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Hart KL, McCoy TH, Henry ME, Seiner SJ, Luccarelli J. Residual symptoms following electroconvulsive therapy: A retrospective cohort study. J Affect Disord 2023; 341:374-378. [PMID: 37661058 PMCID: PMC10530260 DOI: 10.1016/j.jad.2023.08.135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Revised: 08/02/2023] [Accepted: 08/31/2023] [Indexed: 09/05/2023]
Abstract
BACKGROUND Residual depressive symptoms following treatment are a burden for patients and are associated with increased risk of relapse. While this phenomenon has been explored following pharmacotherapy, there is little research into residual symptoms following electroconvulsive therapy (ECT). This study quantifies the frequency and type of residual symptoms following ECT treatment. METHODS This study used retrospective data from patients receiving ECT as part of routine clinical care. Depressive symptomatology was assessed using the Quick Inventory of Depressive Symptomatology - Self-Report 16 item scale (QIDS), which includes 9 symptom domains graded from 0 to 3. We quantified the frequency of mild or greater (QIDS≥1) and moderate or greater (QIDS ≥ 2) residual symptoms following treatment among patients responding to ECT (QIDS decrease ≥50 % from baseline) and non-responders (QIDS decrease <50 %). RESULTS Among 1799 patients, 1015 (56.4 %) responded to ECT and 784 (43.6 %) did not. Among responders, 99.5 % had at least one residual symptom of mild severity or greater (median = 5, IQR = 3-6) and 83.3 % had at least one residual symptom of moderate severity or greater (median = 1, IQR = 1-2). Among non-responders, 100 % had residual symptoms of mild severity or greater (median = 8, IQR = 7-9), and 99.2 % had a residual symptom of moderate severity or greater (median = 4, IQR = 3-5). The most common residual symptoms among both responders and non-responders were sleep disturbances (93.1 % and 98.7 %, respectively) and sadness (68.9 % and 96.4 %, respectively). LIMITATIONS Retrospective data from a single freestanding psychiatric hospital. CONCLUSION Among patients with depression receiving ECT, there were high rates of residual symptoms even among patients responding to treatment.
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Affiliation(s)
- Kamber L Hart
- Harvard Medical School, 25 Shattuck Street, Boston, MA, United States of America
| | - Thomas H McCoy
- Harvard Medical School, 25 Shattuck Street, Boston, MA, United States of America; Department of Psychiatry, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, United States of America
| | - Michael E Henry
- Harvard Medical School, 25 Shattuck Street, Boston, MA, United States of America; Department of Psychiatry, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, United States of America
| | - Stephen J Seiner
- Harvard Medical School, 25 Shattuck Street, Boston, MA, United States of America; Department of Psychiatry, McLean Hospital, 115 Mill Street, Belmont, MA, United States of America
| | - James Luccarelli
- Harvard Medical School, 25 Shattuck Street, Boston, MA, United States of America; Department of Psychiatry, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, United States of America.
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Plemper J, Sartorius A, Karl S. Age-Dependent Dose Increase During an Acute Electroconvulsive Therapy Series. J ECT 2023; 39:193-196. [PMID: 36729704 DOI: 10.1097/yct.0000000000000896] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
INTRODUCTION Electroconvulsive therapy (ECT) dose is highly relevant for ECT efficacy as well as adverse effects. It is often based on seizure threshold (ST). Studies have shown that ST increases over the course of an ECT series. Clinical observation suggests that this rise might be more pronounced in geriatric patients. METHODS Retrospectively, we analyzed ECT dose during the first 20 ECT treatments in 472 patients undergoing ECT. Dose adjustments were assessed in relation to patients' age using generalized least squares regression analysis. Response was defined as Clinical Global Impression Improvement Scale < 4. RESULTS Dose increased in all patients during the course of the ECT series (mean initial dose, 64.97 ± 68.04 mC; at 10th ECT, 385.46 ± 211.28 mC). Dose was significantly correlated with ECT treatment number, electrode placement, and the interaction between age and ECT treatment number. In other words, dose increase was significantly positively correlated with increasing age, that is dose increased more in older compared with younger patients during the course of an ECT series ( z = 9.47, P < 0.001). Response was not correlated with age-dependent dose increase; however, the length of the ECT series in responders was negatively associated with the dose increase from the first to the seventh ECT session ( F = 5.28, P = 0.0228). CONCLUSIONS Our results indicate that ST increases more rapidly during the course of an ECT series in older compared with younger patients. To ensure high efficacy throughout the course of treatment, attention should be paid to decreasing seizure quality, especially in older patients, and dose should be adjusted accordingly.
