Only a few ECTs via right unilateral electrode placement have been carried out in Japan. Right unilateral stimulation induces generalized seizure following stimulus focused on the nondominant hemisphere. Bilateral ECT, generally used today, more rapidly improves symptoms, but more often and severely shows adverse cognitive effects than unilateral ECT. The seizure threshold is lower in the right unilateral ECT, and 2.5-6 times the seizure threshold is required for clinical efficacy. This stimulus intensity is called the therapeutic threshold. To determine the therapeutic threshold, dose-titration is recommended as a stimulus dosing method. In the initial session, starting with an energy setting of 5% (10% in elderly patients) with Thymatron System Ⅳ, clinicians must give stimulations by 10%, 20%, 30% in succession until seizure occurs, when stimulation is stopped. The stimulation dosage at which seizure occurs is considered the patient’s seizure threshold. In the next session, 2.5-6 times the threshold should be given. In contrast, the “Thymatron System Ⅳ Instruction Manual” published by Somatics LLC recommends setting the % dial to the patient’s age in years in the initial session and, if a satisfactory seizure is not obtained, to 100% in the same or next session. Which is the better method still appears controversial. Electroencephalographical evaluation of seizure adequacy, such as regular activity with high amplitude and great post-ictal suppression, is also important.

To ensure good clinical efficacy following electroconvulsive therapy (ECT), adequate therapeutic seizures must be induced using a stimulus intensity that appropriately exceeds seizure threshold. However, it is not uncommon to fail to elicit adequate therapeutic seizures even at the maximum stimulus charge. Right unilateral ultrabrief pulse (RUL-UBP) ECT is an emerging treatment option demonstrating evidence of reduced cognitive side effects. Previous studies have demonstrated that seizure threshold is lower in patients treated with RUL-UBP ECT than in those treated with conventional ECT. For this reason, RUL-UBP ECT may be beneficial for patients in whom seizure induction is difficult with conventional ECT. This case report illustrates a patient suffering from catatonic schizophrenia in whom bilateral brief pulse ECT failed to induce seizures at the maximum charge. However, RUL-UBP ECT successfully elicited therapeutic seizures and enabled the patient to achieve complete remission. Switching to RUL-UBP ECT could be a new alternative for seizure induction in clinical practice.

The presence or absence of generalized seizures is assumed to be a major factor affecting the efficacy of electroconvulsive therapy (ECT). Not only patient factors but also psychiatric drugs have a great effect on the onset of generalized seizures. In addition, the anesthesia procedures and anesthetics, which are essential in nonconvulsive procedures, are also known to play roles in the onset of generalized seizures. Here we outline the influence of anesthesia procedures such as hyperventilation on convulsive seizures, as well as other influential factors, including the most frequently used anesthetics such as propofol and thiopental for ECT in Japan, combined use of intravenous remifentanil and dexmedetomidine, and ketamine anesthesia.

Electroconvulsive therapy (ECT) demonstrates remarkable effectiveness and rapid onset of action without absolute medical contraindication. Therefore, many psychiatrists consider it is relatively safe and easy therapeutic option. However, various adverse effects including hypertension, arrhythmia, asystole, delirium, amnesia, persistent apnea may occur. Anesthesiological risk should be considered because of marked fluctuation in circulation during a short treatment time. We present a case of dementia with Lewy body complicated with pneumonia, electrolyte imbalance, and deep vein thrombosis to review pretreatment assessment, expected adverse effects, preventive planning and informed consent for safe ECT.

Electroconvulsive therapy (ECT) is the most promising therapeutic modality for drug-resistant major depressive disorder (MDD). However, it has been reported that almost 40% of ECT-treated MDD patients experienced a relapse within 6 months. Major Randomized Controlled Trials recommended the combination of lithium (Li) and an antidepressant was more effective for maintenance therapy of post ECT MDD than an antidepressant alone. Moreover, a recent meta-analyses recommended that maintenance electroconvulsive therapy (M-ECT) combined with pharmacotherapy maintains significantly higher remission rates than pharmacotherapy alone since acute ECT was introduced. The factors causing a relapse of depression following ECT has not been assessed in some detail. Relapse often occurs after inadequate ECT, after a partial remission caused by the inadequate remission assessment with a combination pharmacological therapy during ECT, or after misdiagnosis. We found a significantly higher relative risk rate of developing bipolar disorder (BP) in the patients experienced a relapse of depression within 3 months after initial course of ECT than in those without relapse (RR = 2.91, 95% CI = 1.59-5.33). M-ECT combined with Li in maintenance therapy could be useful for maintaining remission of drug-resistant MDD, because both M-ECT and Li could prevent not only depressive but manic episodes. However, even if there is an increased risk of initial recurrence of episodes, minimum prescription or ECT for maintaining remission of MDD with achieving adequate diagnosis could reduce physical and economical adverse consequence of treatments and contribute to long-term QOL and ADL improvements of MDD and BP patients.

