News & Notes printer version TRAINING IN ECT THEORY & PRACTICE We are frequently asked by psychiatrists from all over the world where they can obtain formal post-graduate training in ECT. We recommend the Visiting Fellowship in Electroconvulsive Therapy, a certificate course given quarterly at New York State Psychiatric Institute-Columbia University Department of Psychiatry under the direction of noted ECT expert Dr. Joan Prudic. Attendance for this week-long, 8 AM - 5 PM fellowship is limited to 4 professionals per course, so the experience is intense and individualized. The course dates already set for this year and next are: July 23-27, 2007; October 22-26, 2007; January 14-18, 2008; April 21-25, 2008 At the conclusion of the course, attendees receive a certificate, 41.5 CME credit hours, a copy of the APA Task Force Guidelines on ECT, and a CD containing the lecture slides, readings, self-assessment exam, and handouts. For further information, contact: Joan Prudic, M.D., ECT CME Course Director, 1051 Riverside Drive, Unit 126, New York State Psychiatric Institute, New York, New York 10032 +(212) 543-5616 jp33@columbia.edu The course brochure can be obtained from the DOWNLOADS page on this website top THYMATRON® SYSTEM IV IS ALWAYS STATE-OF-THE-ART Since the Thymatron® System IV was first introduced it has been continually improved and upgraded to meet the expressed clinical needs of its current and prospective users. Each upgrade is accomplished by a simple microchip replacement in which each new version includes all previous upgrades--the equivalent of having a new device each time. The date of each upgrade and what it accomplished is as follows. 6/99 Software made DOS-compatible 9/00 Real time EEG-ECG monitoring via PC screen; Data upload to Palm® computer 5/01 Diagnostic messages revised for auto EEG endpoint report 8/01 LOW 0.25 program introduced to automatically select best frequency and duration at each ultrabrief dosage 5/02 Automatic data upload to PC replaces manual upload; Seizure Energy Index algorithm improved; Seizure Generalization Index retired; Impedance test signal increased to more efficient 800 Hz 11/02 Anesthesia Depth Monitor introduced 2/03 Eliminated need for recalibration after chip upgrade 7/04 Algorithm improved and refined for Postictal Suppression Index; Treatment program made selectable via Percent Energy Dial; EEG gain made adjustable during recording 5/06 Percent Energy dial made fine-tunable (1% increments) up to 10% 7/06 0.3 ms ultrabrief stimulus choice added to existing 0.25 ms 2007 Tell us what you need The Thymatron® System IV is the World's Only ECT Instrument that Never Can Become Obsolete top PROBLEMS WITH THE MECTA SPECTRUM 5000Q 1. Mecta Spectrum's top stimulus dose is weak. Millicoulomb for millicoulomb the Thymatron® is 42% more effective at inducing seizures than the Mecta (Chanpattana 2001; Swartz 2006). The extra strength of the Thymatron® stimulus helps get effective treatments in older patients and towards the end of longer treatment courses. 2. Mecta's top stimulus dose uses a 1 ms or wider pulsewidth. This is far less efficient than the 0.5 ms pulsewidth of the standard Thymatron® stimulus (Swartz, 2000). If you choose Mecta's 0.5 ms pulsewidth you are limited to half the maximum dose, just 288 mC. 3. It is far too easy to make a mistake setting the Mecta stimulus. It has 4 separate knobs that each change stimulus dose. Because each additional knob doubles the chance of an unintended setting, the Mecta Spectrum's 4 knobs make errors 8 times more likely. 4. Are you sure which of the four Mecta knobs to turn to increase or decrease the stimulus dose, and in what order? Mecta's method for doing this is complex, contrived, hard to remember, and without scientific basis. Because just one knob adjusts stimulus dose on the Thymatron®, and a scientifically-based program automatically selects the best frequency and pulsewidth at each setting, you can always be sure of giving the best possible treatment at each dose. top ULTRABRIEF NOT YET ROUTINE Although there has been much promotion lately of a clinical advantage for ultrabrief (e.g., <0.5 ms) stimuli for ECT, the simple fact is that there is no published data. Nothing supports the claim that pulsewidths in the 0.25 to 0.3 ms range can achieve similar clinical improvement as pulsewidths of 0.5 to 1.0 ms range, long the standard for ECT. Preliminary data were presented at the 2001 meeting of the Association for Convulsive Therapy (Sackeim et al, 2001), but 5 years later this pilot work has still not been verified by publication of a completed study. The data have never