Bridging the fields of engineering and psychiatry, this dissertation proposes a novel framework for the rational dosing of electric and magnetic seizure therapy, including electroconvulsive therapy (ECT) and magnetic seizure therapy (MST), for the treatment of psychiatric disorders such as medication resistant major depression and schizophrenia. The objective of this dissertation is to develop computational modeling tools that allow ECT and MST stimulation paradigms to be biophysically optimized ex vivo, prior to testing safety and efficacy in preclinical and clinical trials. Despite therapeutic advances, treatment resistant depression (TRD) remains a largely unmet clinical need. ECT is highly effective for TRD, but its side effects limit its real-world clinical utility. Modifications of treatment technique (e.g., electrode placement, stimulus parameters, novel paradigms such as MST) significantly improve the tolerability of convulsive therapy. However, we know relatively little about the distribution of the electric field (E-field) induced in the brain to inform spatial targeting of ECT and MST. Lacking an understanding of biophysical and physiological mechanisms, refinements in ECT/MST technique rely exclusively on time-consuming and costly clinical trials. Consequently, key questions remain unanswered about how to position the ECT electrodes or MST coil for targeted brain stimulation. Addressing this knowledge gap, this dissertation proposes a new platform that will inform an improved spatial targeting of ECT and MST through state-of-the-art computer simulations of the E-field distribution in human and nonhuman primate (NHP) brain. Part I of this dissertation aims to develop anatomically realistic finite element models of transcranial electric and magnetic stimulation in human and NHPs incorporating tissue heterogeneity and anisotropy derived from structural magnetic resonance imaging (MRI) and diffusion tensor imaging (DTI) data. The NHP models of ECT and MST are created alongside the human model since NHPs are used in preclinical studies on the mechanisms of seizure therapy. Part II of this dissertation aims to apply the model developed in Part I to electric and magnetic seizure therapy. We compute the strength and spatial distributions of the E-field induced in the brain by various ECT and MST paradigms. The relative E-field strength among various regions of interest (ROIs) is examined to select electrode/coil configurations that produce most focal stimulation of target ROIs that are considered to mediate the therapeutic action of ECT and MST. Since E-field alone is insufficient to account for individual differences in neurophysiological response, we calibrate the E-field maps relative to the neural activation threshold via in vivo measurements of the corticospinal tract response to single pulses (motor threshold, MT). We derive an empirical estimate of the neural activation threshold by coupling simulated E-field strength with individually measured MT. The E-field strength relative to an empirical neural activation threshold and corresponding volume of suprathreshold stimulation (focality) is examined to inform the selection of ECT and MST stimulus pulse amplitude that will result in focal ROI stimulation. We contrast the ECT/MST stimulation strength and focality with conventional fixed and individually titrated pulse amplitude necessary to induce a seizure (seizure threshold, ST) to study pulse amplitude adjustment as a novel means of controlling stimulation strength and focality. This work provides a basis for rational dosing of seizure therapies that could help improve their risk/benefit ratio and guide the development of safer alternatives for patients with severe psychiatric disorders.

Diss. (sammanfattning) Stockholm : Karolinska institutet, 2002. / Härtill 6 uppsatser.

(in English): Electroconvulsive therapy (ECT) is a very effective treatment procedure for patients with severe and treatment resistant psychiatric disorders. This Thesis deals with the impact of electroconvulsive therapy on cognitive function, specified as a measurement of cognitive function after electroconvulsive therapy, focusing on the monitoring of cognitive function, eventually their deficits with the passage of time after ECT. At several time points (T1 week after ECT completion; T2: 6-8 weeks after ECT completion) from ECT completion the progression of cognitive performance of patients was repeatedly measured. Respondents were divided according to their diagnosis (mood disorders groop and schizophrenia group). The groups were compared with each other. The aim of the Thesis is the observance of the cognitive changes in patients over time after electroconvulsive therapy. In the final stage 18 subjects were submissed into the study (10 women and 8 men). In terms of diagnosis 39% were diagnosed with the disease in the ICD category F20-F29; 33% were diagnosed with mood disorders (category ICD: F30-F39) and 28% were diagnosed with F06.3 organic affective disorder. The MCCB (MATRICS Consensus Cognitive Battery) was chosen as a method for data scan, it has very good psychometric properties also...

