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Biomedical subjects

D P Devanand

Publications and source records attributed to D P Devanand.

At least 73 records · Page 4Linked to original sources
PubMed1995

Hearing loss and asymmetry in major depression.

To assess patterns of hearing loss and asymmetry in major depressive disorder (MDD), pure-tone and brief-click audiometric thresholds were measured in 59 inpatients with MDD and 40 normal control subjects. For both tasks, patients had higher bilateral thresholds, with marked hearing loss for the highest pure-tone frequency. At lower frequencies, patients displayed significant asymmetry, with poorer hearing in the left ear. After ECT, patients maintained the bilateral hearing losses; however, the baseline asymmetry resolved. These findings suggest that bilateral hearing loss may be a stable characteristic in severe depression. Poorer left ear pure-tone hearing may be present during the depressed state. The baseline asymmetry in audiometric deficits suggests right-hemisphere dysfunction in severe MDD.

Acoustic Stimulation↗
PubMed1995

Neuroleptic treatment of agitation and psychosis in dementia.

Neuroleptics remain the mainstay for the treatment of behavioral disturbance and psychotic symptoms in demented patients. The limited available data suggest that low-dose neuroleptics are significantly more efficacious than placebo, though the magnitude of the effect is moderate in most published studies. Demented patients are particularly prone to neuroleptic side effects, and individualized dose titration may be necessary to achieve the optimal trade-off between efficacy and side effects. Target behavioral symptoms and side effects, including effects on cognition and activities of daily life, should be identified and assessed serially during neuroleptic treatment. The choice of neuroleptic depends more on likely side effects than differential efficacy, and non-response or intolerable side effects should lead to dose adjustment or a switch to an alternative class of neuroleptic (or an alternative type of medication). Further studies of optimal neuroleptic dosage, the optimal duration of continuation neuroleptic treatment, and placebo-controlled studies comparing neuroleptics to other classes of medications are needed.

Aged↗
PubMed1995

Effects of electroconvulsive therapy on plasma GABA.

There are no published data on the effects of seizures on indices of gamma-aminobutyric acid (GABA) function in human subjects. In study 1, the effects of electroconvulsive therapy (ECT) on free plasma GABA were studied in 39 inpatients with major depressive disorder. Acutely after ECT, free plasma GABA was significantly reduced for up to 1 h after seizure termination, and this finding replicated strongly in a subgroup of six patients who received a second course of ECT. In a second study at a different site that compared sham ECT and real ECT in seven patients, some doubt was raised about the replicability of the acute effect of ECT on GABA levels. Nonetheless, the strength of the findings in the larger study 1 sample suggests that, unlike virtually all other biochemical indices, free plasma GABA may be reduced acutely after ECT. This acute decrease could reflect decreased levels of GABA in brain extracellular space or decreased brain turnover. In study 1, compared with ECT nonresponders, ECT responders had higher GABA levels at both baseline and after a course of ECT. Because plasma GABA levels are known to be low in a subset of patients with major depression, the higher GABA levels observed in clinical responders before and after the ECT course indirectly suggest that patients least abnormal in GABA levels may show superior clinical response. This also suggests that low plasma GABA is not a state marker for depression.

Adult↗
PubMed1995

Subjective side effects during electroconvulsive therapy.

In 92 depressed patients who were randomized to unilateral or bilateral electroconvulsive therapy (ECT) at either low dosage (just above seizure threshold) or high dosage (2.5 times the seizure threshold), subjective side effects were assessed with the Columbia ECT Subjective Side Effects Schedule. A research nurse administered the instrument 4 h after each treatment during the ECT course. In 41 patients, the instrument was also administered before the ECT course. Headache, disorientation, and memory complaints were the most common subjective side effects during the ECT course. Somatic side effects did not change from early to late in the ECT course, and were not influenced by ECT electrode placement or dosage. Most individual somatic side effects, including nausea, tiredness, and muscle aches/pains did not change from pre-ECT to during the ECT course, and may have been a function of the persistent somatic symptoms of depression. Cognitive complaints increased from pre-ECT to during the ECT course, but there was no overall change from pre-ECT to immediately after the ECT course. Cognitive complaints were greater with bilateral compared with unilateral ECT, with no significant effect of electrical dosage. During the ECT course, subjective mood improved and psychomotor agitation decreased, particularly in clinical responders. These findings suggest that most putative somatic side effects are related to the depressive state rather than being induced by ECT. The observed changes reinforce the need to evaluate both subjective and objective side effects during ECT.

