Relapse of severe depression after successful treatment with electroconvulsive therapy (ECT) continues to be a major problem. We review the literature on relapse after ECT and factors that predict relapse. Early studies showed that the relapse rate was approximately 50% without follow-up treatment and that the majority of these relapses occurred in the first 6 months. More recent studies have found even higher rates in delusional depression and possibly in "double depression." Studies of biological markers as predictors of relapse were examined. Six of nine studies of the dexamethasone suppression test and one study of cortisol hypersecretion show that post-ECT nonsuppressors are at higher risk; although insensitive for diagnostic purposes, this test may be useful, when persistently abnormal, as a predictor of relapse. Studies of the thyrotropin-releasing hormone stimulation test and shortened rapid eye movement sleep latency are inconclusive. Medication resistance pre-ECT has been shown to predict relapse in two studies and highlights the need for more aggressive and effective treatment in this group. Further research into the prediction and prevention of depressive relapse after ECT is needed, and the field anxiously awaits current trials comparing ECT with combination lithium and nortriptyline.
The level of clinical skill acquired by trainees in psychiatry for performing ECT is significantly superior using HPS- based training, in contrast to the domains of knowledge and confidence, which appear to be equally imparted using either training modality. The acquisition of skills in administering ECT seems to be an independent variable in relation to a clinician's level of knowledge and confidence in performing ECT.
Quality controls are becoming an important part of our health care system. A medical audit is one way of evaluating quality of care, and this paper describes the results of an audit conducted to investigate the reasons for a prolonged stay on a psychiatric inpatient unit. The results showed a decrease in the mean length of stay over a five year period, although the figure remained substantially above provincial norms. A review of the hospital charts of a random sample of one in six patients whose hospital stay exceeded 30 days was carried out. It revealed that in 50.0% of cases the reasons were "medically acceptable," in 10.3% the reasons were "medically unacceptable" and in 39.7% the reasons were "social and administrative" and beyond the control of the treating psychiatrist. The implication of these results are discussed.
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