Journal of ECT • Volume 30, Number 3, September 2014
Letters to the Editor
whereas the therapeutic effect persisted with M-ECT. They concluded that the combination of M-ECT with antipsychotics is a safe and effective strategy for the consolidation of the therapeutic response in elderly and middle-aged experiencing catatonic schizophrenia and who relapse after stopping ECT despite continued antipsychotic treatment. Another study including 19 patients found that the M-ECT was effective on mood, anxiety, and delusional symptoms and on suicidal behavior.3 It allowed also reducing by 80% the average duration of hospitalizations per year. The interval between sessions was 1 to 5 weeks. Synergistic mechanisms of this association are not yet clear. A synergistic effect of this combination is possible through the potentiating of the effect of various neurotransmitters.4 It has also been hypothesized that ECT alter the permeability of the bloodbrain barrier and would increase the crossing of clozapine which would potentiate the efficacy of this molecule without increasing systemic adverse effects.5
CONCLUSION This observation illustrates the value of combining ECT to clozapine in patients with refractory schizophrenia and consolidating the improvement by M-ECT at the rate of 1 session per month. This combination seems effective and well tolerated. Souhail Bannour Saoussen Bouhlel Mohamed Wassim Krir Badii Amamou Selma Ben Nasr Yousri El Kissi Bechir Ben Hadj Ali Department of Psychiatry Farhat Hached Hospital Sousse, Tunisia [email protected]
The authors have no conflicts of interest or financial disclosures to report. REFERENCES 1. Kristensen D, Bauer J, Hageman I, et al. Electroconvulsive therapy for treating schizophrenia: a chart review of patients from two catchment areas. Eur Arch Psychiatry Clin Neurosci. 2011;261:425–432. 2. Suzuki K, Awata S, Takano T, et al. Continuation electroconvulsive therapy for relapse prevention in middle-aged and elderly patients with intractable catatonic schizophrenia. Psychiatry Clin Neurosci. 2005;59:481–489. 3. Levy-Rueff M, Jurgens A, Loo H, et al. [Maintenance electroconvulsive therapy and
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www.ectjournal.com
treatment of refractory schizophrenia]. Encephale. 2008;34:526–533. 4. Havaki-Kontaxaki BJ, Ferentinos PP, Kontaxakis VP, et al. Concurrent administration of clozapine and electroconvulsive therapy in clozapine-resistant schizophrenia. Clin Neuropharmacol. 2006;29:52–56. 5. Kales HC, Dequardo JR, Tandon R. Combined electroconvulsive therapy and clozapine in treatment-resistant schizophrenia. Prog Neuropsychopharmacol Biol Psychiatry. 1999;23: 547–556.
Ketamine as an Electroconvulsive Therapy Anesthetic Agent To the Editor: etamine is a drug recognized for its antidepressant potential.1 Ketamine is an N-methyl-D-aspartate receptor antagonist documented to rapidly augment the antidepressant effects of electroconvulsive therapy (ECT) when used as a preECT anesthetic agent.1,2 However, there is concern about ketamine use; it can induce bothersome perceptual distortions with uncomfortable dissociative symptoms after intravenous infusions.
K
CLINICAL VIGNETTE A 48-year-old woman with major depression was admitted to a partial hospital program owing to a progressively worsening depression. Her medical history included multiple sclerosis for which she had been receiving interferon B. Her initial presentation included profound sadness, hopelessness, poor concentration, weight loss, feeling of worthlessness, and suicidal ideations. Duloxetine, bupropion, escitalopram, and aripiprazole had yielded no efficacy. In the partial program, she quickly became worse and was hospitalized owing to overt suicidal thoughts. Her Hamilton Rating Scale for Depression (HRSD) score on admission was 33. Her depression severity was the indication for recommending ECT. Six ECT procedures were administered. She received 2 treatments using methohexital, 60 mg; succinylcholine, 60 mg; and atropine, 0.4 mg, with no complications. The stimulus was at 15%, pulse width at 0.3 second, and electrode placement was right unilateral. After the second ECT, the patient reported no improvement and felt “extremely anxious and distraught.” The inpatient psychiatrist recommended replacing methohexital with ketamine for the
ECT anesthesia, hoping that it would improve her mood. On the third and fourth treatments, ketamine, 50 mg, was administered as the anesthetic agent. The ECT stimulus intensity was increased to 20%, with other settings unchanged. The patient tolerated these sessions well. The fifth ECT used a 30% stimulus setting. With a better mood and an HRSD score of 15, the patient was discharged. A sixth ECT was administered to the outpatient at previous settings and with the same medications. The patient reported significant anxiety before and after this treatment. She said that after the fifth ECT, she felt more fearful, “being disconnected from myself,” and experienced nightmares. The patient declined further ECT because it was such a “terrifying experience” but continued outpatient management, with complete resolution of these adversities. She remained adamant that the ECT experience was very “distressing.”
