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Dit hoofdstuk behandelt de verschillende soorten cognitieve bijwerkingen, zoals deze door elektroconvulsietherapie (ECT) kunnen worden veroorzaakt. Hierbij worden neurobiologische en klinische aspecten beschreven die geassocieerd zijn met cognitieve effecten. Het hoofdstuk bestaat uit twee delen. Het eerste deel beschrijft de neurobiologie van het menselijk geheugen, waarbij een relatie wordt gelegd met de effecten van ECT. Het tweede deel gaat in op de dagelijkse klinische ECT-praktijk. Uitgebreider dan in hoofdstuk 7 wordt beschreven hoe de verschillende soorten cognitieve bijwerkingen kunnen worden gemeten, kunnen worden gemonitord, nader kunnen worden onderzocht, en hoe deze instrumenten in de dagelijkse ECT-praktijk kunnen worden gebruikt. Ten slotte worden in dit hoofdstuk praktische manieren voorgesteld om de cognitieve bijwerkingen door ECT te beperken en te behandelen (bijvoorbeeld door compensatie of training).

Elektroconvulsietherapie (ECT) is een veilige behandeling, maar kan ongewenste of onbedoelde effecten geven. Deze bijwerkingen zijn geassocieerd met bepaalde patiëntkenmerken, maar ook met de toegepaste anesthesie en spierverslapping, en met bepaalde ECT-behandelkenmerken (zoals de elektrodeplaatsing en de toegediende elektrische stimulus). Cognitieve bijwerkingen, zoals inprentings- en geheugenstoornissen, komen het meeste voor. Daarnaast worden minder frequent de postictale verwardheid, kortdurende desoriëntatie en, zeldzamer, een postictaal delier gezien. Een zich ontwikkelende progressieve anticipatieangst voor de ECT-procedure kan de voortgang belemmeren. De meest genoemde lichamelijke bijwerkingen zijn het ontstaan van postictale hoofdpijn, misselijkheid en spierpijn. Zeldzamer, maar relevante bijwerkingen, zijn de onbedoelde extravasatie van de anesthetica, een niet eerder onderkend glaucoom, een verhoogde intracerebrale, intraorbitale en/of abdominale druk, kaakluxatie, gebitsbeschadigingen en aspiratie. Er zijn ook bijwerkingen die gerelateerd zijn aan de effecten van ECT en die vooral bij cardiaal-gecompromitteerde patiënten tot complicaties kunnen leiden.

In dit hoofdstuk wordt ingegaan op het monitoren van diverse parameters tijdens een afzonderlijke elektroconvulsietherapie (ECT)-sessie, waarmee een indruk wordt verkregen van de technische kwaliteit van het uitgelokte insult. Daarnaast worden diverse metingen verricht voorafgaand, gedurende en na afloop van de ECT-kuur, waarmee de effectiviteit en de eventuele cognitieve bijwerkingen worden vervolgd. De methoden waarmee de insultduur kan worden vastgelegd worden besproken. Het betreft daarbij de motorische en de elektro-encefalografische (EEG)-insultduur. Ingegaan wordt op de EEG-karakteristieken, EEG-indices en piekhartritme tijdens het ECT-insult, die in de wetenschappelijke literatuur gerelateerd zijn aan de behandeleffectiviteit. Om een ECT-kuur zo ‘kort-als-mogelijk-zo-lang-als-noodzakelijk’ te laten duren is het geregeld monitoren van de ernst van de psychiatrische symptomatologie essentieel. Ook worden de voor de praktijk relevante aspecten besproken van de meetinstrumenten, waarmee symptoomreductie en cognitieve effecten kunnen worden geobjectiveerd. Aan de orde komen de meetinstrumenten voor monitoring van depressieve symptomatologie (Montgomery-Åsberg Depression Rating Scale; Hamilton Depression Rating Scale; Inventory of Depressive Symptomatology), van psychotische symptomatologie (Positive and Negative Symptom Scale; Brief Psychiatric Rating Scale), van katatone symptomatologie (Bush-Francis Catatonia Rating Scale) en van agitatie bij dementie (Cohen-Mansfield Agitation Inventory; Social Disability and Aggression Scale). Ten slotte worden de meetinstrumenten beschreven, die in de dagelijkse praktijk gebruikt kunnen worden voor het screenen van het algemeen cognitief functioneren van de patiënt voor aanvang van de ECT-kuur, en het monitoren van dit functioneren gedurende en na afloop van de behandeling (Montreal Cognitive Assessment; tijd-tot-reoriëntatie). De ECT-psychiater en andere betrokken behandelaars zullen de betrouwbaarheid, validiteit, doelmatigheid en praktische haalbaarheid van het gebruik van de meetinstrumenten moeten afwegen.