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Affiliation(s)
- Jana Plemper
- From the Department of Psychiatry and Psychotherapy, Central Institute of Mental Health, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
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Kritzer MD, Peterchev AV, Camprodon JA. Electroconvulsive Therapy: Mechanisms of Action, Clinical Considerations, and Future Directions. Harv Rev Psychiatry 2023; 31:101-113. [PMID: 37171471 PMCID: PMC10198476 DOI: 10.1097/hrp.0000000000000365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/13/2023]
Abstract
LEARNING OBJECTIVES • Outline and discuss the fundamental physiologic, cellular, and molecular mechanisms of ECT to devise strategies to optimize therapeutic outcomes• Summarize the overview of ECT, its efficacy in treating depression, the known effects on cognition, evidence of mechanisms, and future directions. ABSTRACT Electroconvulsive therapy (ECT) is the most effective treatment for a variety of psychiatric illnesses, including treatment-resistant depression, bipolar depression, mania, catatonia, and clozapine-resistant schizophrenia. ECT is a medical and psychiatric procedure whereby electrical current is delivered to the brain under general anesthesia to induce a generalized seizure. ECT has evolved a great deal since the 1930s. Though it has been optimized for safety and to reduce adverse effects on cognition, issues persist. There is a need to understand fundamental physiologic, cellular, and molecular mechanisms of ECT to devise strategies to optimize therapeutic outcomes. Clinical trials that set out to adjust parameters, electrode placement, adjunctive medications, and patient selection are critical steps towards the goal of improving outcomes with ECT. This narrative review provides an overview of ECT, its efficacy in treating depression, its known effects on cognition, evidence of its mechanisms, and future directions.
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Affiliation(s)
- Michael D Kritzer
- From the Department of Psychiatry, Massachusetts General Hospital and Harvard Medical School, Charlestown, MA (Drs. Kritzer, Camprodon); Department of Psychiatry and Behavioral Sciences, Department of Biomedical Engineering, Department of Electrical and Computer Engineering, Department of Neurosurgery, Duke University, Durham, NC (Dr. Peterchev)
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Luccarelli J, McCoy TH, Yip AG, Seiner SJ, Henry ME. The Duration in Treatment With Electroconvulsive Therapy Among Patients Screening Positive or Negative for Borderline Personality Disorder Traits: A Retrospective Cohort Study. J ECT 2022; 38:171-175. [PMID: 35389952 PMCID: PMC9420745 DOI: 10.1097/yct.0000000000000847] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE While emerging evidence suggests that electroconvulsive therapy (ECT) is an effective treatment for depressive symptoms in patients with co-occurring borderline personality disorder (BPD) traits, it is unclear whether the presence of BPD traits modulates the tolerability of ECT. This study estimates the association between BPD traits and retention in acute course ECT treatment. METHODS This study used a retrospective cohort of patients receiving ECT between 2015 and 2020 and who were assessed using the McLean Screening Instrument for BPD, the Quick Inventory of Depressive Symptomatology Self-Report 16-item scale, and the Montreal Cognitive Assessment before initiating treatment. RESULTS One thousand five hundred eight patients received ECT during the study period, of whom 277 (18.4%) screened positive for BPD traits. Borderline personality disorder traits were associated with a higher odds of remaining in ECT for at least 10 treatments (adjusted odds ratio, 1.502; 95% confidence interval, 1.11-2.02; P = 0.007). Among individual symptom domains, only endorsing chronically feeling empty was associated with duration in ECT treatment. CONCLUSIONS Among patients receiving ECT, screening positive for BPD traits was associated with a higher odds of receiving at least 10 ECT treatments. These results support the overall tolerability of ECT in patients with BPD traits.