Affect↗
PubMed1994

Regional cerebral blood flow in mood disorders, III. Treatment and clinical response.

BACKGROUND: Global and regional deficits in cerebral blood flow and glucose metabolism have been reported in major depression, but there is limited information on the effects of somatic treatment and clinical recovery on these abnormalities. METHODS: We assessed cortical blood flow with the xenon 133 technique in depressed patients prior to a course of electroconvulsive therapy (ECT), 30 minutes before and 50 minutes after a single treatment, and during the week following ECT. Acute (preictal and postictal) effects of a single treatment also were studied in manic patients. RESULTS: In the depressed and manic groups, larger blood flow reductions in the acute period, both globally and in particular patterns of brain regions, were associated with a superior clinical outcome following the treatment course. In depressed patients, similar patterns were observed for the blood flow changes over a full treatment course. Blood flow reductions in anterior cortical regions were strongly associated with a positive clinical response in both depression and mania. CONCLUSIONS: The findings indicated that cerebral blood flow abnormalities in major depression were not reversed by successful treatment with ECT. Rather, particularly in responders, ECT resulted in additional perfusion reductions. The therapeutic properties of ECT are related to reduced functional brain activity in specific neural regions.

Adult↗
PubMed1994

Is dysthymia a different disorder in the elderly?

OBJECTIVE: This study evaluated elderly dysthymic patients in a late life depression clinic and compared their clinical features to previous findings in young adult dysthymic patients. METHOD: Of 224 consecutive elderly outpatients, 40 (17.9%) met criteria for dysthymic disorder. A semistructured interview was used to obtain history, the Structured Clinical Interview for DSM-III-R--Patient Version and the Structured Clinical Interview for DSM-III-R Personality Disorders were used to make DSM-III-R diagnoses, and standard rating instruments for depression were administered. RESULTS: The gender distribution was equal and major stressors were common. The mean age at onset of dysthymia was 55.2 years (SD = 15.4), with an average illness duration of 12.5 years (SD = 14.2). Early onset (before 21 years of age) and secondary dysthymia were rare. A history of major depression earlier during the course of dysthymic illness, comorbid anxiety disorders, and personality disorders were relatively uncommon. Cross-sectionally, cognitive and functional symptoms were more prominent than vegetative symptoms. CONCLUSIONS: Dysthymia is not uncommon among depressed elderly outpatients who present for treatment. Elderly dysthymic patients differ from young adult dysthymic patients, who are mostly female with an early onset and who frequently have comorbid axis I and axis II disorders. Most elderly dysthymic patients do not appear to be young dysthymic patients who simply grew older, and the DSM-III-R subtyping of dysthymia into early/late onset and primary/secondary may not apply to the elderly. Further clinical studies of "pure" dysthymic disorder appear feasible in the elderly, and these are clearly needed.

Adult↗
PubMed1994

Does ECT alter brain structure?

