Fortschr Neurol Psychiatr 2002; 70(7): 353-367
DOI: 10.1055/s-2002-32520
Originalarbeit
© Georg Thieme Verlag Stuttgart · New York

Zur Behandlung depressiver Störungen mit modernen Verfahren der Elektrokonvulsionstherapie

Current Use of ECT in the Treatment of Depressive DisordersD.  Klecha1 , M.  Legler2 , M.  Hüll1
  • 1Abteilung für Psychiatrie und Psychotherapie des Universitätsklinikums Freiburg
  • 2Anästhesiologische Universitätsklinik Freiburg
Further Information

Publication History

Publication Date:
28 June 2002 (online)

Zusammenfassung

Die Elektrokrampftherapie ist bei adäquater Indikationsstellung ein sehr effektives und unter Berücksichtigung somatischer Begleiterkrankungen und bei sorgfältigem Management kardiovaskulärer Reaktionen peri- und post-EKT ein sicheres Verfahren. Insbesondere in Deutschland ist diese Therapieform dennoch nicht unumstritten. Im folgenden Artikel wird der gegenwärtige Wissensstand zur EKT-Behandlung, die Indikation, Durchführung, Nebenwirkungen sowie neuere Entwicklungen bezüglich des Einsatzes der EKT bei der Erhaltungstherapie dargestellt. Hiermit soll ein Beitrag zu einer Versachlichung der Diskussion um den Einsatz der EKT geleistet werden.

Abstract

If used with correct indication, electroconvulsive therapy (ECT) is a very effective and safe treatment for some forms of major depression, provided due consideration is given to possibly concomitant somatic conditions and that the cardiovascular reactions during and after the ECT treatments are managed carefully. Despite this, ECT remains controversial, especially in Germany. This article provides an overview of the current state of the art in ECT: appropriate indications, best practice in conducting ECT, side effects and recent developments in the use of ECT as maintenance therapy. This, it is hoped, will contribute to a more factually grounded discussion of the use of ECT.

