http://exhibits.library.stonybrook.edu/mfp/files/original/22f18c569eb94fa57065b3a6d4055fc9.pdf 1ab5a25c2eadde4a30c50b6a85035dc3 PDF Text Text September 17, 1955 Dr. Albert A. Kurland Director of Research Department of Mental Hygiene Spring Grow State Hospital Baltimre 28, Maryland DearAl: The protocol "Conwlsive Therapy md Electroencephalogrephic Change" interested as very such and I found much in the protocol to it contend for study. Rather then describe some gemrelities, perhaps the best I can do is to corrment on each of the sections and then make some general overview cements at the end. introduction and specific aims are quite clear and I would omcur that such a study is needed. The specific aims on page 2 are clear for a md b. Aim c is a specific reflection of Dr. Marshall's The interests , but he should be prepared to defend this since to my kmledge there are no studies which have suggested that the seizure pattern during a cmvulsion is significantly different either depending on type of inducticm nor in terns of the therapeutic result. There are some reports suggesting that there are chmges in the threshold to induced convulsions and that these threshold changes are related to clinical inprovement . However, to ask this question would require omsiderable effort in anesthetizing patients to the same degree of anesthesia and then detemining the threshold for convulsion each treatnent. While this has been done for electro— oonvulsive induction, I wonder if this is a reasonable suggestion for Inddclon. f are mdmdsnt.‘ Aim e is a. good one but the phrase "process electroencephalographic records" is unclear to me . Do you, man the EEG records during each treatment? Aime d and Since the purpose of the program is to relate EEG changes and belavioml response, and you are focussing on some predictors, perhaps you would consider an wditionel aim to determine predictors of neurophysiological response . I do not low if I have sent you a copy of a paper that was never published in which we related some of the pron-treatment EEG mmctefistios and certain psychological of induced slow wave activity. test performances to the mt �up. Kurland ~2~ September 17, 1955 Havever, since you are measuring slow wave activity and will be doing psychological tests , and determining the EEG characteristics in the pro-treatment record, per'haps such a substudy would complement this project . Tm treatuent plan is also sufficiently clear. Hanover, in the prediction of treatment response, there are significant differences in the predictions in depressives and in schizophrenic subjects. The rate of slow wave induction in depressives is generally higher than in schizophrenic; and the behavioral adaptations to these brain changes is different depending on the pre ~treatment persmality of the subject . In our studies we tended to disregard the differences between schizophrenics and depressives and I believe this has hurt our analyses. By providing that you will be studying both depressives and schizophrenics to indicate that the analyses should be done it may be important separately before the two groups with the anticipation that relationships between induced slow wave activity and clinical result may be found in group and not in the other. On page three the treatment paragraph brings in a new topic mich is not related to the aim of the study program. There is little evidence that the two methods of induction are different with regard to the anomt of slow wave activity induced. Perhaps an additional aim should be Specified to determine if the method of induction does bear any relationship to the mmt of EEG change and to the treatmnt result. ' While the number of treatments (9-15) is adequate, in certain schizophrenic patients the amount of slow wave activity induced on a three times a week schedule may not be sufficient to have a significant behavioral response . We have noted frequently that such patients require more than 15 treatments and that often it may be necessary to increase the rate from three to five times a week. Perhaps a disclaimer could be entered into the treatment paragraph indicating that if, after 15 individual treatments , the anount of slow wave activity is less than 20% or- 308, the patient will receive an additional number of treatments so that he has 20 and perhaps even 25 . The inclusion of a three week post~treatment study period is excellent. However, the evidence is fairly clear that this may not be long enough. Later on in the protocol you indicate a six week period and this is mch better. (Some studies have shown that the amount of slow wave activity disappears quickly, but we have observed patients in whom Slowing as still present as long as three months after treatmnt. Equally inportant is the development of long ms and high percent time alpha activity which often replaces the pro-— treatment disorganized or desynchronized records.) �Dr. Kurland ~3- September 17, 1965 page four the evaluations appear to be adequate. The psychometric assessments imply that you are going to reassess the On —‘ ~,.— ‘rxr-J wlirvrw‘m-xwu .-_,.,‘~.=.—,y.