A prospective follow-up study of ECT outcome in older depressed patients

Long-term Outcome Following Electroconvulsive Therapy for Late-Life Depression: Five-Year Follow-up Data From the MODECT Study

OBJECTIVE

Electroconvulsive therapy (ECT) is the most effective treatment for late-life depression (LLD). Research addressing long-term outcome following an acute course of ECT for LLD is limited. We aimed to describe relapse, cognitive impairment and survival 5 years after a treatment with ECT for severe LLD, and assess the association of clinical characteristics with all three outcome measures.

METHODS

This cohort study was part of the Mood Disorders in Elderly treated with ECT (MODECT) study, which included patients aged 55 years and older with major depressive disorder. Data regarding clinical course, cognitive impairment and mortality were collected 5 years after the index ECT course. We used multivariable Cox proportional hazards models and logistic regression models to assess the association of clinical characteristics with relapse and survival, and cognitive impairment, respectively.

RESULTS

We studied 110 patients with a mean age of 72.9 years. 67.1% of patients who showed response at the end of the index ECT course relapsed, and the included clinical characteristics were not significantly associated with the risk of relapse. 38.8% of patients with available data showed cognitive impairment at five-year follow-up. 27.5% were deceased; higher age and a higher number of previous psychiatric admissions were significantly associated with increased risk of mortality.

CONCLUSIONS

Five-year outcome after a course of ECT for severe LLD seems to be in line with long-term outcome following other acute treatments for severe LLD in terms of relapse, cognitive impairment and survival. Additional studies aimed at improving long-term outcome in severe LLD are warranted.

Long-Term Risk of Developing Dementia After Electroconvulsive Therapy for Affective Disorders

OBJECTIVES

Severe depression is associated with an increased risk of developing dementia, however, whether treatment with electroconvulsive therapy (ECT) modify this risk remains unknown.

METHODS

In this matched cohort study, 1089 consecutive in-patients with affective disorders, receiving ECT during the period 1982 to 2000, were matched with 3011 in-patients with affective disorders not treated with ECT (non-ECT), and 108,867 individuals randomly selected from the background population. The comparison cohorts were matched on sex, age, and the non-ECT cohort was further matched according to diagnoses and admission period and hospital. Dementia diagnoses were retrieved from the national patient health registry. Analyses were adjusted for disease severity, somatic, and psychiatric comorbidities.

RESULTS

The cumulative incidence of dementia was 13.45% (10.75-16.46%) in the ECT cohort after 34 years of follow-up, 10.53% (8.5-12.81%) in the non-ECT cohort, and 8.43% (8.17-8.7%) in the background cohort. Using the ECT cohort as reference and age as the underlying time scale, the adjusted hazard ratio of developing dementia was 0.73 (0.52-1.04) in the non-ECT cohort and 0.61 (0.49-0.76) in the background cohort. The stratified analysis based on age at index (<65 years; 65-80 years; >80 years) found no age-related difference in the risk of developing dementia between the ECT cohort and non-ECT cohort.

CONCLUSIONS

The ECT treatment of affective disorders was not associated with an increased long-term risk of developing dementia compared with in-patients with affective disorders not treated with ECT.

Does electroconvulsive therapy cause brain damage: An update

Electroconvulsive therapy (ECT) is an effective modality of treatment for a variety of psychiatric disorders. However, it has always been accused of being a coercive, unethical, and dangerous modality of treatment. The dangerousness of ECT has been mainly attributed to its claimed ability to cause brain damage. This narrative review aims to provide an update of the evidence with regard to whether the practice of ECT is associated with damage to the brain. An accepted definition of brain damage remains elusive. There are also ethical and technical problems in designing studies that look at this question specifically. Thus, even though there are newer technological tools and innovations, any review attempting to answer this question would have to take recourse to indirect methods. These include structural, functional, and metabolic neuroimaging; body fluid biochemical marker studies; and follow-up studies of cognitive impairment and incidence of dementia in people who have received ECT among others. The review of literature and present evidence suggests that ECT has a demonstrable impact on the structure and function of the brain. However, there is a lack of evidence at present to suggest that ECT causes brain damage.

