It was repeatedly reported that low frequency rTMS diminishes treatment-resistant auditory hallucinations. The main drawback to rTMS in general, so far has been the impossibility of precise targeting of the rTMS coil at the given cortical area. Stereotactic neuronavigation is a unique technology utilising the ability of aiming the coil with a high degree of anatomic accuracy based on an evaluation of the structural or functional neuroimaging of the brain.

To prove the clinical effect of using rTMS neuronavigation in the therapy of treatment-resistant auditory hallucinations

Seventeen schizophrenic patients with predominantly symptoms of treatment-resistant auditory hallucinations were treated.

Using double-blind sham-controlled parallel design, we evaluated the effect rTMS neuronavigation focused over the left temporo-parietal area, direct to the place with the highest metabolic activity (SPM II analysed PET contrast).

Parameter settings were: 0.9Hz, MT 100%, 1080 puses/session, 10 sessions, duration: 20 minutes per session.

Clinical effect was assessed using PANNS, AHRS and HCS.

We found a significant improvement in the total on scales of HCS and AHRS, representing more than 30% reduction of the symptoms after neuronavigated rTMS. Sham rTMS did not showed a trend for improvement over time. No side effects during rTMS were observed.

Our study shows the acute effect of rTMS neuronavigation in the therapy of auditory hallucinations in schizophrenia. We believe that using neuronavigation and respecting an individual brain parameters and metabolic changes, we can evaluate higher efficiency of the rTMS method.

Supported by CNS, MZČR MZ0PCP2005 and MŠMT 1M0517

An 83-year old female patient was first admitted to our department at the age of 72 years, after a suicide attempt. She was diagnosed as having psychotic depression and received antidepressive medication with moderate effect. Relapses were multiple despite continuation medication. The failure of administered antidepressive medication to prevent relapse, necessitated the use of index, continuation and eventually maintenance ECT. The additional parallel use of mood stabilisers (lithium and lamotrigine) allowed us to lower the frequency of M-ECT. Attempts to discontinue M-ECT led to relapse and M-ECT is now seen as a life-long treatment for that patient. To date (2007) our patient has received 450 treatments. Her depression remains in remission over the last years. Despite the unusual large number of administered ECT, her memory function appears to be unimpaired and repeated assessments with the MMSE test have not revealed cognitive deterioration.

For some patients long-term M-ECT is the only effective treatment to prevent relapse in depression. The risks of long-term M-ECT, especially regarding its possible adverse effects on cognition, are still under research.

Our case-report provides support for the safety of expanded M-ECT which, in some cases, can be seen as a life-long treatment.

Number of previous studies reported that low-frequency repetitive transcranial magnetic stimulation (rTMS) diminishes treatment-resistant auditory hallucinations. However, little is known about the electrophysiological effect on regional functional activity subsequent to the rTMS treatment.

Eighteen schizophrenic patients with antipsychotic-resistant auditory hallucinations were randomized to either active (n=9) or sham (n=9) rTMS. Low-frequency rTMS (0,9Hz, 100% MP, 1200 stimuli per session) was administered over the left temporo-parietal region for ten days. In case of sham rTMS a coil was tilted at 90°. EEG data were recorded within tree days before and after rTMS treatment. The localization of the differences in electrical activity (current density) was assessed by voxel-by-voxel paired t-tests of the LORETA (low resolution brain electromagnetic tomography) images. The clinical effect was assessed by the Positive and Negative Syndrome Scale (PANSS), Hallucination Change Scale (HCS) and the Auditory Hallucination Rating Scale (AHRS) by a rater blind to the treatment condition.

After two weeks of treatment, both HCS and AHRS scores were significantly improved for patients receiving active rTMS compared to the sham group. LORETA analysis revealed a decrease of current densities in high-frequency bands (alpha 2, beta 1 and beta 2) in the left frontal, temporal and parietal lobes in case of active group. No significant differences in electrical activity were observed in sham group.