DISCUSSION Ketamine as an ECT anesthetic provides some antidepressant effects.1,2 In one study of subjects with therapy-resistant depression who received ECT with either ketamine or thiopental, the ketamine group required significantly fewer ECT sessions and evidenced lower HRSD ratings and higher Mini Mental Status Examination scores after treatment.2 In a study, inpatients administered ECT for treatmentresistant depression with either ketamine or propofol had similar HRSD scores.2 The ketamine-treated subjects were documented with greater improvement early in the course of ECT; until completion of 4 ECTs, the HRSD scores were lower in the ketamine group, despite similar HRSD scores after the eighth and final ECT.2 No investigation is specifically focused on the psychiatric aspects of ketamine use during ECT. Among subjects receiving propofol, 27% experienced fear and hallucinations upon awakening compared to none in a ketamine group.2 However, perceptual distortions are more commonly reported after ketamine infusions than with placebo4; those who received ketamine had significantly higher Clinician Administered Dissociative States Scale scores compared to individuals prescribed a placebo. The ketamine patients had significantly higher scores on items such as “feeling separated from what is happening” and “things seem unreal”4
CONCLUSION Whereas some investigations have shown the potential of ketamine inducing © 2014 Lippincott Williams & Wilkins
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Journal of ECT • Volume 30, Number 3, September 2014
antidepressant effects when used as an anesthetic agent, 1–3 this vignette recounts a case in which significantly uncomfortable psychiatric complaints followed the use of ketamine during ECT. Although little is known about the psychological effects of ketamine during ECT, one study group recorded several patients experiencing fear and hallucinations upon awakening from ketamine anesthesia compared with none who received propofol.4 Perceptual distortions also have been documented during ketamine infusions.4 Therefore, always screen for such feelings after ECT, whenever ketamine is used as an anesthetic agent. Without concern for such perceptual experiences, some people needing ECT might prematurely drop out of treatment, as noted in this vignette. This patient was on interferon B therapy before starting the partial hospital program, and it was discontinued before ECT administration. She reported that her depressive symptoms were not affected by interferon and also noticed no changes when it was discontinued. Thus, in this one case, it seemed unlikely that interferon or its discontinuation had much impact on her depression. Our patient reported increased distress after ECT number 2, even before she ever had ketamine exposure. Since she was “extremely anxious” before receiving ketamine, it is unclear as to whether ketamine actually did or did not contribute to her perceptual distortions. On 2 occasions, she denied any such distortions before receiving ketamine. Before receiving ECT, she denied perceptual concerns, but ketamine in the ECT procedures might have caused her to be upset by inducing dissociative symptoms. Although a few studies have suggested a potential benefit of ketamine as having antidepressant effects when administered as an anesthetic agent,1–3 it is important to recognize that methohexital has been the standard anesthetic medication during ECT for many decades. Over that prolonged period, it is widely accepted as having been proven to be safe and effective. Therefore, whenever ketamine is considered, note that potentially terrifying adverse effects can follow its use. There should always be a powerful reason for prescribing a newer and possibly more dangerous drug than for administering an agent widely demonstrated for decades to be safe and efficacious. Application of a relatively new pharmaceutical, however, is clearly warranted only when an established medicine is not effective or tolerated and there is evidence to document clinical efficacy with the newer drug. Despite antidepressant actions induced by © 2014 Lippincott Williams & Wilkins
Letters to the Editor
ketamine, methohexital remains the usual drug of choice in pre-ECT applications. Jae Lee, DO Hennepin-Regions Psychiatry Program Minneapolis-St. Paul, MN
Puneet Narang, MD Regions Hospital Minneapolis-St. Paul, MN
Steven Lippmann, MD University of Louisville School of Medicine Louisville, KY 40202 [email protected]
The authors have no conflicts of interest or financial disclosures to report.