Cognitive functioning in patients treated with electroconvulsive therapy

BACKGROUND

Electroconvulsive therapy (ECT) is an effective treatment method for severe mental illnesses. ECT has gone through significant modernization. Side effects of ECT have largely decreased. Temporary disturbance of cognitive performance can be still present as a side effect of electroconvulsive treatment.

METHODS

Cognitive functioning in the sample of patients with severe and acute mental illness treated with electroconvulsive therapy (ECT) was assessed. Basic assessment of cognitive functions was applied in the beginning, in the middle, and at the end of ECT course treatment with the Montreal Cognitive Assessment (MoCA). Complex and detailed testing of cognitive functions using the MATRICS Consensus Cognitive Battery (MCCB) was done at two points in time - within the first week of and then 6 weeks after the end of ECT.

RESULTS

Participants had cognitive deficits at baseline, which were most likely influenced markedly by the psychopathology of the illness itself. The improvement in cognition came together with the reduction in psychopathology; psychopathology scores were significantly reduced during ECT treatment. Compared to the baseline, all scores for cognitive testing were significantly improved but remained low in comparison with the controls. After 6 weeks, there was further significant improvement.

CONCLUSION

Our results confirm the safety and efficacy of ECT in the treatment of severe mental disorders.

Electroconvulsive therapy and risk of dementia in patients with affective disorders: a cohort study

BACKGROUND

Electroconvulsive therapy (ECT) is the most effective treatment for severe episodes of mood disorders. Temporary memory loss is a common side-effect, but ongoing discussions exist regarding potential long-term adverse cognitive outcomes. Only a few studies have examined the frequency of dementia in patients after ECT. The aim of this study was to examine the association between ECT and risk of subsequent dementia in patients with a first-time hospital diagnosis of affective disorder.

METHODS

We did a cohort study of patients aged 10 years and older in Denmark with a first-time hospital contact for an affective disorder from Jan 1, 2005, through Dec 31, 2015, identified in the Danish National Patient Registry with ICD-10 codes F30.0 to F39.9. From the registry we retrieved information on all ECTs registered for patients and followed up patients for incidental dementia (defined by hospital discharge diagnoses or acetylcholinesterase inhibitor use) until Oct 31, 2016. We examined the association between ECT and dementia using Cox regression analyses with multiple adjustments and propensity-score matching on sociodemographic and clinical variables.

FINDINGS

Of 168 015 patients included in the study, 5901 (3·5%) patients had at least one ECT. During the median follow-up of 4·9 years (IQR 2·4-7·8) and 872 874 person years, the number of patients who developed dementia was 111 (0·1%) of 99 045 patients aged 10-49 years, 965 (2·7%) of 35 945 aged 50-69 years, and 4128 (12·5%) of 33 025 aged 70-108 years. 217 (3·6%) of the 5901 patients treated with ECT developed dementia, whereas of 162 114 patients not treated with ECT 4987 (3·1%) developed dementia. The corresponding incidences were 70·4 cases per 10 000 person-years (95% CI 61·6-80·5) and 59·2 per 10 000 person-years (57·6-60·8). In patients younger than 50 years and 50-69 years, ECT was not associated with a risk of dementia compared with age-matched patients who were not given ECT (age-adjusted hazard ratio [HR] 1·51, 95% CI 0·67-3·46, p=0·32; and 1·15, 0·91-1·47, p=0·22, respectively). In patients aged 70 years and older, ECT was associated with a decreased rate of dementia (0·68, 95% CI 0·58-0·80; p<0·0001), but in the propensity-score matched sample the HR was attenuated (0·77, 0·59-1·00; p=0·062). 31 754 patients (17·6%) died during follow-up (mortality rate per 1000 person-years 35·7, 95% CI 35·3-36·2) and supplementary analyses suggested that the risk of dementia, taking the competing mortality risk into account, was not significantly associated with ECT (subdistribution HR 0·98, 95% CI 0·76-1·26; p=0·24).