Bakgrund: ECT-behandling har länge varit en metod inom psykiatrin och för patienter med svår depression och suicidala tankar. Behandlingsformen har blivit ifrågasatt och stigmatiserad då den ansetts vara barbarisk och likställts med lobotomi. Rädsla hos patienterna har lett till undvikande av behandlingen eller skam efter behandlingen. Författarna upplever det behövas mer forskning inom ämnet ECT för att förbättra förståelsen kring behandlingen, samt förbättra patienternas trygghet inför, under och efter behandlingen. Syfte: Syftet var att beskriva patienters upplevelse av ECT-behandling vid depression. Metod: En kvalitativ litteraturstudie baserad på tio vetenskapliga artiklar utfördes med en induktiv ansats. Analyserades genom metasyntes. Resultat: Analysen resulterade i 3 kategorier: Stigmatiseringen påverkade upplevelsen, Bemötande som hjälpande eller stjälpande, ECT på vinst eller förlust, med tillhörande underkategorier: Fördomar ledde till skam, Rädsla och oro, Hopp och hopplöshet, Otillräcklig information kring behandlingen, Tvång eller otydliga samtycken, Sjuksköterskans bemötande hade betydelse för upplevelsen, Positiva effekter av ECT, Negativa effekter av ECT. Slutsats(er): Resultatet landade i slutsatsen att vikten av adekvat information mellan sjuksköterska och patient är avgörande för att undvika rädsla och oro hos patienten. Behandlingen kan medföra en hel del biverkningar och därför är det extra viktigt med adekvat information om hur behandlingen går till. I sjuksköterskans arbete finns möjligheter till förbättring inom utbildning, bemötande samt informationsutbyte, vilket kan leda till ökad positivitet i upplevelsen av ECT-behandling

BACKGROUND: Major Depressive Disorder (MDD) is a common mental health illness, characterized by persistent feelings of sadness, diminished interests, guilt, low-self esteem, and disturbances in sleep and appetite. A significant percentage of patients with MDD are treatment resistant. Electroconvulsive Therapy (ECT) is a biological procedure utilized for treatment resistant illnesses. Diagnosis and clinical conditions primarily dictate when ECT is the appropriate treatment modality for an individual. Circumstances requiring rapid clinical response, risks affiliated with alternative treatments, resistance to pharmacotherapy, and medical history are all factors that designate ECT as the treatment of choice. METHODS: The objective of this systematic review was to examine how different anesthetics or combinations of agents affect ECT’s therapeutic efficacy in depressed, adult patients. Electroencephalography (EEG) and motor seizure durations and Hamilton Depression Rating Scale (HDRS) scores were used as primary measures of clinical outcomes. Two rounds of literature searches were conducted in the PubMed, Web of Science, and Google Scholar databases to identify randomized controlled trials and crossover trials that examined the effects of different intravenous sedatives and hypnotic agents on ECT. Two reviewers independently evaluated the internal validity and quality of studies, extracted data, and analyzed statistics. Utilizing all relevant data, standardized mean differences (SMD) with 95% confidence intervals (CIs), and heterogeneity measures were calculated. Ten studies with 373 participants were included. RESULTS: Thiopental only anesthesia was associated with longer EEG seizure duration when compared to propofol only treatment. The pooled effect size from studies with propofol anesthesia also suggests that this agent is associated with shorter seizure durations. If assessed individually with thiopental, the combination of ketamine and thiopental is correlated with increased motor as well as EEG seizure durations. When pooled; however, studies with patient groups assigned to anesthesia consisting of ketamine and another primary agent do not show significant differences either in EEG or motor seizure durations. Additionally, no difference exists in HDRS score reductions between propofol and methohexital. Of note; however, ketamine combined with either propofol or thiopental had significantly greater decreases in HDRS scores. CONCLUSION: Choice of anesthetic should be determined based on anticipated clinical outcome, adverse effect profile, reemergence, and patient preference. If long seizures are preferred, thiopental may be a reasonable option. However, if significantly larger decreases in depression score are preferred, then the combinations of ketamine and propofol or ketamine and thiopental appear to be the therapies of choice. Small sample sizes and insufficient clinical data limit the interpretations of these variables that determine therapeutic efficacy. Larger randomized control trials and crossover trials would provide greater insight into the optimal use of intravenous anesthetic agents with minimal adverse effects.

