Electroconvulsive therapy. Current concepts

Relief of catatonia associated with concurrent relief of sigmoid volvulus after electroconvulsive therapy

A patient with mild learning disability and paranoid schizophrenia developed catatonia. The marked emaciation associated with catatonia resulted in intestinal obstruction secondary to sigmoid volvulus. The patient's mental and physical health continued to deteriorate despite maximal treatment with medication, and therefore, electroconvulsive therapy was initiated. Electroconvulsive therapy resulted in improvement in catatonia; this was also associated with concurrent relief of the intestinal obstruction. This report highlights volvulus of the sigmoid colon as an unusual complication of catatonia.

Short-term effect of ECT in middle-aged and elderly patients with intractable catatonic schizophrenia

BACKGROUND AND OBJECTIVE

The management of middle-aged and elderly patients with catatonic schizophrenia has long been a major problem in clinical geriatric psychiatry. Most cases are intractable because of medication resistance, medication intolerance, or severe medical conditions. Electroconvulsive therapy (ECT) is recognized as one of the most efficacious therapies for catatonic schizophrenia. Thus, we conducted a prospective study of the short-term effect of acute ECT on middle-aged and elderly patients with intractable catatonic schizophrenia.

MATERIALS AND METHODS

Subjects were nine consecutive patients older than 45 years who had fulfilled the DSM-IV criteria for catatonic-type schizophrenia and had been referred for first-time acute ECT after other treatments had failed. The patients were treated at Tohoku University Hospital between January 1998 and March 2002. We evaluated the clinical response of these patients to acute ECT by means of the brief psychiatric rating scale (BPRS). We also evaluated adverse effects of acute ECT.

RESULTS

The response rate was 100%. The total BPRS score was improved in all nine subjects at the end of the ECT course and 1 week after the final session in comparison with the total pre-ECT BPRS score (11.9 +/- 7.5 and 9.3 +/- 9.2 versus 57.1 +/- 13.1, respectively, p = 0.008, p = 0.008). The total Global Assessment of Functioning score was also improved significantly (from 10.8 +/- 9.4 just before ECT to 61.6 +/- 18.9 1 week after ECT, p = 0.008). Guy's five factors (thought disturbance, activation, anxiety-depression, hostility-suspiciousness, and anergia) improved significantly (p = 0.008, p = 0.008, p = 0.018, p = 0.012, p = 0.008, respectively). One patient showed supraventricular premature contractions (SVPCs) during an ECT seizure. After some ECT sessions, three patients exhibited mild to moderate delirium that disappeared within 3 days. However, no patient experienced a severe cognitive or physical adverse effect during the course of ECT.

CONCLUSIONS

Acute ECT has a good short-term effect on middle-aged and elderly patients with intractable catatonic schizophrenia and appears to be safe. Our results indicate that systematic studies on a large scale are warranted for further investigation of the efficacy and safety of acute ECT for treating middle-aged and elderly patients with catatonic schizophrenia.

Clinical and cerebral blood flow changes in catatonic patients treated with ECT

OBJECTIVE

To determine changes in clinical manifestations and cerebral blood flow (CBF) before and after administration of ECT to patients with catatonia due to schizophrenia or mood disorders.

METHODS

A sample of nine patients who met DSM-IV criteria for catatonia was studied. Patients received between 5 and 15 sessions (thrice per week) of ECT. Severity of catatonia was measured with the Modified Rogers Scale (MRS). Changes in CBF were measured with a brain single positron emission computer tomography (SPECT) that was performed 1 week before the first ECT and 1 week after the last ECT.

RESULTS

Catatonia was due to schizophrenia in five patients and mood disorders in four patients. There were no significant clinical and brain SPECT differences between these two groups before treatment. Pre- vs. post-ECT comparisons showed significant reduction of catatonic symptoms in both groups. However, patients with mood disorders needed less ECT sessions and showed greater clinical improvement. Brain SPECT showed significant increase in CBF in parietal, temporal, and occipital regions in patients with mood disorder and no significant changes in patients with schizophrenia.

CONCLUSIONS

These results support the efficacy of ECT for treatment of catatonic patients, especially secondary to mood disorders, which seem to be correlated with improvements in CBF.

