Safety and tolerability of repetitive transcranial magnetic stimulation in patients with epilepsy: a review of the literature.

 
: Epilepsy Behav. 2007 May 8; [Epub ahead of print] Related Articles
Safety and tolerability of repetitive transcranial magnetic stimulation in patients with epilepsy: a review of the literature.

Bae EH, Schrader LM, Machii K, Alonso-Alonso M, Riviello JJ Jr, Pascual-Leone A, Rotenberg A.

Department of Neurology, Children’s Hospital, Harvard Medical School, Boston, MA 02115, USA.

Repetitive transcranial magnetic stimulation (rTMS) is emerging as a new therapeutic tool in epilepsy, where it can be used to suppress seizures or treat comorbid conditions such as mood disorder. However, as rTMS carries a risk of inducing seizures among other adverse events, its safety and tolerability in the population with epilepsy warrant distinct consideration, as this group is especially seizure-prone. Accordingly, we performed a review of the literature to estimate the risk of seizures and other adverse events associated with rTMS in patients with epilepsy. We performed an English-language literature search, and reviewed all studies published from January 1990 to February 2007 in which patients with epilepsy were treated with rTMS, and complemented the literature search with personal correspondence with authors when necessary. We identified 30 publications that described patients with epilepsy who underwent rTMS, and noted total number of relevant subjects, medication usage, incidence of adverse events, and rTMS parameters including stimulus frequency, number of stimuli, train duration, intertrain interval, coil type, and stimulation sites. The data were analyzed for adverse events related to rTMS. Crude per-subject risk, as well as per-subject mean risk weighted by sample size and risk per 1000 stimuli weighted by number of stimuli in each study, were computed for seizures and for other adverse events. Adverse events or lack thereof was reported in 26 studies (n=280 subjects). Adverse events attributed to rTMS were generally mild and occurred in 17.1% of subjects. Headache was most common, occurring in 9.6%. The most serious adverse event was seizure during treatment, which occurred in four patients (1.4% crude per-subject risk). All but one case were the patients’ typical seizures with respect to duration and semiology, and were associated with low-frequency rTMS. A single case of an atypical seizure appearing to arise from the region of stimulation during high-frequency rTMS is reported. No rTMS-related episodes of status epilepticus were reported. We cautiously conclude that the risk of seizure in patients with epilepsy undergoing rTMS is small, and the risk of other mild adverse events is comparable to that seen when rTMS is used to treat other diseases. Status epilepticus or life-threatening seizures have not been reported in patients undergoing rTMS treatment. rTMS thus appears to be nearly as safe in patients with epilepsy as in nonepileptic individuals, and warrants further investigation as a therapy in this population.

PMID: 17493877 [PubMed – as supplied by publisher]

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The neurobiological dimension of meditation–results from neuroimaging studies

 
Psychother Psychosom Med Psychol. 2006 Dec;56(12):488-92. Related Articles, Links
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[The neurobiological dimension of meditation–results from neuroimaging studies]

[Article in German]

Neumann NU, Frasch K.

Klinik fur Psychiatrie, Psychotherapie und Psychosomatik am Bezirkskrankenhaus Gunzburg, Abt. Psychiatrie II der Universitat Ulm.

Meditation in general can be understood as a state of complete and unintentional silent and motionless concentration on an activity, an item or an idea. Subjectively, meditative experience is said to be fundamentally different from “normal” mental states and is characterized by terms like timelessness, boundlessness and lack of self-experience. In recent years, several fMRI- and PET-studies about meditation which are presented in this paper have been published. Due to different methods, especially different meditation types, the results are hardly comparable. Nevertheless, the data suggest the hypothesis of a “special” neural activity during meditative states being different from that during calm alertness. Main findings were increased activation in frontal, prefrontal and cingulate areas which may represent the mental state of altered self-experience. In the present studies, a considerable lack of scientific standards has to be stated making it of just casuistic value. Today’s improved neurobiological examination methods – especially neuroimaging techniques – may contribute to enlighten the phenomenon of qualitatively different states of consciousness.

