Electroconvulsive therapy (ECT) is a potent and successful method for the treatment of severe psychiatric disorders. Severe depressive and psychotic disorders may lead to legal incapacity and ...inability to consent. In Germany, administration of ECT against the patient's will is feasible under certain constellations and is regulated under the terms of the guardianship law.
This article outlines the prevalence, effectiveness and tolerability of ECT when applied in nonconsenting patients.
Case report and literature review.
The literature on ECT as a treatment in nonconsenting patients is relatively sparse. In 2008 the prevalence in Germany was less than 0.5 % of all patients receiving ECT. Case reports and case series suggest a good and equal level of effectiveness when compared to consenting patients. In the course of treatment the majority of patients consented to receive further ECT and retrospectively judged ECT as helpful.
The use of ECT is a highly effective treatment in severe psychiatric disorders even when administered as treatment in nonconsenting patients. It can be lifesaving and lead to a rapid improvement of symptoms and relief from severe suffering also from the patients' perspective. Thus, it seems unethical not to consider ECT as a treatment against the nonautonomous will of legally incompetent patients in individual cases. Nevertheless, physicians should always seek to obtain the patients' consent as soon as possible for both legal and ethical reasons.
Severe affective and psychotic disorders may be accompanied by legal incapacity. If in this case the patient refuses treatment and in parallel there is a risk of serious damage to health, treatment ...can be carried out against the patient's non-autonomous will under defined prerequisites. Due to its good and partly superior effectiveness in the treatment of severe and pharmacotherapy-resistant affective and psychotic disorders, electroconvulsive therapy (ECT) is an important treatment option in such constellations.
Description of the general principles and prerequisites of therapeutic measures against the patient's will.
Based on a case report, the application of ECT as a medical measure against the patient's will is discussed and assessed in an interdisciplinary approach from clinical, legal, and ethical perspectives.
The (empirical) evidence on the general effectiveness of ECT, as well as its application against the will of patients with legal incapacity, clearly shows a positive benefit-risk ratio. When performed against the patient's will, ECT as all compulsory medical interventions, represents a severe encroachment on the individual's fundamental rights of both physical integrity and self-determination. Nevertheless, its application may be medically indicated, legally admissible and ethically appropriate in individual cases to prevent the threat of serious damage to the patient's health. Ethical and legal prerequisites of treatment against the patient's will should be evaluated by a multiprofessional team and the patient's legal guardian should be involved from an early stage.
Depressive disorders are common and lead to both individual suffering and high socioeconomic costs. Despite the fact that several effective therapies are available, remission is often not achieved. ...Electroconvulsive therapy (ECT) can be a therapeutic option in these cases.
This review outlines the current evidence for the efficacy, safety and tolerability of ECT for depressive disorders.
A selective literature search was carried out with particular consideration of meta-analyses, systematic reviews, and recommendations of national and international therapy guidelines.
For the majority of patients ECT is an effective, safe and well-tolerated therapy for the treatment of depressive disorders. There are relatively high remission rates even in patients with pharmacoresistant depression. There is evidence for a particularly high responsiveness in specific populations. In contrast to the proven effectiveness in the acute treatment of depressive disorders, there is a relative lack of data concerning maintenance therapy. Side effects including cognitive deficits are mostly transient. Modifications in the ECT technique have an impact on effectiveness and tolerability.
When administered correctly ECT is a highly effective therapy for the treatment of depressive disorders. In the light of the abundance of depressive disorders and lack of remission despite adequate pharmacological treatment, a broader availability and application of ECT would be desirable. The same is true for a more intensive research into the mechanisms of action and response predictors of ECT.
The diacylglycerol kinase eta (
DGKH
) gene, first identified in a genome-wide association study, is one of the few replicated risk genes of bipolar affective disorder (BD). Following initial ...positive studies, it not only was found to be associated with BD but also implicated in the etiology of other psychiatric disorders featuring affective symptoms, rendering
DGKH
a cross-disorder risk gene. However, the (patho-)physiological role of the encoded enzyme is still elusive. In the present study, we investigated primarily the influence of a risk haplotype on amygdala volume in patients suffering from schizophrenia or BD as well as healthy controls and four single nucleotide polymorphisms conveying risk. There was a significant association of the
DGKH
risk haplotype with increased amygdala volume in BD, but not in schizophrenia or healthy controls. These findings add to the notion of a role of
DGKH
in the pathogenesis of BD.
Agitation is a common symptom occurring in different psychiatric disorders. As a state of severe excitement and tension, agitation may also be associated with aggressive behavior. Thus, there is a ...great need for treatment options, in particular drug therapies, that have a rapid short-term effect. We treated a 26-year-old patient with mixed personality disorder with antisocial and impulsive features (ICD-10:F61) who frequently presented himself with states of severe agitation and aggression and urgently demanded medication to calm down. In the course of treatment, high doses of several antipsychotics (i. e. quetiapine 1000 mg/d, haloperidole 40 mg/d, olanzapine 50 mg/d) and benzodiazepins (i. e. diazepam 40 mg/d) were given as acute medication, but didn’t show any significant effect on the described states. In the subsequent inpatient care, the patient received inhalative loxapine (Adasuve 9,1 mg) for the first time. Following the first drug administration, there was a rapid and strong improvement of agitation and aggression that lasted for more than 24 hours. In this period, no other medication was required. However, the patient also reported side effects in terms of a marked sedation and sleepiness. Also in subsequent administrations of inhalative loxapine, there was a reliable improvement of symptoms for at least four hours. After discharge from hospital, a comparable effect was obtained by an off-label pnr medication with oral loxapine (up to 3 × 25 mg/d). This case demonstrates that inhalative loxapine may be a beneficial treatment option for agitation in psychiatric patients also beyond the official approval for schizophrenia and bipolar disorder.