Literatur

  • 1 Peters U H. Die Einführung der Schockbehandlungen und die psychiatrische Emigration.  Fortschr Neurol Psychiat. 1992;  60 356-369
  • 2 Kellner C H, Pritchett J T, Beale M D, Coffey C E. Handbook of ECT. Washington DC: American Psychiatric Press Inc 1997
  • 3 Fink M. Electroshock. Restoring the mind. New York: Oxford University Press 1999
  • 4 Fink M. Convulsive therapy: a review of the first 55 years.  J of Affect Disord. 2001;  63 1-15
  • 5 Hirschfeld R M. Efficacy of SSRIs and newer antidepressants in severe depression: comparison with TCAs.  J Clin Psychiatry. 1999;  60 326-335
  • 6 Folkerts H W. Der Stellenwert der EKT bei therapieresistenten Depressionen. In: Bauer M, Berghöfer A (Hrsg). Therapieresistente Depressionen Berlin: Springer 1997: 187-185
  • 7 The Practice of Electroconvulsive Therapy: Recommendations for Treatment, Training, and Privileging: A Task Force Report of the American Psychiatric Association. Washington DC: APA 1990
  • 8 The Practice of Electroconvulsive Therapy: Recommendations for Treatment, Training and Privileging: A Task Force Report of the American Psychiatric Association. Second Edition. Washington DC: APA 2001
  • 9 Praxisleitlinien in Psychiatrie und Psychotherapie. Band 5: Behandlungsleitlinie Affektive Erkrankungen. Deutsche Gesellschaft für Psychiatrie, Psychotherapie und Nervenheilkunde (Hrsg.). Darmstadt: Steinkopff 2000
  • 10 Berger M. Affektive Erkrankungen. In: Berger M (Hrsg). Psychiatrie und Psychotherapie. München: Urban & Fischer 2000: 483-566
  • 11 Abrams R. Electroconvulsive therapy. New York: Oxford University Press 1997
  • 12 Scott A IF. The efficacy of electroconvulsive therapy. In: Checkley S (ed). The management of depression. Oxford: Blackwell Science 1998: 252-275
  • 13 Jadad A R, Moore R A, Carroll D, Jenkinson C, Reynolds D J, Gavaghan D J, McQuay H J. Assessing the quality of reports of randomized clinical trials: is blinding necessary?.  Conrolled clinical trials. 1996;  17 1-12
  • 14 Selvan C P, Mayur P M, Gangadhar B N, Janakiramaiah N, Subbakrishna D K, Murali N. Comparison of the therapeutic efficacy of ECT and imipramine: a randomized controlled trial.  Indian J Psychiatry. 1999;  41 228-235
  • 15 Janakiramaiah N, Gangadhar B N, Naga Venkatesha Murthy P J, Harish M G, Subbakrishna D K, Vedamurthachar A. Antidepressant efficacy of Sudarshan Kriya Yoga (SKY) in melancholia: a randomized comparison with electroconvulsive therapy (ECT) and imipramine.  J Affect Disord. 2000;  57 255-259
  • 16 Flint A J, Rifat S L. The treatment of psychotic depression in later life: A comparison of pharmacotherapy and ECT.  Int J Geriatr Psychiat. 1998;  13 23-28
  • 17 Folkerts H W, Tölle M N, Schonauer K, Mücke S, Schulze-Mönking H. Electroconvulsive therapy vs. paroxetine in treatment-resistant depression - a randomized study.  Acta Psychiatr Scand. 1997;  96 334-342
  • 18 Dubovsky S, Buzan R. Mood disorders. In: Hales R, Yudofsky SC, Talbott JA (eds). Textbook of Psychiatry Washington: American Psychiatric Press 1999: 479-567
  • 19 Buchan H, Johnstone E, McPherson K, Palmer R L, Crow T J, Brandon S. Who benefits from electroconvulsive therapy? Combined results of the Leicester and Northwick Park Trials.  Br J Psychiatry. 1992;  160 355-359
  • 20 Hickie I, Mason C, Parker G, Brodaty H. Prediction of ECT response: validation of a refined sign-based (CORE) system for defining melancholia.  Br J Psychiatry. 1996;  169 68-74
  • 21 O'Leary D, Gill D, Gregory S, Shawcross C. Which depressed patients respond to ECT? The Nottingham results.  J Affect Disord. 1995;  33 245-250
  • 22 Sobin C, Prudic J, Devenand D P, Nobler M S, Sackeim H A. Who responds to electroconvulsive therapy? A comparison of effective and ineffective forms of treatment.  Br J Psychiatry. 1996;  169 322-328
