Based on a True Story? The Portrayal of ECT in International Movies and Television Programs

Clinical and Legal Differences in the Use of Involuntary Electroconvulsive Therapy for Life-Threatening Illness Across European Countries

OBJECTIVES

Electroconvulsive therapy (ECT) can be life-saving in situations where patients are at risk of dying from severe manifestations of psychiatric illness. In some of these cases, patients are unwilling/unable to consent to ECT, and involuntary ECT is required. Such use of involuntary ECT varies substantially across European countries for unclear reasons. The aim of this study was to examine clinical and legal differences in this use of involuntary ECT across European countries.

METHODS

A questionnaire based on a case vignette (a 55-year-old female inpatient with psychotic depression at imminent risk of dying from metabolic derangement because of refusal to eat and drink) was sent to an ECT practitioner in each of 31 European countries.

RESULTS

We received responses from ECT practitioners in 18 countries. In 7 of these countries, involuntary ECT could be carried out without approval from others and/or involvement of the court system in the case described in the vignette. Practitioners in the remaining 11 countries responded that they either could not carry out involuntary ECT or would have to meet certain requirements before initiating involuntary ECT (e.g., approval from medical/ethics committee and second opinion from an independent psychiatrist). Notably, the rules regarding involuntary ECT differed for adults and minors (more restrictive for the latter) in 6 of the 18 countries.

CONCLUSIONS

In many European countries, legislation precludes or delays the use of involuntary ECT. Harmonization of the legislation on involuntary ECT across European countries to allow for better access to this potentially life-saving treatment seems warranted.

Availability of Electroconvulsive Therapy in Public Health Services in the Last Decade in Brazil

OBJECTIVE

To identify the current treatment options for electroconvulsive therapy (ECT) therapy in public services linked to the Unified Health System in Brazil and compare them with data published in 2012 based on their availability.

METHODS

In this retrospective observational study, we mapped institutions that perform ECT under public health services in Brazil. A questionnaire was administered to active and inactive service centers between August 2022 and June 2023.

RESULTS

We identified 16 institutions that performed ECT, including 12 linked to public universities and 4 with various links. In the last decade, 2 new public services that perform ECT in the country have emerged, whereas 4 services have ceased function. In 2022, the number of individuals treated with ECT per 100,000 population was 1.86, whereas the number of procedures performed per 100,000 people was 6.55.

CONCLUSIONS

Although 2 new public ECT services have been identified, 4 have turned inactive. Most services are linked to public universities, and inactive service points to financial issues as the main factor in service interruption. Brazil has one of the lowest rates of individuals treated with ECT per 100,000 population compared with countries in North America and Europe. Thus, it is essential to raise awareness to improve ECT adoption rates and bring it out of the shadows in Brazil.

The ethical imperative of trauma-sensitive care for electroconvulsive therapy (ECT)

BACKGROUND

The empirical literature on the lived experience of electroconvulsive therapy (ECT) is limited, divergent, and largely focused on the experiences of procedures, (adverse) effects, information provision, or decision-making.

AIMS

This study aimed to investigate aspects related to the lived experience and meaning-making of people who have had ECT.

METHOD

In-depth interviews with 21 women (21-65 years old) were analyzed using interpretative phenomenological analysis (IPA).

FINDINGS

A subgroup of nine participants described more negative experiences with ECT. A common factor for these participants was the experience of trauma that remained under-treated. The superordinate themes identified were a lack of trauma-based and recovery-oriented treatment. The rest of the sample (12) expressed more positive experiences with ECT.

CONCLUSIONS

This study suggests that exploring more broadly the impacts of ECT at the long term offers insights that can help design more person-centered services aligned to the needs of the treatment recipients. Educational modules for mental health care staff should include, besides knowledge on the methods' effectiveness, additional evidence about treatment recipients' subjective concerns and the relevance of trauma and recovery-oriented care models.

Electroconvulsive therapy portrayal in contemporary video games

Electroconvulsive therapy (ECT) is an important treatment modality in psychiatry, considered to be the most effective option for pharmaco-resistant affective and psychotic disorders. Despite its great efficacy, it still remains a rather controversial method, which hinders its full potential. It is feasible to say that in part, this controversy is caused by a largely negative image of ECT displayed through media. The depiction of ECT in movies has been studied and well documented in the past. The aim of our study was to provide an overview of how ECT is represented in video games - a form of media where ECT representation has been overlooked in scientific literature so far. As with movies, most of these portrayals are negative, depicting ECT as an obsolete, aggressive or torturous treatment method.

What Our Patients and Their Families Are Reading: Quality and Readability of Internet Information About Electroconvulsive Therapy

OBJECTIVES

The Internet is now more widely used than before by psychiatric patients and their families to search for medical conditions and treatments. To our knowledge, no study has addressed the quality and readability of online information about electroconvulsive therapy (ECT). We aimed to examine the quality and readability of English-language Internet information related to ECT.

METHODS

An advanced search of Internet Web sites containing information about ECT was conducted by using the search term "ECT or electroconvulsive therapy." The resulting Web sites were categorized into 1 of 3 categories (commercial, nonprofit, or professional organizations). Their quality was evaluated using Health on the Net code certification, the Journal of the American Medical Association (JAMA) benchmark criteria, and the DISCERN tool. The readability of the Web sites was assessed using the Flesch Reading Ease, Flesch-Kincaid Grade Level Formula, Simple Measure of Gobbledygook, and Gunning Fog indexes.

RESULTS

A total of 86 Web sites were included in the analysis. Of all these Web sites, 18 (20.9%) had a Health on the Net code certificate, and 16 (18.6%) were accepted as high quality (JAMA total score ≥3). The commercial Web sites had significantly lower DISCERN and JAMA benchmark scores compared with the other Web sites. A total of 30.23% of all the Web sites reached the recommended readability level (Flesch-Kincaid Grade Level Formula ≤ 8). Moreover, only 4 scored at the grade 5 to 6 reading level, which is considered ideal for patient educational materials.

CONCLUSIONS

Our study indicates that both the quality and readability of online information about ECT are not at the desired level. Physicians, patients, and their families should consider this failure in relation to online information about ECT. In addition, Web site creators and health authorities should be aware of their responsibilities for providing quality and readable health information to the public.

Whole Person Modeling: a transdisciplinary approach to mental health research

The growing global burden of mental illness has prompted calls for innovative research strategies. Theoretical models of mental health include complex contributions of biological, psychosocial, experiential, and other environmental influences. Accordingly, neuropsychiatric research has self-organized into largely isolated disciplines working to decode each individual contribution. However, research directly modeling objective biological measurements in combination with cognitive, psychological, demographic, or other environmental measurements is only now beginning to proliferate. This review aims to (1) to describe the landscape of modern mental health research and current movement towards integrative study, (2) to provide a concrete framework for quantitative integrative research, which we call Whole Person Modeling, (3) to explore existing and emerging techniques and methods used in Whole Person Modeling, and (4) to discuss our observations about the scarcity, potential value, and untested aspects of highly transdisciplinary research in general. Whole Person Modeling studies have the potential to provide a better understanding of multilevel phenomena, deliver more accurate diagnostic and prognostic tests to aid in clinical decision making, and test long standing theoretical models of mental illness. Some current barriers to progress include challenges with interdisciplinary communication and collaboration, systemic cultural barriers to transdisciplinary career paths, technical challenges in model specification, bias, and data harmonization, and gaps in transdisciplinary educational programs. We hope to ease anxiety in the field surrounding the often mysterious and intimidating world of transdisciplinary, data-driven mental health research and provide a useful orientation for students or highly specialized researchers who are new to this area.

Knowledge and Attitudes of First- and Final-Year Medical Students about Electroconvulsive Therapy: The Impact of Media

OBJECTIVE

The aim of this study is to evaluate medical students' knowledge about and attitudes towards electroconvulsive therapy (ECT) and to assess the impact of information sources (including those within and outside the curriculum) on knowledge and attitudes by comparing first- and final-year medical students.