materialized. Moreover, this pilot study did not compare ultrabrief stimuli against 0.5 ms pulsewidth stimuli, which are the standard for comparison. This absence of data makes any ultrabrief stimulus primarily an investigational tool, regardless of ECT device. Without data its clinical use appears justifiable only for those patients who have shown unusual or unacceptable cognitive side-effects with standard pulsewidths. We say this even though the Somatics’ Thymatron® System IV was the first modern ECT device to provide an ultrabrief stimulus (0.25 ms pulsewidth), and is the only instrument that can deliver its ultrabrief stimulus across the entire dosage range. If you choose the Mecta's 0.3 ms stimulus you are limited to a maximum dose of 460.8 mC, compared with 504 mC for the Thymatron® System IV. The standard stimulus of the Thymatron® System IV is a 0.5 ms brief pulse delivered via a special program (LOW 0.5) that automatically adjusts frequency to maximize stimulus train duration at every dose. This is the most effective way to administer ECT because, other things being equal, longer stimulus trains are more effective than shorter ones (Abrams, 2002). The only ECT instrument that can deliver its maximum dose at 0.5 ms pulsewidth is the Somatics Thymatron® System IV. top MECTA CORPORATION ABANDONS SR-1 OWNERS According to a recent notice from Mecta Corporation, if your hospital owns a Mecta SR-1 (or SR-2, JR-1, JR-2) you are faced with the problem that you will no longer be able to get it checked or serviced by the manufacturer, and parts are not available. Is it medically prudent to continue using your old Mecta under these circumstances? Somatics can help you solve this problem: On your request we will immediately ship you a Thymatron® System IV to use for 30 days at no cost, and give you a $500 allowance for your old SR-1 (SR-2, JR-1, JR-2) if your hospital purchases the Thymatron® System IV. Call David Mirkovich at 1(800)642-6761 today to find out more about this offer. This offer applies only to US/Canadian hospitals and may be withdrawn without notice at the discretion of Somatics top GOOD NEWS FOR THYMATRON® DGx FANS If you’re a dyed-in-the-wool Thymatron® DGx fan who’s been holding off on upgrading to a Thymatron® System IV because of apprehension over having to acquire new skills, we have good news: a simple click of the System IV’s FlexDial™ reproduces the standard stimulus of the Thymatron® DGx, allowing you to treat patients just as you’ve always done. (And you can monitor with just 1 or 2 channels, too!) top THYMATRON®-BASED STUDY RECOMMENDS ROUTINE EEG MONITORING FOR ALL UK ECT CLINICS A recent study headed by a core member of the Special Committee on ECT of the UK's Royal College of Psychiatrists has concluded that EEG should be routinely monitored during ECT. Using a Thymatron® ECT instrument Dr. Susan Benbow and colleagues (2003) measured EEG seizure threshold and duration during 95 courses of ECT in 67 patients and found that almost 20% of ECT courses included at least one prolonged seizure, defined as lasting longer than 120 s. Most importantly, during 19 individual treatments without an observed motor seizure, EEG seizure duration varied from 16 to 123 s., demonstrating conclusively that observation of the motor seizure alone is inadequate for determining whether a cerebral seizure—even one that is prolonged—has occurred. In their study, the authors relied on the EEG seizure endpoint as automatically determined by the Thymatron®, because not all the doctors administering ECT in the study were trained to interpret EEG recordings clinically. The authors recommend that the Royal College of Psychiatrists’ ECT Guidelines should include a requirement for routine EEG monitoring in all UK ECT clinics. top THYMATRON® IDEAL FOR SCANDINAVIAN ECT TECHNIQUE For more than 40 years Professor Jan-Otto Ottosson of Sweden has recommended a unique method for administering ECT that uses the observation of a strong plantar flexion response as a guide to ECT stimulus adequacy. (In fact, he and his colleagues considered this method so important that they published versions in Swedish, Danish, and English: d’Elia, Ottosson, and Strömgren, 1982; 1982; 1983). First introduced using the old partial sine-wave Siemens Konvulsator, Professor Ottosson’s method consists simply of setting stimulus duration to the maximum and then pressing and holding down the stimulus delivery button while observing the patient’s feet. When a pronounced and persistent plantar flexion response is observed, the stimulus button is then released, terminating stimulation. (In fact, although Siemens discontinued manufacture