Stimulus intensity determined by dose-titration versus age-based methods in electroconvulsive therapy in Thai patients

Pichai Ittasakul,1 Apichaya Likitnukul,1 Umporn Pitidhrammabhorn,1 Punjaporn Waleeprakhon,1 Morris B Goldman2 1Department of Psychiatry, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand; 2Department of Psychiatry and Behavioral Sciences, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA Objectives: This study aimed to compare the accuracy of the stimulus intensity (SI) calculated by age-based methods with that using the dose-titration method. Methods: The initial seizure threshold (IST) was determined using a standardized dose titration in hospitalized Thai patients treated with right unilateral (RUL, n=32) and bilateral (BL, n=57) electrode placement. The correlation between the IST and clinical variables was analyzed. The estimated SI based on the patient’s age was compared with the SI determined by dose titration. Results: Age was highly predictive of the IST for both groups (RUL, P=0.012; BL, P=0.045). Gender (P=0.006) and anticholinergic drug use (P=0.025) predicted the IST for the BL group. For the RUL group, the mean±SD (median) SI estimated using the half-age and age methods was 158±46 (169) mC and 315±92 (338) mC, respectively. The SI determined using the dose-titration method was higher compared with the half-age method and lower compared with the age method. For the RUL group, 31% of subjects using the half-age method and 22% of subjects using the age method would have received an SI within ±20% of that computed using dose titration. Additionally, 19% of subjects using the half-age method and 19% using the age method would have received unacceptably low (<50%) or high (>200%) intensities. For the BL group, 18% of subjects using the half-age method and 32% using the age method would have received an SI within ±20% of that computed using dose titration. Additionally, 39% with the half-age method and 18% with the age method would have received an unacceptably low or high SI, respectively. Conclusion: Age strongly predicts the IST, but it does not robustly predict the SI compared with dose titration because the SI calculated using age-based methods results in an unacceptably low or high SI that is associated with a marked risk of adverse effects or inadequate response. We recommend the dose-titration method to determine the SI. Keywords: electroconvulsive therapy, dosing, Thai patients, dose titration, age-based methods, seizure threshold, predictor

Depressive disorders in Thai medical students: an exploratory study of institutional, cultural, and individual factors

Objectives: This exploratory qualitative study conducted among Thai medical students aimed to investigate factors related to the development of medical students' depression and how these factors interact in contributing to depressive disorders.Methods: Forty-three undergraduate medical students of the six-year Doctor of Medicine program were identified as having moderate to severe depression on an annual depression screening. From these, eighteen students agreed to participate in individual in-depth interviews. Transcriptions of the interviews were analyzed by independent reviewers using a thematic analysis approach.Results: Among 43 participants screened as having moderate-to-severe depression, major depressive disorder and adjustment disorder were 9.3% and 14.0%, respectively. Reported factors related to medical students' disorders were personal vulnerabilities, medical educational administration, academic achievement, learning environment, intrinsic motivation, self-care and self-management, relationship and community. In particular, lack of social support and relationship problems were mentioned among those with more severe and persistent symptoms. Protective factors were social support, positive relationships, a growth mindset, spiritual and mindfulness practices, and an adequate mentoring program.Conclusions: Medical students' depression and suicidal ideations are significant concerns in Thai medical education. Besides personal vulnerabilities, high expectations, the value placed on academic achievement and relationship problems can precipitate the onset of depressive disorders, if not being properly addressed. The 4P framework of predisposing, precipitating, perpetuating and protective factors are suggested to understand the onset and development of students' depressive disorders and to identify targets for institutional and educational intervention