METHODS

Two hundred and ninety-five first-year and one hundred forty-nine final-year medical students of the University of Leuven (KU Leuven) in Belgium responded to an anonymous self-administered survey which consisted of questions about sociodemographic background, self-perceived knowledge about medicine, psychiatry and ECT, interest in psychiatry, experience with psychiatric disorders, information sources of ECT, and knowledge about and attitudes towards ECT.

RESULTS

Compared to first-year medical students, final-year students had better knowledge about and more positive attitudes towards ECT, partially explained by differences in information sources. Nevertheless, both student groups showed an average knowledge score below 50%. Whereas freshmen attributed their knowledge to movies or documentaries, senior students gained knowledge mainly at university courses, scientific journals, and attending live ECT sessions. A significant positive correlation was found between knowledge about and positive attitudes towards ECT.

CONCLUSIONS

The knowledge of first- and final-year medical students remains limited, potentially due to limited instruction about ECT in medical courses. The use of media as an information source predicted negative attitudes towards ECT. Therefore, the stigma and misinformation provided in the media need to be addressed in the medical curriculum.

Management for A Depressive Patient with Femoral Neck Fracture by Electroconvulsive Therapy during COVID-19 Pandemic: A Case Report and Literature Review

Electroconvulsive therapy (ECT) is an effective treatment for refractory major depressive disorder with suicidal ideation. The most common adverse medical events are transient retrograde amnesia, falls and pneumonia. Hip fractures, associated with high-energy trauma by convulsions, were occasionally reported in western countries, in the period before the COVID-19 pandemic. Strict COVID-19 regulations influenced the course and further investigation of the treatment of post-ECT complications. A 33-year-old man, previously diagnosed with major depressive disorder, had a history of nine successful sessions of ECT treatment for depression five years ago. He was hospitalized again for 12 sessions of ECT for recurrent depression. Unfortunately, an ECT-induced right hip-neck fracture was noted after the ninth session of ECT, in March 2021. After receiving close reduction and internal fixation of the right femoral neck fracture, with three screws, his original daily function was restored. His treatment was regularly followed up at the outpatient clinic for 20 months; he achieved partial remission with three combined antidepressants. This case of ECT-induced right hip-neck fracture informed psychiatric staff to be aware of this rare adverse complication and ensure its appropriate management, especially during the COVID-19 pandemic.

Assessment of beliefs and attitudes about electroconvulsive therapy posted on Twitter: An observational study

BACKGROUND

Electroconvulsive therapy (ECT) is an effective and safe medical procedure that mainly indicated for depression, but is also indicated for patients with other conditions. However, ECT is among the most stigmatized and controversial treatments in medicine. Our objective was to examine social media contents on Twitter related to ECT to identify and evaluate public views on the matter.

METHODS

We collected Twitter posts in English and Spanish mentioning ECT between January 1, 2019 and October 31, 2020. Identified tweets were subject to a mixed method quantitative-qualitative content and sentiment analysis combining manual and semi-supervised natural language processing machine-learning analyses. Such analyses identified the distribution of tweets, their public interest (retweets and likes per tweet), and sentiment for the observed different categories of Twitter users and contents.

RESULTS

"Healthcare providers" users produced more tweets (25%) than "people with lived experience" and their "relatives" (including family members and close friends or acquaintances) (10% combined), and were the main publishers of "medical" content (mostly related to ECT's main indications). However, more than half of the total tweets had "joke or trivializing" contents, and such had a higher like and retweet ratio. Among those tweets manifesting personal opinions on ECT, around 75% of them had a negative sentiment.

CONCLUSIONS

Mixed method analysis of social media contents on Twitter offers a novel perspective to examine public opinion on ECT, and our results show attitudes more negative than those reflected in studies using surveys and other traditional methods.

Contemporary Approaches Toward Neuromodulation of Fear Extinction and Its Underlying Neural Circuits

Neuroscience and neuroimaging research have now identified brain nodes that are involved in the acquisition, storage, and expression of conditioned fear and its extinction. These brain regions include the ventromedial prefrontal cortex (vmPFC), dorsal anterior cingulate cortex (dACC), amygdala, insular cortex, and hippocampus. Psychiatric neuroimaging research shows that functional dysregulation of these brain regions might contribute to the etiology and symptomatology of various psychopathologies, including anxiety disorders and post traumatic stress disorder (PTSD) (Barad et al. Biol Psychiatry 60:322-328, 2006; Greco and Liberzon Neuropsychopharmacology 41:320-334, 2015; Milad et al. Biol Psychiatry 62:1191-1194, 2007a, Biol Psychiatry 62:446-454, b; Maren and Quirk Nat Rev Neurosci 5:844-852, 2004; Milad and Quirk Annu Rev Psychol 63:129, 2012; Phelps et al. Neuron 43:897-905, 2004; Shin and Liberzon Neuropsychopharmacology 35:169-191, 2009). Combined, these findings indicate that targeting the activation of these nodes and modulating their functional interactions might offer an opportunity to further our understanding of how fear and threat responses are formed and regulated in the human brain, which could lead to enhancing the efficacy of current treatments or creating novel treatments for PTSD and other psychiatric disorders (Marin et al. Depress Anxiety 31:269-278, 2014; Milad et al. Behav Res Ther 62:17-23, 2014). Device-based neuromodulation techniques provide a promising means for directly changing or regulating activity in the fear extinction network by targeting functionally connected brain regions via stimulation patterns (Raij et al. Biol Psychiatry 84:129-137, 2018; Marković et al. Front Hum Neurosci 15:138, 2021). In the past ten years, notable advancements in the precision, safety, comfort, accessibility, and control of administration have been made to the established device-based neuromodulation techniques to improve their efficacy. In this chapter we discuss ten years of progress surrounding device-based neuromodulation techniques-Electroconvulsive Therapy (ECT), Transcranial Magnetic Stimulation (TMS), Magnetic Seizure Therapy (MST), Transcranial Focused Ultrasound (TUS), Deep Brain Stimulation (DBS), Vagus Nerve Stimulation (VNS), and Transcranial Electrical Stimulation (tES)-as research and clinical tools for enhancing fear extinction and treating PTSD symptoms. Additionally, we consider the emerging research, current limitations, and possible future directions for these techniques.

Parent preferences for adolescent depression treatment: The role of past treatment experience and biological etiological beliefs

BACKGROUND

Parents play a crucial role in facilitating depression treatment for adolescents, yet parental preferences for adolescent treatments are ill-understood. Past treatment experience and belief in a biological model of depression may impact preferences, and warrant investigation.

METHODS

Parents (N = 143) of teens (12-18 years) completed a survey assessing preference for adolescent depression treatments, treatment knowledge, and beliefs about the biological etiology of depression. Details about parents' and adolescents' past mental health concerns and treatment were obtained. Parents indicated degree of preference from 0 (Not at all preferable) - 10 (Highly preferable) for six treatment options (counselling, antidepressant medication, repetitive transcranial magnetic stimulation, electroconvulsive therapy, exercise, no treatment) for three adolescents vignettes depicting varying depression severity (Mild/Moderate, Severe, and Treatment-Resistant).

RESULTS

Mean preference ratings across all vignette severities were high for counselling (range: 8.57-9.38) and exercise (range: 9.04-9.25). Multiple regression revealed parental past experience of psychopharmacological treatment was significantly associated with current preference for adolescent antidepressant medication, with increased helpfulness and milder/fewer adverse events associated with stronger preference. Greater perceived helpfulness of past teen psychopharmacological treatment was significantly associated with greater current parental preference for adolescent antidepressant medication. Strength of biological beliefs and counselling preference were significantly positively associated.

LIMITATIONS

Sample was highly educated, predominately female, and majority treatment-utilizing limiting the generalizability of findings.

CONCLUSIONS

Parents' own past medication experiences and degree of biological etiological beliefs appear to be associated with current teen depression treatment preferences. Counselling and exercise were highly preferred across depression severity.