  • 23 Tew J D, Mulsant B H, Haskett R F, Prudic J, Thase M E, Crowe R R, Dolata D, Begley A E, Reynolds C F, Sackeim H A. Acute efficacy of ECT in the treatment of major depression in the old-old.  Am J Psychiatry. 1999;  156 1865-1870
  • 24 Wesson L M, Wilkinson A M, Anderson D N, McCracken C. Does age predict long-term outcome of depression treated with ECT? (a prospective study of the long-term outcome of ECT-treated depression with respect to age).  Int J Geriatr Psychiat. 1997;  12 45-51
  • 25 Shapira B, Lerer B. Speed of response to bilateral ECT: An examination of possible predictors in two controlled trials.  J ECT. 1999;  15 202-206
  • 26 Grunhaus L, Shipley J E, Eiser A, Pande A C, Tandon R, Remen A, Greden J F. Polysomnographic studies in patients referred for ECT: pre-ECT studies.  Convulsive Ther. 1997;  12 224-231
  • 27 DeQuardo J R, Oladapo T, Brunberg J A, Rajiv T. Does neuroanatomy predict ECT response?.  Prog Neuro-Psychopharmacol & Biol Psychiat. 1997;  21 1339-1352
  • 28 Gupta N, Avasthi A, Kulhara P. Response to first ECT in depression: A predictor of outcome?.  Indian J Psychiatry. 1998;  40 322-326
  • 29 Anrade C. Prediction of antidepressant efficacy from response to the first ECT.  Indian J Psychiatry. 1998;  40 394-395
  • 30 Beale M D. Stimulus dosing methods in electroconvulsive therapy.  Psychiatr Ann. 1998;  28 510-511
  • 31 Sackeim H A. Pulse with and frequency of ECT.  J ECT. 1999;  15 288-289
  • 32 Schwartz C M, Manly D T. Efficiency of the stimulus characteristics of ECT.  Am J Psychiatry. 2000;  157 1504-1506
  • 33 Abrams R. ECT stimulus parameters as determinants of seizure quality.  Psychiatr Ann. 1996;  26 701-704
  • 34 Pisvejc J, Hyrman V, Sikora J, Berankova A, Kobeda B, Auerova M, Sochorova V. A comparison of brief and ultrabrief pulse stimuli in unilateral ECT.  J ECT. 1998;  14 68-75
  • 35 Harrigan P. Debate on ECT use in depression continues.  Lancet. 1999;  354 401
  • 36 Beale M D, Kellner C H, Pritchett J T, Bernstein H J, Bruns C M, Knapp R. Stimulus dose-titration in ECT: a 2-year clinical experience.  Convulsive Ther. 1994;  10 171-176
  • 37 Beale M D, Kellner C H. Proposed titration schedule.  Convulsive Ther. 1997;  13 44
  • 38 Sackeim H A, Prudic J, Devanand D P, Nobler M S, Lisanby S H, Peyser S, Fitzsimons L, Moody B J, Clark J. A prospective, randomized, double-blind comparison of bilateral and right unilateral electroconvulsive therapy at different stimulus intensities.  Arch Gen Psychiatry. 2000;  57 425-434
  • 39 Fink M, Bailine S, Petrides G. Electrode Placement and Electroconvulsive Therapy: The Search for the Chimera.  Arch Gen Psychiatry. 2001;  58 607-609
  • 40 Fink M. Energy dosing in ECT: threshold stimulation or formula?.  Convulsive Ther. 1997;  13 4-6
  • 41 Weiner R D. Stimulus dosing with ECT: to titrate or not to titrate - that is the question.  Convulsive Ther. 1997;  13 7-9
  • 42 Petrides G, Fink M. The “half-age” stimulation strategy for ECT dosing.  Convulsive Ther. 1996;  12 138-146
  • 43 Folkerts H W. Elektrokrampftherapie. Untersuchungen zum Monitoring, zur Effektivität und zum pathischen Aspekt. Darmstadt: Steinkopff 1999
  • 44 Girish K, Mayur P M, Saravanan E SM, Janakiramaiah N, Gangadhar B N, Subbakrishna D K, Umamaheswara Rao G S. Seizure threshold estimation by formula method: a prospective study in unilateral ECT.  J ECT. 2000;  16 258-262
  • 45 Vaughn McCall W, Reboussin D M, Weiner R D, Sackeim H A. Titrated moderately suprathreshold vs fixed high-dose right unilateral electroconvulsive therapy.  Arch Gen Psychiatry. 2000;  57 438-444
  • 46 McCall W V, Shelp F E, Weiner R D, Austin S, Norris J. Convulsive threshold differences in right unilateral and bilateral ECT.  Biol Psychiatry. 1993;  34 606-611
  • 47 Coffey C E, Lucke J, Weiner R D, Krystal A D, Aque M. Seizure threshold in electroconvulsive therapy (ECT) II. The anticonvulsant effect of ECT.  Biol Psychiatry. 1995;  37 777-788