Huntington's disease (HD) is a devastating autosomal dominantly inherited neurological disorder caused by an abnormal expansion of CAG trinucleotide repeats in the gene coding for the Nterminal region of the huntingtin (Htt) protein, which leads to the formation of a polyglutamine stretch. The greater the CAG repeats, the earlier the onset of the disease. The polyglutamine stretch destabilizes the Htt protein leading to misfolding, abnormal processing, aggregation, and inclusion formation. Mutant Htt protein is believed to damage and kill neurons in the striatum by a mechanism involving increased oxidative and metabolic stress, and impaired adaptive cellular stress responses. A large number of abnormalities have been reported in HD, including transcription deficits, energy impairment, excitotoxicity, and lack of trophic support. Reduced trophic support contributes importantly to striatal degeneration in human HD. Specifically, brainderived neurotrophic factor (BDNF) expression is reduced in patients with HD. BDNF is also decreased in brain tissue from mice transgenic for mutant Htt. BDNF levels influences the onset and the severity of motor dysfunction in HD mice. In addition to BDNF, levels of the molecular chaperones heat shock proteins (Hsp40 and 70) decrease progressively in HD brain. Hsp70 is a highly stress-inducible member of a chaperone family of proteins that functions to prevent misfolding and aggregation of newly synthesized mutant proteins and stress-denatured proteins. Hsps appear to play a critical role in HD since expression of active heat shock factor HSF1, a transcription factor responsible for the induction of Hsps, markedly reduces polyglutamine aggregate formation in both cell and mouse models. Many efforts have been made to develop preventive treatments for HD because of the strong genetic link and a freely available genetic test to identify individuals at risk. At present, only symptomatic therapy is available and effective therapeutic approaches to slow the disease iv process have yet to be developed. Previous studies have shown that electroconvulsive shock (ECS) induces the production of growth factors including BDNF and the molecular chaperones HSP40 and HSP70. Because ECS can stimulate the production of neuroprotective proteins, we determined whether ECS treatment could slow the progressive nature of the disease process and provide a therapeutic benefit in a mouse model of HD. ECS or sham treatment was administered to male N171-82Q Htt mutant mice. End points measured included motor function, striatal and cortical pathology, and levels of neurotrophic factors, protein chaperones, and proteins involved in synaptic plasticity. ECS treatment delayed the onset of motor symptoms, reduced body weight loss and extended the survival of HD mice. Striatal neurodegeneration was attenuated and levels of neurotrophic factors, protein chaperones and mitochondria-stabilizing protein were elevated in striatal cells of ECS-treated compared to sham-treated HD mice. Our findings suggest that ECS can increase the resistance of neurons to mutant huntingtin resulting in improved functional outcome and extended survival. The potential of ECS as a treatment for HD patients merits further consideration.