INTERPRETATION

ECT was not associated with risk of incidental dementia in patients with affective disorders after correcting for the potential effect of patient selection or competing mortality. The findings from this study support the continued use of ECT in patients with severe episodes of mood disorders, including those who are elderly.

FUNDING

Danish Council for Independent Research, Danish Medical Research Council, the Velux Foundation, the Jascha Foundation, and the Doctor Sofus Carl Emil Friis and Olga Doris Friis grant.

Electroconvulsive therapy and age: Age-related clinical features and effectiveness in treatment resistant major depressive episode

OBJECTIVE

This study was aimed to compare clinical features, treatments outcomes and tolerability between young (18-45 years), middle age (46-64 years) and old (≥ 65 years) patients treated with bilateral ECT for treatment resistant major depressive episode.

METHOD

402 patients were evaluated 1 day prior to ECT and a week after the treatment termination using the Clinical Global Impression Scale (CGI), the Hamilton Rating Scale for Depression-17 items (HAM-D-17), the Brief Psychiatric Rating Scale (BPRS), the Young Mania Rating Scale (YMRS) and the Mini Mental State Examination (MMSE). Response was defined as a reduction of at least 50% from baseline on the HAM-D-17 score. Remission was defined as a score ≤ 7 on the HAM-D-17 at the final evaluation.

RESULTS

Rates of response were not statistically different in the three groups (69.6% in old versus 63.5% in young and 55.5% in middle age groups). No significant differences were also observed in the proportions of remitters between the age groups (31.4% in young group, 27.7% in middle age group and 29.3% in old group). One week after the end of the ECT course the middle and old age groups showed a statistically significant increase in the MMSE score compared to baseline. We did not find significant differences between the three age groups in rates of premature drops-out due to ECT-related side effects.

CONCLUSION

Our data support the use of ECT in elderly patients with treatment-resistant major depressive episode, with rates of response around 70% and effectiveness being independent from age. In the old age group the baseline cognitive impairment improved after ECT and no life-threatening adverse event was detected.

Cognitive rehabilitation: assessment and treatment of persistent memory impairments following ECT

Few tests address the types of memory problem commonly reported after electroconvulsive therapy (ECT). Here, we focus on the importance of neuropsychological assessment in ECT-treated patients and describe a number of tasks that may be useful in measuring the everyday memory problems of such patients with ongoing memory difficulties. At the time of writing, no attempts have been made to rehabilitate patients who experience persistent adverse cognitive effects, but clinicians should be aware of the potential beneficial role of cognitive rehabilitation in the treatment and management of these effects.

Electroconvulsive Therapy and Risk of Dementia-A Nationwide Cohort Study in Taiwan

Background: Electroconvulsive therapy (ECT) is an effective treatment for schizophrenia, bipolar disorder, and major depressive disorder, and a temporary memory loss may occur after ECT. However, the association between ECT in patients with schizophrenia, bipolar disorder, and major depressive disorder, and the risk of dementia is yet to be examined. Objective: This study aimed to clarify as to whether ECT is associated with the risk of dementia after ECT in patients with schizophrenia, bipolar disorder, and major depressive disorder, using Taiwan's National Health Insurance Research Database (NHIRD). Methods: A total of 3,796 enrolled participants (schizophrenia, 46.68%; bipolar disorder, 11.77%; and major depressive disorder, 41.55%) with 994 patients who had received ECT and 2,982 controls matched for sex and age, between January 1, and December 31, 2000, were selected from the NHIRD. After adjusting for confounding factors, Fine and Gray's survival analysis was used to compare the risk of developing dementia during the 10 years of follow-up. Results: Of the study patients, 45 (4.53%) of them developed dementia when compared to 149 (5.0%) in the control group. Fine and Gray's survival analysis revealed that the study patients were not associated with an increased risk of dementia [hazard ratio (HR) = 0.612, 95% confidence interval (CI) = 0.438-1.854, P = 0.325]. After adjusting for sex, age, monthly income, urbanization level, geographic region, and comorbidities, the adjusted HR was 0.633 (95% CI = 0.448 - 1.895, P = 0.304). Conclusion: This study supports that ECT was not associated with the increased risk of dementia in patients with schizophrenia, bipolar disorder, and major depressive disorder, using the NHIRD.

