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Few substances are as enigmatic as ketamine. Is it an effective anesthetic? A useful tool for the psychiatrist? A doorway to transcendence and spiritual awakening? A dangerously addictive drug? The opinions are as plentiful as the individuals who encounter it. As its use in the psychiatric setting expands, however, it's important for clinicians and patients alike to move past preconceived notions and misconceptions and truly understand ketamine: its history, its uses, its effects, and what the future might hold. They'll find no better resource than Ketamine: The Story of Modern Psychiatry's Most Fascinating Molecule. Meticulously researched, engagingly written, and comprehensive in scope, this book traces ketamine's history, examining: • Its origins as an alternative to PCP as an analgesic and anesthetic• The consequences of its widespread use as a recreational drug• Its complex pharmacology• Its role in understanding and treating schizophrenia• Its use to manage chronic pain, depression, anxiety disorders, and other conditions Each chapter beings with key points that frame the discussion and synthesize the information that follows. The guide concludes with hundreds of references that invite the reader to further study. Far from simply a dry chronology of ketamine, this book is a well-rounded exploration of a substance of tremendous consequence to psychiatry and neurology alike.

Even with the rise of newer neuropsychiatric brain stimulation methods, electroconvulsive therapy (ECT) remains a widely used treatment for severe mental illness -- and perhaps the most effective for serious mental illness. Optimal treatment requires that psychiatrists be skilled in diagnosis and familiar with the techniques of treatment. That's where Principles and Practice of Electroconvulsive Therapy comes in. With its up-to-date, comprehensive coverage of all aspects of ECT, this is an unrivaled resource for psychiatrists, whether in practice or still in training, striving for maximum treatment efficacy. The book begins with an overview of what ECT is and how it is carried out, followed by a brief history of the therapy, from its earliest applications to its use in modern times. The guide follows the typical course of treatment, discussing the following: • Understanding the indications for ECT and selecting patients who might benefit from this therapy -- whether they suffer from depression, mania, schizophrenia, or catatonia• Educating patients and their families on ECT and obtaining patient consent• Conducting a pretreatment medical evaluation and understanding the role of anesthesia• Managing an individual ECT treatment, including choosing the electrical stimulus dose and parameter combination, delivering the electrical stimulus, assisting with recovery problems, etc.• Overseeing the course of treatments, particularly for practitioners not personally conducting the treatments• Managing patients after a course of treatments and preventing relapse• Assessing and managing the memory side effects of ECT The final chapter examines other neuropsychiatric stimulation therapies in relation to ECT and explains how to choose among them. All chapters conclude with easily referenced key points that summarize the most salient ideas. Readers seeking to further educate themselves on ECT will also benefit from the exhaustive reference list. Though particularly useful for psychiatrists and psychiatric residents, Principles and Practice of Electroconvulsive Therapy, with its straightforward style, is a ready resource for any mental health or medical professionals interested in ECT.

To assess the psychiatric side effects of ketamine when administered in subanesthetic doses to hospitalized patients. It is hypothesized that such effects occur frequently. In this retrospective study, the medical records of 50 patients hospitalized on medical and surgical units at our facility who had continuous intravenous infusions of ketamine for pain or mild sedation were reviewed. Patient progress in the days following the start of ketamine infusion was reviewed and response to ketamine was noted. Twenty-two percent of the patients were noted to have some type of psychiatric reaction to ketamine, including agitation, confusion, and hallucinations. These reactions were relatively short lived, namely, occurring during or shortly after the infusions. No association was found between patient response to ketamine and gender, age, or infusion rate. Awareness of the psychiatric side effects of ketamine is an important consideration for clinicians administering this medication either for pain control or for depressive illness.

Little is known about the safety of electroconvulsive therapy (ECT) in patients with severe aortic stenosis and depression and other psychiatric syndromes. We conducted a retrospective review of the medical records of 10 patients with severe aortic stenosis who underwent ECT at Mayo Clinic, Rochester, MN, between January 1, 1995, and June 30, 2006. Of the 10 patients, 6 (60%) were women. The median age was 79.5 years (range, 65-93 years). All patients had an aortic valve area of 1.0 cm2 or less (median, 0.9 cm2 ). The median aortic transvalvular pressure gradient was 43.5 mm Hg (range, 32-58 mm Hg). The 10 patients underwent a total of 144 ECT sessions (range, 1-37 sessions per patient). Despite this large number of sessions, only 2 patients experienced single episodes of blood pressure perceived to be low 1 minute after an electroshock; these episodes were successfully treated. Hypertensive systolic blood pressure (>180 mm Hg) and tachycardia (>100 beats/min) in response to ECT prompted treatment in 7 patients during 70 ECT sessions (49%). None of the patients died within 24 hours after dismissal from the postanesthesia care unit (95% confidence interval for death rate per person, 0%-26%). Hence, ECT was safe in 10 patients with severe aortic stenosis treated at our institution. Our findings may be informative to clinicians who manage the care of patients with severe aortic stenosis who are undergoing ECT.