  • 48 Girish K, Prasad K MR, Gangadhar B N, Janakiramiah N, Subbakrishna D K, Parameshwara G. Clinical predictors of seizure threshold in bilateral ECT.  Indian J Psychiatry. 1998;  40 327-330
  • 49 Mayur P M, Subbakrishna D K, Gangadhar B N, Girish K, Janakiramaiah N, Rajam K K. Predicting seizure threshold at first ECT: a discriminant analysis study.  NIMHANS. 1998;  16 193-196
  • 50 Krystal A D, Weiner R D, McCall W V, Shelp F E, Arias R, Smith P. The effects of ECT stimulus dose and electrode placement on the ictal electroencephalogram: An intraindividual crossover study.  Biol Psychiatry. 1993;  34 759-767
  • 51 Nobler M S, Sackeim H A, Solomou M, Luber B, Devenand D P, Prudic J. EEG manifestations during ECT: Effects of electrode placement and stimulus intensity.  Biol Psychiatry. 1993;  34 321-330
  • 52 Sackeim H A, Devenand D P, Prudic J. Stimulus intensity, seizure threshold, and seizure duration: impact on the efficacy and safety of electroconvulsive therapy.  Psychiatr Clin North Am. 1991;  14 803-843
  • 53 Krystal A D, Weiner R D. ECT seizure therapeutic adequacy.  Convulsive Ther. 1994;  10 153-164
  • 54 Krystal A D, Weiner R D, Coffey C E. The ictal EEG as a marker of adequate stimulus intensity with unilateral ECT.  J Neuropsychiatry Clin Neurosci. 1995;  7 295-303
  • 55 Suppes T, Webb A, Carmody T, Gordon E, Gutierrez-Esteinou R, Hudson J I, Pope Jr H G. Is postictal silence a predictor of response to electroconvulsive therapy?.  J Affect Disord. 1996;  41 55-58
  • 56 Gangadhar B N, Subbakrishna D K, Janakiramaiah N, Motreja S, Dutt D N, Paramehwara G. Post-seizure EEG fractal dimension of first ECT predicts antidepressant response at two weeks.  J Affect Disord. 1999;  52 235-238
  • 57 Anrade C. Assessment of the therapeutic adequacy of the ECT seizure: current status.  NIMHANS. 1997;  15 319-329
  • 58 Abrams R, Schwartz C M. Thymatron-IV. Beschreibung und Bedienungsanleitung. Taufkirchen: Fred Berninger Importe 1999
  • 59 Freeman C P. The ECT Handbook. The Second Report of the Royal College of Psychiatrists' Special Committee on ECT. Dorchester: Dorset Press 1995
  • 60 Bailine S H, Rifkin A, Kayne E, Jeffrey A, Selzer J A, Vital-Herne J, Blieka M, Pollack S. Comparison of bifrontal and bitemporal ECT for major depression.  Am J Psychiatry. 2000;  177 121-123
  • 61 Krystal A D, Dean M D, Weiner R D, Tramontozzi L A, Connor K M, Lindahl V H, Massie R W. ECT stimulus intensity: are present ECT devices too limited?.  Am J Psychiatry. 2000;  157 963-967
  • 62 Gangadhar B N, Janakiramaiah N, Subbakrishna D K, Praveen J, Reddy A K. Twice versus thrice weekly ECT in melancholia: a double-blind prospective comparison.  J Affect Disord. 1993;  27 273-278
  • 63 Shapira B, Tubi N, Drexler H, Lidsky D, Calev A, Lerer B. Cost and benefit in the choice of ECT schedule.  Br J Psychiatry. 1998;  172 44-48
  • 64 Vieweg R, Shawcross C R. A trial to determine any difference between two and three times a week ECT in the rate of recovery from depression.  J Mental Health. 1998;  7 403-409
  • 65 Abrams R. The mortality rate with ECT.  Convulsive Ther. 1997;  13 125-127
  • 66 Thorogood M, Cown P, Mann J, Murphey M, Vessey M. Fatal myocardial infarction and use of psychotropic drugs.  Lancet. 1992;  340 1067-1070
  • 67 Beukelmann D. Antihypertensiva. In: Kochs E, Krier C, Buzello W, Adams HA (Hrsg). Anästhesiologie Stuttgart, New York: Thieme 2001: 286
  • 68 Stern L, Hirschmann S, Grunhaus L. ECT in Patients with major depressive disorder and low cardiac output.  Convulsive Ther. 1997;  13 68-73
  • 69 Nemes C, Niemer M, Noak G. Datenbuch Anästhesiologie. Stuttgart, New York: G. Fischer 1985: 78
  • 70 Modica P A, Templehoff R, White P F. Pro- and anticonvulsant effects of anesthetics (Part II).  Anesth Analg. 1990;  70 433-444
  • 71 Nadstawek J, Lier H, Thees Ch. Epilepsie. In: Kochs E, Krier C, Buzello W, Adams HA (Hrsg). Anästhesiologie Stuttgart, New York: Thieme 2001: 886