The Rise, Fall, and Resurgence of Electroconvulsive Therapy

Electroconvulsive therapy (ECT) is one of the most effective treatments for depression. However, significant stigma from the media and the antipsychiatry movement has biased the public toward ECT, leading to underutilization, particularly among those most in need. This report reviews some of the key historical events in the rise, fall, and resurgence of ECT and how modern ECT knowledge and practice are more refined, including an improved understanding of its mechanisms of action and optimal treatment parameters.

Effect of an Educational Video and Information Pamphlet on Knowledge and Attitudes About Electroconvulsive Therapy: A Randomized, Blind, Controlled Study

OBJECTIVE

Electroconvulsive therapy (ECT) is considered an effective, yet underused and stigmatized form of psychiatric treatment. Public misconception can impact informed decision making, and therefore, it is important to educate the community with accurate and realistic representations of modern ECT. The aim of this study was to determine whether exposure to brief information packages developed in Australia leads to changes in attitudes and knowledge about ECT.

METHODS

A sample of 100 undergraduate psychology students and 88 volunteers from the general public were randomly allocated to view 1 of 3 resource packages (each containing an information pamphlet and videos totaling ~15 minutes): Concord Centre for Mental Health-Revised, Concord Centre for Mental Health-Original, and a generic information package on depression. Participants' attitudes and knowledge of ECT were assessed before and after psychoeducation using the Questionnaire on Attitudes and Knowledge of ECT (QuAKE).

RESULTS

Participants in the student and general population exposed to either ECT resource package showed significantly improved attitudes and knowledge of ECT compared with participants exposed to generic information about depression and its treatment. A fine-grained analysis of the QuAKE revealed that, although many aspects of knowledge and attitudes improved after exposure to ECT information packages, some remained unchanged.

CONCLUSIONS

Brief education through information resources in video and written format can markedly improve attitudes and knowledge toward ECT. Further research is recommended to determine whether the resources contribute to informed decision making of consumers with mental illness, especially those who are candidates for ECT.

Addressing Electroconvulsive Therapy Knowledge Gaps and Stigmatized Views Among Nursing Students Through a Psychiatrist-APRN Didactic Partnership

BACKGROUND: Knowledge gaps and stigmatized perceptions regarding electroconvulsive therapy (ECT) among patients and health providers contribute to the underutilization of an important therapeutic modality. The proactive education of future advanced practice registered nurses (APRNs) provides an opportunity to optimize the use of this evidence-based clinical practice. AIMS: As part of a general course in psychiatry during the first year of nursing school, we dedicated 1 hour to treatment-refractory depression, including ECT, and a second hour to a summary discussion of mood disorders. We evaluated the efficacy of this didactic offering, which was co-taught by a psychiatrist and a psychiatric APRN. METHOD: At baseline, consenting students (n = 94) provided three words they associated with ECT and then completed three validated instruments: (a) Questionnaire on Attitudes and Knowledge of ECT, (b) Opening Minds Stigma Scale for Health Care Providers, and (c) Self-Stigma of Seeking Help. Among the 67 students who repeated the assessment at endpoint, 39 attended the ECT didactic (Intervention group, 58%) and 28 did not (Control, 42%). RESULTS: After completion of the 3-month course, students showed improvement across all measures (p < .001). The only outcomes that improved differentially between the Intervention and Control groups were the Questionnaire on Attitudes and Knowledge of ECT Attitudes and Knowledge scales (p = .01). Word choice valence associated with ECT shifted favorably by endpoint (p < .001). CONCLUSIONS: An educational intervention co-led by a psychiatric-mental health APRN had a significant impact on nursing students' knowledge and perceptions of ECT. This approach can be readily implemented at other institutions. Future refinements will include the videotaped depiction of a simulated patient undergoing the consent, treatment, and recovery phases of ECT.

Knowledge, attitudes and beliefs about electroconvulsive therapy among Polish students

Introduction: Electroconvulsive therapy (ECT) is an effective and safe treatment for many mental disorders. Nevertheless, the attitudes towards ECT are negative and the use of this method in Poland is decreasing.

Aim: The aim of the study was to investigate the general knowledge and attitudes towards electroconvulsive therapy among Polish university students, including students of medicine, psychology and other faculties.

Material and methods: An original online questionnaire containing 39 questions was used, distributed through student groups on social networking sites. A total of 418 questionnaires were completed. The collected data were statistically analyzed.

Results: Significant knowledge gaps and negative beliefs about electroconvulsive therapy were observed among Polish students. Medical and psychology students had more extensive knowledge and more positive beliefs about this method of treatment than students of other faculties. Greater knowledge of the therapy was associated with a more positive attitude towards it. The main source of knowledge about ECT for students of medicine and psychology were lectures and courses, and for students of other faculties – movies. Students, who considered psychiatry as their future specialization, had less knowledge and a more negative attitude towards ECT, relative to the rest of the respondents.

Conclusions: There is a need for educational interventions that will change the way how ECT is perceived both in the public opinion and in the medical community. An effective solution to low levels of knowledge for medical students may be the observation of the procedure included in the study programme.

What are the ethical dilemmas in the decision-making processes of nursing people given electroconvulsive therapy? A critical realist review of qualitative evidence

WHAT IS KNOWN ON THE SUBJECT?: ECT is a treatment which has a long and complicated history. There is no consensus on its effectiveness and there is a great deal of polarized debate as to whether it should be used. MHNs are asked to work with people who are receiving ECT as part of their duties. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: The paper seeks to move beyond the polarized arguments and to consider how MHNs can work with people where ECT is being considered or administered as part of their treatment in a manner which satisfies their professional obligations. IMPLICATIONS FOR PRACTICE: MHNs may need to broaden their understanding of ethics beyond the traditional biomedical ethics model of beneficence, non-maleficence, justice and autonomy, as well as improving their understanding of social and political factors which may have an unseen effect of the use of ECT as a treatment in order to meet their professional obligations when working with people being administered ECT. ABSTRACT: INTRODUCTION Electroconvulsive therapy (ECT) has a complex and contentious place in psychiatric care. Mental health nurses (MHNs) are of obligated to be part of this practice despite ethical concerns. Aim To consider the ethical dilemmas and decision-making processes facing MHNs involved in the administration of ECT. Method A critical realist review of the literature surrounding ethical considerations and ECT was undertaken using thematic analysis. Findings Four key themes emerged: the MHN as an advocate and conflict in their role, issues surrounding consent, questionable efficacy and unknown method of action, side effects, and legal issues and clinical guidelines. Discussion Using a critical realist framework for understanding, the decision-making process and ethical considerations are viewed as part of the empirical and actual parts of reality, while the potential for other, unseen causal powers to be at play is acknowledged. Implications for practice MHNs need to ensure they have an adequate ethical underpinning to their practice to enable them to navigate contentious areas of practice such as ECT to practice effectively and preserve safety. This may require moving beyond the traditional biomedical model of ethics. Developing an appreciation of unseen causal factors is also an essential part of MHNs' developing professional competency.

A comparison of the safety, feasibility, and tolerability of ECT and ketamine for treatment-resistant depression

INTRODUCTION

Treatment-resistant depression (TRD) is a problematic and prevalent public health and societal concern. Although electroconvulsive therapy (ECT) is the gold standard TRD intervention, the treatment evokes apprehension due to public perceptions, feasibility, and tolerability. Despite significant medical advancements, few medications have been approved by the U.S. Food and Drug Administration for TRD. In 2019, intranasal esketamine, the S-isomer of racemic ketamine, was approved for TRD, garnering significant excitement about the potential for the drug to act as an alternative treatment to ECT.

AREAS COVERED

The goal of this narrative review is to compare the safety, efficacy, and tolerability of ketamine and ECT; clarify whether ketamine is a reasonable alternative to ECT; and to facilitate improved treatment assignment for TRD. Empirical quantitative and qualitative studies and national and international guidelines these treatments are reviewed.

EXPERT OPINION

: The field awaits the results of two ongoing large comparative effectiveness trials of ECT and IV ketamine for TRD, which should help guide clinicians and patients as to the relative risk and benefit of these interventions. Over the next five years we anticipate further innovations in neuromodulation and in drug development which broadly aim to develop more tolerable versions of ECT and ketamine, respectively.