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Luccarelli J, McCoy TH, Seiner SJ, Henry ME. Electroconvulsive therapy is associated with a reduction in self-reported suicidal ideation in adolescents. Brain Stimul 2022; 15:1181-1183. [PMID: 36028156 DOI: 10.1016/j.brs.2022.08.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Revised: 08/17/2022] [Accepted: 08/18/2022] [Indexed: 11/02/2022] Open
Affiliation(s)
- James Luccarelli
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA; Department of Psychiatry, McLean Hospital, Belmont, MA, USA; Harvard Medical School, Boston, MA, USA.
| | - Thomas H McCoy
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Stephen J Seiner
- Department of Psychiatry, McLean Hospital, Belmont, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Michael E Henry
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
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The Effects of Baseline Impaired Global Cognitive Function on the Efficacy and Cognitive Effects of Electroconvulsive Therapy in Geriatric Patients: A Retrospective Cohort Study. Am J Geriatr Psychiatry 2022; 30:790-798. [PMID: 34996701 PMCID: PMC9177530 DOI: 10.1016/j.jagp.2021.12.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Revised: 12/10/2021] [Accepted: 12/11/2021] [Indexed: 10/19/2022]
Abstract
OBJECTIVES This study explores the association between baseline impaired global cognitive function and changes in global cognitive function and depression among geriatric patients undergoing acute course electroconvulsive therapy (ECT). DESIGN Retrospective cohort study. SETTING Single freestanding psychiatric hospital. PARTICIPANTS Patients aged 50 and older receiving ECT. INTERVENTIONS 10 ECT treatments. MEASUREMENTS Cognitive assessments with the Montreal Cognitive Assessment (MoCA). Depression assessment with the Quick Inventory of Depressive Symptomatology Self Report 16 item scale (QIDS). RESULTS Baseline and follow-up data were available for 684 patients. On average, patients with baseline normal cognition (MoCA ≥26; N = 371) had a decrease in MoCA of -1.44±0.26 points over the course of treatment, while those with baseline impaired global cognitive function (MoCA <26; N = 313) had an increase in MoCA of 1.72±0.25 points. Baseline cognitive status was not associated with a differential response on the QIDS. CONCLUSIONS Patients with baseline impaired global cognitive function did not demonstrate a worsening in cognition following ECT, and baseline global cognitive function was not associated with a differential change in depression with ECT. These results suggest that impaired global cognitive function should not be viewed as a contraindication to ECT in geriatric patients.
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Luccarelli J, McCoy TH, Yip AG, Seiner SJ, Henry ME. Borderline personality disorder traits are not associated with a differential change in global cognitive function during acute course ECT. Brain Stimul 2022; 15:638-640. [PMID: 35436592 PMCID: PMC9233119 DOI: 10.1016/j.brs.2022.04.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Revised: 03/22/2022] [Accepted: 04/05/2022] [Indexed: 11/02/2022] Open
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Individual response to electroconvulsive therapy is not correlated between multiple treatment courses. J Affect Disord 2022; 298:256-261. [PMID: 34742999 PMCID: PMC8709707 DOI: 10.1016/j.jad.2021.11.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2021] [Revised: 10/24/2021] [Accepted: 11/02/2021] [Indexed: 02/03/2023]
Abstract
OBJECTIVES Electroconvulsive therapy (ECT) effectively treats depressive disorders, but many patients will have subsequent relapses. While some guidelines suggest prior response to ECT is an indication for ECT in a subsequent mood episode, it is unknown whether response to ECT is correlated between treatment courses. This study explores whether response to ECT at a first treatment correlates with response to treatment in a second independent ECT course. METHODS Single-center retrospective cohort of patients receiving two different ECT treatment courses between 2011 and 2020 and who self-reported depression symptoms using the Quick Inventory of Depressive Symptomatology (QIDS) at baseline and following treatment #5. RESULTS 286 patients received two independent ECT series during the study period, of whom 153 received at least 5 treatments in both series. Patients had similar QIDS scores at the start of each treatment series (Pearson's correlation, r = 0.58, p <0.001), but the change in QIDS following 5 ECT treatments was not correlated between series for individual patients (Pearson's correlation, r = 0.083, p = 0.31). In multivariate analyses, change in QIDS was similar for both treatment series, but patients were less likely to receive 5 treatments in the second treatment series. LIMITATIONS retrospective cohort cannot control for factors influencing access to repeat ECT treatment CONCLUSIONS: While on average final QIDS score was the same following two independent treatment courses, for individual patients the change in depression symptoms was not correlated between treatment series. Further research is needed to identify factors that may predict longitudinal ECT response.