The assessment of response to lithium maintenance treatment in bipolar disorder (BD) is complicated by variable length of treatment, unpredictable clinical course, and often inconsistent compliance. ...Prospective and retrospective methods of assessment of lithium response have been proposed in the literature. In this study we report the key phenotypic measures of the "Retrospective Criteria of Long-Term Treatment Response in Research Subjects with Bipolar Disorder" scale currently used in the Consortium on Lithium Genetics (ConLiGen) study.
Twenty-nine ConLiGen sites took part in a two-stage case-vignette rating procedure to examine inter-rater agreement Kappa (κ) and reliability intra-class correlation coefficient (ICC) of lithium response. Annotated first-round vignettes and rating guidelines were circulated to expert research clinicians for training purposes between the two stages. Further, we analyzed the distributional properties of the treatment response scores available for 1,308 patients using mixture modeling.
Substantial and moderate agreement was shown across sites in the first and second sets of vignettes (κ = 0.66 and κ = 0.54, respectively), without significant improvement from training. However, definition of response using the A score as a quantitative trait and selecting cases with B criteria of 4 or less showed an improvement between the two stages (ICC1 = 0.71 and ICC2 = 0.75, respectively). Mixture modeling of score distribution indicated three subpopulations (full responders, partial responders, non responders).
We identified two definitions of lithium response, one dichotomous and the other continuous, with moderate to substantial inter-rater agreement and reliability. Accurate phenotypic measurement of lithium response is crucial for the ongoing ConLiGen pharmacogenomic study.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Zusammenfassung
Hintergrund
Schwerwiegende affektive und psychotische Störungen können bei entsprechender Ausprägung mit Einwilligungsunfähigkeit einhergehen. Lehnt in diesem Fall ein Patient mit ...seinem natürlichen Willen die Behandlung ab und besteht parallel die Gefahr einer erheblichen gesundheitlichen Schädigung, kann unter definierten, engen Voraussetzungen eine Behandlung auch gegen den Patientenwillen erfolgen. Die Elektrokonvulsionstherapie (EKT) stellt hier aufgrund ihrer guten und zum Teil überlegenen Wirksamkeit bei schweren oder auch pharmakotherapieresistenten affektiven und psychotischen Störungen eine wichtige Behandlungsoption dar.
Ziel der Arbeit
Darstellung der Grundlagen und allgemeinen Voraussetzungen therapeutischer Maßnahmen gegen den natürlichen Patientenwillen.
Methoden
Ausgehend von einem Fallbericht erfolgt in einem interdisziplinären Ansatz eine Diskussion und Bewertung des Einsatzes der EKT als ärztliche Zwangsmaßnahme aus klinischer, juristischer und ethischer Perspektive.
Ergebnisse und Diskussion
Die (empirische) Evidenz zur allgemeinen Wirksamkeit der EKT wie auch zu ihrem Einsatz gegen den natürlichen Patientenwillen zeigt ein klar positives Nutzen-Risiko-Verhältnis. Obwohl die EKT als ärztliche Zwangsmaßnahme, wie jede Behandlung gegen den natürlichen Patientenwillen, einen schweren Eingriff in das Grundrecht auf körperliche Unversehrtheit und das Selbstbestimmungsrecht darstellt, kann ihr Einsatz im Einzelfall medizinisch indiziert, rechtlich zulässig und ethisch geboten sein, um einen drohenden schwerwiegenden Gesundheitsschaden abzuwenden. Ethische wie auch rechtliche Voraussetzungen der Behandlung gegen den Patientenwillen sollten im multiprofessionellen Team geprüft und der gesetzliche Vertreter frühzeitig einbezogen werden.
Zusammenfassung
Hintergrund
Depressive Störungen sind häufig und führen zu hohem individuellem Leiden sowie sozioökonomischen Kosten. Trotz verschiedener effektiver Therapieoptionen wird die ...Remission als Ziel der Behandlung oft nicht erreicht. Der Einsatz der Elektrokonvulsionstherapie (EKT) kann hier eine sinnvolle Option sein.
Ziel der Arbeit
Diese Arbeit stellt die aktuelle Evidenz zu Wirksamkeit, Sicherheit und Verträglichkeit der EKT bei depressiven Störungen dar.
Material und Methoden
Es wurde eine selektive Literaturrecherche unter besonderer Berücksichtigung von Metaanalysen, systematischen Reviews sowie Empfehlungen nationaler und internationaler Leitlinien durchgeführt.
Ergebnisse
EKT stellt ein wirksames und für die meisten Patienten sicheres und gut verträgliches Verfahren zur Therapie depressiver Störungen dar. Auch bei Pharmakotherapieresistenz finden sich noch relativ hohe Remissionsraten. Für bestimmte Populationen scheint eine besonders gute Wirksamkeit zu bestehen. Im Gegensatz zur gut belegten Wirksamkeit der Akuttherapie fehlen weitgehend belastbare Daten zur Erhaltungstherapie. Unerwünschte Wirkungen, insbesondere kognitive Störungen, sind in der Regel nur kurzfristig vorhanden. Modifikationen in der Durchführung haben Auswirkungen auf die Wirksamkeit und Verträglichkeit.
Diskussion
Mit der EKT steht ein bei korrekter Anwendung hochwirksames Therapieverfahren zur Behandlung depressiver Störungen zur Verfügung. Angesichts der Häufigkeit depressiver Störungen und einer vielfach nicht erreichten Remission wäre eine weitere Ausweitung der Verfügbarkeit und Anwendung der EKT genauso wünschenswert wie eine intensivierte, ggf. multizentrische Forschung zu den Wirkmechanismen und Responseprädiktoren der EKT.
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