<— r— —w—wA—vwmvv VF! mun-um m vufwv-wmqrniru “,w—«m role of c‘agfirm disorganization and memory change . The relation between cognitive disorganization and mmry loss to treatment response has been studied extensively and there is considerable evidence that momory (arranges are often seen in patients who favorably respond, but that the usual menory tests are too insensitive to show changes in brain function. When these tests lave been applied by sophisticated obscmrs like those in Sweden, the relationships have been well documented. For this reason, I am not clear as to why so much effort will be expendcd in this direction. However, I would like to make two Specific suggestions which can augment this battery. In our studies we were very much impressed that the amount of slw wave activity was related to certain pm-tmatrent psychological characteristics of the patients. The two tests that mm most important were the hidden figures test and the California F—Scale . Perfonnance on those tests was related to the amomt of induced slowing. Homver, mom inportant from the point of View of therapeutic response, the California F-Scale seemed related to the clinical behavioml msponsc . The other psychological tests did not show such a relationship. However, Dr. Kahn had developed a denial personality inventory and this , when applied to the patients behavior prior to treatment, was higily predictive of the behavioral evaluation. We did not find this related to the amount of EEG change, however. l1-"~w :;~.vnmn (aw , warn—w . . .A w ‘0" Thus, depending on the amount of effort you wish to make in should be clarified and perhaps psyclmtric assessments, the goals two sets of tasks included; those which may wave activity and those that mount of slow inprovcmnt . be related to the related to may be wow-w: vw .wr 'x' rwv-vl warn, "rm w: r Mum . Wr'm r-a‘a ‘ " v 1-. A yrc' —~M u,“ y...“ wwvu.‘ “or”-.. Ur .‘Z-vvj'ln‘t‘ V7377 -nwfiu to the EEG records, the section on baseline EEG five, section 2 , brings up the focus of the study coca again. Previous studies have shown that the mount of slow wave activity which may be related to therapeutic is the amomt of slowing found between treatment sessions. response is the It early dovelomsnt and mintenanos of high voltage slow wave activity which has been shown to be related to therapeutic response . By ouplmsising the EEG during the tmatnont itself, if will be difficult to develop any parallels with other studies except during the posttmatmont period. At one time was attempted to measure the m; chmges inmd‘iatoly postuscizurc and to relate these to the treatment outccnm . In runny patients for periods up to one hour we found oontimous low voltage one to three cycle per second activity which was oomlatcd with the extent of post~soizurc confusion and. disorientation. When those patients were recalled u to 6 hours later, the mum: of delta activity was often little , shaving that tho patient had a very active Mmostatic very mechanism and that the induced slog wave activity disappeared quickly. For this reason With regards is excellent . Pogo. �Dr. Ktufland 4.4-» ' September 17, 1955 in our studies we took our EEG record 2» to 32 hours after an induced convulsion. (Seizures were given on Monday, Wednesday and Friday, and all EEGs were taken on Tuesday, Thursday, or? A Saturday.) To relate the present study to previous studies , I believe records should be taken during the interseizure period, amm‘ingthetreaunentcourseaswell.. Section 3 on page five is excellent and I attempt wekly records up to six weeks minimn. Page ‘ would urge you to six technique is fine. Data analysis is unclear. If the purpose of the study program is to corroborate earlier observations , then perhaps the mthods used should be spelled out and described to indicate that you are willing to undertake such ccnfimatim. If the ted'miques are new ones and I believe that this is what you would prefer, then the quantitative methods should be described in sufficient detail. Nowhere in this outline nor in the supplemntary letter from Dr. Marshall is the technique of analysis described except the visual. Now, I believe the visual is more than adequate to accomplish the missions assigned. However, if the recording on mgnetic tape and subsequent quantitative analysis is to be done , then these methods should be spelled out. In View of the present status of EEG analysis , I mnder why you have not considered one of the analog analytic systems. “more are two encellent ems, the pacer spectral density using GreyWalters original filter model and the period analysis . Equipment for both is commercially available and while the Grey Walter system will not give you frequencies below 3 ops with any fidelity, the period analytic progress will. In either case, the reviewing group will be very critical of such a paragraph on data analysis. letter, I imagine he is considering the eventual use of digital cmputem for the analysis of these tapes . If that is so, than these methods should be described in greater detail. Our studies are now being written in a form suitable for presentation but we have described three different digital analytic programs: the power spectral density analysis, period analysis, and a random shapes sodel. These analytic methods are expensive but we are mw analyzing tapes sent to us from Dr. Denber. If the volmue of tapes provided by your laboratories is not too great , we can, starting next owner, analyze sane of your tapes and provide you with frequency spectra and period analytic spectra at different stages for any or all of the lead cmbinations you may select. I would recomuend that you include a paragraph in your application stating that if you are given an opportunity to collect tapes, that these my be analyzed by me assuming that this facility is still operational at that time. (We are now mesmerizing the programs that we have worked on these past three years and will ourselves go to NIH for additional support late this winter, as our grunt support ends October 1, 1956.) Fran Dr. Marshall's �m. zmvlwwwy-ur') "q—w—M -m.