BACKGROUND: Care provided by consultation-liaison (CL) psychiatry and general hospital (GH) psychiatry varies widely. This means that certain services are almost unrecognisable and therefore less readily available to patients. AIM: To describe the core tasks of current CL- and GH-psychiatry care and to suggest how these tasks can best be performed and developed in the future. METHOD: We conducted a selective review of relevant CL- and GH-related literature and combined the information we obtained with the results of a consultation with CL-psychiatrists about how CL- and GL psychiatry should function in the future. RESULTS: Core tasks of CL- and GH-psychiatry are: 1. inpatient and outpatient care for complex patients with combined somatic and psychiatric problems (including addiction) and 2. acute care, diagnosis and treatment of patients referred to the Emergency Department. We gave an outline of how the quality of training can be maintained and/or improved and we suggest ways in which the funding of CL- and GH-psychiatry can be safeguarded and, if possible, increased in the future. CONCLUSION: We strongly recommend that large teaching hospitals and all university hospitals should have at their disposal a psychiatric consultation service that includes psychiatric Emergency Department facilities and specialised CL and GH inpatient and outpatient facility such as a medical-psychiatric unit. The CL- and GH-service should have a psychiatrist as gatekeeper and should be integrated into the hospital's chain of care. Partners in this chain of care are interns who have other medical specialisms, mental health specialists employed at other (mainly psychiatric) hospitals and general practitioners (GPs).

BACKGROUND: Care provided by consultation-liaison (CL) psychiatry and general hospital (GH) psychiatry varies widely. This means that certain services are almost unrecognisable and therefore less readily available to patients. AIM: To describe the core tasks of current CL- and GH-psychiatry care and to suggest how these tasks can best be performed and developed in the future. METHOD: We conducted a selective review of relevant CL- and GH-related literature and combined the information we obtained with the results of a consultation with CL-psychiatrists about how CL- and GL psychiatry should function in the future. RESULTS: Core tasks of CL- and GH-psychiatry are: 1. inpatient and outpatient care for complex patients with combined somatic and psychiatric problems (including addiction) and 2. acute care, diagnosis and treatment of patients referred to the Emergency Department. We gave an outline of how the quality of training can be maintained and/or improved and we suggest ways in which the funding of CL- and GH-psychiatry can be safeguarded and, if possible, increased in the future. CONCLUSION: We strongly recommend that large teaching hospitals and all university hospitals should have at their disposal a psychiatric consultation service that includes psychiatric Emergency Department facilities and specialised CL and GH inpatient and outpatient facility such as a medical-psychiatric unit. The CL- and GH-service should have a psychiatrist as gatekeeper and should be integrated into the hospital's chain of care. Partners in this chain of care are interns who have other medical specialisms, mental health specialists employed at other (mainly psychiatric) hospitals and general practitioners (GPs).

Dit is een korte versie van de Multidisciplinaire richtlijn diagnostieken behandeling van suïcidaal gedrag. Deze samenvatting heeft als doel om de richtlijn en de belangrijkste aanbevelingen toegankelijk te maken voor de praktijk. De volledige tekst van de richtlijn (hoofdstuk 1-10) bevat de wetenschappelijke onderbouwing voor de vele vraagstukken over diagnostiek en behandeling van suïcidaal gedrag. Die wetenschappelijke onderbouwing heeft met de overige overwegingen geleid tot de aanbevelingen (zie hoofdstuk 3 tot en met 10 en bijlage 1). De werkgroep realiseert zich dat er behoefte is aan een handzame, praktisch te gebruiken samenvatting. Het is onvermijdelijk dat bij het samenvatten nuanceringen verloren zijn gegaan. Voor toelichting en achtergrondinformatie verwijzen wij dan ook met nadruk naar de integrale tekst van de richtlijn (hoofdstuk 1 tot en met 10).

Objectives: Electroconvulsive therapy (ECT) has been described as an effective treatment option for catatonia in retrospective case series. We aimed to investigate treatment characteristics and outcomes of patients with catatonia who were treated with ECT. Methods: The medical records of 27 patients with catatonia treated with ECT (between 1991 and 2009) were scrutinized for clinical and treatment characteristics. Outcomes were measured using the Clinical Global Impression-Improvement (CGI-I) scale. Patients who improved (defined as CGI-I score "very much" or "much improved") were compared with those who did not improve (defined as a CGI-I score "no change" or "very much worse"). Results: Mean age of all patients was 49 +/- 19 years, of whom 15 (56%) were women. Of all patients, 13 (48%) had a diagnosis of a mood disorder and 12 (44%) of a psychotic disorder. Electroconvulsive therapy was mostly started after ineffective pharmacotherapy (n = 23; 85%) within 2 to 3 months after catatonia had been diagnosed. In total, 16 (59%) patients improved. Improvement was significantly associated with younger age (P = 0.05), presence of autonomic dysregulation at baseline (P = 0.02), especially higher body temperature (P = 0.02), daily ECT during the first treatment week (n = 15 [56%]; P = 0.03), longer duration of electroencephalogram seizure activity at last ECT session (P = 0.04), and less morbidity in the year after ECT (P = 0.03). Three of 11 nonimproved patients died in the year after ECT compared with none of the improved patients. Conclusions: Most of our patients with catatonia benefited from ECT, especially younger patients with autonomic dysregulation. Daily administration of ECT may be more effective, whereas longer duration of seizure activity at the final ECT session was related to better response to ECT.