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PMID: 17160792 [PubMed – indexed for MEDLINE]

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Listening to Turkish classical music decreases patients’ anxiety, pain, dissatisfaction and the dose of sedative and analgesic drugs during colonoscopy: a prospective randomized controlled trial.

World J Gastroenterol. 2006 Dec 14;12(46):7532-6. Related Articles,Links

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Listening to Turkish classical music decreases patients’ anxiety, pain, dissatisfaction and the dose of sedative and analgesic drugs during colonoscopy: a prospective randomized controlled trial.Ovayolu N, Ucan O, Pehlivan S, Pehlivan Y, Buyukhatipoglu H, Savas MC, Gulsen MT.

Gaziantep University, School of Medicine, Department of Internal Medicine, 27310 Gaziantep, Turkey.

AIM: To determine whether listening to music decreases the requirement for dosages of sedative drugs, patients’ anxiety, pain and dissatisfaction feelings during colonoscopy and makes the procedure more comfortable and acceptable. METHODS: Patients undergoing elective colonoscopy between October 2005 and February 2006 were randomized into either listening to music (Group 1, n = 30) or not listening to music (Group 2, n = 30). Anxiolytic and analgesic drugs (intravenous midazolam and meperidine) were given according to the patients’ demand. Administered medications were monitored. We determined their levels of anxiety using the State-Trait Anxiety Inventory Test form. Patients’ satisfaction, pain, and willingness to undergo a repeated procedure were self-assessed using a visual analog scale. RESULTS: The mean dose of sedative and analgesic drugs used in group 1 (midazolam: 2.1 +/- 1.4, meperidine: 18.1 +/- 11.7) was smaller than group 2 (midazolam: 2.4 +/- 1.0, meperidine: 20.6 +/- 11.5), but without a significant difference (P > 0.05). The mean anxiety level in group 1 was lower than group 2 (36.7 +/- 2.2 vs 251.0 +/- 1.9, P < 0.001). The mean satisfaction score was higher in group 1 compared to group 2 (87.8 +/- 3.1 vs 58.1 +/- 3.4, P < 0.001). The mean pain score in group 1 was lower than group 2 (74.1 +/- 4.7 vs 39.0 +/- 3.9, P < 0.001). CONCLUSION: Listening to music during colonoscopy helps reduce the dose of sedative medications, as well as patients’ anxiety, pain, dissatisfaction during the procedure. Therefore, we believe that listening to music can play an adjunctive role to sedation in colonoscopy. It is a simple, inexpensive way to improve patients’ comfort during the procedure.

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PMID: 17167846 [PubMed – indexed for MEDLINE]

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Electroconvulsive Therapy: Administrative Codes, Legislation, and Professional Recommendations

 
 J Am Acad Psychiatry Law 34:3:406-411 (2006)
Copyright © 2006 by the American Academy of Psychiatry and the Law.

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ANALYSIS AND COMMENTARY

Electroconvulsive Therapy: Administrative Codes, Legislation, and Professional Recommendations

Victoria Harris, MD, MPH

Dr. Harris is Medical Director of Psychiatric Services, Stevens Hospital, Edmonds, WA. Address correspondence to: Victoria Harris, MD, MPH, Stevens Hospital, 9 West, 21601 76th Avenue West, Edmonds, WA 98026. E-mail: vharris@u.washington.edu

Government regulatory involvement in electroconvulsive therapy (ECT) is due to several factors, including patient advocate groups, prior abuse by psychiatrists, and a general trend of state authority to move into areas traditionally governed by medical authorities. Regardless of the specific reasons, ECT is both highly effective in the treatment of many psychiatric disorders and heavily regulated by state administrative codes and legislation. The purpose of this article is to conduct a systematic review of the state administrative codes and legislation for the 50 states, the District of Columbia, and Puerto Rico and to compare the findings with professional recommendations for the administration of ECT.