'Shock tactics', ethics and fear: an academic and personal perspective on the case against electroconvulsive therapy

Despite extensive evidence for its effectiveness, electroconvulsive therapy remains the subject of fierce opposition from those contesting its benefits and claiming extreme harms. Alongside some reflections on my experiences of this treatment, I examine the case against electroconvulsive therapy and find that it appears to rest primarily on unsubstantiated claims about major ethical violations, rather than clinical factors such as effectiveness and risk.

Cognitive Adverse Effects of Electroconvulsive Therapy: A Discrepancy Between Subjective and Objective Measures?

OBJECTIVES

The character and duration of cognitive adverse effects of electroconvulsive therapy (ECT) are unclear. This study investigated (1) the sensitivity of a short cognitive test battery to cognitive adverse effects of ECT, (2) the relation between subjective and objective cognitive adverse effects, and (3) patient characteristics associated with more subjective than objective adverse effects.

METHODS

Forty-one patients with unipolar or bipolar depression referred to ECT underwent assessments at baseline, 5 to 7 days post-ECT, and 3 months post-ECT. Patients rated their fear of various aspects of ECT on a visual analog scale. At each assessment, patients were evaluated for depressive symptoms, completed the Screen for Cognitive Impairment in Psychiatry (SCIP) and Trail Making Test-Part B (TMT-B), and rated their cognitive difficulties.

RESULTS

Patients feared cognitive adverse effects and lack of treatment efficacy more than other aspects of ECT. The SCIP and TMT-B revealed transient decline in objective cognition after ECT, which was reversed after 3 months. Patients presented with more subjective than objective cognitive difficulties at baseline and more subjective than objective cognitive adverse effects of ECT. This discrepancy was significantly reduced at follow-up. Younger age and poorer objective cognition pretreatment were associated with more subjective than objective cognitive adverse effects 5 to 7 days after ECT.

CONCLUSIONS

The SCIP and TMT-B are sensitive to cognitive adverse effects of ECT. Patients show more subjective than objective cognitive adverse effects of ECT. These insights can be used clinically to inform patients of treatment choice and expected cognitive consequences.

Recipients' experience with information provision for electroconvulsive therapy (ECT)

BACKGROUND

Despite improvements, studies continue to report unsatisfactory provision of information before, during and after electroconvulsive treatment (ECT).

AIMS

The study explores participants' experiences with information provision about ECT.

METHODS

In-depth interviews with 21 participants (21- 65 year-old) were conducted. Thematic analysis resulted in identification of four themes: pre-treatment knowledge, experience of informed consent, the need for information depth and life after ECT. The study includes user involvement.

RESULTS

Although some participants were satisfied with information provision, the majority experienced an education deficit throughout the treatment period. Their consent was based mostly on oral information, insufficient and unvaried information on official health websites and media. Further, patients reported a lack of follow-up services that can attend to (neuro) psychological concerns.

CONCLUSIONS

Better access to updated factual and narrative information should support patient education and autonomy. Active use of diary writing, better follow-up and more varied representations of experience with ECT in media and health information sites are necessary to educate, improve consent processes and reduce stigma.

Depiction of mental illness and psychiatry in popular video games over the last 20 years

Video games represent a rapidly growing media form that is a daily activity for many youths. So far, only a little attention has been paid to the portrayal of mental illnesses and psychiatric intervention within them. In our research, we explored the best-selling video games released between 2002-2021 in order to analyse these representations. We came to the conclusion that approximately 1 out of 10 popular games attempts to portray symptoms of mental illness - with a majority of 75% of them in a negative and stereotypical way. Despite the majority of mental illness depiction in popular video games being negative, there are mounting reports that certain representations have a positive impact on their player bases. Further studies are required, as to how much videogames influence the player's attitude toward this topic.

High-frequency repetitive transcranial magnetic stimulation alleviates the cognitive side effects of electroconvulsive therapy in major depression

OBJECTIVE

The retrospective study aimed to explore the difference in mood outcomes and cognitive function between high-frequency repetitive transcranial magnetic stimulation (HF-rTMS) over dorsolateral prefrontal cortex (DLPFC) and electroconvulsive therapy in major depression disorder (MDD) patients and to examine the improvement of HF-rTMS on cognitive impairment evoked by electroconvulsive therapy (ECT).

MATERIALS AND METHODS

A total of 116 participants with MDD, who completed a 4-week follow-up assessment, were enrolled. The cohort consisted of 26 cases classed as control, 46 participants administrated with HF-rTMS (HF-rTMS group), 22 patients treated with ECT (ECT group), and 23 cases treated with HF-rTMS and ECT at the course of hospitalization (HF-rTMS + ECT group). Medication was kept constant as well in all participants. The 17-item Hamilton Depression Rating Scale for Depression (HAMD-17) and 14-item Hamilton Anxiety Rating Scale (HAMA-14) were used to assess depression and anxiety, respectively. Montreal Cognitive Assessment (MoCA) was to elevate cognitive function.

RESULTS

No statistical significance was found for baseline in sociodemographic, characteristics of depression, anxiety and cognition, and psychopharmaceutic dosages among control, HF-rTMS, ECT, and HF-rTMS + ECT groups (p > 0.05). Compared with baseline level, total scores of HAMD-17 and HAMA-14 significantly decreased at the end of 4 weeks after treatment (p < 0.001). Furthermore, the decline in scores of HAMD-17 and its sleep disorder and retardation factors from baseline to post-treatment was greater in HF-rTMS, ECT, and HF-rTMS + ECT group than in control (p < 0.05), and there was a significant difference between control and HF-rTMS group in the decline of psychological factor of HAMA-14 (p < 0.01). ECT treatment evoked total score of MoCA to decrease significantly at the end of 4-week after intervention (p < 0.001), and the decline in scores of MoCA and its delayed recall and language performances from baseline to post-treatment was greater in ECT than control, HF-rTMS, and HF-rTMS + ECT (p < 0.05).

CONCLUSION

High-frequency repetitive transcranial magnetic stimulation improved psychological anxiety and ameliorated the cognition impairment evoked by ECT though it had the same anti-depressant efficacy as ECT.

Use of electroconvulsive therapy for individuals receiving inpatient psychiatric care on a nationwide scale in France: Variations linked to health care supply

BACKGROUND

A comprehensive understanding of variations in the use of electroconvulsive therapy (ECT) among health care providers in charge of ECT referrals is lacking.

OBJECTIVE

Our objectives were to document ECT use and its variations on a nationwide scale in France and to identify the factors that were significantly associated with these variations.

METHODS

Administrative health claims data on hospitalization were used to perform a descriptive analysis of ECT use for adult patients receiving inpatient psychiatric care in mainland France in 2019 and its variations across hospitals in charge of ECT referrals. Based on a conceptual framework drawn from the literature on medical practice variations, a multilevel logistic regression was then conducted to identify patients, hospitals and contextual characteristics that were significantly associated with ECT treatment using non-ECT-treated patients receiving inpatient psychiatric care as the reference population.

RESULTS

Patients receiving ECT (n = 3288) were older, more frequently female and had more severe diagnoses than other patients seen in inpatient care (n = 295,678). Significant variations were observed in the rate of ECT use across hospitals (n = 468), with a coefficient of variation largely above one. In the multivariable analysis, ECT treatment was associated with patient characteristics (which accounted for 6% of the variations) but also with characteristics of the hospitals and their environments (44% of the variations), including the type of hospital and its distance to the closest facility providing ECT.

CONCLUSIONS

Variations in ECT use were strongly linked to health care supply characteristics, which raises questions about access to quality mental health care.

The Effects of Focal Electrically Administered Seizure Therapy Compared With Ultrabrief Pulse Right Unilateral Electroconvulsive Therapy on Suicidal Ideation: A 2-Site Clinical Trial

BACKGROUND

Preliminary data suggest that focal electrically administered seizure therapy (FEAST) has antidepressant effects and less adverse cognitive effects than traditional forms of electroconvulsive therapy (ECT). This study compared the impact of FEAST and ultrabrief pulse, right unilateral (UB-RUL) ECT on suicidal ideation.

