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Epitomes Important Advances in Clinical Medicine
Psychiatry The Scientific Board ofthe California Medical Association presents the following inventory of items ofprogress in psychiatry. Each item, in thejudgment of a panel of knowledgeable physicians, has recently become reasonablyfirmly established, both as to scientificfact and important clinical significance. The items are presented in simple epitome, and an authoritative reference, both to the item itselfand to the subject as a whole, is generally given for those who may be unfamiliar with a particular item. The purpose is to assist busy practitioners, students, researchers, or scholars to stay abreast ofthese items ofprogress in psychiatry that have recently achieved a substantial degree of authoritative acceptance, whether in their own field of special interest or another. The items ofprogress listed below were selected by the Advisory Panel to the Section on Psychiatry ofthe California Medical Association, and the summaries were prepared under its direction. Reprint requests to Division of Scientific and Educational Activities, Califomia Medical Association, PO Box 7690, San Francisco, CA 94120-7690
Electroconvulsive Therapy THERE IS A PERSISTENT ANTIPATHY to the use of electroconvulsive therapy (ECT), despite repeated evidence of its efficacy and safety. In response to public demands, the National Institutes of Health held a consensus conference in 1985. The conferees endorsed the efficacy of ECT in a number ofconditions, noted its safety when properly done, and asked for the development of guidelines to treatment as the basis for its broader use. In response, the American Psychiatric Association established its second Task Force on Electroconvulsive Treatment, the report of which was published in May 1990. The recommendations summarize the present standard of care and its rationale and include a bibliography of sources. The safety and efficacy of ECT in treating patients who have major depressive disorders, with melancholia or psychosis, make these diagnoses the main indications for its use. Its effectiveness in patients with manic delirium; with acute schizophrenia with symptoms of hallucinations, delusions, and paranoia; schizoaffective disorders; and catatonia is now
recognized. The report describes situations in which ECT may be the first treatment: when a rapid definitive response is required for medical or psychiatric reasons, when the risks of other treatments outweigh those of ECT, when there is a history of poor drug response or of good ECT response in previous episodes, and when a patient prefers it. Conditions that may require a rapid response include manic delirium, catatonic excitement, suicidality, inanition, or severe motor inhibition (catatonia). A common use is in patients admitted to hospital with affective and psychiatric disorders in whom other therapies failed or who were unable to tolerate other treatments because of side effects. There are no absolute contraindications to using ECT, but conditions of substantial risk may require special skills. The presence of increased intracranial pressure, unstable cardiovascular function, aneurysm, or conditions that are rated as anesthetic risks-American Society of Anesthesiologists level 4 or 5-are examples. Much of the skill in treating highrisk medically ill patients lies in the treatment "team," consisting of a psychiatrist, an ECT nurse, and an anesthetist. Consent is an important consideration, and the task force urges the signing of a specific consent document that outlines
the reasons for the treatment, alternative remedies, a description of the treatment, the number and frequency of treatments, and the caveat that the patient may end the course at any time. Modern ECT is "modified," in which treatments are given under anesthesia with ventilation and oxygenation, with special attention to electrode placement, brief-pulse currents, and low doses of energy. Under these conditions, the side effects described in the earlier literature-panic, delirium, fracture, organic psychosis, and cognitive deficits-no longer occur. Present ECT practice is described in sufficient detail to provide standards for care. The early training of practitioners in ECT remains a function of medical school and residency training programs. To supplement these, the report encourages continuing medical education courses. In the past year, these have been developed at the Chicago Medical School (North Chicago, Illinois), Duke University (Durham, North Carolina), State University of New York at Stony Brook, Washington University (Saint Louis, Missouri), and CME, Inc (Tustin, California). Because ECT is generally given in a hospital or other medical facility, the granting of ECT privileges is the responsibility of the medical director or medical board of each institution, and each organization is encouraged to develop guidelines for granting privileges. Electroconvulsive therapy remains "controversial" because of professional and lay misperceptions. It is a tragedy that the principal beneficiaries of the treatment, those who require admission to hospital, are denied the treatment by its unavailability in most state, federal, and municipal psychiatric hospitals-precisely the places where most of the candidates with the best indications and prognosis are treated. The present American Psychiatric Association's Task Force report is a rational, detailed, and thoughtful document that should be the basis for improved training in medical schools and residencies and for the establishment of ECT treatment teams at psychiatric and medical centers. MAX FINK, MD Stony Brook, New York
REFERENCES Abrams R (Ed): ECT in the high-risk patient. Convulsive Ther 1989; 5(1; special
issue) The Practice of Electroconvulsive Therapy: Recommendations for Treatment, Training and Privileging. Washington, DC, American Psychiatric Press, 1990
