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Brief-pulse electroconvulsive therapy (ECT) is the most acutely effective treatment for severe depression though concerns persist about cognitive side-effects. While bitemporal electrode placement is the most commonly used form worldwide, right unilateral ECT causes less cognitive side-effects though historically it has been deemed less effective. Several randomized trials have now compared high-dose (>5× seizure threshold) unilateral ECT with moderate-dose (1.0–2.5× seizure threshold) bitemporal ECT to investigate if it is as effective as bitemporal ECT but still has less cognitive side-effects. We aimed to systematically review these trials and meta-analyse clinical and cognitive outcomes where appropriate.
We searched PubMed, PsycINFO, Web of Science, Cochrane Library and EMBASE for randomized trials comparing these forms of ECT using the terms ‘electroconvulsive’ OR ‘electroshock’ AND ‘trial’.
Seven trials (n = 792) met inclusion criteria. Bitemporal ECT did not differ from high-dose unilateral ECT on depression rating change scores [Hedges's g = −0.03, 95% confidence interval (CI) −0.17 to 0.11], remission (RR 1.06, 95% CI 0.93–1.20), or relapse at 12 months (RR 1.42, 95% CI 0.90–2.23). There was an advantage for unilateral ECT on reorientation time after individual ECT sessions (mean difference in minutes = −8.28, 95% CI −12.86 to −3.70) and retrograde autobiographical memory (Hedges's g = −0.46, 95% CI −0.87 to −0.04) after completing an ECT course. There were no differences for general cognition, category fluency and delayed visual and verbal memory.
High-dose unilateral ECT does not differ from moderate-dose bitemporal ECT in antidepressant efficacy but has some cognitive advantages.
A major cause of death in Irish men aged 15–24 is suicide and the rates for those aged 15–19 are amongst the highest in Europe. Despite concerns over suicidal ideation or behaviour, little research has been done in the Irish primary care context. We therefore aimed to carry out a study of Irish General Practitioners (GPs)’ experience regarding suicidal ideation or behaviour in children and adolescents.
The study design was a descriptive, cross-sectional, questionnaire survey. We randomly selected 480 GPs and invited them to participate via post.
In total, 198 GPs replied, representing a response rate of 41% with a sampling error of ±6.8%. In total, 184 of respondents (93%) saw more than 50 children and adolescent patients annually, however, presentations of suicidal ideation and behaviour were relatively rare, with 36% reporting seeing none, 58% seeing between one and five and 6% seeing more than five such presentations annually. In total, 119 (62%) of GPs reported a willingness to prescribe antidepressants for this age group. In total, 66% of GPs felt this was either ‘always’ or ‘usually’ a difficult patient group to manage, and the single most commonly reported difficulty by GPs was access to services [n=48 (33%)].
GPs reported that their management of children and adolescents with suicidal ideation or behaviour is often difficult. GPs play a key liaison role in the area of child and adolescent mental health, but our results indicate that GPs are also involved in the treatment of this patient group. However, ongoing education was not a priority according to GPs themselves.
More people are living beyond their 90s, yet this group has not been much studied. This study aimed to describe a sample of non-agenarians and centerians attending an old age psychiatry service with a focus on pharmacotherapy.
Retrospective, cross-sectional survey of patients aged >90 in contact with the Department of Old Age Psychiatry in a university hospital over a 1-year period. Results were compared with the Beers, the Canadian and Screening Tool of Older Persons’ potentially inappropriate Prescriptions (STOPP) criteria.
A total of 65 nonagenarians or centerians were identified (mean age 93, 82% female). The majority (65%) resided in a nursing home; dementia was the most common diagnosis (77%), followed by depression (29%). The most commonly prescribed psychotropics were antidepressants (58%), followed by antipsychotics (45%), hypnotics (42%), anti-dementia agents (31%) and anxiolytics (26%). Overall, patients were on a mean of 2.1 (S.D. 1.3, range 0–5) psychotropics and 4.99 (S.D. 2.7, range 0–11) non-psychotropics. Mean Mini Mental State Examination (MMSE) score was 15 (S.D. 8.1). Increasing anticholinergic burden was negatively associated with MMSE scores (B = −1.72, p = 0.013). Residing in a nursing home was associated with a higher rate of antidepressant [OR 5.71 (95% CI 1.9–17.4)], anxiolytic [OR 13.5 (95% CI 1.7–110.4)] and antipsychotic [OR 3.4 (95% CI 1.1–10.4)] use. Potentially inappropriate prescribing included long-term benzodiazepine use (26%) and long-term antipsychotic use (25%).
Our sample had a high psychiatric morbidity burden with high levels of psychotropic use. Ongoing review and audit of psychotropic use in elderly patients can identify potentially inappropriate prescribing in a group vulnerable to high levels of polypharmacy and extended psychotropic use.
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