METHODS

At 2 sites, patients in a major depressive episode were treated openly with FEAST or UB-RUL ECT, depending on their preference. The primary outcome measure was scores on the Beck Scale for Suicide Ideation (SSI). Scores on the suicide item of the Hamilton Rating Scale for Depression (HRSD-SI) provided a secondary outcome measure.

RESULTS

Thirty-nine patients were included in the intent-to-treat sample (FEAST, n = 20; UB-RUL ECT, n = 19). Scores on both the SSI and HRSD-SI were equivalently reduced with both interventions. Both responders and nonresponders to the interventions showed substantial reductions in SSI and HRSD-SI scores, although the magnitude of improvement was greater among treatment responders.

CONCLUSIONS

Although limited by the open-label, nonrandomized design, FEAST showed comparable effects on suicidal ideation when compared with routine use of UB-RUL ECT. These results are encouraging and support the need for further research and a noninferiority trial.

Making It Real: From Telling to Showing, Sharing, and Doing in Psychiatric Education

OBJECTIVE

Innovations in contemporary medical education could inform remedies to address enduring challenges such as the marginalization and stigmatization of psychiatry, of mental illnesses, and of those affected by them.

METHODS

In blending the works of Bleakley, Bligh, and Brown (2011) and of Kumagai and Naidu (2015), we developed an overarching heuristic with practical relevance and concrete applications to psychiatric education.

RESULTS

We identify three areas to enhance psychiatric education embedded into this blended framework: 1) Showing, or the more accurate depiction or imaging of mental illnesses and of psychiatric practice, as exemplified by the incorporation into didactic content of asynchronous video-based clinical materials produced with specific educational objectives in mind; 2) Sharing, or addressing the image problem of mental illnesses, of those living with or affected by them, and of psychiatry as a profession, as exemplified by psychiatrists embracing their role as experts by professional and personal experience when sharing their own journeys with mental illness, treatment, and recovery; and 3) Doing, or reimagining reflective psychiatric practice, as exemplified by the novel methodology of co-constructive patient simulation (CCPS), through which learners can engage in reflective practice and supervision in a participatory and democratic setting that does not privilege participants' hierarchical standing.

CONCLUSION

The blended model and the sample applications we describe offer a range of teaching, learning, and professional development opportunities, should psychiatric educators choose to pursue them and reap their promise.

Are we withholding the most effective treatment for severe depression from our patients?

In response to an article on recent advances in the use of ECT for depression, this commentary supports earlier and more extensive use of the treatment. It challenges the belief that ECT is associated with a higher risk of cognitive deficits and mortality and points out its rapid effect compared with antidepressant medication. It calls for clinicians to remain up to date regarding ECT and consider its opportune use in severe depression.

Autonomy and consent assessment for electroconvulsive therapy (ECT). A retrospective study of medical records

The Norwegian Mental Health Act allows involuntary treatment for patients who lack consent capacity, however it allows only administration of pharmaceutical treatment and nutrition and not ECT. In lack of specific regulations, the legal access to ECT without valid consent has been grounded on the general rule of necessity in the Norwegian Penal code. This restriction and lack of legal regulation has implications for patients' rights and legal security. The study's aim was to assess the documented consent provided by patients for electroconvulsive therapy (ECT), whether ECT was administered without valid consent or under coercion, and the documented reasons, and ultimately compare practice with the legal requirements. We analysed systematically all the relevant medical records for hospitalised patients and outpatients receiving ECT during 2011-2016. We categorized data from these two groups into seven defined categories describing the attitude and quality of the consents to the ECT (or lack thereof). 378 patients received 498 ECT series´. The noted consents varied from treatment based on request (54 treatments), consent upon recommendation (209 treatments), consent after hesitation (88 treatments), consent presumed or noted without specification (114 treatments), to no consent (21 treatments) whereof the majority with documented coercion applied (19 treatments). All cases of ECT without consent referred to a "plea of necessity". The remaining treatments (12) lacked notifications specifying the consent (or attitude) expressed. Specific notes on the patient's capacity to consent for the respective ECT were generally lacking. This study indicates a large spread in patients´ acceptance and valid consent to ECT. The main reason for administering ECT without consent and/or against patients' will was for life-saving reasons. Such treatments were justified legal under a plea of necessity in the Penal Code or lacked noted legal justification. The legal vacuum for ECT without a valid consent needs to be addressed as this kind of disputed treatment is used in some cases.

Barriers to the Implementation of Electroconvulsive Therapy (ECT): Results From a Nationwide Survey of ECT Practitioners

OBJECTIVE

Electroconvulsive therapy (ECT) is an effective treatment for major depressive disorder; yet, its use is confined to <1% of individuals with this disorder. The authors aimed to examine barriers to ECT from the perspective of the provider.

METHODS

Qualitative interviews were conducted with U.S.-based ECT providers to identify potential barriers. A quantitative survey was created asking providers to rank-order barriers to starting a new ECT service or expanding existing services.

RESULTS

Survey responses were received from 192 physicians. Respondents were representative of all ECT providers found in the Medicare Provider Utilization and Payment Database with respect to gender and geographic distribution. Approximately one-third (N=58, 30%) of survey respondents graduated from one of 12 residency programs. Programs with dedicated hospital space were more likely to have larger services than those borrowing surgical recovery space (χ²=25.87, df=1, p<0.001). The most prominent provider-reported barriers to expanding an existing ECT service were lack of physical space, stigma on the part of patients, and transportation difficulties. The most prominent barriers to initiating a new service were lack of well-trained colleagues and ECT practitioners, lack of a champion within the institution, and lack of physical space. Wide geographic variation was found in the availability of ECT, with the highest concentration of ECT providers per 1 million individuals found in New England (6.4), and the lowest found in the West South Central (1.1).

CONCLUSIONS

Coordinated efforts to overcome identified barriers may allow ECT to be more broadly implemented. Investments in education may increase the number of competent practitioners.

[Impact of an educational video on the representations of electroconvulsive therapy among psychiatrists in Hauts-de-France and Occitanie]

INTRODUCTION

Despite its effectiveness and good tolerance, electro-convulsive therapy (ECT) is under-used in current clinical practice probably because of stigma and the negative image of this treatment. The main objective of this study was to evaluate the impact of an educational video on the representations of ECT among psychiatrists and psychiatric residents in the North and in Occitanie districts of France.

METHOD

We evaluated the representations of ECT through the Questionnaire on Attitudes and Knowledge of ECT (QuAKE) before (T0) and after (T1) viewing a short educational video. Scores at T0 and T1 were compared with a paired t-test. Factors associated with the improvement of the representations were investigated using a logistic regression model.

RESULTS

In all, 195 responses were obtained. The QuAKE score at T1 was significantly better than at T0 (29.4 at T1 vs. 31.5 at T0, P<0.001). The more negative the representations were at T0, the higher the probability of a decrease in the score at T1 (OR=1.07 [1.02-1.13], P=0.003).

DISCUSSION

Our study showed a beneficial effect of a short educational video on psychiatrists' representations of ECT. The wide use of this type of media, allowing information and destigmatization, could considerably optimize access to ECT for patients.

Survival Rate Following Involuntary Electroconvulsive Therapy: A Population-Based Study

OBJECTIVE

Involuntary electroconvulsive therapy (ECT) can be a lifesaving intervention for patients suffering from potentially lethal conditions who are unable to give informed consent. However, its use is not widespread, probably partly because of the scarce data on hard outcomes following involuntary ECT. In Denmark, involuntary ECT is only used when patients are at imminent/potential risk of dying if not receiving ECT. Here, we aimed to estimate the 1-year survival rate after the administration of involuntary ECT as a proxy for the effectiveness of this treatment.

METHODS

We conducted a register-based cohort study involving (i) all patients receiving involuntary ECT in Denmark between 2008 and 2019, (ii) age- and sex-matched patients receiving voluntary ECT, and (iii) age- and sex-matched individuals from the general population. One-year survival rates were compared via mortality rate ratios.