  • 72 Hering W, Schüttler J. Intravenöse Anästhetika. In: Kochs E, Krier C, Buzello W, Adams HA (Hrsg). Anästhesiologie Stuttgart, New York: Thieme 2001: 219-220
  • 73 Möllenberg O. Psychiatrie. In: Kochs E, Krier C, Buzello W, Adams HA (Hrsg). Anästhesiologie Stuttgart, New York: Thieme 2001: 1279
  • 74 Simpson K H. et al . Propofol reduces seizure duration in patients having anesthesia for electroconvulsive therapy.  Br J Anesth. 1988;  61 343-344
  • 75 Swartz C M. Propofol anesthesia in ECT.  Convuls Ther. 1992;  8 262-266
  • 76 Produktmonographie Disoprivan. Zeneca. DI 12 (1/94) 5D 71-72
  • 77 Motsch J, Böttiger B W, Bock M. Muskelrelaxantien - Pharmakologie und klinischer Einsatz.  Anästhesiologie & Intensivmedizin. 2001;  42 237-253
  • 78 Devanand D P, Dwork A J, Hutchinson E R, Bolwig T G, Sackeim H A. Does ECT alter brain structure?.  Am J Psychiatry. 1994;  151 957-970
  • 79 Ende G, Braus D F, Walter S, Weber-Fahr W, Henn F A. The hippocampus in patients treated with electroconvulsive therapy: a proton magnetic resonance spectroscopic imaging study.  Arch Gen Psychiatry. 2000;  57 937-943
  • 80 Scott B W, Wojtowicz J M, Burnham W M. Neurogenesis in the dentate gyrus of the rat following electroconvulsive shock seizures.  Exp Neurol. 2000;  165 231-236
  • 81 Madsen T M, Treschow A, Bengzon J, Bolwig T G, Lindvall O, Tingstrom A. Increased neurogenesis in a model of electroconvulsive therapy.  Biol Psychiatry. 2000;  15 1043-1049
  • 82 Duman R S, Vaidya V A. Molecular and cellular actions of chronic electroconvulsive therapy.  J ECT. 1998;  14 181-193
  • 83 Jowsey S G. The effect of medications on ECT.  Psychiatr Ann. 1993;  23 33-37
  • 84 Grunhaus L, Dolberg O, Lustig M. Relapse and recurrence following a course of ECT: reasons for concern and strategies for further investigation.  J Psychiat Res. 1995;  29 165-172
  • 85 Kellner C H, Bourgon L N. Combining ECT and antidepressants: time to reassess.  J ECT. 1998;  14 65-67
  • 86 Hamner M, Huber M. Discontinuation of antidepressant medications before ECT.  Convulsive Ther. 1996;  12 125-126
  • 87 Potokar J, Wilson S, Nutt D J. Do SSRIs prolong seizure duration during ECT?.  International Journal of Psychiatry in Clinical Practice. 1997;  1 277-280
  • 88 Prichtett J T, Bernstein H J, Kellner C H. Combined ECT and antidepressant drug therapy.  Convulsive Ther. 1993;  9 256-261
  • 89 Krahn L E, Hanson C A, Pileggi T S, Rummans T A. Electroconvulsive therapy and cardiovascular complications in patients taking Trazodone for insomnia.  J Clin Psychiatry. 2001;  62 108-110
  • 90 Pettinati H M, Stephens R N, Willis K M, Robin S. Evidence for less improvement in depression in patients taking benzodiazepines during unilateral ECT.  Am J Psychiatry. 1990;  147 1029-1035
  • 91 Guthrie S A, Sung J C-Y, Goodson R N, Grunhaus L, Tandon R. Triazolam and Diphenhydramine effects on seizure duration in depressed patients receiving ECT.  J Convulsive Ther. 1996;  12 261-265
  • 92 Krystal A D, Watts B V, Weiner R D, Moore S, Steffens D C, Lindahl V. The use of flumazenil in the anxious and benzodiazepine-dependent ECT patient.  J ECT. 1998;  14 5-14
  • 93 Klapheke M M. Combining ECT and antipsychotic agents: benefits and risks.  Convulsive Ther. 1993;  9 241-255
  • 94 Kelsey M C, Grossberg G T. Safety and efficacy of caffeine-augmented ECT in elderly depressives: a retrospective study.  J Geriatr Psychiatry Neurol. 1995;  8 168-172
  • 95 Lisanby S H, Maddox J H, Prudic J, Devanand D P, Sackeim H A. The Effect of Electroconvulsive Therapy on Memory of Autobiographical and Public Events.  Arch Gen Psychiatry. 2000;  57 581-590
  • 96 Coleman E A, Sackeim H A, Prudic J, Devenand D P, McElhiney M C, Moody B J. Subjective memory complaints prior and following electroconvulsive therapy.  Biol Psychiatry. 1996;  39 346-356
  • 97 Prudic J, Peyser S, Sackeim H A. Subjective memory complaints: a review of patient self-assessment of memory after electroconvulsive therapy.  J ECT. 2000;  16 121-132