A long-term longitudinal follow-up of depressed patients treated with ECT with special focus on development of dementia

BACKGROUND

In this study, the long term effects of ECT on patients with depression were investigated through repeated rCBF and EEG measures as well as clinical characteristics over several years. The aim of the investigation was to establish an association with the eventual development of dementia.

METHOD

A cohort of forty-nine patients (21 men and 28 women) with a mean age of 61 years underwent ECT. A subsequent evaluation from medical records and three rating-scales for diagnosis of Alzheimer´s disease (AD), fronto-temporal dementia (FTD), and for vascular dementia (VaD), revealed that 17 patients (8 men and 9 women), had developed dementia. These cases were compared to the 32 patients (13 men and 19 women), who had not developed dementia.

RESULT

Initially, the dementia group, compared to those without dementia, showed a lower hemispheric CBF (left side; p=.029, right side; p=.033), and a lower mean occipital EEG frequency (p=.048). After the first ECT-series, an increase in general disorientation (p=.015), personal disorientation (p=.009), and subsequently, spatial disorientation (p=.021), were seen in the dementia group. There were no differences in the clinical response or remissions after treatment in the groups.

LIMITATIONS

The small sample-size, which did not allow for the comparison of characteristics between different dementias.

CONCLUSION

Depressed older patients who later developed dementia showed lower hemispheric mean level of CBF and EEG mean frequency before ECT and higher personal and spatial disorientation following ECT.

Systematic Review of Cognitive Effects of Electroconvulsive Therapy in Late-Life Depression

OBJECTIVE

Late-life depression (LLD) is known to negatively impact cognition even after remission of mood symptoms. Electroconvulsive therapy (ECT) and newer nonconvulsive electrical and magnetic brain stimulation interventions have been shown to have cognitive effects in patients with neuropsychiatric disorders.

METHODS

This review systematically assessed the effects of ECT on cognition in LLD. EMBASE, Ovid Medline, and PsycINFO were systematically searched through June 2015. The search was limited to publications from peer-reviewed journals in the English language.

RESULTS

A total of 5,154 publications was identified; 318 were reviewed in full text, of which 39 publications related to ECT were included. We focused this review only on ECT because evidence on newer interventions was deemed insufficient for a systematic review. This literature suggests increased rates of interictal and postictal cognitive decline with ECT but no long-term (i.e., 6 months or longer) deleterious effects on cognition. Instead, long-term cognitive outcomes with ECT have been reported as either not changed or improved. This literature favors nondominant unilateral ECT over bilateral ECT for cognition.

CONCLUSION

Published literature on brain stimulation interventions in LLD is mainly limited to ECT. This literature suggests that deleterious effects of ECT in LLD are limited and transient, with better cognitive outcomes with unilateral ECT. There is not enough evidence to fully characterize long-term deleterious effects of ECT or effects of newer brain stimulation techniques on cognition in LLD.

Effect of Age on Psychiatric Rehospitalization Rates After Electroconvulsive Therapy for Patients With Depression

OBJECTIVES

The aims of this naturalistic study are to examine psychiatric rehospitalization rates in geriatric compared to nongeriatric patients who receive electroconvulsive therapy (ECT) and to characterize the sustained effectiveness of ECT for treatment of depression.