of the Konvulsator almost 20 years ago, some Scandinavian doctors still retain their old devices in order to be able to use this particular method.) The good news is that the Thymatron® System IV can be used exactly as the old Konvulsator: Just set the Thymatron® to deliver its maximum stimulus duration of 8 seconds and then press the TREAT button while observing the patient’s feet. As soon as the desired degree of plantar flexion is observed, remove your finger from the TREAT button to terminate stimulation—achieving the same result as with the Konvulsator. Moreover, the Thymatron® System IV also features an intermittent stimulus mode that is modeled after the intermittent stimulus of the Konvulsator, allowing Scandinavian doctors to essentially duplicate all of the Konvulsator’s perceived advantages while using the latest modern equipment (in fact, the Thymatron® is the only ECT device manufactured today that offers an intermittent stimulus mode). top ANESTHESIA DEPTH MONITOR NOW INCLUDED! When the anesthetic Brevital© (methohexital) suddenly became unavailable in late 2001, many doctors switched to propofol (which is now used in many if not most ECT units worldwide). Propofol is more problematic to use than methohexital because it has a biphasic action and can shorten seizures. Because of this an increasing number of doctors--especially anesthesiologists--have been using costly OR monitors to measure depth of anesthesia for ECT (e.g., the Aspect© monitors, which incorporate their patented Bispectral Index©, or BIS©). The good news is that Somatics has now incorporated an EEG Anesthesia Depth Monitor into the Thymatron® System IV at no increase in price. This feature allows the doctor to select a continuous display in the 8-character LED of one of 3 monitoring measures: 95% Spectral Edge Frequency (SEF-95), relative delta power (% delta), or median frequency (MF), each of which has been shown in several studies to correlate with anesthesia depth and with the BIS© (Billard et al, 1997; Alkire, 1998; Hirota et al,1999; McDonald et al, 1999; Sakai et al, 1999; Singh et al, 1999; Hans et al, 2001; Kuizenga et al, 2001; Koitabashi et al, 2002). Of the 3 measures, the SEF-95 (which is the EEG frequency below which 95% of the EEG power is contained) has been most thoroughly documented and remains widely-used throughout the world today; it is useful with all anesthetic agents. This remarkable new upgrade is a prime example of how Somatics is continually improving its products in response to the needs of practicing clinicians--it is the latest in a long series of important upgrades introduced for the Thymatron® System IV. top THYMATRON® SAFETY VERIFIED BY MRI SPECTROSCOPY Ende et al (2000) recently used proton magnetic resonance spectroscopic imaging to study hippocampal effects of ECT given with a Thymatron® instrument. In 17 patients receiving either unilateral or bilateral ECT (all of whom improved with treatment), no differences were found from 30 control subjects in hippocampal N-acetylaspartate signals, supporting numerous earlier studies failing to find evidence for central nervous system abnormalities after ECT (Abrams, 1997). top MECTA PATENT #5,626,627 PROVIDES USELESS SEIZURE MEASURE According to the MECTA’s Instruction Manual for the Spectrum 5000, a "stimulus adequacy" measure (pat. # 5,626,627) is available as a costly optional extra. This measure ranges from 0-99%. MECTA claims that “higher numbers [are] associated with a greater likelihood of seizure adequacy”. But is this true? Mecta admits that “The stimulus adequacy measure provides an estimation, for both unilateral and bilateral ECT, of the likelihood that the induced seizure differs from that associated with barely suprathreshold unilateral ECT (a type of ECT shown by Sackeim and colleagues to be subtherapeutic).” Indeed. Sackeim and colleagues (1987) achieved only a 17% response rate to barely suprathreshold unilateral ECT, lower than response rates reported for sham ECT (Abrams, 1997). Thus, MECTA’s measure actually describes inadequacy: how much the seizure is better than no seizure at all. Because higher numbers reflect only a lesser degree of seizure inadequacy, even a result of 99% would just mean that the seizure was 99% less inadequate than no seizure or a subtherapeutic seizure. In marked contrast, the Postictal Suppression Index of Thymatron® instruments (US Pat. #5269302) truly reflects seizure adequacy. A recent study (Petrides et al, 2000) obtained an 85% remission rate in major depressives with a Thymatron®. The average Postictal Suppression Index for these remitters was 87%, significantly higher than