OBJECTIVE: The purpose of this study was to evaluate whether ECT causes structural brain damage. METHOD: The literature review covered the following areas: cognitive side effects, structural brain imaging, autopsies of patients who had received ECT, post-mortem studies of epileptic subjects, animal studies of electroconvulsive shock (ECS) and epilepsy, and the neuropathological effects of the passage of electricity, heat generation, and blood-brain barrier disruption. RESULTS: ECT-induced cognitive deficits are transient, although spotty memory loss may persist for events immediately surrounding the ECT course. Prospective computerized tomography and magnetic resonance imaging studies show no evidence of ECT-induced structural changes. Some early human autopsy case reports from the unmodified ECT era reported cerebrovascular lesions that were due to agonal changes or undiagnosed disease. In animal ECS studies that used a stimulus intensity and frequency comparable to human ECT, no neuronal loss was seen when appropriate control animals, blind ratings, and perfusion fixation techniques were employed. Controlled studies using quantitative cell counts have failed to show neuronal loss even after prolonged courses of ECS. Several well-controlled studies have demonstrated that neuronal loss occurs only after 1.5 to 2 hours of continuous seizure activity in primates, and adequate muscle paralysis and oxygenation further delay these changes. These conditions are not approached during ECT. Other findings indicate that the passage of electricity, thermal effects, and the transient disruption of the blood-brain barrier during ECS do not result in structural brain damage. CONCLUSIONS: There is no credible evidence that ECT causes structural brain damage.

Adult↗
PubMed1994

Utility of extrapyramidal signs and psychosis as predictors of cognitive and functional decline, nursing home admission, and death in Alzheimer's disease: prospective analyses from the Predictors Study.

OBJECTIVE: To examine whether either extrapyramidal signs or psychotic features are associated with more rapid progression of Alzheimer's disease. BACKGROUND: It has been unclear whether extrapyramidal signs and psychosis are predictors of faster course or are simply late signs. METHODS: Two hundred thirty-six patients with mild Alzheimer's disease were recruited in three cities and followed semiannually. RESULTS: Using Cox proportional hazards models that adjusted for age, sex, disease severity, and estimated duration of illness at study entry, the presence of extrapyramidal signs at entry was associated with higher relative risk (RR) of reaching moderate cognitive (RR = 2.35, 95% CI = 1.12 to 4.92) or functional (RR = 2.31, 95% CI = 1.37 to 3.90) severity, nursing home entry (RR = 2.51, 95% CI = 1.32 to 4.76), or death (RR = 3.04, 95% CI = 1.31 to 7.05). Psychosis predicted only the functional end point (RR = 1.85, 95% CI = 1.18 to 2.90). Using regression models, modified Mini-Mental State scores declined 1.30 points (95% CI = 0.16 to 2.44) per 6-month interval, more among patients with than those without extrapyramidal signs; patients with psychosis declined 1.15 (95% CI = 0.52 to 1.77) more mMMS points per interval. CONCLUSIONS: This study confirms extrapyramidal signs and psychosis as robust predictors of disease end points and rapid progression in Alzheimer's disease.

Age Factors↗
PubMed1994

The significance of clinical EEG abnormalities in depressed patients treated with ECT.

Standard pretreatment clinical electroencephalograms (EEGs) were abnormal in 18.6% of 140 consecutive patients with Research Diagnostic Criteria (RDC) endogenous major depression. The patients were randomized to unilateral or bilateral and low- and high-dosage electroconvulsive therapy (ECT) conditions. Clinical features, short-term treatment response, and the rate and timing of relapse were contrasted in patients with normal and abnormal clinical EEG examinations. Psychotic depression was more common among abnormal EEG (61.5%) than normal EEG (38.9%) patients. Otherwise, the two groups were equivalent in a variety of demographic, clinical, and pharmacological variables. Patients with abnormal EEG findings tended to show a poorer rate of response to unilateral ECT, but a strong rate of response to bilateral ECT. Rates and timing of relapse were equivalent in the two groups. Other than the suggestion that bilateral ECT may be preferable in patients with clinical EEG abnormalities, little evidence was found that such abnormalities characterize discrete subgroups or have preductive utility with respect to ECT outcome.

Cross-Over Studies↗
PubMed1994

Acute cognitive effects of subconvulsive electrical stimulation.

Empirical titration procedures increasingly are being used to estimate initial seizure threshold. These procedures involve the administration of subconvulsive electrical stimulation. There has yet to be evaluation of the impact of such stimulation on the acute cognitive consequences of electroconvulsive therapy. In two studies we randomized depressed patients to right unilateral or bilateral ECT, with stimulus intensity maintained just above seizure threshold throughout the treatment course. These low dosage treatment groups received one or more subconvulsive stimuli in approximately 40% of treatment sessions, with a grand mal seizure also elicited at each session. Extensive neuropsychological evaluation was conducted at each session. We contrasted treatment sessions in which generalized seizures were preceded by subconvulsive stimulation with treatment sessions in which a single convulsive stimulation was applied. Across a variety of neuropsychological measures, there were no adverse cognitive consequences of subconvulsive stimulation.