REFERENCES 1. Kranaster L, Kammerer-Ciernioch J, Hoyer C, et al. Clinically favourable effects of ketamine as an anesthetic agent for electroconvulsive therapy; a retrospective study. Eur Arch Psychiatry Clin Neurosci. 2011;261:575–582. 2. Okamoto N, Tetsuji N. Rapid antidepressant effect of ketamine anesthesia during electroconvulsive therapy of treatment-resistant depression. J ECT. 2010;26:223–227. 3. Abdallah C, Fascula M, Kelmendi B, et al. The rapid antidepressant effects of ketamine in the electroconvulsive therapy setting. J ECT. 2012;28:157–161. 4. Pomarol-Clotet E, Honey G, Murray G. Psychological effects of ketamine in healthy volunteers; phenomenological study. Br J Psychiatry. 2006;189:173–179.
Remission of Treatment-Resistant Depression With Electroconvulsive Therapy and Ketamine To the Editor: lectroconvulsive therapy (ECT) is a highly efficacious treatment for treatmentresistant depression. However, some patients do not or just poorly respond. As ECT has a high success rate, limited evidence is available for standard practice or augmentation strategies for ECT-resistant patients. We present a case of ECT-resistant depression that responded by using ketamine for anesthesia induction. A 75-yearold woman was hospitalized owing to a severe major depressive episode with psychotic features, already lasting almost a year. The patient experienced low mood, psychomotor retardation, decreased appetite and energy, hopelessness, paranoid and somatic delusions, and suicidal
E
ideation. During her life, she already had at least 5 depressive episodes, with the first one at the age of 21 years. Previously, she had been adequately treated with courses of several tricyclic antidepressants, without clinical improvement but with substantially impairing adverse effects. Addition of several antipsychotics (haloperidol, olanzapine, risperidone, flupentixol, and pipamperone) had no effect. Given the serious physical and mental deterioration, ECT was started. Routine examinations before the start of ECT (ie, blood examination, electroencephalogram, and computed tomographic scan of the head) did not reveal any relevant abnormalities. The patient scored 34 on the Hamilton Depression Rating Scale (HDRS), indicating severe depression, and 9 on the Bush-Francis Catatonia Rating Scale (with a score of 3 for mutism, stupor, and withdrawal). Her score on the Mini Mental State Examination (MMSE) was 28/30. At the start of the ECT treatment, the patient took amitriptyline, 25 mg daily; lorazepam, 1 mg daily; and pipamperone, 60 mg daily. After the second ECT, owing to persisting agitation and suicidal ideation, clozapine was started and titrated up to 150 mg. As neither lorazepam nor pipamperone had any positive effect, both were discontinued. During the ECT course, amitriptyline was increased to 50 mg and aripiprazole, 10 mg, was added. From session 17, the medication scheme was unchanged. Initially, bifrontal electrode placement was chosen at a frequency of 2 stimulations per week. A constant-current Thymatron System IV device (Somatics LLC, Lake Bluff, Ill) was used. Induction and modification were achieved with propofol, 80 mg (1.5 mg/kg), and succinylcholine, 25 mg (0.5 mg/kg), before each treatment. Dosing was age based and stimulus parameters were energy, 35%; pulse width, 0.5 milliseconds (ms); frequency, 30 Hz; and stimulus duration, 6.52 seconds. Adequate seizures were obtained ranging from 44 to 55 seconds. As no clinical improvement occurred after 8 sessions, propofol was switched to etomidate (20 mg, 0.4 mg/kg), and bitemporal stimulation was started with stimulus parameters ranging between 35% and 40% energy (pulse width, 0.5 ms; frequency, 30 Hz; and stimulus duration, 6.52–7.45 seconds), without any improvement after 10 sessions. Owing to cognitive adverse effects, bitemporal electrode placement was switched back to bifrontal placement at the 19th session, and racemic ketamine was used for induction (40 mg, 0.7 mg/kg), resulting in adequate seizures. After 4 sessions, a spectacular improvement was observed, with a decrease of HDRS www.ectjournal.com
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
e31
Letters to the Editor