  • 98 Cohen D, Taieb O, Flament M, Benoit N, Chevret S, Corcos M, Fossati P, Jeammet P, Allilaire J-F, Basquin M. Absence of cognitive impairment at long-term follow-up in adolescents treated with ECT for severe mood disorder.  Am J Psychiatry. 2000;  157 460-462
  • 99 Coffey C E. The pre-ECT evaluation.  Psychiatr Ann. 1998;  28 506-508
  • 100 Sackeim H A, Haskett R F, Mulsant B H, Thase M E, Mann J J, Pettinati H M, Greenberg R M, Crowe R R, Cooper T B, Prudic J. Continuation Pharmacotherapy in the Prevention of Relapse Following Electroconvulsive Therapy. A Randomized Controlled Trial.  JAMA. 2001;  285 1299-1307
  • 101 Sackeim H A. Continuation therapy following ECT: directions for future research.  Psychopharmacol Bull. 1994;  30 501-521
  • 102 Petrides G. Continuation ECT: a review.  Psychiatr Ann. 1998;  28 517-523
  • 103 Sackeim H, Prudic J, Devenand D P, Decina P, Kerr B, Malitz S. The impact of medication resistence and continuation pharmacotherapy on relapse following response to electroconvulsive therapy in major depression.  J Clin Psychopharmacol. 1990;  10 76-104
  • 104 Prudic J M, Sackeim H A, Rifas S. Medication resistance, response to ECT, and prevention of relapse.  Psychiatr Ann. 1994;  24 228-231
  • 105 Petrides G, Dhossche D, Fink M, Francis A. Continuation ECT: relapse prevention in affective disorders.  Convulsive Ther. 1994;  10 189-194
  • 106 Clarke T, Coffey C, Hoffmann G, Weiner R. Continuation therapy for depression using outpatient electroconvulsive therapy.  Convulsive Ther. 1989;  4 330-337
  • 107 Jaffe R, Dubin W R, Roemer R. Continuation and maintenance ECT - efficacy and safety. Proceedings of the 142nd Annual Meeting from the American Psychiatric Association, New Research Program and Abstracts. 1989
  • 108 Jaffe R, Dubin W, Shoyer B, Roemer R, Sharon D, Lipschutz L. Outpatient electroconvulsive therapy: efficacy and safety.  Convulsive Ther. 1990;  6 231-238
  • 109 Schwarz T, Loewenstein R N, Isenberg K E. Maintenance ECT: Indications and outcome.  Convulsive Ther. 1995;  11 14-23
  • 110 Beale M D, Bernstein H J, Kellner C H. Maintenance electroconvulsive therapy for geriatric depression: a one year follow-up.  Clinical gerontologist. 1996;  16 86-90
  • 111 McDonald W M, Phillips V L, Figiel G S, Marsteller F A, Simpson C D, Bailey M C. Cost-effective maintenance treatment of resistant geriatric depression.  Psychiatr Ann. 1998;  28 47-52
  • 112 Kramer B A. A Naturalistic review of maintenance ECT at a university setting.  J ECT. 1999;  15 262-269
  • 113 Gagné G G, Furman M J, Carpenter L L, Price L H. Efficacy of continuation ECT and antidepressant drugs compared to long-term antidepressants alone in depressed patients.  Am J Psychiatry. 2000;  157 1960-1965
  • 114 Swoboda E, Conca A, König P, Waanders R, Hausen M. Maintenance Electroconvulsive Therapy in Affective and Schizoaffective Disorder.  Neuropsychobiology. 2001;  43 23-28
  • 115 Wijkstra J, Nolen W A, Algra A, van Vliet I M, Kahn R S. Relapse prevention in major depressive disorder after successful ECT. A literature review and a naturalistic case series.  Acta Psychiatr Scand. 2000;  102 454-460
  • 116 Fink M, Kellner C H. A second quiet revolution: ambulatory ECT.  Convulsive Ther. 1996;  12 1-2
  • 117 Vanelle J-M, Loo H, Galinowski A, deCarvalho W, Bourdel M-C, Brochier P, Bouvet O, Brochier T, Olie J-P. Maintenance ECT in intractable manic-depressives disorders.  Convulsive Ther. 1994;  10 195-205
  • 118 Steffens D C, Krystal A D, Sibert T E, Moore S D, Weiner R D. Cost effectiveness of maintenance ECT.  Convulsive Ther. 1995;  11 283-287

Dr. med. Dipl.-Psych. D. Klecha

Abteilung für Psychiatrie und Psychotherapie des Universitätsklinikums Freiburg

Hauptstr. 5

79104 Freiburg

Email: dorothee_klecha@psyallg.ukl.uni-freiburg.de

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