Aged↗
PubMed1994

Physical properties and quantification of the ECT stimulus: I. Basic principles.

The physical properties of the electroconvulsive therapy (ECT) stimulus markedly affect both efficacy and side effects. We review basic principles in characterizing these physical properties and in quantifying the ECT stimulus. The topics discussed include the application of Ohm's law, alternative composite units of ECT dosage (energy and charge), the use of constant-current, constant-voltage, and constant-energy principles in ECT devices, the nature of current shunting in ECT and the determinants of impedance, the relations between impedance and seizure threshold, the seizure-eliciting efficiency of alternative stimulus waveforms and of stimulus parameter configurations, and the role of reactive components (capacitance and inductance) in the ECT circuit. New findings are also presented regarding several of these issues.

Electric Impedance↗
PubMed1993

EEG manifestations during ECT: effects of electrode placement and stimulus intensity.

This study examined the ictal electroencephalographic (EEG) characteristics of four forms of electroconvulsive therapy (ECT) known to differ in efficacy. Previously, we demonstrated that titrated, low-dose right unilateral ECT reliably produces generalized seizures of adequate duration, but is remarkably weak in antidepressant effects. Using a new rating scale, we found that specific features of the ictal and immediate postictal EEG varied significantly with ECT stimulus intensity and electrode placement. The low-dose right unilateral condition differed from more effective forms of ECT in having the longest polyspike phase duration, averaging twice that of the other conditions; it was also the condition least likely to manifest bioelectric suppression immediately following seizure termination. In contrast, high-dose bilateral ECT--a treatment with particularly rapid antidepressant effects--resulted in the greatest peak slow-wave amplitude in both hemispheres. Total seizure duration did not differ among the four treatment conditions. These findings indicate that seizure duration is not a useful marker of therapeutic efficacy, and instead provide preliminary evidence that other features of the EEG may be more useful markers of treatment adequacy.

Adult↗
PubMed1993

Effects of stimulus intensity and electrode placement on the efficacy and cognitive effects of electroconvulsive therapy.

BACKGROUND: The efficacy of electroconvulsive therapy in major depression is established, but the importance of the electrical dosage and electrode placement in relation to efficacy and side effects is uncertain. METHODS: In a double-blind study, we randomly assigned 96 depressed patients to receive right unilateral or bilateral electroconvulsive therapy at either a low electrical dose (just above the seizure threshold) or a high dose (2.5 times the threshold). Symptoms of depression and cognitive functioning were assessed before, during, immediately after, and two months after therapy. Patients who responded to treatment were followed for one year to assess the rate of relapse. RESULTS: The response rate for low-dose unilateral electroconvulsive therapy was 17 percent, as compared with 43 percent for high-dose unilateral therapy (P = 0.054), 65 percent for low-dose bilateral therapy (P = 0.001), and 63 percent for high-dose bilateral therapy (P = 0.001). Regardless of electrode placement, high dosage resulted in more rapid improvement (P < 0.05). Compared with the low-dose unilateral group, the high-dose unilateral group took 83 percent longer (P < 0.001) to recover orientation after seizure induction, whereas the combined bilateral groups took 252 percent longer (P < 0.001). During the week after treatment, there was three times more retrograde amnesia about personal information with bilateral therapy (P < 0.001). There were no differences between treatment groups in cognitive effects two months after treatment. Forty-one of the 70 patients who responded to therapy (59 percent) relapsed, and there were no differences between treatment groups. CONCLUSIONS: Increasing the electrical dosage increases the efficacy of right unilateral electroconvulsive therapy, although not to the level of bilateral therapy. High electrical dosage is associated with a more rapid response, and unilateral treatment is associated with less severe cognitive side effects after treatment.