Visually handicapped patients can be tormented by complex visual hallucinations (Charles Bonnet syndrome). Likewise, deaf patients and patients with impaired hearing can be plagued by auditory hallucinations, mostly involving music. Our article focuses on three female patients who suffered from musical hallucinations. In one of these patients the hallucinations ceased when her hearing was restored. In the second patient the hallucinations ceased when carbamazepine was prescribed. Quetiapine reduced the musical hallucinations in the third patient. The differential diagnoses and therapeutic options are discussed.

Contains fulltext : 53247.pdf (Publisher’s version ) (Open Access) BACKGROUND: Attempted suicide is a frequent occurrence, even in mental health institutions (mhis). The World Health Organization strongly supports the development and implementation of guidelines for dealing with cases of attempted suicide in mhis. aim To check on the existence, content and quality of guidelines for dealing with persons attempting suicide within mhis in the Netherlands and to compare these guidelines with those available in university and general hospitals. METHOD: A questionnaire was sent to all mhis. Criteria for assessing the content of existing guidelines were derived from the literature. The quality of the guidelines was then assessed on the basis of the Appraisal of Guidelines for Research and Evaluation (agree), a tool developed to evaluate guideline quality. results Thirty-eight out of 48 (72.2%) psychiatric institutions responded, giving us access to 12 sets of guidelines. The content and quality of these guidelines were compared with the content and quality of the guidelines available in university and general hospitals; there were several differences, but on the whole the mhi-guidelines were better. CONCLUSION: Guidelines were only available in a limited number of mhis. Most of the guidelines were adequate with regard to content, but some of the mhi-guidelines lacked some important elements. The quality of the mhi-guidelines was rather low but nevertheless better that that of the hospital guidelines.

Item does not contain fulltext The relationship between anterograde amnesia, sedation and plasma levels of benzodiazepines was studied prospectively in a group of 24 patients who took an overdose of benzodiazepines. Patients were tested on two sequential days after having taken an overdose. Anterograde amnesia was tested by using a verbal recall test and a photo recognition test. Sedation was scored on a visual analogue scale (VAS) by the patient and the interviewer. The concentration of benzodiazepines in plasma was measured by using a radioreceptor assay that adds benzodiazepines and their active metabolites. The cumulative amount of benzodiazepines was expressed as diazepam equivalents (DZE). Diazepam equivalents determined by this radioreceptor assay were significantly higher on the first day than on the second day. Ratings on the verbal recall test were significantly lower on the first day than on the second day. There was a significant relation between decrease of diazepam equivalents and increase of verbal recall: more than 30% of increase of verbal recall was explained by decrease of diazepam equivalents. There was not a strong relation between decrease of diazepam equivalents and reduction of level of sedation as scored by the patients. There was almost no relation between decrease of diazepam equivalents and reduction of level of sedation as scored by the interviewer. No relation was found between verbal recall, sedation and diazepam equivalents. There was no relation between diazepam equivalents and photo recognition. It was concluded that anterograde amnesia was strongly associated with benzodiazepines in patients who take benzodiazepines in an overdose. Sedation does not predict the degree of anterograde amnesia.

Electroconvulsive therapy is an important treatment of depressive states in late life. However in the Netherlands ECT is not often practiced and mostly indicated after a long period of fruitless clinical therapy. The primary aims of this literature study were to review the efficacy of ECT in late life depression, to identify predictors of good response, to discuss contraindications, side effects and finally modifications of technique. Eighteen studies were found addressing the topic of efficacy. Outcome ranged between 50%-100% clinically significant improvement. Positive predictors are melancholic features and delusional depression. Unlike in younger patients hypochondriacal symptoms and anxiety do not predict a negative outcome in older patients. ECT has been used succesfully in depression complicated by dementia, cognitive decline and cerebrovascular disease. Depression in Parkinson's disease may be a special indication where ECT may have a positive effect on motor symptoms. There are no firm indications of long term cognitive decline associated with ECT. Guidelines for practicing ECT (unipolar, brief pulse and anaesthesia) are in line with the state of the art in the literature. It is concluded that, especially in severe depression associated with comorbidity, current Dutch practice in using ECT, often leads to unwarranted delay.