METHODS

Retrospective review of electronic medical records at a tertiary care center for patients with major depressive disorder who received an acute course of ECT at an index psychiatric hospitalization over a 5-year period. Data for subsequent psychiatric and primary care encounters were ascertained by chart review. Outcomes of interest included between-group differences in rates of psychiatric rehospitalization, time to rehospitalization, rates of other types of clinical follow-up care, and effect of demographic variables on clinical outcome.

RESULTS

Of 482 total patients, there were 210 (44%) geriatric patients (≥65 years). These patients experienced lower overall rates of psychiatric rehospitalization after ECT (6.2% vs 22%; P < 0.0001) compared to the nongeriatric group. Cox proportional hazard models indicated that older age, assessed both as a dichotomous and continuous variable, was associated with lower risk of rehospitalization. The majority (76.9%) of detected rehospitalizations among geriatric patients occurred within 6 months. In comparison, rates of outpatient primary care and psychiatric follow-up after ECT did not differ as a function of age.

CONCLUSIONS

Our findings suggest that geriatric patients with major depression receive greater long-term benefit from an acute course of ECT than do nongeriatric patients. Much more research is needed on this topic to rigorously evaluate the long-term efficacy of ECT in geriatric populations.

Contribution of white matter hyperintensities, medial temporal lobe atrophy and cortical atrophy on outcome, seven to twelve years after ECT in severely depressed geriatric patients

BACKGROUND

Depression and cognitive decline are highly prevalent and often coexisting, however, the association between depression and dementia remains unclear. White matter hyperintensities (WMH), medial temporal lobe atrophy (MTA) and global cortical atrophy (GCA) are associated with depression, mild cognitive impairment and dementia; these structural abnormalities may therefore represent a common underlying mechanism of these diseases. We conducted a naturalistic prospective follow-up study in patients with severe geriatric depression who were formerly treated with ECT. The aim of the study was to investigate the effects of structural abnormalities in the brain on cognitive decline, dementia and survival.

METHOD

Survival data of 76 patients was obtained. 39 (51.3%) of them also participated in the follow-up study. Cognitive decline was identified 7-12 years after ECT (median 8.0), using the Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE). A diagnosis of dementia was obtained from the family doctor of the patients.

RESULTS

Forty-two out of the 76 (55.3%) of the patients died during follow-up. Twenty-four out of the remained 39 (65.1%) patients who participated in the follow-up study reported cognitive decline and 7 among the 39 patients (17.9%) were diagnosed with dementia. Depression with psychotic symptoms was significantly associated with absence of cognitive decline at follow-up (p=0.007). WMH was significantly associated with mortality (plog rank=0.048). Finally, we observed a trend in significance between the association of GCA and cognitive decline at follow-up (p=0.078), CONCLUSIONS: Depression with psychotic symptoms is a depression subtype that might not be associated with cognitive decline at follow-up. Moderate or severe WMH before ECT in our cohort of depressed patients was associated with higher mortality and GCA was possibly associated with cognitive decline at follow-up.

Multifactorial determinants of the neurocognitive effects of electroconvulsive therapy

For many patients with neuropsychiatric illnesses, standard psychiatric treatments with mono or combination pharmacotherapy, psychotherapy, and transcranial magnetic stimulation are ineffective. For these patients with treatment-resistant neuropsychiatric illnesses, a main therapeutic option is electroconvulsive therapy (ECT). Decades of research have found ECT to be highly effective; however, it can also result in adverse neurocognitive effects. Specifically, ECT results in disorientation after each session, anterograde amnesia for recently learned information, and retrograde amnesia for previously learned information. Unfortunately, the neurocognitive effects and underlying mechanisms of action of ECT remain poorly understood. The purpose of this paper was to synthesize the multiple moderating and mediating factors that are thought to underlie the neurocognitive effects of ECT into a coherent model. Such factors include demographic and neuropsychological characteristics, neuropsychiatric symptoms, ECT technical parameters, and ECT-associated neurophysiological changes. Future research is warranted to evaluate and test this model, so that these findings may support the development of more refined clinical seizure therapy delivery approaches and efficacious cognitive remediation strategies to improve the use of this important and widely used intervention tool for neuropsychiatric diseases.