Amnesia, Retrograde↗
PubMed1993

Does ECT permanently alter seizure threshold?

Recent research has raised the possibility that electroconvulsive therapy (ECT) results in a persistent elevation of seizure threshold among males. In this study, seizure threshold, quantified by the method of limits procedure, was assessed at the first and last treatments of 148 consecutive depressed patients. Patients with and without a prior history of ECT did not differ in seizure threshold at the first treatment, seizure duration at the first treatment or averaged across all treatments, or in the magnitude of the seizure threshold increase over the ECT course. No evidence was obtained that history of ECT was associated with alterations of seizure threshold or seizure duration.

Adult↗
PubMed1993

Cardiovascular complications of ECT in depressed patients with cardiac disease.

OBJECTIVE: This study was conducted to determine the safety of electroconvulsive therapy (ECT) for depressed patients with serious cardiac disease. METHOD: The rate of complications in 40 patients with major depressive disorder and left ventricular impairment, ventricular arrhythmias, and/or conduction delay who received ECT was compared to the rate of complications in a matched comparison group of 40 depressed patients without cardiac disease who also received ECT. In addition, 21 of the patients with cardiac illness had received one or more inpatient trials of tricyclic antidepressants before receiving ECT, thereby permitting a comparison of cardiovascular complications of medication and ECT in the same patients. RESULTS: The patients with cardiac disease had a significantly higher rate of cardiac complications during ECT than did the comparison group without cardiac disease. The type of preexisting cardiac abnormality strongly predicted the type of cardiac complication that occurred during ECT. However, most of the complications were transitory and did not prevent the completion of ECT. Of the 21 patients with cardiac disease who had received tricyclic trials before ECT, 11 had been forced to discontinue drug treatment because of substantial cardiovascular side effects. In comparison, 38 of the 40 cardiac patients completed the course of ECT. CONCLUSIONS: With close monitoring for the development of arrhythmia and ischemic episodes, ECT can be given with relative safety to patients with severe cardiovascular disease.

Aged↗
PubMed1993

Regional cerebral blood flow in mood disorders. II. Comparison of major depression and Alzheimer's disease.

We contrasted regional cerebral blood flow in matched groups of 30 patients with major depression, 30 patients with Alzheimer's disease and 30 normal controls using the 133Xe inhalation technique. Whereas both the depressed and Alzheimer's disease groups had markedly reduced global cortical blood flow, the Scaled Subprofile Model, developed to identify abnormalities in regional networks, indicated that they had distinct topographic profiles. Previous findings of an abnormal regional network in major depression were unaltered by the inclusion of Alzheimer's disease patients in the analysis. Alzheimer's disease was associated with a distinct parietotemporal deficit and the degree of this abnormality strongly covaried with cognitive impairment. Alzheimer's disease patients also had abnormal manifestation of three other regional networks. We illustrate a method for distinguishing when a disease imposes a new pattern of interactions among brain regions and when a disease alters the expression of regional patterns characteristic of normal functioning.

Aged↗
PubMed1992

The Columbia University Scale for Psychopathology in Alzheimer's disease.

The Columbia University Scale for Psychopathology in Alzheimer's disease is a new screening instrument developed for use by clinicians or trained lay interviewers. Interrater reliability was established between a psychiatrist and a lay interviewer in 20 patients. In an independent sample of 91 outpatients with very mild to moderate probable Alzheimer's disease, caregiver informants reported that depressed mood was common (46.2%) but rarely persistent (2.2%), and that sleep disturbance occurred frequently (41.8%) but was never severe (0%). There were significant but weak associations between the presence of specific subtypes of delusions and severity of dementia. Although a variety of delusional symptoms were reported, they were frequently transient and patients often accepted the truth if corrected by the caregiver. As a result, few patients met broad or narrow operational criteria used to define delusions. Prior studies may have overestimated the prevalence of psychotic features in Alzheimer's disease by not employing standard definitional criteria. The findings also indicate that new methodology such as that employed in this instrument needs to be evaluated more widely.

Aged↗