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Downward Departures in the Post-Booker Era.

 
 J Am Acad Psychiatry Law 35:1:128-130 (2007)
Copyright © 2007 by the American Academy of Psychiatry and the Law.

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LEGAL DIGEST

Downward Departures in the Post-Booker Era

How Is Diminished Capacity Defined?

In U.S. v. Valdez, 426 F.3d 178 (2nd Cir. 2005), the United States Court of Appeals for the Second Circuit reviewed the sentencing of Felix Valdez by the District (trial) Court for the Southern District of New York to determine if the court had incorrectly applied the insanity defense legal standard rather than the diminished-capacity downward-departure legal standard when denying the defendant’s request for a downward departure.

Facts of the Case

Valdez confessed to obtaining and selling telephone calling cards in other people’s names. He was recorded on a public pay phone while opening calling card accounts by offering various false explanations such as posing as a building owner attempting to obtain numbers on behalf of his tenants. The government estimated that Valdez had obtained over 1,176 calling card numbers and suggested that he was even able to obtain phone access to countries that had fraud protection mechanisms in place.

Upon his guilty plea, Valdez was convicted of wire fraud by the U. S. District Court for the Southern District of New York. At sentencing he requested a downward departure from the recommended sentence secondary to his diminished capacity. He based his petition for a diminished-capacity departure on his IQ of 55, documented learning difficulties, history of special education classes provided as a result of brain injury and severe emotional disturbance, history of dependency on others, and family psychiatric history. The defense’s psychiatric expert opined that as a result of Valdez’s generalized anxiety disorder, “marked dependency needs … overly compliant” behavior, low IQ, and essential illiteracy, he was easily manipulated by his coconspirator (Guillermo) into performing the fraud with the belief that he, the defendant, would then have access to calling cards to call his son. The defense asserted that without Guillermo, Valdez would have been incapable of developing the fraud that led to his indictment; therefore, Valdez’s diminished capacity was causally linked to the commission of the offense as a result of his vulnerability to Guillermo’s manipulation. However, on cross-examination the defense’s expert psychiatrist testified that Valdez knew that what he was doing was wrong and that he could have written the hundreds of names and calling card numbers himself. The expert’s report also documented that Valdez had refused to pay his co-conspirator, Guillermo.

The district court denied Valdez’s petition for a downward departure and sentenced the defendant according to the Federal Sentencing Guidelines. The court concluded that the defendant did not meet the definition of “significantly reduced mental capacity” (one prong necessary in defining diminished capacity) as evidenced by information that contradicted the defendant’s contention that he had trouble understanding the wrongfulness of his actions. The court also dismissed the validity of the nexus between any psychiatric or cognitive impairment that Valdez had and his fraudulent behavior.

Valdez appealed this decision to the U. S. Court of Appeals for the Second Circuit. He contended that the district court had incorrectly applied the criteria for the insanity defense rather than the criteria for the diminished capacity departure when considering him for a downward departure from the Federal Sentencing Guidelines. Valdez asserted that the court, in doing so, had thereby failed to make use of the availability of this departure when a defendant understands the stark difference between right and wrong but has significantly impaired ability to understand the wrongfulness of his conduct.

Valdez also appealed on the grounds that the court’s holding was based on clearly erroneous fact finding, asserting that the court based its holding on its own lay opinion of Valdez’s mental capacity, which was contrary to evidence submitted by medical professionals.

Ruling

The U. S. Court of Appeals for the Second Circuit affirmed the district court’s calculation of the defendant’s sentence and found that the district court did not apply an incorrect legal standard in denying a downward departure and had not erred in fact finding. The court remanded the case to the district court to consider whether the defendant’s sentencing would have been different if the district court had understood the Federal Sentencing Guidelines to be advisory rather than mandatory.