Brain stimulation in the treatment of late-life severe mental illness other than unipolar nonpsychotic depression

Late-life mental illness is a growing concern. Current medications have limited efficacy and are associated with safety concerns. A variety of brain stimulation approaches offers alternative treatments. We performed a systematic literature search on the efficacy and safety of brain stimulation in late-life mental illnesses, excluding unipolar nonpsychotic depression. Studies on deep brain stimulation, electroconvulsive therapy (ECT), repetitive transcranial magnetic stimulation (rTMS), and vagal nerve stimulation that enrolled exclusively older adults (≥65 years) or analyzed older adults as a separate group were included. The search identified 1,181 publications, of which 43 met the above inclusion criteria: 24 were related to the treatment of non-unipolar depression (ECT: 21; rTMS: 2; ECT and rTMS: 1), 14 related to dementia (ECT: 7[2 of these studies were also related to depression]; vagal nerve stimulation: 2; rTMS: 4; deep brain stimulation: 1), and 7 to schizophrenia (ECT: 7). These studies reported a high degree of variability in efficacy and safety with promising results in general, particularly in the treatment of dementia and schizophrenia. Most publications were limited by small sample sizes, lack of control conditions, and lack of randomization. Large studies with a randomized controlled design or other designs such as crossover or off-on-off-on are needed. In contrast to the empiric and nonspecific use of ECT, future studies using modalities other than ECT could focus on novel biologically based interventions that target specific circuitry. These interventions could also be combined with other non-brain stimulation treatments for possible synergistic effects.

Current electroconvulsive therapy practice and research in the geriatric population

Electroconvulsive therapy (ECT) is utilized worldwide for various severe and treatment-resistant psychiatric disorders. Research studies have shown that ECT is the most effective and rapid treatment available for elderly patients with depression, bipolar disorder and psychosis. For patients who suffer from intractable catatonia and neuroleptic malignant syndrome, ECT can be life saving. For elderly patients who cannot tolerate or respond poorly to medications and who are at a high risk for drug-induced toxicity or toxic drug interactions, ECT is the safest treatment option. Organic causes are frequently associated with late-life onset of neuropsychiatric conditions, such as parkinsonism, dementia and stroke. ECT has proven to be efficacious even when these conditions are present. During the next decade, research studies should focus on the use of ECT as a synergistic therapy, to enhance other biological and psychological treatments, and prevent symptom relapse and recurrence.

Short- and long-term neurocognitive functioning after electroconvulsive therapy in depressed elderly: a prospective naturalistic study

BACKGROUND

It is generally assumed that the elderly patients are more vulnerable to cognitive side effects after electroconvulsive therapy (ECT) than younger depressed patients. The current study aims to evaluate the nature and extent of changes across multiple domains of neurocognitive functioning in a group of elderly depressed patients after ECT.

METHODS

In this prospective naturalistic study, we included 42 depressed patients aged ≥55 years. Global cognitive function, memory, and executive function were assessed before ECT treatment and within one week (short-term post-ECT) and six months after ECT (long-term post-ECT). Associations between cognitive functioning and electrode placement, total number of treatment sessions, age, and the severity of depression at the time of cognitive measurement were studied.

RESULTS

Our data offered no evidence of decline for any of the neurocognitive tests after ECT, given its power to detect the difference. Post-ECT improvement of neurocognitive functioning was statistically significant for the Mini-Mental State Examination, Visual Association Test, 10 Words Verbal Learning Test, and Expanded Mental Control Test. Effect sizes were medium to large. After six months, compared with post-ECT performance, statistically significant improvement was found only for the Trail Making Test-A and the Letter Fluency Test with small to medium effect sizes.