Differential effects of electroconvulsive shock on the glutamate receptor mRNAs for NR2A, NR2B and mGluR5b

We have studied the effects of single and repeated electroconvulsive shock (ECS) treatment on the mRNA levels of several glutamate receptors in the dentate gyrus and CA1 regions of the rat brain. In the dentate gyrus, such treatment elevated the mRNAs for the NMDA subunits NR2A and NR2B, but it reduced the mRNA for the metabotropic glutamate receptor mGlu5b. With the exception of NR2A, this effect was specific to the dentate gyrus. The changes in NR2B mRNA lasted the longest, but all changes had returned to control values after 48 h. The possible significance of such changes to the antidepressant effect of ECT is discussed.

Changes in mRNA abundance of microtubule-associated proteins in the rat brain following electroconvulsive shock

Microtubule-associated proteins (MAPs) are involved in the maintenance of mature neuronal morphology, neurite outgrowth and neuronal plasticity. Alteration in MAP expression may underlie neuronal structural changes in response to seizure activity. The aim of the present study was to investigate whether electroconvulsive shock (ECS), an animal model of electroconvulsive therapy (ECT) in clinical treatment of depression, affected gene expression of MAPs in the rat brain. Using in situ hybridization, we studied the expression of encoding mRNA for MAPs in the brains of rats treated with ECS 5 times over 10 days. The abundance of mRNA encoding microtubule-associated protein 2 (MAP2), a dendritic MAP, was significantly increased (142% compared with controls) in the dentate gyrus 6 and 24 h after the last shock, and had returned to baseline levels within 48 h. These changes were confined to the dentate gyrus no significant changes were observed in CA1 and CA3 of the hippocampus. The increase in MAP2 expression was accompanied by an increase in MAP2 immunoreactivity in the molecular layer of the dentate gyrus. The abundance of mRNA encoding for tau, an axon-specific MAP, and MAP1B, an embryonic MAP, was unaffected by ECS. These data demonstrate that ECS specifically altered the mRNA and protein expression of MAP2 but had no effect on tau or MAP1B, and suggest that changes in MAP2 expression may be related to morphological changes in the dentate gyrus, particularly in the dendrites.

Acute and repeated ECS treatment increases CRF, POMC and PENK gene expression in selected regions of the rat hypothalamus

The purpose of this study was to investigate the effects of acute and repeated electroconvulsive shock (ECS) on corticotropin releasing factor (CRF), proopiomelanocortin (POMC) and proenkephalin (PENK) gene expression in selected regions of the brain and pituitary of the rat. Acute ECS increased CRF gene expression in the paraventricular nucleus (PVN) by 20%, an effect that was further enhanced to 38% when rats received repeated ECS treatment. Acute and repeated ECS increased POMC gene expression in the arcuate nucleus (ARC) by 49-59% but failed to alter these mRNA levels in the anterior lobe (AL) of the pituitary gland. PENK gene expression was increased by 35% in the nucleus accumbens (NA) and by 180% the ventromedial nucleus (VMN) after acute or repeated ECS treatment but no significant changes were found in the PVN or striatum (ST). Taken together, these results indicate a differential CRF and opioid gene expression regulation after acute or repeated ECS treatment that may be relevant to their therapeutic or side effects in depression.

Synergism of lorazepam and electroconvulsive therapy in the treatment of catatonia

Electroconvulsive therapy (ECT) and lorazepam are effective treatments for catatonia. ECT combined with benzodiazepines has been associated with reduced efficacy and efficiency and therefore is not recommended in the routine practice of ECT. We report 5 prospectively identified cases of catatonia treated either sequentially or concurrently with lorazepam and ECT. In each case, the combination of lorazepam with ECT was superior to monotherapy. This apparent synergism, its possible mechanisms, and its implications for treating catatonia are discussed.

Differential effects of acute and chronic electroconvulsive shock on the abundance of messenger RNAs for voltage-dependent potassium channel subunits in the rat brain

The effect of acute and chronic electroconvulsive shock on the abundance of messenger RNAs encoding voltage-dependent potassium channel subunits in the rat brain was determined by in situ hybridization histochemistry with [35S]dATP-labelled oligonucleotides at 6 h, 24 h and three weeks following the last shock. The messenger RNA abundance of two voltage-dependent potassium channel subunits, Kv1.2 and Kv4.2, was altered by electroconvulsive shock but in different ways. In acute electroconvulsive shock experiments, Kv1.2 and Kv4.2 messenger RNA abundance in the dentate gyrus were reduced 6 h following the shock and returned to control levels after 24 h. In chronic electroconvulsive shock-treated rats, Kv1.2 messenger RNA abundance showed similar changes to those in acute electroconvulsive shock: it was reduced 6 h after the last shock and had recovered after 24 h. Kv4.2 messenger RNA abundance in chronic electroconvulsive shock-treated rats, however, showed adaptive changes: 6 h after the last shock there were no changes in its abundance while 24 h after the last shock there was a significant increase in the dentate gyrus. The changes in Kv1.2 and Kv4.2 messenger RNA abundance following electroconvulsive shock were only observed in the dentate gyrus and not in cornu ammonis 1 and cornu ammonis 3 of hippocampus or frontal-parietal cortex. Two other potassium channel subunits, Kv1.1 and Kv1.4, were not affected by either acute or chronic electroconvulsive shock. These findings indicate that acute and chronic electroconvulsive shock affect the gene expression of voltage-dependent potassium channel subunits with specificities for channel type, anatomical region and timing.