whereas the therapeutic effect persisted with M-ECT. They concluded that the combination of M-ECT with antipsychotics is a safe and effective strategy for the consolidation of the therapeutic response in elderly and middle-aged experiencing catatonic schizophrenia and who relapse after stopping ECT despite continued antipsychotic treatment. Another study including 19 patients found that the M-ECT was effective on mood, anxiety, and delusional symptoms and on suicidal behavior.3 It allowed also reducing by 80% the average duration of hospitalizations per year. The interval between sessions was 1 to 5 weeks. Synergistic mechanisms of this association are not yet clear. A synergistic effect of this combination is possible through the potentiating of the effect of various neurotransmitters.4 It has also been hypothesized that ECT alter the permeability of the bloodbrain barrier and would increase the crossing of clozapine which would potentiate the efficacy of this molecule without increasing systemic adverse effects.5
CONCLUSION This observation illustrates the value of combining ECT to clozapine in patients with refractory schizophrenia and consolidating the improvement by M-ECT at the rate of 1 session per month. This combination seems effective and well tolerated. Souhail Bannour Saoussen Bouhlel Mohamed Wassim Krir Badii Amamou Selma Ben Nasr Yousri El Kissi Bechir Ben Hadj Ali Department of Psychiatry Farhat Hached Hospital Sousse, Tunisia [email protected]
The authors have no conflicts of interest or financial disclosures to report. REFERENCES 1. Kristensen D, Bauer J, Hageman I, et al. Electroconvulsive therapy for treating schizophrenia: a chart review of patients from two catchment areas. Eur Arch Psychiatry Clin Neurosci. 2011;261:425–432. 2. Suzuki K, Awata S, Takano T, et al. Continuation electroconvulsive therapy for relapse prevention in middle-aged and elderly patients with intractable catatonic schizophrenia. Psychiatry Clin Neurosci. 2005;59:481–489. 3. Levy-Rueff M, Jurgens A, Loo H, et al. [Maintenance electroconvulsive therapy and
e30
www.ectjournal.com
treatment of refractory schizophrenia]. Encephale. 2008;34:526–533. 4. Havaki-Kontaxaki BJ, Ferentinos PP, Kontaxakis VP, et al. Concurrent administration of clozapine and electroconvulsive therapy in clozapine-resistant schizophrenia. Clin Neuropharmacol. 2006;29:52–56. 5. Kales HC, Dequardo JR, Tandon R. Combined electroconvulsive therapy and clozapine in treatment-resistant schizophrenia. Prog Neuropsychopharmacol Biol Psychiatry. 1999;23: 547–556.
Ketamine as an Electroconvulsive Therapy Anesthetic Agent To the Editor: etamine is a drug recognized for its antidepressant potential.1 Ketamine is an N-methyl-D-aspartate receptor antagonist documented to rapidly augment the antidepressant effects of electroconvulsive therapy (ECT) when used as a preECT anesthetic agent.1,2 However, there is concern about ketamine use; it can induce bothersome perceptual distortions with uncomfortable dissociative symptoms after intravenous infusions.
K
CLINICAL VIGNETTE A 48-year-old woman with major depression was admitted to a partial hospital program owing to a progressively worsening depression. Her medical history included multiple sclerosis for which she had been receiving interferon B. Her initial presentation included profound sadness, hopelessness, poor concentration, weight loss, feeling of worthlessness, and suicidal ideations. Duloxetine, bupropion, escitalopram, and aripiprazole had yielded no efficacy. In the partial program, she quickly became worse and was hospitalized owing to overt suicidal thoughts. Her Hamilton Rating Scale for Depression (HRSD) score on admission was 33. Her depression severity was the indication for recommending ECT. Six ECT procedures were administered. She received 2 treatments using methohexital, 60 mg; succinylcholine, 60 mg; and atropine, 0.4 mg, with no complications. The stimulus was at 15%, pulse width at 0.3 second, and electrode placement was right unilateral. After the second ECT, the patient reported no improvement and felt “extremely anxious and distraught.” The inpatient psychiatrist recommended replacing methohexital with ketamine for the
ECT anesthesia, hoping that it would improve her mood. On the third and fourth treatments, ketamine, 50 mg, was administered as the anesthetic agent. The ECT stimulus intensity was increased to 20%, with other settings unchanged. The patient tolerated these sessions well. The fifth ECT used a 30% stimulus setting. With a better mood and an HRSD score of 15, the patient was discharged. A sixth ECT was administered to the outpatient at previous settings and with the same medications. The patient reported significant anxiety before and after this treatment. She said that after the fifth ECT, she felt more fearful, “being disconnected from myself,” and experienced nightmares. The patient declined further ECT because it was such a “terrifying experience” but continued outpatient management, with complete resolution of these adversities. She remained adamant that the ECT experience was very “distressing.”