Denna uppsats har undersökt hur elektrokonvulsiv terapi (ECT) har gestaltats i de fyra svenska tidningarna Aftonbladet, Dagens Nyheter, Expressen och Svenska Dagbladet mellan åren 1938 och 1989. Detta för att analysera om medias gestaltning av ECT kan ha bidragit till stigmatiseringen av behandlingen och att behandlingen fick ett dåligt rykte under 1960- och 1970-talen och på så vis kan ha påverkat den allmänna opinionen. Detta syfte har preciserats utifrån fyra frågeställningar och uppnås genom att källmaterialet undersöks utifrån en kvalitativ textanalys med kvantitativa inslag. Uppsatsens teoretiska utgångspunkt är gestaltningsteorin. Undersökningen har visat att ECT har gestaltats på olika sätt under den undersökta tidsperioden. Det har skett både en positiv partiskhet som bedöms ha bidragit till att ge ECT ett bra rykte samt en negativ partiskhet som bedöms ha bidragit till att ge ECT ett dåligt rykte och som bedöms ha bidragit till att stigmatisera behandlingen. Det har även visats att det finns likheter mellan medias gestaltning av ECT och medias gestaltning av behandlingen lobotomi. / This essay has examined how electroconvulsice therapy (ECT) has been portrayed in the four Swedish newspapers Aftonbladet, Dagens Nyheter, Expressen and Svenska Dagbladet between the years 1938 and 1989. This has been done to analyze whether the media’s portrayal of ECT may have contributed to the stigmatization of the treatment and to the fact that the treatment gained a bad reputation during the 1960s and 1970s and if the media thus might have influenced the public opinion with its portrayal. The purpose of the essay has been specified by four questions and is achieved by examining the empirical evidence based on a qualitative text analysis with quantitative elements. The theory that is used in this essay is the framing theory, or gestaltningsteorin. The examination has shown that ECT has been portrayed in different ways during the investigated time period. There has been both a posivie bias which has been analyzed to have contributed to giving ECT a good reputation, and a negative bias which has been analyzed to have contributed to giving ECT a bad reputation and to have contributed to the stigmatizing of the treatment. The examination also showed that there are both similarities and differences between the media’s portrayal of ECT and the media’s portrayal of the treatment lobotomy.

The response deficit following exposure to inescapable shock has been termed "learned helplessness." This experiment was designed (a) to determine whether learned helplessness following an inescapable footshock induction procedure extends to 48 hours, and (b) to test the hypothesis that electroconvulsive shock (ECS) reverses learned helplessness in rats. Subjects were tested for helplessness in a bar-press shock-escape task. Results indicated that helplessness was not present 48 hours after exposure to inescapable shock. A slight indication of helplessness was observed in the first 10 trials of the 60-trial task. In addition, ECS was shown to enhance performance in the test task; however, this facilitation effect was seen only in control animals that were not previously exposed to inescapable footshock.

A depressao refrataria e caracterizada por ciclos recorrentes de longa duracao de episodios severos, que nao remitem ao utilizar varios tipos de antidepressivos. Ate 20% desses pacientes necessitam de tratamentos com a utilizacao de multiplos antidepressivos e/ou eletroconvulsoterapia (ECT). Para minimizar a duracao da doenca, o surgimento de reacoes adversas a medicamentos e os custos medicos com o tratamento, torna-se util o conhecimento previo da terapia que provavelmente sera mais efetiva e melhor tolerada para cada paciente. Um dos objetivos deste trabalho foi identificar polimorfismos de DNA em genes envolvidos na farmacocinetica e farmacodinamica dos antidepressivos, que poderiam estar envolvidos com a resposta terapeutica na depressao unipolar ou bipolar. Para tanto, avaliamos polimorfismos de DNA tais como: CYP2D6, CYP2C19, CYP2C9, ABCB1, SCL6A2, SLC6A3, HTR1A, HTR2A, TPH1, TPH2, COMT. Desse modo, polimorfismos nos genes selecionados foram genotipados em pacientes com depressao que respondem ao tratamento e em pacientes com os mesmos diagnosticos que sao refratarios ao tratamento medicamentoso e, por esse motivo, sao submetidos a ECT. Em nosso estudo, encontramos somente diferencas significativas no genotipo entre refratarios e respondedores para o gene ABCB1 [aumento da frequencia do genotipo CT em pacientes refratários para o polimorfismo rs1128503 (p=0,007) ] e para o polimorfismo rs6314 no gene HTR2A [ aumento da frequencia do genotipo AG em pacientes respondedores (p=0,042) ]. Para os demais genes nao encontramos