Regional cerebral oxygen saturation during electroconvulsive therapy: monitoring by near-infrared spectrophotometry

Electroconvulsive therapy (ECT) increases neuronal energy consumption and alters systemic hemodynamics. We examined the effects of ECT on regional cerebral oxygen saturation (rSo2) using a near-infrared spectro-photometer. Heart rate (HR), mean arterial blood pressure (MAP), and rSo2 were continuously monitored throughout ECT under general anesthesia in 43 patients. In all subjects, rSo2 changed in a consistent pattern during ECT, initially decreasing (-9.4% +/- 0.9%) just after application of the electrical current and subsequent increasing (8.7% +/- 0.9%) beyond the pre-ECT value. A close correlation was demonstrated between the increase in rSo2 and the mean blood pressure after the electrical shock (r2 = 0.832, P < 0.0001). We conclude that ECT initially may increase cerebral metabolic rate of oxygen more than cerebral blood flow and that rapidly increasing blood pressure transiently may overwhelm cerebral pressure autoregulation.

Catatonia. II. Treatment with lorazepam and electroconvulsive therapy

Case material and retrospective studies support the use of both lorazepam and ECT in treating catatonia, but few prospective investigations exist and none employ quantitative monitoring of response. In this study we test their efficacy in an open, prospective protocol, and define a "lorazepam test' with predictive value for treatment. Twenty-eight patients with catatonia were treated systematically with parenteral and/or oral lorazepam for up to 5 days, and with ECT if lorazepam failed. Outcome was monitored quantitatively during the treatment phase with the Bush-Francis Catatonia Rating Scale (BFCRS). In 16 of 21 patients (76%) who received a complete trial of lorazepam (11 with initial intravenous challenge), catatonic signs resolved. A positive response to an initial parenteral challenge predicted final lorazepam response, as did length of catatonic symptoms prior to treatment. Neither demographic variables nor severity of catatonia predicted response to lorazepam. Four patients failing lorazepam responded promptly to ECT. It is concluded that lorazepam and ECT are effective treatments for catatonia. The rating scale has predictive value and displays sensitivity to change in clinical status.

The cerebral hemodynamic response to electrically induced seizures in man

The hemodynamic response to seizure has long been a topic for discussion in association with the neuronal damage resulting from convulsion. Electroconvulsive therapy (ECT) is an appropriate clinical model for the investigation of the cerebral physiology of seizure. In this study, we monitored the oxygenation state of brain tissue using near infrared (NIR) spectrophotometry, and flow velocity at the middle cerebral artery (MCA) using transcranial Doppler ultrasonography (tc-Doppler) in ninety cases where flow velocity at the middle cerebral artery (MCA) using transcranial Doppler ultrasonography (tc-Doppler) in ninety cases where ECT was prescribed to patients suffering from endogenous depression. Under general anesthesia with thiopental and succinyl choline, an electrical current was applied bilaterally at the minimal energy level. Throughout the therapy, end-tidal CO2 tension was maintained at 30-35 mmHg, and the SpO2 value was maintained above 98% by manual ventilation assistance. The total- and oxy-hemoglobin contents in the brain were reduced during the electrical shock, and then recovered to the pre-shock value (total-hemoglobin; 44.13 +/- 12.88 s after the shock, oxy-hemoglobin; 88.62 +/- 11.69 s after the shock). Subsequently, these values further increased beyond the preshock value. On the other hand, the deoxy-hemoglobin content increased for 90.73 +/- 15.88 s during and after the electrical shock, and decreased afterward. Reduction of cytochrome aa3 began 3.04 +/- 0.51 s after the electrical shock, and this was reoxygenated at 171.88 +/- 12.95 s after the shock.(ABSTRACT TRUNCATED AT 250 WORDS)

Repeated electroconvulsive shock produces long-lasting increases in messenger RNA expression of corticotropin-releasing hormone and tyrosine hydroxylase in rat brain. Therapeutic implications