DISCUSSION Ketamine as an ECT anesthetic provides some antidepressant effects.1,2 In one study of subjects with therapy-resistant depression who received ECT with either ketamine or thiopental, the ketamine group required significantly fewer ECT sessions and evidenced lower HRSD ratings and higher Mini Mental Status Examination scores after treatment.2 In a study, inpatients administered ECT for treatmentresistant depression with either ketamine or propofol had similar HRSD scores.2 The ketamine-treated subjects were documented with greater improvement early in the course of ECT; until completion of 4 ECTs, the HRSD scores were lower in the ketamine group, despite similar HRSD scores after the eighth and final ECT.2 No investigation is specifically focused on the psychiatric aspects of ketamine use during ECT. Among subjects receiving propofol, 27% experienced fear and hallucinations upon awakening compared to none in a ketamine group.2 However, perceptual distortions are more commonly reported after ketamine infusions than with placebo4; those who received ketamine had significantly higher Clinician Administered Dissociative States Scale scores compared to individuals prescribed a placebo. The ketamine patients had significantly higher scores on items such as “feeling separated from what is happening” and “things seem unreal”4
CONCLUSION Whereas some investigations have shown the potential of ketamine inducing © 2014 Lippincott Williams & Wilkins
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Journal of ECT • Volume 30, Number 3, September 2014
antidepressant effects when used as an anesthetic agent, 1–3 this vignette recounts a case in which significantly uncomfortable psychiatric complaints followed the use of ketamine during ECT. Although little is known about the psychological effects of ketamine during ECT, one study group recorded several patients experiencing fear and hallucinations upon awakening from ketamine anesthesia compared with none who received propofol.4 Perceptual distortions also have been documented during ketamine infusions.4 Therefore, always screen for such feelings after ECT, whenever ketamine is used as an anesthetic agent. Without concern for such perceptual experiences, some people needing ECT might prematurely drop out of treatment, as noted in this vignette. This patient was on interferon B therapy before starting the partial hospital program, and it was discontinued before ECT administration. She reported that her depressive symptoms were not affected by interferon and also noticed no changes when it was discontinued. Thus, in this one case, it seemed unlikely that interferon or its discontinuation had much impact on her depression. Our patient reported increased distress after ECT number 2, even before she ever had ketamine exposure. Since she was “extremely anxious” before receiving ketamine, it is unclear as to whether ketamine actually did or did not contribute to her perceptual distortions. On 2 occasions, she denied any such distortions before receiving ketamine. Before receiving ECT, she denied perceptual concerns, but ketamine in the ECT procedures might have caused her to be upset by inducing dissociative symptoms. Although a few studies have suggested a potential benefit of ketamine as having antidepressant effects when administered as an anesthetic agent,1–3 it is important to recognize that methohexital has been the standard anesthetic medication during ECT for many decades. Over that prolonged period, it is widely accepted as having been proven to be safe and effective. Therefore, whenever ketamine is considered, note that potentially terrifying adverse effects can follow its use. There should always be a powerful reason for prescribing a newer and possibly more dangerous drug than for administering an agent widely demonstrated for decades to be safe and efficacious. Application of a relatively new pharmaceutical, however, is clearly warranted only when an established medicine is not effective or tolerated and there is evidence to document clinical efficacy with the newer drug. Despite antidepressant actions induced by © 2014 Lippincott Williams & Wilkins
Letters to the Editor
ketamine, methohexital remains the usual drug of choice in pre-ECT applications. Jae Lee, DO Hennepin-Regions Psychiatry Program Minneapolis-St. Paul, MN
Puneet Narang, MD Regions Hospital Minneapolis-St. Paul, MN
Steven Lippmann, MD University of Louisville School of Medicine Louisville, KY 40202 [email protected]
The authors have no conflicts of interest or financial disclosures to report.