for the 15% of patients who failed to achieve remission. The authors concluded: “These data support that higher PSI values (more abrupt ending of ictal EEG) are correlated with better clinical outcome of ECT in depression. This putative marker of seizure generalization may be useful as an index of treatment adequacy.” top MECTA SPECTRUM NO IMPROVEMENT OVER SR-1 In a recent study of ECT-device seizure efficacy Krystal et al (2000) found they had to set their old Mecta SR-1 machine to the maximum dose in 15% of their patients in order to get a barely acceptable seizure, and even at this dose, the MECTA failed to produce adequate seizures 5% of the time. If you were hoping to improve this poor performance by trading in your old SR-1 towards a new Spectrum you will certainly be disappointed. Krystal and Weiner (2001) repeated their study using a Spectrum and got even worse results than with their SR-1 despite the Spectrum's somewhat longer stimulus: 30% of patients now required the maximum dose and 10% failed to obtain adequate seizures. top MECTA SR-1 FORCES USE OF INEFFICIENT STIMULI You knew the MECTA SR-1 was discontinued several years ago, but did you know it was already long obsolete? If your hospital owns an SR-1 the most efficient stimulus you can deliver has a 2-second duration and 1 msec pulsewidth, and it’s just not good enough—here’s why. The Washington University study of Isenberg et al (1996) illustrates this point decisively, because these authors actually compared the MECTA SR-1 with the Thymatron® DGx for efficiency in stimulus induction in a sample of 403 patients. They used the Thymatron® to deliver a 0.5 msec pulse for the longest possible duration (up to 8 sec), and the MECTA to deliver a 1 - 2 msec pulse for up to its 2-second maximum. It was no contest: 80% of patients receiving unilateral ECT with the Thymatron® had seizures with 50 mC or less, compared with only 37% of patients treated with the MECTA. For bilateral ECT, the results were even more dramatic: 100% of Thymatron®-treated patients seized at 100 mC or less (thresholds are higher with bilateral ECT), compared with only 29% of patients treated with the MECTA. Striking confirmation of this result comes from a recent report that titrated seizure thresholds to bilateral ECT were significantly higher with the MECTA SR-1 than the Thymatron® DGx in 79% of patients studied, averaging 61% higher overall despite careful matching of stimuli and patient titration increments (Chanpattana, 2001). [See DOWNLOAD page for PDF file of article] As these studies abundantly demonstrate, inefficient electrical stimuli require higher doses to produce seizures, and unfortunately, higher doses cause more memory and cognitive side-effects without enhancing therapeutic potency (Abrams, 2002). Moreover, because the MECTA SR-1 limits stimulus duration to a maximum of 2 seconds, doctors using it are forced to select the highly-inefficient 2 msec pulsewidth in order to deliver the higher dosages needed for elderly patients or to administer unilateral ECT in the recommended range of 6 times threshold (Sackeim et al, 2000). Incredibly, the Mecta Spectrum is hardly any improvement over the SR-1: you still have to use a 1 or 2 msec pulsewidth to deliver the maximum dose. The amply documented inefficiency of the MECTA SR-1 is doubtless also responsible for its recently reported failure to produce adequate seizures in 5 of every hundred patients treated, and for the necessity of employing the maximum dosage in 72 out of 471 patients (Krystal et al, 2000). It was already suspected over a decade ago that longer stimuli and shorter pulsewidths were most effective for ECT, which is when Somatics first introduced the Thymatron® DGx with its 8-second maximum stimulus and 0.5 msec minimum pulsewidth. Since then, the greater efficacy of longer-duration and shorter-pulsewidth stimuli has been repeatedly confirmed (Swartz and Larson, 1989; Rasmussen et al, 1994; Isenberg et al, 1996; Devanand et al, 1998; Swartz and Manly, 2000; Chanpattana, 2001). The fact is, Somatics Thymatron® instruments are the only ones capable of delivering a 0.5 ms or even a 0.25 msec stimulus over the entire standard dosage range. And, with the new Optimal Charge Rate programs, a single button press assures you of always automatically delivering the most efficient stimulus (Swartz, 1994) at any dose you select Isn’t It Time To Upgrade To A Thymatron®? top contact a Somatics dealer near you links  |  contact us  |  downloads  |  references ©1983-2008 Somatics, LLC.  All rights reserved. The Somatics logo and the Thymatron® name are registered trademarks of Somatics, LLC.