Real rTMS but not sham stimulation attenuated an auditory hallucinations and was associated with a decrease of activity in high-frequency bands on the left hemisphere.

Electroconvulsive therapy (ECT) is a safe and effective treatment for severe and persistent depression, bipolar disorder and schizophrenia. The authors pretend to describe their experience and evaluate the efficacy of the technique on clinical practice.

We present our experience of ECT use at a University Hospital in Lisbon, Portugal, over the course of 5 years, thought a naturalistic review.

During the study period, 81 patients received ECT. ECT was conducted under the supervision of consultant psychiatrist and anaesthetist with continuous monitoring during and after the procedure. Bitemporal electrode placement was used twice or thrice weekly. Most commonly used sleep induction agents were thiopental and propofol. The average number of ECTs administered per patient was 8. Patients who received ECT were diagnosed unipolar major depression (49.4%), bipolar disorder (29.6%), schizophrenia (19.8%) and schizoaffective disorder (1.2%). Mean age of patients who received ECT were 44 years, in a great range between 16 and 81 years-old. The majority was female (65.4%). Almost all patients showed improvement in their clinical condition (90%). The most frequent complication was bradycardia followed by hypertension. No major complication was observed in any of the patients. Thirty-three percent of patients repeat the ECT along those 5 years. When support ECT started to be realized, recurrence decreased.

Our study demonstrates the effectiveness of ECT. We strongly recommend following guidelines to ensure patient safety and minimizing side effects. This will ensure better patient acceptability and compliance.

Major depression is one of the most prevalent diagnoses in the elderly and represents an important cause of morbidity and mortality in this group. There exists evidence that electroconvulsive therapy (ECT) is particularly efficient and safe in the elderly patient.

Bibliographic review on Pubmed, Medline and Textbooks of Psychiatry

The use of ECT in the psychogeriatric patient has indication in episodes of major depression, mania, schizophrenia and other psychotic disorders, and also when there exists concomitant neurological (affective disorders in dementia, Parkinson´s disease, and post stroke depression). or other mental syndromes (catatonia or delirium secondary to various medical conditions).

Because the geriatric population suffers multiple organic comorbidities, the following risk factors require evaluation: history of head trauma, focal or general neurological complaints (recent stroke, intracranial tumour, hypertension or aneurysm), angina, congestive heart failure, bone fractures, osteoporosis, spinal disease and oesophageal reflux.

The following adverse effects have been described: cardiac ischemia, arrhythmia (tachycardia and bradycardia), hypertension, pneumonia secondary to aspiration of gastric contents, musculoskeletal and dental injury, increase of intraocular pressure, post ictal confusion and disorientation, impaired retrograde and anterograde memory.

The indication, risks factors and possible adverse effects of ECT should be carefully evaluated in the elderly patient.

Cognitive side-effects are the most troublesome side-effects after electroconvulsive therapy (ECT). Efforts to reduce side-effects, maintaining a high efficacy are ongoing. Cognitive effects of bifrontal and unilateral ultra-brief pulse ECT were compared, in the treatment of patients with a depressive episode.

Sixty four patients with a depressive episode that was highly medication refractory, and with a high degree of comorbidity completed a course of bifrontal ECT at 1.5 times seizure threshold (ST) or unilateral ECT at 6 times ST, with a pulse width of 0.3 msec by random assignment. An extensive cognitive battery was performed at baseline and at 1 and 6 weeks post-treatment, by a blinded rater.

At the end of the treatment course, 78.1% of patients responded (≥ 50% decrease HDRS-scores). There was a significant increase in global cognitive function (MMSE), verbal memory (RAVLT), attention (CPT), executive function (WCST) and autobiographical memory (AMI). Patients reported a significant increase of their subjective memory function both during and after the ECT-course. There were no significant differences between the patients given bifrontal ECT and those given unilateral ECT.