RESULTS

We identified 618 patients receiving involuntary ECT, 547 patients receiving voluntary ECT, and 3080 population-based controls. The survival rate in the year after involuntary ECT was 90%. For patients receiving involuntary ECT, the 1-year mortality rate ratios were 3.1 (95% confidence interval, 1.9-5.2) and 5.8 (95% confidence interval, 4.0-8.2) compared with those receiving voluntarily ECT and to the population-based controls, respectively. Risk factors for early death among patients receiving involuntary ECT were male sex, being 70 years or older and having organic mental disorder as the treatment indication.

CONCLUSIONS

Treatment with involuntary ECT is associated with a high survival rate, suggesting that the intervention is effective. However, patients receiving involuntary ECT constitute a high-risk population that should be monitored closely after this treatment.

The Nomenclature of Electroconvulsive Therapy

ABSTRACT

Electroconvulsive therapy (ECT) is an established but stigmatized psychiatric treatment. The term ECT reflects the treatment's modality and action. Several authors proposed different names for ECT to deal with stigma; however, available literature that promoted different names did not address the risk/benefit ratio or offer evidence-based approach to the efficacy of this approach. We aim to examine proposed names for their specificity, accuracy, understandability, and popularity. In addition, we aim to find evidence-based methods to combat the ECT-related stigma. We reviewed the literature relating to the proposed names using snowballing technique for literature search. Known ECT alternative names were used for search, and whenever another name appears, it was added to our search list. We conducted Medline, PsycINFO, Google Scholar, and PubMed search to check for popularity and cross examine whether proposed terms refer back to ECT. We searched for ECT and stigma, to find evidence for methods to tackle ECT-related stigma. Once, the search stopped yielding newer ideas, we stopped the search at a point of saturation, where no more ideas where generated. Our name search yielded 14 terms. Nine names avoided "electricity" and "convulsion," because of perceived associated stigma. Presence of different terminology can affect the clarity of patient-doctor communication, with no evidence of added benefit. Alternative names may affect doctor-doctor communication about this treatment. We concluded that it is safer to retain the term ECT for the sake of consistency and clarity of communication. Education and experience are evidence-based effective methods of tackling ECT-related stigma.

Is There Evidence That Stimulus Parameters and Electrode Placement Affect the Cognitive Side Effects of Electroconvulsive Therapy in Patients With Schizophrenia and Schizoaffective Disorder?: A Systematic Review

ABSTRACT

Seventy percent of patients with treatment-resistant schizophrenia do not respond to clozapine. Electroconvulsive therapy (ECT) can potentially offer significant benefit in clozapine-resistant patients. However, cognitive side effects can occur with ECT and are a function of stimulus parameters and electrode placements. Thus, the objective of this article is to systematically review published clinical trials related to the effect of ECT stimulus parameters and electrode placements on cognitive side effects. We performed a systematic review of the literature up to July of 2020 for clinical studies published in English or German examining the effect of ECT stimulus parameters and/or electrode placement on cognitive side effects in patients with schizophrenia or schizoaffective disorder. The literature search generated 3 randomized, double-blind, clinical trials, 1 randomized, nonblinded trial, and 1 retrospective study. There are mixed findings regarding whether pulse width and stimulus dose impact on cognitive side effects. One study showed less cognitive side effect for right unilateral (RUL) than bitemporal (BT) electrode placement, and 2 studies showed a cognitive advantage for bifrontal (BF) compared with BT ECT. Only 1 retrospective study measured global cognition and showed post-ECT cognitive improvement with all treatment modalities using Montreal Cognitive Assessment in comparison to pre-ECT Montreal Cognitive Assessment scores. Current data are limited, but evolving. The evidence suggests that RUL or BF ECT have more favorable cognitive outcomes than BT ECT. Definitive larger clinical trials are needed to optimize parameter and electrode placement selection to minimize adverse cognitive effects.

The Neurostimulation of the Brain in Depression Trial: Protocol for a Randomized Controlled Trial of Transcranial Direct Current Stimulation in Treatment-Resistant Depression

Background

Major depressive disorder (MDD) is the second highest cause of disability worldwide. Standard treatments for MDD include medicine and talk therapy; however, approximately 1 in 5 Canadians fail to respond to these approaches and must consider alternatives. Transcranial direct current stimulation (tDCS) is a safe, noninvasive method that uses electrical stimulation to change the activation pattern of different brain regions. By targeting those regions known to be affected in MDD, tDCS may be useful in ameliorating treatment-resistant depression.

Objective

The objective of the Neurostimulation of the Brain in Depression trial is to compare the effectiveness of active versus sham tDCS in treating patients with ultraresistant MDD. The primary outcome will be the improvement in depressive symptoms, as measured by the change on the Mongtomery-Asberg Depression Rating Scale. Secondary outcomes will include changes in the Quick Inventory of Depressive Symptomatology Scale (subjective assessment), the World Health Organization Disability Assessment Schedule 2.0 (functional assessment), and the Screen for Cognitive Impairment in Psychiatry (cognitive assessment). Adverse events will be captured using the Young Mania Rating Scale; tDCS Adverse Events Questionnaire; Frequency, Intensity, and Burden of Side Effects Rating Scale; and Patient-Rated Inventory of Side Effects Scale. A parallel component of the study will involve assaying for baseline language function and the effect of treatment on language using an exploratory acoustic and semantic corpus analysis on recorded interviews. Participant accuracy and response latency on an auditory lexical decision task will also be evaluated.

Methods

We will recruit inpatients and outpatients in the city of Edmonton, Alberta, and will deliver the study interventions at the Grey Nuns and University of Alberta Hospitals. Written informed consent will be obtained from all participants before enrollment. Eligible participants will be randomly assigned, in a double-blinded fashion, to receive active or sham tDCS, and they will continue receiving their usual pharmacotherapy and psychotherapy throughout the trial. In both groups, participants will receive 30 weekday stimulation sessions, each session being 30 minutes in length, with the anode over the left dorsolateral prefrontal cortex and the cathode over the right. Participants in the active group will be stimulated at 2 mA throughout, whereas the sham group will receive only a brief period of stimulation to mimic skin sensations felt in the active group. Measurements will be conducted at regular points throughout the trial and 30 days after trial completion.

Results

The trial has been approved by the University of Alberta Research Ethics Board and is scheduled to commence in June 2021. The target sample size is 60 participants.

Conclusions

This is a protocol for a multicenter, double-blinded, randomized controlled superiority trial comparing active versus sham tDCS in patients with treatment-resistant MDD.

Trial Registration

ClinicalTrials.gov NCT04159012; http://clinicaltrials.gov/ct2/show/NCT04159012.

International Registered Report Identifier (IRRID)

PRR1-10.2196/22805

Need for Standardization of Measurement of Time to Reorientation as a Predictor of Cognitive Adverse Effects of Electroconvulsive Therapy

ABSTRACT

Testing for time to reorientation (TRO) after electroconvulsive therapy (ECT) has been one of the most predictive measures for cognitive adverse effects of ECT. However, measuring TRO varies between clinical trials, and there is no standardized approach on its measurement between studies. The objective of this report is to systematically review the literature on the different ways of measuring TRO. This would be a first step to establish a consensus on a standard method for TRO. We performed a systematic literature review from 1968 to October 2019 for clinical trials with a sample size of more than 50 and published in English that describe measures of TRO. We searched both PubMed and Web of Science databases. The literature search generated 12 clinical trials, which met the inclusion criteria. Studies measured TRO using 3-, 5-, or 10-item questionnaires. Most studies measured full orientation as answering 4/5 questions. Other studies smaller than 50 required 14/14 items to be answered correctly. There was wide variation between studies on how often and when orientation questions were initiated. These factors have obvious implications to the results and interpretation of the ECT literature.There was no clear consensus on measuring TRO in a uniform fashion. Research and clinical care would benefit from a standardized approach to measuring TRO. Measuring TRO using a 4/5 method seems the most common and quickest way, whereas using a 14/14 method seems to be the most rigorous and sensitive to change in trials.