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Luccarelli J, McCoy TH, Seiner SJ, Henry ME. Real-world evidence of age-independent electroconvulsive therapy efficacy: A retrospective cohort study. Acta Psychiatr Scand 2022; 145:100-108. [PMID: 34662429 PMCID: PMC8709695 DOI: 10.1111/acps.13378] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Revised: 10/11/2021] [Accepted: 10/17/2021] [Indexed: 01/03/2023]
Abstract
OBJECTIVES Electroconvulsive therapy (ECT) is an effective treatment for depressive disorders and approved for use in adolescents and adults, but it is unclear whether efficacy or cognitive side effect burden differs with age or if effectiveness in usual clinical practice matches that in prospective studies. We examined the effects of ECT on depression and cognition in a large clinical cohort. METHODS A retrospective cohort study of patients ages 16 and older receiving ECT between 2011 and 2020 and who were evaluated with the Quick Inventory of Depressive Symptomatology (QIDS), the Behavior and Symptom Identification Scale-24 (BASIS-24), and the Montreal Cognitive Assessment (MoCA) at baseline and after treatment #10. RESULTS Among 1698 patients, ECT was associated with a decrease in depression symptoms (QIDS reduction from 17.1 ± 4.9 to 10.1 ± 5.2) and improvement in self-reported mental health (BASIS-24 scores improved from 1.92 ± 0.55 to 1.17 ± 0.60). There was a reduction in MoCA scores from 25.8 ± 3.1 to 25.4 ± 3.1. In multivariate models, age was not associated with a differential QIDS or BASIS-24 response, but older age was associated with a lesser reduction in MoCA. CONCLUSION Among 1698 patients aged 16 and older, ECT was associated with improvement in depression and overall self-reported mental health, with a slight decrease in cognition. Age was not associated with changes in efficacy, but older age was associated with a lesser cognitive change as measured by the MoCA. These results provide normative data of real-world effectiveness of ECT, and add further support to its utility in patients with severe psychiatric illness.
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Affiliation(s)
- James Luccarelli
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA 02114,Department of Psychiatry, McLean Hospital, Belmont, MA 02478,Harvard Medical School, Boston, MA 02115
| | - Thomas H. McCoy
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA 02114,Harvard Medical School, Boston, MA 02115
| | - Stephen J. Seiner
- Department of Psychiatry, McLean Hospital, Belmont, MA 02478,Harvard Medical School, Boston, MA 02115
| | - Michael E. Henry
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA 02114,Harvard Medical School, Boston, MA 02115
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Luccarelli J, McCoy TH, Uchida M, Green A, Seiner SJ, Henry ME. The Efficacy and Cognitive Effects of Acute Course Electroconvulsive Therapy Are Equal in Adolescents, Transitional Age Youth, and Young Adults. J Child Adolesc Psychopharmacol 2021; 31:538-544. [PMID: 34619038 PMCID: PMC8669295 DOI: 10.1089/cap.2021.0064] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Objective: Electroconvulsive therapy (ECT) is the most effective acute treatment for depression, but its use in younger patients is rare and heavily regulated in many U.S. states. It is unclear whether age modifies treatment response or tolerability in adolescents, transitional age youth, and young adults. We examined the effects of ECT on depression and cognition in patients aged 16-30 years. Methods: A retrospective cohort study of patients aged 16-30 years receiving ECT between 2011 and 2020 who were evaluated with the Quick Inventory of Depressive Symptomatology (QIDS), the Behavior and Symptom Identification Scale-24 (BASIS-24), and the Montreal Cognitive Assessment (MoCA) at baseline and following treatment #10. Results: Among the 424 patients who met the inclusion criteria, ECT was associated with a decrease in depression symptoms (ΔQIDS -6.7; Kruskal-Wallis rank sum test; χ2 = 293.37; df = 2; p < 0.0001) and improvement in overall self-reported mental health status (ΔBASIS-24 - 0.70; Kruskal-Wallis rank sum test; χ2 = 258.5; df = 2; p < 0.0001) during the first 10 treatments, with a slight reduction in cognition as measured by the MoCA (ΔMoCA -1.1; Kruskal-Wallis rank sum test; χ2 = 33.7; df = 1; p < 0.0001). Age was not a significant predictor of QIDS, BASIS-24, or MoCA changes. Conclusions: Among 424 patients aged 16-30 years receiving acute course ECT, age was not a significant predictor of improvement in depression, change in overall self-reported mental health status, or change in cognition. These results support the utility of ECT in the treatment of adolescents and young adults.