The mesolimbic dopamine (DA) system is associated with pathogenesis of schizophrenia. We examined DA-containing neuronal structures of the ventral tegmental area (VTA) of 7 autopsy cases of schizophrenia aging from 24 to 78 (post-mortem period (PMI): 4-13 hours), and 5 control cases aging from 24 to 64 (PMI: 4-5 hour), using tyrosine hydroxylase (TH) immunohistochemistry. Three cases among schizophrenia group were leucotomized. A free floating method using 50-µm cryostat sections and three dimensional imaging analyzer AxioVision were applied to observe a wide range neuronal structures. In a case of a disorganized type (75-year-old female), TH-ir neuronal cell bodies in the VTA had an irregular shape and varied in sizes, and TH-ir nerve fibers were waved or formed straightened bundles running across each other. In a case of an undifferentiated-type (51-year-old female), the VTA contained various-sized TH-ir cell bodies, thick processes, and fibers having irregular thickness and a curved shape with many corners, when compared to controls with no detectable neuropsychiatric diseases. The VTA of a leucotomized case of a paranoid type (78-year-old female) contained TH-ir neurons of irregular shapes and various sizes, and also coiled-shaped or nappy fibers, suggesting wallerian degeneration. Morphological findings of TH-ir neurons differed between cases. The size of the VTA TH-ir cell bodies of the schizophrenia showed a tendency to be smaller than that of the controls. Generally, the VTA of schizophrenia contained morphologically heterogeneous TH-ir neurons of irregular shapes and various sizes, TH-ir fiber bundles, and straightened, curved or woven shaped fibers. The mechanisms underlying these characteristics of DA neurons of schizophrenia should be elucidated epigenetically as well as genetically.

This study used a qualitative approach to investigate differences in return to work by workers that had taken leave for mood disorders. Data from semi-structured interviews conducted with participants (N = 10) that were reinstated or not reinstated after leave were categorized by using the KJ method. This method generated 93 small, 35 medium, and 7 large categories. The number of categories between the two groups were analyzed, which indicated that workers reinstated after leave resulted in significantly more categories concerning support in the workplace, whereas workers that were not-reinstated resulted in significantly more categories concerning the degree of stress and inadequate support in the workplace. Therefore, it is suggested that offering psychological treatment for patients with mood disorders and supporting them in the workplace are both necessary to facilitate patient reinstatement.

“Epileptic psychosis” is a generic term comprising several clinical states that have various etiologies and need different treatments, such as postictal psychosis and interictal psychosis. In this paper, we presented a case of interictal psychosis in which the psychotic symptoms showed insidious onset a dozen years after alleviation of epileptic seizures and elicited sudden and repetitive suicidal behavior in the patient. In spite of the involvement of several general psychiatrists in the treatment of this case, several years were required to arrive at an accurate diagnosis and treatment. The number of psychiatrist in Japan specializing in epilepsy has been decreasing. On the other hand, treatments for epileptic psychosis continue to be in demand even in general psychiatric departments. Thus knowledge about epileptic psychoses, a regularly encountered form of organic psychosis, should be shared by more psychiatrists. With this purpose in mind, we summarized the considerations and pitfalls in the treatment of epileptic psychoses.

A 57-year-old woman with a 15-year history of post surgically treated right temporal lobe epilepsy and subsequent chronic psychosis controlled on carbamazepine (CBZ), valproate (VPA), and bromperidol was seen for a regular medical check-up. CBZ was increased in dosage 7 months prior to admission. Laboratory tests taken after an 11-month interval showed an increase in serum creatinine (1.2 mg/dl) compared to baseline concentration (0.6 mg/dl), without any systemic manifestations such as fever and rash. CBZ and VPA were discontinued in suspect of drug-induced renal impairment, and lamotrigine was initiated for replacement. Histological confirmation of acute interstitial nephritis (AIN) was made by renal biopsy. Elevated levels of indicator proteins for renal tubular dysfunction decreased after discontinuation of CBZ, albeit with kidney injury remaining thereafter. Recently, complications among those receiving long-term therapy by conventional antiepileptic drugs are becoming an increasing concern, and it is of interest to psychiatrists in the general hospitals to manage such potential harm. Herein we report a case of drug-induced AIN, with CBZ being the probable cause. As AIN presents with non-specific symptoms, delays in recognition are common and may result in serious kidney injury. Therefore, even among patients with a stable course, regular laboratory evaluations are warranted to recognize any early organ involvement when changes in medication are made.

Steroid psychosis is a well-known mental disorder; it is one of the side effects of taking adrenocortical steroid drugs. We present the case of a male who developed steroid psychosis and was successfully treated by modified electroconvulsive therapy (m-ECT). Our case was a 23-year-old male with no psychiatric history. He was initially active; however, he developed depressive illness after steroid pulse therapy for nephrotic syndrome. His depressive symptoms persisted even after discontinuation of steroids; internal medications of antidepressants and antipsychotic drugs were initiated, but the symptoms did not improve. However, the symptoms dramatically improved by m-ECT. After m-ECT, he was transitioned to lamotrigine for maintenance therapy. We report the case of a patient with depressive illness who did not improve even after steroid discontinuation, possibly representing a steroid psychiatric disorder due to drug resistance. The maintenance therapy was successful, indicating that mood stabilizers could be effmective. m-ECT is a valid treatment method for treating steroid psychosis.