REFERENCES 1. Kranaster L, Kammerer-Ciernioch J, Hoyer C, et al. Clinically favourable effects of ketamine as an anesthetic agent for electroconvulsive therapy; a retrospective study. Eur Arch Psychiatry Clin Neurosci. 2011;261:575–582. 2. Okamoto N, Tetsuji N. Rapid antidepressant effect of ketamine anesthesia during electroconvulsive therapy of treatment-resistant depression. J ECT. 2010;26:223–227. 3. Abdallah C, Fascula M, Kelmendi B, et al. The rapid antidepressant effects of ketamine in the electroconvulsive therapy setting. J ECT. 2012;28:157–161. 4. Pomarol-Clotet E, Honey G, Murray G. Psychological effects of ketamine in healthy volunteers; phenomenological study. Br J Psychiatry. 2006;189:173–179.
Remission of Treatment-Resistant Depression With Electroconvulsive Therapy and Ketamine To the Editor: lectroconvulsive therapy (ECT) is a highly efficacious treatment for treatmentresistant depression. However, some patients do not or just poorly respond. As ECT has a high success rate, limited evidence is available for standard practice or augmentation strategies for ECT-resistant patients. We present a case of ECT-resistant depression that responded by using ketamine for anesthesia induction. A 75-yearold woman was hospitalized owing to a severe major depressive episode with psychotic features, already lasting almost a year. The patient experienced low mood, psychomotor retardation, decreased appetite and energy, hopelessness, paranoid and somatic delusions, and suicidal
E
ideation. During her life, she already had at least 5 depressive episodes, with the first one at the age of 21 years. Previously, she had been adequately treated with courses of several tricyclic antidepressants, without clinical improvement but with substantially impairing adverse effects. Addition of several antipsychotics (haloperidol, olanzapine, risperidone, flupentixol, and pipamperone) had no effect. Given the serious physical and mental deterioration, ECT was started. Routine examinations before the start of ECT (ie, blood examination, electroencephalogram, and computed tomographic scan of the head) did not reveal any relevant abnormalities. The patient scored 34 on the Hamilton Depression Rating Scale (HDRS), indicating severe depression, and 9 on the Bush-Francis Catatonia Rating Scale (with a score of 3 for mutism, stupor, and withdrawal). Her score on the Mini Mental State Examination (MMSE) was 28/30. At the start of the ECT treatment, the patient took amitriptyline, 25 mg daily; lorazepam, 1 mg daily; and pipamperone, 60 mg daily. After the second ECT, owing to persisting agitation and suicidal ideation, clozapine was started and titrated up to 150 mg. As neither lorazepam nor pipamperone had any positive effect, both were discontinued. During the ECT course, amitriptyline was increased to 50 mg and aripiprazole, 10 mg, was added. From session 17, the medication scheme was unchanged. Initially, bifrontal electrode placement was chosen at a frequency of 2 stimulations per week. A constant-current Thymatron System IV device (Somatics LLC, Lake Bluff, Ill) was used. Induction and modification were achieved with propofol, 80 mg (1.5 mg/kg), and succinylcholine, 25 mg (0.5 mg/kg), before each treatment. Dosing was age based and stimulus parameters were energy, 35%; pulse width, 0.5 milliseconds (ms); frequency, 30 Hz; and stimulus duration, 6.52 seconds. Adequate seizures were obtained ranging from 44 to 55 seconds. As no clinical improvement occurred after 8 sessions, propofol was switched to etomidate (20 mg, 0.4 mg/kg), and bitemporal stimulation was started with stimulus parameters ranging between 35% and 40% energy (pulse width, 0.5 ms; frequency, 30 Hz; and stimulus duration, 6.52–7.45 seconds), without any improvement after 10 sessions. Owing to cognitive adverse effects, bitemporal electrode placement was switched back to bifrontal placement at the 19th session, and racemic ketamine was used for induction (40 mg, 0.7 mg/kg), resulting in adequate seizures. After 4 sessions, a spectacular improvement was observed, with a decrease of HDRS www.ectjournal.com
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
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![[Ketamine as anesthetic agent in electroconvulsion therapy].](/assets/img/hold.png)