Electroconvulsive shock (ECS) is a highly effective therapy for the treatment of major depression, but its mechanisms of action are not known. We report that repeated ECS in rats produces enduring changes in two clinically relevant stress-responsive brain systems: (a) the hypothalamic-pituitary-adrenal axis regulated by corticotropin-releasing hormone (CRH) in the paraventricular nucleus; and (b) the NE system in the locus coeruleus regulated by tyrosine hydroxylase (TH). CRH and TH mRNA levels in these brain regions were assessed by in situ hybridization histochemistry. A single interaural ECS elevated TH but not CRH mRNA measured 24 h later. Repeated daily treatments (3, 7, or 14) elevated both mRNAs, maximally with 7, correlating with the time course of clinical efficacy. The elevations persisted for 3 (CRH) or 8 wk (TH) after the ECS. No other therapeutic treatment is known to produce such long-lasting changes in central nervous system gene expression. The time course of events (delayed onset, long duration) implicate CRH as a principal mediator of the antidepressant effects of ECS. The locus coeruleus-NE system may be important in initiating the central nervous system response.

ECT in the treatment of the catatonic syndrome

OBJECTIVE

To determine the efficacy of ECT in the treatment of the catatonic syndrome and to identify predictors of good response.

METHOD

28 cases of catatonia in 22 patients admitted to a psychiatry or medical psychiatry inpatient unit between January 1989 and June 1992 were retrospectively evaluated. Cases were included if they met criteria for catatonia as described by Kahlbaum, i.e., 4 or more signs including immobility, mutism, withdrawal, staring, rigidity, posturing/gimacing, negativism, waxy flexibility, echo phenomena, stereotypy, and verbigeration. Primary diagnoses were: Major Depressive Disorder (8), Bipolar Affective Disorder (5), schizophrenia (5), schizoaffective disorder (2) and organic mental disorder (2). Mean age was 54.5 years; sex ratio was 15 females to 7 males. Patients received a mean of 12.0 treatments with mean seizure duration 50.9 s (by EEG) per treatment.

RESULTS

By Kahlbaum criteria, resolution of the catatonic syndrome occurred in 26 out of 28 cases (93%). The mean number of signs present per patient prior to ECT was 5.6 versus 0.93 following ECT (p = 0.00001). Overall, ECT brought about resolution of 83.5% of all symptoms with 98% resolution of primary symptoms and 74% resolution of secondary symptoms.

CONCLUSIONS

ECT is an effective treatment of the catatonic syndrome. ECT is effective in the resolution of both cardinal (primary) and secondary signs of catatonia. In this study, there is not a statistically significant difference in the effectiveness of the resolution of catatonic symptoms in persons with affective disorder versus schizophrenia.

Etomidate anesthesia increases seizure duration during ECT. A retrospective study

We reviewed charts of 28 consecutive depressed psychiatric inpatients who had received electroconvulsive therapy (ECT). As a preliminary investigation, we compared the effects of thiopental and etomidate anesthesia on seizure duration. Etomidate, a nonbarbiturate, has been shown to enhance seizure activity in other contexts. The mean age of our sample was 64 years. Because each patient received both etomidate and thiopental at various sessions during their course of ECT, each patient served as his or her own control. The mean proportion of etomidate sessions per patient was 54%. Mean seizure durations were significantly longer (p < 0.001) for the etomidate sessions as compared with the thiopental sessions. In contrast to some prior reports we found that the use of etomidate anesthesia in our sample of 28 consecutive inpatients enhanced seizure duration in ECT. Although controversial, some have advocated that longer seizure times will enhance effectiveness of ECT. We could not compare the anesthetic agents' clinical efficacy in relieving depression due to the retrospective nature of our study.

Midazolam shortens seizure duration following electroconvulsive therapy

In an open, prospective clinical trial, midazolam anaesthesia was compared with thiopental (plus suxamethonium chloride as a muscle relaxant) to clinically evaluate the former as an anaesthetic and a muscle relaxant during electroconvulsive therapy (ECT). Twelve depressed patients underwent a course of ECT, receiving midazolam or thiopental anaesthesia alternatively. Significant differences were found in seizure duration between the two anaesthetics. Midazolam shortened the seizures to a duration that was not therapeutically desirable. There were no differences in stimulus parameters between the two groups. The muscle relaxant effect of midazolam failed to provide optimal paralysis. Thus, midazolam anaesthesia offers no advantage over standard anaesthetic agents for ECT.