Electroconvulsive therapy (ECT) was first developed in Italy in 1938 and has been widely used, with some modification of its methods, for the treatment of refractory mental disorders. Although ECT was introduced in Japan as early as 1939, its safety has not been improved for a long time. Brief-pulse ECT was approved in 2002 under conditions in which well-trained psychiatrists should administer ECT and in which modified ECT would be mandatory. As a consequence, the image of ECT has been improved, and more and more studies on ECT have been published in international journals. However, not a few unmodified ECT procedures are still performed in Japan. We have to improve safety and efficacy of ECT further.

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Modified electroconvulsive therapy (m-ECT) is administered under general anesthesia with intravenous anesthetics and muscle relaxants to reduce patient anxiety and avoid adverse events such as bone fractures. Improvements in anesthetic techniques have been made with the use of new drugs and strategies aimed at preventing complications. It is necessary to further improve the safety of this treatment modality by careful assessment of each patient's systemic condition by fostering close cooperation between anesthesiologists and internists.

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To optimize the effectiveness of pulse-wave electroconvulsive therapy (ECT), determination of seizure adequacy and methods of stimulus dosing are essential. In Japan, however, this has been poorly recognized. There are four important points in the clinical practice of pulse-wave ECT. The first is to determine seizure adequacy by confirming ictal “regularity” and greater postictal suppression on electroencephalogram instead of measuring seizure duration. It is very unfortunate that not a few Japanese psychiatrists still believe that a longer duration indicates seizure adequacy. When the stimulus is barely suprathreshold, increasing stimulus intensity is associated with a longer seizure duration. However, when the stimulus greatly exceeds the seizure threshold, the higher the intensity becomes, the shorter the seizure duration is expected to be. The second is to induce adequate seizures at a stimulus intensity above the “therapeutic threshold,” which means 1.5 to 2.5 times above the seizure threshold in bilateral electrode placement. Given that the seizure threshold rises through the ECT course in an unpredictable fashion, it is appropriate to increase the stimulus dose by 1.5 times the previous dose during the following session after an inadequate seizure, which is considered a product of barely suprathreshold stimulation. The method of increasing the dose by 5 to 10% (with Thymatron System IV), often observed in Japanese clinical settings, is considered inappropriate. The resulting barely suprathreshold seizure is not effective and can be a prolonged or late seizure. Starting ECT at maximum dose of 100% is also irrational, because the fixed high dose may not only accentuate cognitive disturbances but also enhance the extent and speed of the rise of the seizure threshold. The third is to use the optimal class and dose of anesthetics and stop administering benzodiazepines (BZ), in order to avoid possible rise of the seizure threshold. If BZ is hard to discontinue, flumazenil is recommended as pre-anesthetic agent. The fourth is to apply augmentation methods of seizure induction (if necessary) including oral theophylline the night before ECT. ECT is no doubt an essential treatment in psychiatry. These above techniques and methods do support its effectiveness and safety.

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ECT is unique and one of the most effective somatic therapy in psychiatry; however, biomarkers for ECT outperforming clinical indication have not been established. Near Infrared Spectroscopy (NIRS) is a non-invasive method to measure blood flow in the human brain; in Japan, this method has been identified as a tool for an adjunct to the diagnosis of psychiatric disorders. To examine whether NIRS can be useful as a biomarker for ECT, we investigated the changes in the regional cerebral blood flow (rCBF) in the prefrontal cortex (PFC) using NIRS in comparison between schizophrenia and mood disorders. The rCBF caused by bilateral ECT at the PFC increased during ECT and there was a left dominant asymmetric alteration of rCBF for schizophrenia. The asymmetric alteration appeared not to be state-dependent, rather trait-dependent. Because the asymmetry alteration was negatively correlated with the period of illness for schizophrenia, but not with any other clinical data, the left dominant asymmetric hemodynamic response might be a marker of schizophrenia, especially in the early stages. These results indicate the possibility that the ECT-induced hemodynamic response using NIRS might be useful for adjunct estimation of diagnosis and symptoms and further study is needed.