Bifrontal and unilateral ultra-brief pulse ECT are effective treatment techniques that do not cause measurable cognitive side-effects or cognitive complaints.

Electroconvulsive therapy (ECT) involves the administration of a variable frequency electrical stimulus shock via electrodes applied to the scalp to induce a seizure for therapeutic purposes. In 2001, the American Psychiatric Association (APA) task force on ECT concluded that convincing data exists to support use for major depression, bipolar depression and mania, schizophrenia, and schizoaffective and schizophreniform disorders. However, the National Institute for Clinical Excellence in the UK (NICE 2003) does not recommend that ECT be used as a long-term treatment to prevent recurrence of depressive illness, and that it recommends that ECT should not be used in the general management of schizophrenia.

To review and describe the practice of ECT in the largest psychiatric hospital in Singapore.

This was a retrospective descriptive study performed on all patients who were administered electroconvulsive therapy at the Institute of Mental Health in Singapore during the 2-year study period of 1st July 2005 – 30th June 2007. Data was collected from existing medical records on the demographics, indications, frequency and the complications of the patients given ECT. The frequency of missed fits was also determined as measuring the number of missed-fits provided one way of assessing an ECT clinic's efficiency.

The main indications for electroconvulsive therapy at the Institute of Mental Health in Singapore were patients with Schizophrenia or Schizoaffective Disorders with poor response to medications, followed by patients with mood disorders. The rate of complications of ECT and the frequency of missed-fits were found to be low.

The previous studies have detected changes of brain electrical activity after the cerebellar hemisphere rTMS and the vermis rTMS. We supposed that right cerebellar 1Hz rTMS evokes changes in the left frontal cortex. The aim of our study was to determine if 1Hz cerebellar hemisphere and 1 Hz vermis rTMS induces different effect in frontal electrical activity.

We used 10 minutes of 1 Hz rTMS (with 600 impulses) in two sessions (first session- application over the right cerebellar hemisphere, second over the vermis). 31-channel EEG was recorded in 5 right-handed healthy volunteers before and after rTMS. The 3D distribution of the current density was revealed by a method of qEEG- Low Resolution Brain Electromagentic Tomography (LORETA, Pascual-Marqui et al. 1994; 1999).

After 1 Hz right cerebellar hemisphere rTMS the current density decreased in the alfa2, beta1, beta2 and beta3 band over the frontal cortex including medial frontal cortex and the anterior cingulate (p<0.01). After 1 Hz vermis rTMS we found no significant changes.

Our results suggest the possibility to influence the frontal cortical activity by means of the cerebellar hemisphere rTMS. No significant changes after 1Hz vermis rTMS may suggest either large distance between the rTMS coil and the vermis or our sample is too small to make definitive conclusions.

Supported by MZ0PCP2005 and 1M0517

This paper reviews electroconvulsive therapy (ECT) in children and adults with autism and concomitant psychopathology, including affective illness, catatonia and self-injury. Case examples are highlighted.

A review of the English-language literature on ECT in pediatric, adult, autistic and mentally retarded populations was conducted, with focus on catatonia, drug-resistant psychiatric illness and self-injury. This was combined with the author's experience with two autistic adolescents in catatonic stupor, and an autistic child and young adult with severe affective disturbance and self-injury. All four patients underwent ECT with excellent symptom resolution.

ECT is an effective and safe treatment modality across the lifespan for a wide range of psychopathology. Current literature supports the appropriateness, safety and efficacy of ECT in autistic and intellectually disabled populations, where patients suffer from an increased incidence of psychiatric and behavioral disturbances. The following cases are presented:

Pt 1: An 18-year-old female with autism, MR and self-injury in classic catatonic stupor.

Pt 2: A 15 year-old male with autism and MR in catatonic stupor confounded by bradycardia and arrhythmias.

Pt 3: A 19-year-old male with autism, MR, profound depression, tics, compulsions and catatonic symptoms accompanied by self-injury.

