disorder. Most investigations have been carried out either on experimental animals—with results not easily comparable to man—or in deceased patients in whom the picture is usually obscured by the presence of complications. The various causes of death following convulsive treatment have recently been reviewed by Maclay (1953).