—m _ 7“ Dr. leand -S- September 17, 1965 Returning to page six, section a, the descriptims provided are excellent, even though I would argue with the "abmml". Somehow, the development of slow wave in activity a post-seizure record is the normal effect of such seizures and very much to be desired. The use of the word-"abnomal" has a negative connotation which prejudices an observers view of these changes. by Dr. Marshall use of the word The section b on page seven is satisfactory since Dr. Marshall has been identified with such analyses in the past. Section c, page seven, can be criticized only as I did earlier. The ten minutes follwing the post-ictal depression is not going to be sufficient for the study that you invisage. I think this paragraph should be rewritten after you have considered the need for interseizure records . ‘ page sight, the suggestion that "the relative amount of this activity after each convulsive treatment will be examined for its utility as a regulating index for further treatment” is a good suggestion. However, from my own experience , I believe that the intemeizm record will probably be more helpful. However, both slow On may be done . section d on page eight is very important and my provide a Special focus of your study. I would like to suggest that this paragraph not onphasize the reappearance of the individuals pre~ treatmnt brain potentials, for this is higuly unlikely. What is often seen is the development of incmased rhythmicity, higher The percent time alpha, and increased voltages which persist for many to soothe . In those patients who fail the treatment and who regress quickly, this rhythmicity is often lacking. A focus on this period of time My be very valuable. weeks mwym 'm. m WWW. W "rWWWW—Jrnkuwm—wwmv—m The significance paragraph is good and I would suggest a few additions . In the first paragraph the issue is the relationship between the mount of delta activity in the EEG both during; a series of convulsive treatmnts and after. It seems to me that the sigfificance should emphasize the psychological and behavioral tests which you are including. I would urge that the significance such statements that some observers have indicated that slow wave activity is an outward sigu that biochemical changes of the brain have been induced and that these changes are persistent in some patients and not in others. When these changes persist, then the likelfinood of inprovement is high especially in patients who have had ‘a depressive disorder and in whom the denial personality is permanent. In those patients in whom these changes disappear W3 quickly or in whom they fail to appear, the biochemical changes in the brain are too weak to induce behavioral change or are transient . The persomlity and psychological factors which may be related both to the induction of high voltage slow wave activity and behavioral hpmomnt of a persistent variety will be studied in this program. �mmrfl . _ up. Kurland ' -6— September 17, 1965 paragraph mgaxding tape moomings is not part of significance but rather part of the justification for special ‘Iho equipmant. \ Reviewing Dr. Mamball's lot-tor, my continents follow the the original grant application. comments on The justificatim for an I believe that if you wem‘ to is not made clear. for analog equipment to analyze tapes or to analyze on—going records this would be highly commendable . To record tapes in the quantity that you have requested is; also a mummdable suggestion, but for this I think his com-onto on page two are sufficient. The mltichml memory device as a Nuclear micago RIDL is too small for the operations which you envisage and this is probably not, to be considered. With regard to tape Incoming, the use of an ESP-800 even with 7 channels costs about 1$10,000 and this ohould be included in your request, especially you decide to include the possibility of having tapes analyzed if by my facility. You should he prepared, however, to indicate the present program outlined includes 21 tapes per patient andthat mat if both moment prooodms am to be carried out with appmximtely 30 subjects in each cell, then a minim of €93 W00 tapes will be needed and since Dr. Marshall indicates that he would like these as a library, the investment is approximately a: cm!) I haw no criticism of the use of krohn~hite filtem for these are helpful for visual analysis. However, I thirk an analog analytic system is probably to be preferred although you my still wish to use filters for pmpmcccsing. . antpex Eds-100 ask A » . ’ _ In reviewing the application there a nmnber of things which omitted and those are largely in the clinical ama. I think an you should suggest the numbers of subjects to be considered and the rate at which you think you can bring them into your program from your facility. Perhaps one should focus a little more clearly on the decision making process mgarding umber of momma because this will effect the analysis of the post-troaimnt 1368. Setting nine mammal as a minimun is satisfactory, for depressivcs but not for schizoohmnics. In either case , however, tho criterion for clinical judgcmont should be described as either memory changes, or behavioral immvemnt with msolutidn of certain symptoms or the developmnt of a denial syndrome. v ‘ ‘ I review these notes, the program is a good one and I would to 8% it undertaken. As I mad these notes, I am indeed sorry that I did not have an opportunity to visit with you becauseinmch could be clarified in a oonferexm situation. Nevertheless , I home these comnts As be plowed - are helpful. > ' ‘ ‘ , �Ir. Kurlmd ~7- September 17, 1965 I will and them out this afternoon and then call you early in the week so that we can discuss this can the telephone. My best regards . Sincerely yours , Fink, PM). Professor of Psychiatry Max MF:kp � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence to: Kurland, Albert A. 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