Pt 4: An 8-year-old boy with autism, MR, cyclical mood disturbance and intractable self-injury confined to full-body protective equipment.

Electroconvulsive therapy affords excellent symptom remission in autistic individuals with affective illnesses and catatonia, which may be complicated by dangerous self-injury. Prompt diagnosis and pursuit of ECT significantly improve clinical outcome in this patient population.

Uncertainty prevailing about the role of lithium for the development of chronic renal failure; and the prevalence of lithium-induced end-stage renal disease (ESRD) being virtually unknown, we decided to clarify these issues.

Using a questionnaire we counted the number of former or present lithium patients among all ESRD patients on renal replacement therapy (RRT, i.e. dialysis or renal transplant) in two defined regions in Sweden, comprising 30 % of 9 million Swedes. We also counted the number of all lithium patients in the areas. A chart review is under way to retrieve clinical data for the assessment of the nephrotoxic effect of the lithium therapy.

There were 2,270 RRT patients (0.08 % of the general population). Twenty-seven of them (1.2 %) acknowledged long-term lithium treatment. Seventeen were on dialysis, ten were transplanted. The concurrent number of lithium patients was 3,567.

Based on our own earlier studies we estimate that 900 (25 %) of the lithium patients in the two regions had been on lithium ≥15 years. Thus, twenty-seven of the long-term lithium patients in this study were subject to RRT.

The prevalence of lithium nephropathy in the RRT population is at least 1 %, 0.8 % in the entire lithium population, and approximately 3 % among long-term lithium patients. The risk of developing ESRD is higher when on lithium therapy compared to the general population. Our results so far underscore the need for adequate safety programs, ascertaining the early detection of lithium nephropathy.

Behçet's Disease(BD) is a primary vasculitis with wide variety of symptoms, in which psychiatric disorders as Bipolar Affective Disorder(BPD) are seen. In such cases; as in all comorbidities, the importance of preferring appropriate treatment is emphasized.

We present a case of hematologic toxicity associated with a valproate level of 116 mg/l in of BPD and BD comorbidity.

The 38 years old male patient, who was diagnosed as BPD 10 years ago and BD 3 years ago, was hospitalized for mixed episode with psychotic features. His routine laboratory parameters were in normal ranges. Olanzapine 10mg/d and valproate 500mg/d were started and Valprote was titrated up to 1000 mg/d. At the 8th day of medication he complained of fatigue and somnolence. By the following 6 days a decrease in the hematologic values as: haemoglobin:15,0/11,4g/dl, hematocrit:%42/32, platelets:334000/202000 microg/ml was noticed. He had no active symptoms of BD. The liver enzymes were moderately high and because of the hepatoxicity with valproate was reported in previous studies, Valprote was stopped and Olanzapine was continued. The hematological and biochemical parameters normalized in two weeks.

The decrease of hematological parameters could not be explained by BD itself or any other organic pathology and normalized after cessation of valproate. Thus a hematotoxicty associated by valproate was considered.

Although the effects of the comorbidity of BPD-BD to hemototoxicity are not clear exactly, this case underlies the importance of careful monitoring the Valprote levels and associated parameters in BPD particularly if comorbidity is present.

Lithium occurs naturally in food and water. While low environmental concentrations in drinking water are associated with mental illnesses and behavioral offences, at therapeutic dosages it is used to treat psychiatric disorders, partly by facilitating serotonergic (5-HT) neurotransmission. However, as little is known about the physiological role of nutritional lithium for neurobiological functioning and emotional processing in the general population, endogenous lithium concentrations were hypothesized to be associated with measurable effects on emotional liability and the loudness dependence (LD) that is proposed one of the most valid indicators of 5-HT neurotransmission.

Auditory evoked potentials (AEP) of healthy volunteers with either high or low lithium serum concentrations were recorded using multi-channel EEG. Emotional liability was assessed using the Brief Symptom Inventory (BSI).