Value of Electroconvulsive Therapy in the General Public: A Willingness to Pay Study in Germany

OBJECTIVE

The aims of this study were to estimate the value a population-representative sample places on electroconvulsive therapy (ECT) through willingness to pay (WTP) and to assess the effects of individual characteristics on WTP for ECT.

METHODS

A German population-representative sample of 518 was presented with a hypothetical health loss scenario of depression and was asked to indicate WTP for ECT. Probit and quantile regression were used to estimate the effects of individual characteristics on the probability of stating a positive WTP and on the amount of money respondents were willing to pay.

RESULTS

Two thirds of respondents stated that they had no knowledge about ECT. Most (56.5%) respondents indicated zero WTP for health gains through ECT treatment. Mean WTP was €5201 ($5612); median WTP was €1000 ($1079). Respondents' monthly household income had a significant effect on the probability of stating a positive WTP. Assessing WTP above zero, income showed a significant positive effect, whereas a higher score of depressive complaints showed a significant negative effect on the amount respondents were willing to pay.

CONCLUSION

Knowledge about ECT treatment is particularly low in the German public.

"An apple pie a day does not keep the doctor away": Fictional depictions of gout in contemporary film and television

Background

Fictional portrayals of illness and medical management in film and television can reflect and perpetuate cultural stereotypes about illness. The aim of this study was to analyse fictional depictions of gout in contemporary film and television.

Methods

We conducted a search for English language depictions of gout in film and television since 1990 using the Internet Movie Database (IMDb), other internet media databases, and member suggestions from the Gout, Hyperuricemia and Crystal-Associated Disease Network (G-CAN). Film and television episodes with gout content were analysed for depictions of characters with gout, causal factors, and management strategies (n=44).

Results

Gout was used to denote royalty or nobility in historical settings, and as a plot device to explain the absence of characters from key events. The most commonly depicted causes of gout were overindulgence of food and alcohol (61%), and portrayals of biological causes were infrequent (12%). Common management strategies were change in diet (36%) and short-term pain relief (32%), with only one mention of urate-lowering therapy (5%). The majority of films and television episodes depicted gout as humorous (59%) and embarrassing (50%).

Conclusions

In contemporary film and television, gout is portrayed as a humorous and embarrassing condition, caused by dietary indulgence. These depictions may reinforce inaccurate beliefs about the causes of gout and its management.

Supplementary Information

The online version contains supplementary material available at 10.1186/s41927-020-00174-z.

Double-Blinded Randomized Pilot Clinical Trial Comparing Cognitive Side Effects of Standard Ultra-Brief Right Unilateral ECT to 0.5 A Low Amplitude Seizure Therapy (LAP-ST)

BACKGROUND

Concerns over cognitive side effects (CSE) of electroconvulsive therapy (ECT) still limit its broader usage for treatment-resistant depression (TRD). The objectives of this study were to (1) examine the CSE of Low Amplitude Seizure Therapy (LAP-ST) at 0.5 A compared to Ultra-brief Right Unilateral (UB-RUL) ECT using Time to Reorientation (TRO) as the main acute primary outcome, and (2) to compare effects on depressive symptoms between the two treatment groups.

METHODS

Participants were referred for ECT, consented for the study, and were randomized to a course of LAP-ST or standard UB-RUL ECT. TRO and depression were measured by the Montgomery-Åsberg Depression Rating Scale (MADRS).

RESULTS

Eleven patients consented. Of these, eight with a current major depressive episode (MDE) of unipolar or bipolar disorders were randomized. TRO was faster for the LAP-ST (mean = 6.8 min; SE = 4.9) than standard RUL ECT (mean = 15.5 min; SE = 6.5). Depression improved similarly in the two arms of the study from baseline (MADRS: LAP-ST = 41.0; SE = 2.0, RUL = 39.0; SE = 3.8) to endpoint (MADRS score: LAP-ST = 8.0; SE7.2, RUL = 9.5; SE = 3.8).

CONCLUSIONS

This pilot, randomized and blinded clinical trial, suggests that the LAP-ST (at 0.5 A) has faster reorientation and possibly lower CSE compared to standard RUL-UB ECT. Caution is advised in interpreting these results due to the small sample size of this pilot study. Thus, future studies with similar design are warranted for replicating these findings.

Electroconvulsive Therapy in Italy-Current Dissemination of Treatment and Determining Factors of the Past

OBJECTIVES

The history of electroconvulsive therapy (ECT) spans eight decades, over which period this method of treatment has been modernized. At the same time, however, the conflict between acceptance and rejection of ECT therapy remains unresolved today. This ambivalence is particularly noticeable in Italy, where the number of uses of ECT has been declining for several years. The aim of the present study is to examine the distribution and use of ECT in Italy today in comparison to 2009 and to analyze the factors that have influenced this downward development.

METHODS

A cross-sectional study using a standardized Italian-language questionnaire was conducted in 2017 to investigate the dissemination and practice of ECT in Italy. The study was addressed to all public and private hospitals providing ECT as a treatment.

RESULTS

Of the 145 mental health facilities in Italy, only 9 offered ECT. A total of 293 patients were treated with ECT within 1 year (mainly for depression). Rates for 3-year treatments in the centers yielded an uneven picture: 4 centers showed an increase in cases and just as many a decline. A north-south divide existed in terms of geographical distribution: centers were mainly located in the north in 2017.

CONCLUSIONS

The study shows that the dissemination and use of ECT have reached a historical low in Italy. It further documents the extent to which the use of ECT declined after 2009. Three factors that have accompanied this development are discussed. If this downward trend is to be reversed, it will be necessary to develop a new approach so as to engender a perception of ECT as a viable treatment option.

Electroconvulsive Therapy: a Video-Based Educational Resource Using Standardized Patients

OBJECTIVE

Video-based depictions of electroconvulsive therapy (ECT) can be useful for educational purposes, but many of the readily available resources may worsen already stigmatized views of the procedure. Educators' common reliance on such material highlights the paucity of equipoised depictions of modern ECT well suited for the training of health professionals. The authors developed and tested a new educational module enhanced by videotaped depictions of a simulated patient undergoing the consent, treatment, recovery, and follow-up phases of ECT.

METHODS

The didactic intervention interspersed 7 short video clips (totaling 14 min) into a 55-min lecture on treatment-resistant depression. The session, part of an intensive course of preclinical psychiatry, was delivered online through synchronous videoconferencing with Zoom. The primary outcome measure was change in the Questionnaire on Attitudes and Knowledge of ECT (QuAKE).

RESULTS

Fifty-three out of 63 (87%) eligible second-year medical students completed assessments at baseline and after exposure to the didactic intervention. QuAKE scores improved between baseline and endpoint: the Attitudes composite increased from 49.4 ± 6.1 to 59.1 ± 5.7 (paired t 10.65, p < 0.001, Cohen's d 0.69), and the Knowledge composite from 13.3 ± 1.2 to 13.9 ± 0.8 (paired t 3.97, p < 0.001, Cohen's d 0.23).

CONCLUSIONS

These video-based educational materials proved easy to implement in the virtual classroom, were amenable to adaptation by end-use instructors, were well received by learners, and led to measurable changes in students' knowledge of and attitudes toward ECT.

Monitoring Electroconvulsive Therapy-Related Anxiety: The ECT-Related Anxiety Questionnaire

OBJECTIVES

A reliable questionnaire designed to measure electroconvulsive therapy (ECT)-related anxiety is currently not available. We report the development and evaluation of the ECT-Related Anxiety Questionnaire (ERAQ), a questionnaire that measures anxiety with respect to ECT in clinical practice.

METHODS

Patients 18 years or older who were about to start with or were having an ECT course were asked to complete a self-designed 17-item ECT-related anxiety questionnaire. We investigated the psychometric properties of the ERAQ through the use of an exploratory and confirmatory factor analysis and Item Response Theory analysis.

RESULTS

One hundred eighty-three patients were included. From the exploratory factor analysis, we conclude that the scale is unidimensional. The confirmatory factor analysis model did not fit well to the data. The Item Response Theory analysis showed that the slope estimates ranged from 1.23 to 2.95 and that location parameters reflected a sizable underlying anxiety for ECT.

