Class 8

Question 1

Fastest most effective antidepressant

Answer 1

ECT

Question 2

Mechanism of ECT

Answer 2

seizure induced changes neurotransmitters, neuro plasticity and functional connectivity, increase levels of BDNF (antidepressant effect and neurogenesis)

Question 3

ECT technical aspects

Answer 3

800 mA 100 ms- 6s  
(6 x threshold for inducing seizure)
bitemporal (temple to temple, worse for memory loss because close to hippocampus) or right unilateral (front to back on one side of the head), bifrontal (frontal cortex) 
plus width brief or ultra brief
2-3 times weekly for 6- 12 sessions

Question 4

Response rate of ECT

Answer 4

70-80%

Question 5

Higher response ECT

Answer 5

older, psychotic, less severe and more acute depressive episode.

Question 6

Remission rate ECT

Answer 6

50%

Question 7

Relative contra-indications to ECT

Answer 7

Space occupying lesion, increased ICP, recent MI, recent ICH, unstable vascular malforamtion/ aneurism, pheochromocytoma, class 3 or 4 anesthesia risk

Question 8

S/E transient ECT

Answer 8

no, headaches, muscle soreness, manic or hypomanic switch

Question 9

Cog s/e ECT

Answer 9

post ictal confusion

retrograde and anterograde amnesia

Question 10

Clinical factors associated with most cog s/e ECT

Answer 10

Age
pre-existing cog impairment,
bitemporal ECT

Question 11

1st line ECT

Answer 11

BP RUL 5-6 x seizure threshold

BP BF 1.5-2 x seizure threshold

Question 12

Clinical indicators for ECT as 1st line trx

Answer 12

Acute suicidal ideation, psychotic features, trx resistant, repeated rx intolerance, catatonic, pregnancy, prior favorable response, rapidly deteriorating physical status, pt preference

Question 13

rTMS, mechanism

Answer 13

Look for a motor twitch= motor threshold when put coil on motor cortex. Magnetic coil delivers electromagnetic pulses, induces electricity in synapses of superficial neutrons in dorsal lateral prefrontal cortex= excitatory or inhibitory effect= strengthen or weaken synaptic connections. Excitability of the brain is maintained beyond the time of stimulation. Facilitation of monoamingergic neurotransmission + modulation of synaptic plasticity.

Question 14

rTMS therapy

Answer 14

20-30 daily treatments, 30 minutes each 
sequential/ bilateral
10 Hz DLPFC, left because is hypoactive in depression 
1 Hz DLPFC
theta burst

Question 15

s/e of rTMS

Answer 15

mild and temporary headache

mild and temporary no and dizziness

Question 16

contraindications rTMS

Answer 16

intracranial metallic or magnetic pieces
pacemakers
history of seizures or epilepsy or 1st degree relatives
Rx
pregnant, child bearing potential

Question 17

rTMS CANMAT

Answer 17

1st line for people who have failed one antidepressant trial

Question 18

1st line rTMS

Answer 18

High frequency L DLPFC
Low frequency R DLPFC
Stimulate at 110-120% of motor threshold

Question 19

rTMS, after 6 months, x% have relapsed

Answer 19

50%

Question 20

tDCS, mechanism

Answer 20

transcranial direct current stimulation. very small current. 1-2 mamps continuously = alter the membrane potential = more neutrons reach the threshold to depolarizes= neuroplastic effects. Anode decreases resting membrane potential, cathode increases membrane potential = hyperpolarisation.
Target L DLPC.

Question 21

s/E of tDCS

Answer 21

tingling, itching, headache, burning under electrodes (need to be moist), dizziness