diferencas entre as frequencias alelicas e genotipicas. Para realizarmos uma analise mais abrangente, utilizamos o metodo CART (Classification regression tree). Com ele pudemos fazer um modelo de Arvore de Decisao que possibilitou unificar os resultados dos genotipos dos polimorfismos estudados nos genes CYP2D6, CYP2C19, CYP2C9, ABCB1, SCL6A2, SLC6A3, HTR1A, HTR2A, TPH1, TPH2, COMT, afim de identificar o conjunto de genotipos que poderiam mostrar o percentual de chance dos pacientes serem refratarios ou respondedores, ou seja, conseguimos adequar uma metodologia estatistica que avalia os genótipos de diferentes genes em conjunto, identificando assim, qual e a contribuicao dos genotipos para a condicao de refratario ou respondedor. Com isso, criamos um modelo de analise de varios genotipos ao mesmo tempo que seleciona aqueles que melhor classificam os grupos (refratarios e respondedores). O que seria mais eficaz do que fazer associacoes individuais, porque, a arvore de decisao e capaz de encontrar interacao entre os genotipos, alem de evitar colinearidade. Com nossos dados de genotipagem, conseguimos uma arvore que apresenta uma sensibilidade de 81,6%, especificidade de 58,1% e precisao de 71,5%. Acreditamos que futuramente a utilizacao da combinacao de genotipos de um grupo de genes relacionados a farmacocinetica e dinamica de medicamentos utilizados no tratamento de diferentes doencas, possa ser simplesmente inserido em um banco de dados que determine as possibilidades do paciente responda ou nao a determinado tratamento (baseado no modelo da Arvore de Decisao). Acreditamos tambem que a determinacao de um conjunto de polimorfismos relacionados a resposta e refratariedade ao tratamento com antidepressivos pode trazer beneficios clinicos ao paciente, contribuindo para a personalização da terapia, melhorando a eficacia do tratamento da depressao unipolar ou bipolar / Refractory depression is characterized by recurrent cycles of long and severe episodes which did not remit even with the use various classes of antidepressants. Up to 20% of patients need treatments with the use of multiple antidepressants and/or electroconvulsive therapy (ECT). To minimize the duration of the disease, the adverse drug reactions and medical costs with treatment, it is useful to have prior knowledge of the therapy that will probably be more effective and better tolerated for each patient. One of the objectives of the work was to identify DNA polymorphisms in genes involved in pharmacokinetics and pharmacodynamics of antidepressants, which could be involved in the therapeutic response in unipolar or bipolar depression. To this end, we evaluated the DNA polymorphisms on the genes: CYP2D6, CYP2C19, CYP2C9, ABCB1, SCL6A2, SLC6A3, HTR1A, HTR2A, TPH1, TPH2, and COMT. Thus, polymorphisms in selected genes were genotyped in patients with depression who respond to treatment and in patients with the same diagnosis who are refractory to drug treatment and, therefore, are subjected to ECT. In our study, only significant differences between the genotype of refractories and nonrefractory patients were in the ABCB1 gene [increase of the CT genotype frequency in patients refractory to the rs1128503 polymorphism (p=0.007)] and the rs6314 polymorphisms in the HTR2A gene [the increased frequency AG genotype in non-refractory patients (p=0.042)]. For other genes we found no differences between the allele and genotype frequencies. In order to conduct a more comprehensive analysis, we used the CART method (classification regression tree). With it, we could make a decision tree model that made it possible to unify the results of the genotypes of the polymorphisms studied in the CYP2D6, CYP2C19, CYP2C9, ABCB1, SCL6A2, SLC6A3, HTR1A, HTR2A, TPH1, TPH2, COMT genes, in order to identify a set of genotypes that could show the probability of one patient being refractory or non-refractory to treatment, i.e., we can tailor a statistical methodology that evaluates the genotypes of different genes together, thereby identifying which is the contribution of genotypes for the condition of refractory or non-refractory. Therefore, we created a model of analysis of various genotypes at the same time selecting those that best classify groups (refractory and non-refractory), what would be more effective than do individual associations, because the decision tree is able to find interaction between genotypes and avoids collinearity. With our data genotyping, we got a tree that has a sensitivity of 81.6%, specificity of 58.1% and accuracy of 71.5%. We believe that the future use of the combination of genotypes of a group of genes related to pharmacokinetics and dynamics of drugs used to treat different diseases can be simply inserted into a database to determine the chances of the patient to respond or not to the treatment (according to the decision making tree model). We also believe that the determination of a set of polymorphisms related to the response and non-response to treatment with antidepressants can bring clinical benefits to patients, contributing to customize therapy, improving the effectiveness of the treatment of unipolar or bipolar depression