CONCLUSIONS

The ERAQ is a questionnaire that assesses ECT-related anxiety. It offers a measure of global severity and differentiates between various topics of anxiety. The ERAQ thus informs the clinician about the specific aspects of an ECT course that could trigger a patient's anxiety and can guide clinicians in how to discuss ECT-related anxieties with patients.

Image of Electroconvulsive Therapy in YouTube Videos

OBJECTIVES

Image of electroconvulsive therapy (ECT) in TV shows and movies have been studied before. However, there is no study about image of ECT on YouTube as one of the most commonly used social media platforms for disseminating health information. Our study aims to study the image of ECT in YouTube videos.

METHODS

Key word "Electroconvulsive therapy and ECT" were used to search on Youtube.com and only videos over 50,000 view counts and in English were selected. Above videos were reviewed by an ECT physician and were classified into neutral, negative, and positive groups based on the image of ECT.

RESULTS

There were 41 YouTube videos selected based on the criteria as stated above, among which 14 were unrelated with ECT treatment, 8 were neutral, 9 were positive, and 10 were reflecting negative image about ECT. There was no significant difference among view counts of the positive, negative and neutral videos (χ = 2.746, P = 0.253). Furthermore, the most viewed 3 videos showed negative image of ECT. Additionally, only 6 videos showed the modified ECT and one showed both modified and nonmodified ECT.

CONCLUSIONS

This is the first study conducted on image of ECT in YouTube videos. We found the stigma against ECT may persist in digital video platforms, such as YouTube.

A crossed-disciplinary evaluation of parental perceptions surrounding pediatric non-invasive brain stimulation research

Purpose –

Recruitment for pediatric non-invasive brain stimulation (NIBS) studies is often challenged by low enrollment. Understanding parental perceptions regarding NIBS is crucial to develop new communication strategies to increase enrollment.

Design/methodology/approach –

Integrating a crossed-disciplinary approach, the authors conducted a survey at the 2018 Minnesota State Fair querying the perception of risk and preferences of current and future parents associated with pediatric NIBS research. The survey consisted of 28 closed-text questions including demographics, photographs portraying NIBS, terminologies and factors related to NIBS studies.

Findings –

Complete surveys were analyzed from 622 parent participants. A significant number of participants (42.8%) perceived the photographs of NIBS as "risky." Additionally, 65.43% perceived the term "Non-invasive brain therapy" as not risky, a word combination not currently being used when recruiting potential participants. Over 90% (561/622) of participants chose the photograph of child-friendly MRI suite.

Research limitations/implications –

Although this survey identified aspects crucial in recruitment for pediatric NIBS research, there were limitations. For example, the authors did not record the sex or demographic distribution (e.g. rural versus urban setting) of the participants. These factors may also influence recruitment messaging.

Originality/value –

For important medical research to impact and improve the lives of the potential remedies, participation by the public in clinical trials is necessary. Often the general public perceives the trials as risky as a result of poor marketing communication recruitment material. This study sought to be understood if how the message is encoded has an impact on the decoding by the receiver.

Understanding electroconvulsive therapy-related anxiety: a prospective study

AIMS OF STUDY

Although electroconvulsive therapy (ECT)-related anxiety is experienced by a significant proportion of patients, it remains understudied. Our aim was to study the course of ECT-related anxiety during ECT.

METHODS

Seventy-four patients with unipolar or bipolar depression, referred for ECT, were included. ECT-related anxiety was assessed the morning before each ECT session using the ECT-related Anxiety Questionnaire (ERAQ).

RESULTS

Female patients reported more anxiety than men (F(1,64.6) = 3.95, P = 0.05). Patients with a psychotic depression were more anxious before the start of ECT (F(64.8) = 4.57, P = 0.04), but experienced a significant decrease in ECT-related anxiety (t(63.9) = -3.63, P = 0.0006), whereas patients with a non-psychotic depression remained stable on anxiety during their ECT course (t(63,9) = 0.76, P = 0.45). In addition, we found a significant correlation between the decrease of ECT-related anxiety and the decrease of depression-severity (r = 0.35; P = 0.04).

CONCLUSION

There are individual differences in ECT-related anxiety trajectories during ECT. Both female patients and patients with psychotic depression experienced more ECT-related anxiety before the start of ECT. The severity of ECT-related anxiety decreased significantly in patients with a psychotic depression, but remained stable in patients without a psychotic depression during ECT. In addition, patients who showed a stronger decrease in depression-severity also showed a stronger decrease in ECT-related anxiety. A better understanding of ECT-related anxiety trajectories can help in designing anxiety-reducing interventions.

Attitudes to psychiatry and to mental illness among nursing students: Adaptation and use of two validated instruments in preclinical education

WHAT IS KNOWN ON THE SUBJECT

Stigma towards psychiatry and people with serious mental illness (SMI) is prevalent among healthcare providers and can adversely affect patient care. Internalized stigma among nurses can affect personal self-care and limit help-seeking behaviours. Stigma around mental health nursing can adversely affect recruitment into this already underserved field.

WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE

This is the first report on the adaptation and use in a nursing student sample of two widely used stigma-related instruments that have been normed among medical students. The attitudes to psychiatry (ATP-30) and the attitudes to mental illness (AMI) instruments proved sensitive to change and can be useful in tracking specific anti-stigma curricular interventions. Interactive and participatory student activities in courses such as ours (that include simulation with standardized patients, clinical placements and patient interaction) need to be complemented by exposure to individuals with lived experience with mental illness in order to address stigmatized views of SMI. Nursing educators and fellow nurses willing to share their own experiences with mental illness-including diagnosis, health-seeking, treatment and recovery-may prove especially powerful and germane during nursing school.

WHAT ARE THE IMPLICATIONS FOR PRACTICE

Even a strong academic curriculum is not sufficient to change stigmatized perceptions about mental illness, psychiatric care and mental health nursing as a profession. Comparison and potential synergy between ATP-30, AMI and OMS-HC (Opening Minds Scale for Health Care Providers) could prove fruitful in identifying a more comprehensive approach to stigma assessment over time. The addition of validated instruments, such as the Self-Compassion Scale-Short Form (SCS-SF) and the Self-Stigma of Seeking Help (SSOSH), which tap into internalized stigma and into health-seeking behaviours and intervening barriers could prove particularly useful in evaluating innovative interventions for stigma-decreasing initiatives in nursing education. Interactive and participatory didactic offerings need to be complemented by exposure to individuals with lived experience with mental illness and ideally to nursing educators and practicing nurses willing to share their histories of diagnosis, help-seeking, treatment and recovery.

ABSTRACT

Introduction Stigma towards psychiatry and to people with serious mental illness (SMI) is prevalent among healthcare providers and can adversely affect patient care. Such stigmatized views can adversely affect recruitment into the already underserved field of mental health nursing. Aim/question We adapted two stigma-related instruments in a sample of nursing students and examined change in scores after participation in an eight-week preclinical psychiatry curriculum. Our goal was to identify stigma-malleable opportunities that would inform refinements in future iterations of a preclinical psychiatry curriculum in nursing. Method We made minor adaptations to the attitudes to psychiatry (ATP-30) and the attitudes to mental illness (AMI) instruments. We invited first-year nursing students to complete assessments at two time points: before and after completion of an eight-week core course in preclinical psychiatry. Results Seventy-one students completed the assessment at both time points. ATP-30 and three of its eight subscale scores improved by course's endpoint. By contrast, AMI scores did not change. Compared with medical student published norms, nursing students in our sample had higher (less stigmatized) average scores. Discussion The ATP-30 and the AMI can be easily adapted to a nursing student population and may prove useful in tracking specific anti-stigma educational interventions. Implications for practice A general psychiatry course during nursing school is, it and of itself, unlikely to change biased views about SMI and should be enhanced with exposure to, and interaction with individuals with lived experiences of mental illness, ideally by nurse educators and practicing nurses.