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Affiliation(s)
- James Luccarelli
- Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts, USA.,Department of Psychiatry, McLean Hospital, Belmont, Massachusetts, USA.,Department of Psychiatry, Harvard Medical School, Boston, Massachusetts, USA.,Address correspondence to: James Luccarelli, MD, DPhil, Department of Psychiatry, Massachusetts General Hospital, 32 Fruit Street, Yawkey 6A, Boston, MA 02114, USA
| | - Thomas H. McCoy
- Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts, USA.,Department of Psychiatry, Harvard Medical School, Boston, Massachusetts, USA
| | - Mai Uchida
- Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts, USA.,Department of Psychiatry, Harvard Medical School, Boston, Massachusetts, USA
| | - Allison Green
- Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Stephen J. Seiner
- Department of Psychiatry, McLean Hospital, Belmont, Massachusetts, USA.,Department of Psychiatry, Harvard Medical School, Boston, Massachusetts, USA
| | - Michael E. Henry
- Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts, USA.,Department of Psychiatry, Harvard Medical School, Boston, Massachusetts, USA
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The effects of anesthetic change on electrographic seizure duration during electroconvulsive therapy. Brain Stimul 2021; 14:1084-1086. [PMID: 34293513 DOI: 10.1016/j.brs.2021.07.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 07/06/2021] [Accepted: 07/16/2021] [Indexed: 11/21/2022] Open
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Changes in seizure duration during acute course electroconvulsive therapy. Brain Stimul 2021; 14:941-946. [PMID: 34119670 DOI: 10.1016/j.brs.2021.05.016] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Revised: 04/30/2021] [Accepted: 05/19/2021] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Seizure duration has long been measured as a potential marker of ECT treatment efficacy, with concern that short seizures may be clinically ineffective. Relatively small studies have documented a trend towards shorter seizures during acute course ECT, but data from large cohorts would help provide normative data on seizure duration changes during treatment. OBJECTIVE This study analyzes the effects of age, sex, ECT dose, and treatment number on the duration of electrographic seizures during acute course ECT in a large single-center cohort. METHODS A single-center retrospective chart review was conducted of adult patients receiving a first course of ECT from 2000 to 2017 at a large freestanding psychiatric hospital. RESULTS 3648 patients met inclusion criteria, receiving 32,879 acute course ECT treatments. There was a shortening of mean ECT seizure duration over the acute course, with the greatest decrease in duration over the first 3 treatments but continuing decreases over the entire acute course. Older age, higher ECT dose, and increasing treatment number were all associated with shorter seizures, while sex was not significantly associated. Increasing treatment dose was associated with shorter seizures relative to no dose increase, with those patients receiving the highest cumulative doses also having the shortest cumulative seizure time. CONCLUSIONS Among patients undergoing acute-course ECT treatment, seizure duration decreased over the treatment course, and increases in applied electrical charge were associated with shorter seizures.
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