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ECT is effective for treatment-resistant depression, schizophrenia, and catatonic features. A number of psychiatric diseases and related conditions do not sufficiently respond to current pharmacotherapy. To release patients from suffering, various treatments have been tried. Neuropathic pain, fibromyalgia, and Parkinson's disease with psychotic symptoms are the cases. We discuss herewith the effectiveness of ECT on neuropathic pain, such as postherpetic neuralgia and post-operative thoracotomy pain syndrome, fibromyalgia, and Parkinson's disease with psychotic symptoms, showing changes in regional cerebral blood flow.

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Aims: The objectives of the present study were to clarify eating problems, depressive and dissociative tendencies, and the experiences of intentional self-harm in Japanese early adolescents with insulin dependent diabetes mellitus (IDDM). Methods: Subjects consisted of 24 early adolescents (age 10-15 years) who had IDDM. A total of 1109 students in grades 5 to 9 in Yokohama were used as controls. They were assessed with anonymous self-reporting questionnaires including questions about the Eating Attitudes Test26 (EAT26), the Depression Self-Rating Scale for Children (DSRSC), the Adolescent Dissociative Experiences Scale (A-DES), and the experiences of intentional self-harm. The IDDM patients and the control group were compared. Results: The IDDM patients had a higher proportion of the EAT26 which exceeded the cut off score. There were no significant differences between the scores of the DSRSC and the A-DES, and the scores of those who experienced intentional self-harm. Furthermore, the score of the EAT26 was correlated with the score of the DSRSC. Conclusions: The IDDM patients in early adolescence are likely to coexist with eating problems. Depressive tendencies are likely to be correlated with eating problems.

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Functioning as a regional acute care hospital, our emergency medical center widely accepts patients in primary ~ tertiary emergencies. A preliminary study revealed that 18.5% of all inpatients experience delirium which is similar to the percent reported by other institutes. The study also states that half of falling accidents among the incident cases occurs during periods of delirium. Because delirium greatly complicates medical management, detection and intervention to prevent delirium in its early stage is important. In 2009, we and other medical professionals formed a delirium care team (DCT), whose main goal is the prevention of occurrence and worsening of delirium by early intervention. Our DCT consists of psychiatrists, nurses, pharmacists and physical therapists. DCT members make the rounds of all wards every day, consulting with inpatients with delirium or a high risk of delirium. The DCT arranges medication, reinforces cognitive orientation, estimates pain and educates inpatients and their relatives about delirium. DCT members hold a conference about inpatients with delirium every month. Once a year, an educational conference about delirium is held for the hospital staff. Because many wards rely on DCT activities for a rapid response to delirium, team intervention to prevent delirium can decrease psychological distress of the hospital staff caring for inpatients with delirium. The number of interventions by the DCT has been increasing reaching 413 inpatients in 2011. Based on our recent experience, the DCT has been most successful in preventing the worsening of delirium rather than preventing delirium itself. Because our hospital is obligated to treat emergencies, making the rounds of the wards by the DCT consisting of various medical professions has made a significant contribution to the treatment of delirium.

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We present a case of a terminal cancer patient who resisted therapeutic interventions and attempted suicide, and discuss an psychotherapeutic approach to terminal cancer patients. It was challenging to deal with this patient, because psychological symptoms were not properly controlled for various reasons, such as a strong sense of resistance toward psychological interventions, disturbance of consciousness caused by delirium, and initiation of the treatment without sufficient prognosis notification. However, since the health care providers involved strove towards a multilevel understanding of the patient, accurately evaluated changes in psychological symptoms or physical states, and steadily continued to provide appropriate supportive interventions, psychological symptoms were reduced before the patient's death. The provision of stable treatment structure and a sympathetic attitude along with a deep understanding based on supportive psychotherapy may facilitate the support of such patients.

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