Epitomes Important Advances in Clinical Medicine
Psychiatry The Scientific Board ofthe California Medical Association presents the following inventory of items ofprogress in psychiatry. Each item, in thejudgment of a panel of knowledgeable physicians, has recently become reasonablyfirmly established, both as to scientificfact and important clinical significance. The items are presented in simple epitome, and an authoritative reference, both to the item itselfand to the subject as a whole, is generally given for those who may be unfamiliar with a particular item. The purpose is to assist busy practitioners, students, researchers, or scholars to stay abreast ofthese items ofprogress in psychiatry that have recently achieved a substantial degree of authoritative acceptance, whether in their own field of special interest or another. The items ofprogress listed below were selected by the Advisory Panel to the Section on Psychiatry ofthe California Medical Association, and the summaries were prepared under its direction. Reprint requests to Division of Scientific and Educational Activities, Califomia Medical Association, PO Box 7690, San Francisco, CA 94120-7690
Electroconvulsive Therapy THERE IS A PERSISTENT ANTIPATHY to the use of electroconvulsive therapy (ECT), despite repeated evidence of its efficacy and safety. In response to public demands, the National Institutes of Health held a consensus conference in 1985. The conferees endorsed the efficacy of ECT in a number ofconditions, noted its safety when properly done, and asked for the development of guidelines to treatment as the basis for its broader use. In response, the American Psychiatric Association established its second Task Force on Electroconvulsive Treatment, the report of which was published in May 1990. The recommendations summarize the present standard of care and its rationale and include a bibliography of sources. The safety and efficacy of ECT in treating patients who have major depressive disorders, with melancholia or psychosis, make these diagnoses the main indications for its use. Its effectiveness in patients with manic delirium; with acute schizophrenia with symptoms of hallucinations, delusions, and paranoia; schizoaffective disorders; and catatonia is now
recognized. The report describes situations in which ECT may be the first treatment: when a rapid definitive response is required for medical or psychiatric reasons, when the risks of other treatments outweigh those of ECT, when there is a history of poor drug response or of good ECT response in previous episodes, and when a patient prefers it. Conditions that may require a rapid response include manic delirium, catatonic excitement, suicidality, inanition, or severe motor inhibition (catatonia). A common use is in patients admitted to hospital with affective and psychiatric disorders in whom other therapies failed or who were unable to tolerate other treatments because of side effects. There are no absolute contraindications to using ECT, but conditions of substantial risk may require special skills. The presence of increased intracranial pressure, unstable cardiovascular function, aneurysm, or conditions that are rated as anesthetic risks-American Society of Anesthesiologists level 4 or 5-are examples. Much of the skill in treating highrisk medically ill patients lies in the treatment "team," consisting of a psychiatrist, an ECT nurse, and an anesthetist. Consent is an important consideration, and the task force urges the signing of a specific consent document that outlines
the reasons for the treatment, alternative remedies, a description of the treatment, the number and frequency of treatments, and the caveat that the patient may end the course at any time. Modern ECT is "modified," in which treatments are given under anesthesia with ventilation and oxygenation, with special attention to electrode placement, brief-pulse currents, and low doses of energy. Under these conditions, the side effects described in the earlier literature-panic, delirium, fracture, organic psychosis, and cognitive deficits-no longer occur. Present ECT practice is described in sufficient detail to provide standards for care. The early training of practitioners in ECT remains a function of medical school and residency training programs. To supplement these, the report encourages continuing medical education courses. In the past year, these have been developed at the Chicago Medical School (North Chicago, Illinois), Duke University (Durham, North Carolina), State University of New York at Stony Brook, Washington University (Saint Louis, Missouri), and CME, Inc (Tustin, California). Because ECT is generally given in a hospital or other medical facility, the granting of ECT privileges is the responsibility of the medical director or medical board of each institution, and each organization is encouraged to develop guidelines for granting privileges. Electroconvulsive therapy remains "controversial" because of professional and lay misperceptions. It is a tragedy that the principal beneficiaries of the treatment, those who require admission to hospital, are denied the treatment by its unavailability in most state, federal, and municipal psychiatric hospitals-precisely the places where most of the candidates with the best indications and prognosis are treated. The present American Psychiatric Association's Task Force report is a rational, detailed, and thoughtful document that should be the basis for improved training in medical schools and residencies and for the establishment of ECT treatment teams at psychiatric and medical centers. MAX FINK, MD Stony Brook, New York
REFERENCES Abrams R (Ed): ECT in the high-risk patient. Convulsive Ther 1989; 5(1; special
issue) The Practice of Electroconvulsive Therapy: Recommendations for Treatment, Training and Privileging. Washington, DC, American Psychiatric Press, 1990