Serum lithium concentrations varied widely, low levels correlating with symptoms of Somatization. While there were no significant correlations between LD and lithium concentrations, LD correlated positively with Paranoid Ideation, and in the high-lithium group inversely with further aspects of emotional liability (Depression, Psychological Distress).

Effects of low levels of endogenous lithium are associated with an increase in emotional liability, and high levels with some protective effects. Findings on the mediating neural correlates point to the 5-HT system, but remain inconclusive regarding LD. Potential benefits of endogenous lithium as a neurobiological trace element on neurobehavioral functioning especially in high-risk individuals would have public health implications.

In the last decades there has been a steady increase in the usage of mood stabilizers (MS); especially for prevention of affective disorders and those illnesses with important loss of impulse control. Our objective was to evaluate trends in the use of MS in our Unit.

113 patients prescribed a MS when admitted, or discharged, from our acute unit, were selected between March 2007 and August 2007. Clinical and demographic relevant variables were taken into consideration. Diagnoses were divided into 10 different categories. Statistical methods were used when appropriated.

40.37% of all the admitted patients were taking MS (100% of all the patients with Borderline Personality Disorders, BPD; 80% of all the patients with Bipolar Disorders, BD). Topiramate (40.71%), Oxcarbamazepine (27.43%) and Lamotrigine (23.89%), were the most used MS. In BD, the use of lithium was common but usually in combination therapy. Topiramate was used for BPD and Lamotrigine for unipolar depression. The largest increase of prescription during admission was observed with oxcarbamazepine.

Nearly a third of the patients admitted received MS, which indicates a high prevalence of use. Lithium remains the first choice MS for the treatment of BD, usually used in association with another MS.

New MS are widely used, especially in disorders which include impulsivity, probably due to a better profile of adverse reactions/interactions than classic MS. However more solid evidence of their efficacy is needed.

Acid sphingomyelinase (A-SMase) is a glycoprotein that functions as a lysosomal hydrolase, catalysing the degradation of sphyngomyelin to phosphorylcholine and ceramide. Several lines of evidence suggest its central role in all three types of apoptosis. The activation of neuronal A-SMase has been shown to be important in the stress-induced apoptotic death of hippocampal neurons. The aim of the present study was to investigate the association between the activity of A-SMase, hippocampal volume and memories function in healthy young volunteers.

The activity of A-SMase was measured in peripheral blood mononuclear cells of 19 healthy female students of the University of Erlangen- Nuernberg (26,32 ± 3,95 years old, Body mass: 22,29 ± 2,63 kgr/m2). The hippocampal formation was outlined in high-resolution anatomical magnetic resonance imaging data. The memory function was assessed with the Inventory for Memory diagnostics (Inventar zur Gedaechtnisdiagnostik). Correlations between continuous variables were examined, using Spearman's rank correlation coefficient.

The activity of A-SMase did not correlate with hippocampal volume and memory performance.

These findings indicate that the activity of the A-SMase influences neither the brain hippocampal volume of young healthy females, nor their memory performance.

Delirium is an organic mental disorder defined as a confusional state, attention deficit, and disorganised thinking, whit a fluctuating course and acute development. It is a common disorder occurring in general hospital patients. Underlying causes are multiple: medical, surgical, and drug related.

Evaluation of one year requests in a Liaison Psychiatric Unit in a general Hospital due to Delirium/Agitation of inpatients.

Retrospective study of requests due to delirium/agitation (inpatients) to Liaison Psychiatric Unit, during the year of 2006. Requests were made to the Unit through a screening questionnaire previously elaborated to hospital services. It contained information about: social demographic, requiring services, medical diagnostic/information, referral psychiatric symptoms. Evaluation of mismatch of initial referral and final diagnosis was made.