A Eletroconvulsoterapia (ECT) é o tratamento biológico mais eficaz para quadros depressivos. Os estudos de seus aspectos técnicos são fundamentais tanto para compreensão dos mecanismos da ECT quanto para maximizar a eficácia e minimizar seus efeitos cognitivos. Existem muitos métodos para o cálculo da dose do estímulo elétrico e não há consenso em relação ao melhor. Sabe-se que doses muito elevadas tendem a ser eficazes, mas à custa de efeitos na memória. Embora o método de titulação seja recomendado pela Associação Psiquiátrica Americana, muitos profissionais tem preocupação sobre a segurança cardiovascular deste procedimento, devido aos sucessivos estímulos frustros que levam a um aumento na incidência de bradicardia e/ou assistolia. O objetivo deste trabalho foi traçar o perfil dos pacientes submetidos ao método da titulação do limiar, verificando sua segurança cardiovascular. Para isso foi feito um estudo retrospectivo e 113 casos foram revistos no ano de 2007. A maioria (70,3%) recebeu aplicação bilateral e (62,8%) eram mulheres. O diagnóstico de depressão apareceu com mais freqüência (50,5%). A maioria (57,5%) necessitou de dois estímulos, (12,4%) necessitou de apenas um, (28,3%) necessitou de três e (1,8%) realizou quatro estímulos. A média de frequência cardíaca inicial foi de 79,6 bpm (DP = 17). O limiar convulsígeno variou de 16mC a 128mC (média = 58,9; DP 25,4). A relação do limiar convulsígeno foi significativamente menor com o posicionamento unilateral dos eletrodos (p < 0,001), mas não com sexo ou idade. Não foi encontrada associação com a medicação concomitante. A incidência de bradicardia aumentou com os estímulos frustros, mas não foi significante a relação entre o primeiro e segundo estímulos. Não houve complicações cardíacas significativas e nenhum paciente apresentou assistolia. Conclui-se que o método da titulação do limiar pode ser uma estratégia segura e mais precisa, uma vez que os fatores (sexo, idade e uso de medicamentos) não foram relacionados com o LCT; a baixa incidência de complicações cardiovasculares reforça-o como método de escolha. Não se pode descartar um efeito protetor do uso da atropina. / Electroconvulsive therapy (ECT) is the most effective biological treatment for depression. Studies of the technical aspects are fundamental for understanding the mechanisms of ECT and to maximize efficiency and minimize their cognitive effects. There are many methods to determine the dose of electrical stimulation and there is no consensus on which is the best one. It is known that very high doses are effective, but at the expense of effects on memory. Although the method of limits (titration method) is generally accepted, being encouraged by the American Psychiatric Association, many practitioners have concerns regarding cardiac safety of this method. Due to repetitive subthreshold stimuli until the seizure is elicited, an increased risk of bradiarrhythmia and/or asystole is believed to be present. The objective of this study was to establish the profile of patients undergoing the method of titration of the threshold, checking their cardiovascular safety. A retrospective study was performed including 113 cases that receive their treatment in the year of 2007. The majority (70.3%%) received bilateral ECT, (62.8%) were women. The diagnosis of depression appeared more frequently (50.5%). The majority (57.5%) needed two stimuli; 12.4% needed only one; 28.3% needed three and 1.8% required four stimuli. The average initial heart rate was 79.6 bpm (SD = 17). The seizure threshold ranged from 16mC to 128mC (mean = 58.9, SD 25.4). The ratio seizure threshold was significantly lower with unilateral electrode placement (p <0.001) but not with sex or age. No association was found with concomitant medication. There was an increased incidence of bradycardia with subthreshold stimuli , but there was not a relationship between the first and second stimuli. There were no significant cardiac complications and no patient had asystole. In conclusion, the method of titration of the threshold seems to be a safe and more precise to determined electrical dose, since the factors usually used to predict the threshold (gender, age and medication use) were not related to the LCT The low incidence of cardiovascular complications adds up to its use as the method of choice.. A protective effect of atropine cannot be ruled out.