The use of the word \"melancholia\" or its variants is quite old in the English language, originally referring to a variety of dysphoric states of everyday life. With the development of psychiatry as a branch of medicine in the late 18th century, melancholia was used in a medical context to describe morbid states of depressed mood and associated features. The concept of melancholia as a specific subtype of a broader illness known as \"depressive disorder\" is fairly recent in modern psychiatry, arising predominantly in Great Britain and becoming a formal part of mood disorder nosology in 1980 with the DSM-III. Despite attempts to validate the concept of melancholia as an illness separate from nonmelancholic depression, no consensus has been reached. In this article, the author outlines what he believes are methodological problems that have been common in research studies to validate melancholia.

Electroconvulsive therapy (ECT) is an effective treatment for major depression. Optimising efficacy and minimising cognitive impairment are goals of ongoing technical refinements. To compare the efficacy and cognitive effects of a novel electrode placement, bifrontal, with two standard electrode placements, bitemporal and right unilateral in ECT. This multicentre randomised, double-blind, controlled trial (NCT00069407) was carried out from 2001 to 2006. A total of 230 individuals with major depression, bipolar and unipolar, were randomly assigned to one of three electrode placements during a course of ECT: bifrontal at one and a half times seizure threshold, bitemporal at one and a half times seizure threshold and right unilateral at six times seizure threshold. All three electrode placements resulted in both clinically and statistically significant antidepressant outcomes. Remission rates were 55% (95% CI 43-66%) with right unilateral, 61% with bifrontal (95% CI 50-71%) and 64% (95% CI 53-75%) with bitemporal. Bitemporal resulted in a more rapid decline in symptom ratings over the early course of treatment. Cognitive data revealed few differences between the electrode placements on a variety of neuropsychological instruments. Each electrode placement is a very effective antidepressant treatment when given with appropriate electrical dosing. Bitemporal leads to more rapid symptom reduction and should be considered the preferred placement for urgent clinical situations. The cognitive profile of bifrontal is not substantially different from that of bitemporal.

Severe mental illnesses often remain chronic and refractory to medication, leading to substantial morbidity and mortality. For more than 60 years, electroconvulsive therapy has been the only nonpharmacological psychiatric procedure available to treat severe or medication-refractory major depressive disorder and other psychiatric conditions. Memory dysfunction remains the most serious adverse effect, and current research focuses on attempts to ameliorate this complication. Transcranial magnetic stimulation and vagus nerve stimulation, 2 new neuropsychiatric technologies, are emerging as possible additions to our therapeutic armamentarium. Besides providing therapeutic benefits, these 3 methods may help elucidate the pathophysiology of psychiatric illness.

The most common arrhythmia in patients receiving ECT is atrial fibrillation. There are numerous reports of safe use of ECT in patients with atrial fibrillation, but conversion to normal sinus rhythm has been described and the risk of thrombus/embolus formation is also present.7 Thus, maintaining anticoagulation with warfarin or heparin during ECT is usually recommended in such patients.

Electroconvulsive therapy (ECT) is used predominantly to treat major depressive illness but has also been used for chronic pain. ECT causes a variety of neurochemical and neurophysiologic effects, some of which may interact with the pathophysiologic mechanisms in complex pain states. An extensive literature on the use of ECT in pain patients identifies subgroups for whom ECT may result in substantial pain relief. In this article, we review the literature on the use of ECT in pain patients, suggest possible neurobiologic bases for the efficacy of ECT in such patients, and conclude with our recommendations for current clinical practice.

Electroconvulsive therapy (ECT) has been in use since the late 1930s to treat a variety of severe mental illnesses, most notably major depression. Current research efforts focus on patient selection, memory impairment, and high posttreatment relapse rates. Psychopathological factors such as psychosis and severe psychomotor retardation predict favorable response to ECT in depression. Technical variables that affect memory include electrode placement, stimulus intensity, and treatment frequency. Strategies to reduce posttreatment relapse rates include maintenance ECT and aggressive medication combinations. In this article, I review recent research that bears on these aspects of ECT practice. Additionally, I review some findings on the neurobiological effects of ECT.