Delirium diagnoses accounted for 8,87% of the total patients attended in this Unit during 2006. The age average was 66,75 years. 56% were male. Majority of patients were referred by Medicine 3,94% and Surgery 4,93% (N=406) requests. In 75% of the cases of Delirium, the referral symptoms were psychomotor agitation. Psychopharmacologic procedures were made in 77,78% of cases; 55,56% used antipsychotic, 27,78% benzodiazepines. In 72,22% of all cases, there wasn't any previous psychiatric history.

The number of requests for delirium was inferior to most of described series. Most of cases were characterized by psychomotor agitation. Psychopharmacologic procedures were necessary for most of cases. When request was made, diagnostic accuracy of medical practitioners was high. Data supports the statement that delirium is more frequent in Surgical patients.

To study the long term effects of delirium in elderly hip-surgery patients on cognitive outcome.

Prospective matched controlled cohort study. Medical school-affiliated general hospital in Alkmaar, The Netherlands.

Hip-surgery patients (n=112) aged 70 and older who participated in a controlled clinical trial of haloperidol prophylaxis for delirium, were followed for an average of 30 months after discharge. Patients with a diagnosis of dementia or mild cognitive impairment (MCI) were identified based on psychiatric interviews. Proportions of patients with dementia or MCI were compared across patients who had postoperative delirium and selected control patients matched for preoperatively assessed risk factors who had not developed delirium during hospitalization. Other outcomes were mortality rate and rate of institutionalization.

During follow-up 54.9% of delirium patients had died compared to 34.1% controls (relative risk = 1.5, 95% CI = 1.04-2.1). Dementia or MCI was diagnosed in 77.8% of the surviving patients with postoperative delirium and in 40.1% of control patients (relative risk = 2.7, 95% CI = 1.2-5.8). Group differences for rate of institutionalization were not significant.

The risk of dementia or MCI at follow-up is more than doubled in elderly hip-surgery patients with postoperative delirium compared with patients without delirium.

Semantic knowledge (long-established knowledge about objects, facts, and word meanings) is known to be impaired in schizophrenia. It has been hypothesized that language disorder in schizophrenia is linked both to executive and semantic dysfunctions.

To examine this hypothesis we assessed 32 patients with schizophrenia (with and without formal thought disorder) and 30 matched normal controls. We compared the performances obtained by the two groups on the tests that evaluate executive functions (WCST) and semantic knowledge (Pyramids and Palm Tree Test). Test of verbal fluency were also applied.

Patients generally performed at a lower level than controls. Patient with thought disorder performed at a lower level on tests sensitive to executive dysfunction and semantic impairments.

The results provide support for a dysexecutive hypothesis of formal thought disorder in schizophrenia and semantic processing.

Despite its high prevalence and association with increased morbidity, mortality and health services utilization, delirium is often under-recognized and under-treated in general hospitals.

We report our experience of consultation in the treatment of medical patients with delirium in a General Hospital.

During the last 12 months our department has accepted 93 requests for consultation with patients diagnosed as having delirium, which represents a percentage of 9,59% of the total requests for psychiatric assessment. The mean duration of the symptoms was 2 days prior to the request for consultation. The main symptoms that were reported were agitation and delusions even when other important symptoms such as disorientation and insomnia co-existed. Medication had already been administered by the physicians in 63,44 % of cases (in 69,49% haloperidol and in 30,51% a benzodiazepine had been administered). No preventive interventions had been made even in patients at high risk. It is noteworthy that 9,67 % were physically restrained before consultation. Laboratory tests for the investigation of the disorder were performed only in 12,9 % . The duration of hospitalization was prolonged from 3 to 8 days because of the delirium.

Although delirium is a common condition in patients admitted to General Hospitals, preventive interventions are lacking, the diagnosis is often delayed and the treatment is inadequate. The role of Consultation-Liaison Psychiatrists is not only to treat the patients’ delirium but also to inform and educate the physicians and the hospital stuff of other disciplines about the management of the syndrome.