Reasoning

The appeals court agreed with the defendant’s assertion that the insanity defense standard, in which the defendant does not recognize the difference between right and wrong, is not the appropriate standard when considering a downward departure based on diminished capacity. The appeals court agreed that the standard for granting a downward departure on the basis of diminished mental capacity requires significant impairment in a defendant’s judgment or ability to understand the wrongfulness of his actions. Therefore, the standard for diminished capacity does not require that a defendant lack criminal intent.

However, the appeals court held that the district court did not confuse the insanity defense standard with the diminished-capacity downward-departure standard in denying a downward departure for Valdez. The court found that the district court had considered his understanding of right and wrong only to assess at which point along the continuum his understanding fell. Furthermore, the appeals court noted that the lower court had rejected the diminished-capacity departure based on both Valdez’s ability to carry out a complex crime and its perception of a lack of evidence supporting Valdez’s having a psychiatric diagnosis.

The appeals court remanded the case to the district court as a result of the possibility that the district court had made a procedural error in imposing a sentence on the assumption that the Federal Sentencing Guidelines (FSG) were mandatory rather than advisory. The appeals court opined that a court properly sentences even if it decides to depart from the FSG, providing it first considers them. However, to avoid procedural error (e.g., failing to attend to the various factors contained in 18 U.S.C. § 3553 (a) of the guidelines that sentencing courts must take account of in deciding on an appropriate sentence), the court must be aware of its authority to depart from the guidelines. Therefore, the appeals court remanded the case for the district court judge to consider if the sentence rendered would be different if the guidelines were recognized as advisory.

Further, the appeals court found that the district court had not made clearly erroneous fact findings. It reasoned that the district court based its findings of the defendant’s mental capacity on various pieces of proof, including Valdez’s success in performing the complex fraudulent scheme. The appeals court also ruled that the rejection of the defense expert’s opinion is not an error of law, because there is no rule that obliges a trial court to adopt expert testimony.

Discussion

According to the Federal Sentencing Guidelines Policy Statement that defines diminished capacity (18 U.S.C.S. Appx 5K2.13), a downward departure may be warranted if (1) the defendant committed the offense while suffering from a significantly reduced mental capacity and (2) the significantly reduced mental capacity contributed substantially to the commission of the offense. Significantly reduced mental capacity is defined as a “significantly impaired ability to understand the wrongfulness of the behavior comprising the offense or to exercise the power of reason or control the behavior that the defendant knows is wrongful.” As stated in U.S. v. Leandre, 132 F.3d 796 (D.C. Cir. 1998), and in reference to the definition of reduced mental capacity, “… little substantive guidance has been provided by the Sentencing Commission, either in the language of the guidelines themselves or in the commentary or application notes.” In light of this history of the difficulty with the definition of reduced mental capacity, U.S. v. Valdez helped to clarify the distinction between the more narrowly defined insanity defense standard (the absolute lack of knowledge of wrong-doing) and the more broadly defined diminished capacity relevant to the downward-departure legal standard (the significantly impaired ability to understand the wrongfulness of the behavior).

In remanding this case to the district court, the appeals court underscored the court’s relatively new ability (following the Supreme Court’s decision in U.S. v. Booker, 543 U.S. 220 (2005)) to sentence a defendant outside the Federal Sentencing Guidelines and therefore to sentence a defendant without applying a mandated, rigid application of the sentencing committee’s policy statements. Therefore, the courts may now be less constrained by the guidelines in their determinations of which defendants can qualify for a downward departure. Without having to rely on the language of a policy statement, courts may become more open to the testimony and recommendations of mental health expert witnesses. This case may, therefore, represent a nascent trend toward an increase in influence of effective and credible psychiatric expert witnesses regarding a defendant’s diminished capacity and an increase in the number of downward departures.

Sarah L. Xavier, DO

Forensic Fellow
Yale University School of Medicine
New Haven, CT

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