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LE1TERS

TO THE

EDITOR

ness, intrusiveness, and episodic excessive water drinking, but he was generally friendly and cheerful. In addition, he had repetitive stereotypical behaviors with an evident compulsive quality. For example, he would stand in the hall or day room, repeatedly taking his shoes off and putting them

Oral

Caffeine

Augmentation

of ECT

on and lacing them up, with move until he had finished,


Similarly, he would put and unbutton his pants,

periodic pauses. He would not even during ward meetings. his shirt on and take it off, button
and touch walls, doors, and gar-

Sut: For geriatric major depression, ECT is one of the most effective and safe treatments available. However, the practice of ECT continues to be refined in order to improve further its efficacy and side effect profile.

One
old;

area

of research

is the factors

affecting

seizure

thresh-

bage cans in a compulsive manner. When asked engaged in these ritualistic behaviors, he generally explanation. These symptoms had not responded

why he had no at all to

treatment with numerous antipsychotics including clozapine. There was no sign of onganicity on mental status, neunological, and CT scan examinations.

Mr.

A had

previously
hostility, fluoxetine,

shown

no response

and

some

in-

creased agitation, tion when taking

insomnia, and paranoid idea60 mg/day, added to thiothixene. A regimen of clomipramine, 25 mg/day, was started and slowly increased oven 10 weeks to 250 mg/day, while

he continued

to take mesonidazine,

300 mg/day.

No change

in his compulsions was observed during this time, but between weeks 2 and 6 he was reported to be more hostile, paranoid, and angry. The dose of mesonidazine was increased to 400 mg/day, and there was temporary improvement. Two weeks after his dose of clomipramine had reached 250 mg/day, he was again suspicious and hostile, abusive, aggressive, and more deluded. The mesomidazine

seizure threshold increases with age and during a course of ECT (1). These factors are important in the treatment of elderly patients. Missed or inadequate seizures may preclude a response in patients for whom ECT is the last viable treatment option. if bilateral ECT is used, acute cognitive side effects may result. Intravenous caffeine will extend seizure duration during ECT without causing anxiety or affecting hemodynamics associated with ECT (2-4). Intravenous caffeine sodium benzoate is not available in Canada, and theme are no published reports on the use of oral caffeine augmentation. We have been prescribing oral caffeine and successfully lengthening seizumes that had previously fallen below 25 seconds in duration. For more than 30 depressed geriatric patients, we have used 100-mg caffeine tablets dissolved in S ml of water, administened 1 hour before treatment. We titrated the dose (300-1000 mg pen treatment) according to response. The higher dose was usually required later in treatment. Our geriatric patients did not experience any additional complications when caffeine was added to their ECT regimen.

was stopped, to 64 mg/day.


increased to 6 his aggressiveness. mipramine for behavior. After the clonazepam cumrence of the

and perphenazine Two weeks later,

was started clonazepam

and increased was added and

We found

no evidence

of pemi-ECT

complaints

of anxiety

or

mg/day, which calmed him and controlled He continued to take 250 mg/day of do8 weeks, with no change in his compulsive the clomipramine was reduced and stopped, was also reduced and stopped without mehostility and aggressiveness.

In this case clomipramine

caused

a slight

worsening

of the

psychosis and agitation, with no effect on the obsessive-compulsive symptoms. Clomipramine is a relatively selective senotonin reuptake inhibitor and has been found to be helpful in obsessive-compulsive disorder, suggesting a central serotonergic dysfunction in patients with this disorder. The lack of effectiveness of senotonin-enhancing strategies in this patient with schizophrenia and obsessive-compulsive rituals argues against a serotonergic dysfunction mediating his obsessivecompulsive symptoms.

dysphonia and no serious cardiovascular, hemodynamic, on anesthetic complications. While none of our patients who received the caffeine augmentation displayed abnormally prolonged seizures or dmamatic cognitive deficits, there are reports suggesting that postECT delirium and memory loss may be associated not only with stimulus intensity but also with seizure duration (5). Therefore, the potential benefits of oral caffeine may be diminished if seizure duration becomes excessive. However, it has been our experience that oral caffeine augmentation will decrease the frequency of missed or inadequate seizures without an increase in adverse effects, thus minimizing the need for higher stimulus dosing and a protracted course of treatment. Further work needs to be done to determine whether caffeine-augmented ECT would not only convert failed seizures but also allow for successful unilateral ECT in cases in which bilateral treatment had been previously used.

REFERENCES 1 . Rosen I: The clinical significance of obsessions in schizophrenia. J Ment Sci 1957; 103:773-785 2. Fenton WS, McGlashan TH: The prognostic significance of obsessive-compulsive symptoms in schizophrenia. Am J Psychiatry 1986; 143:437-441 3. Stroebel CF, Szarek BL, Glueck BC: Use ofclomipramine in treatment of obsessive-compulsive symptomatology. J Clin Psychopharmacol 1984; 4(2):98-100 4. Pulman J, Yassa R, Anath J: Clomipramine treatment of repetitive behavior. Can J Psychiatry 1984; 29:245-255 S. Yaryura-Tobias JA, Neziroglu F, Bergman L: Chlorimipramine for obsessive-compulsive neurosis: an organic approach. Curr Ther Res 1976; 20:541-548 NIGEL BARK, M.B., B.CHIR. JEAN-PIERRE LINDENMAYER, M.D. Bronx, N.Y.

REFERENCES 1. Sackeim H, Decina P, Prohovnik I, Malitz 5: Seizure threshold in electroconvulsive therapy. Arch Gen Psychiatry 1987; 44:355360 2. Coffey CE, Figiel GS, Weiner RD, Saunders WB: Caffeine augmentation of ECT. Am J Psychiatry 1990; 147:579-585 3. Hinkle PE, Coffey CE, Weiner RD, Cress M, Christison C: Use of caffeine to lengthen seizures in ECT. Am J Psychiatry I 987; 144:1143-1148 4. Coffey CE, Weiner RD, Hinkle PE, Cress M, Daughtry G, Wilson WH: Augmentation of ECT seizures with caffeine. Biol Psychiatry 1987; 22:637-649 S. Miller AL, Faber RA, Hatch JP, Alexander HE: Factors affecting amnesia, seizure duration, and efficacy in ECT. Am J Psychiatry 1985; 142:692-696 R.J. ANCILL, M.B., M.R.C.PSYCH., F.R.C.P. W. CARLYLE, M.D. Port Coquitlam, B.C., Canada

Am

J Psychiatry

149:1,

January

1992

137

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