CONCLUSIONS

In our severely depressed elderly patients, neurocognitive performance improved or did not change after ECT. Patients with poor cognitive function were not able to participate in neuropsychological assessment before ECT started. Consequently these results may not apply to patients with more severe cognitive impairment prior to the start of ECT.

The role of electroconvulsive and neuromodulation therapies in the treatment of geriatric depression

Geriatric depression is associated with increased mortality because of suicide and decreases in functional and physical health. Many elders' depression is resistant to psychotherapy and medication and can become chronic. Electroconvulsive therapy (ECT) is increasingly used in the treatment of medication-resistant or life-threatening geriatric depression. Neuromodulation therapies (subconvulsive, focal, or subconvulsive and focal) are alternatives for the management of treatment-resistant depression in the elderly. Therapies that combine both strategies could be safer but may not be as effective as ECT. This review covers the evidence on the safety and efficacy of ECT and the neuromodulation therapies in geriatric depression.

Electroconvulsive therapy: is there a role for treating older patients?

Electroconvulsive therapy (ECT) is a powerful acute treatment for severe and resistant depression. We review literature related to the efficacy, safety and tolerability of ECT in older people, with an emphasis on research studies and reviews published in the last 25 years. In general ECT has been considered a very effective and safe treatment for depression and other psychiatric and non-psychiatric disorders in older people. Amnesia is commonly attributed to ECT treatment, but studies suggest that the negative effects of ECT on cognition are probably small in older patients. Currently the balance of risks and benefits of ECT justify its use for severe depression in older patients, both with and without dementia.

Electroconvulsive therapy for treatment of major depression in a 100-year-old patient with severe aortic stenosis: a 5-year follow-up report

Although there is no specific age cutoff for electroconvulsive therapy (ECT) and no absolute contraindication to its use, very old age and the presence of cardiac conditions such as aortic stenosis are factors that may negatively affect the physician's decision to administer ECT in individual cases. We report our follow-up of a 100-year-old woman with severe aortic stenosis who has received ECT safely for 5 years now. No cardiac complications have emerged during this period. Her prior unipolar depressive episode with catatonic features remains in remission with a single prophylactic ECT session every 3 months. We have observed from our experience with this unique case that periodic multidisciplinary re-evaluation of the evolving risk-benefit profile of ECT is essential along with the inclusion of family members in this dialogue. Our patient's course illustrates that neither advanced age nor severe aortic stenosis is an absolute contraindication to ECT even over an extended period of time. Each case needs to be evaluated on its merits. To our knowledge, this case represents the oldest patient in the literature where ECT has been administered safely for such an extended period in the setting of severe aortic stenosis.

The effectiveness of electroconvulsive therapy: A literature review

Aim – To review the literature on the efficacy of electroconvulsive therapy [ECT], with a particular focus on depression, its primary target group. Methods – PsycINFO, Medline, previous reviews and meta-analyses were searched in an attempt to identify all studies comparing ECT with simulated-ECT [SECT]. Results – These placebo controlled studies show minimal support for effectiveness with either depression or ‘schizophrenia’ during the course of treatment (i.e. only for some patients, on some measures, sometimes perceived only by psychiatrists but not by other raters), and no evidence, for either diagnostic group, of any benefits beyond the treatment period. There are no placebo-controlled studies evaluating the hypothesis that ECT prevents suicide, and no robust evidence from other kinds of studies to support the hypothesis. Conclusions – Given the strong evidence (summarised here) of persistent and, for some, permanent brain dysfunction, primarily evidenced in the form of retrograde and anterograde amnesia, and the evidence of a slight but significant increased risk of death, the cost-benefit analysis for ECT is so poor that its use cannot be scientifically justified.

Declaration of Interest: Neither author has any financial conflicts of interest in relation to this paper.

Electroconvulsive therapy in a 96-year-old patient with severe aortic stenosis: a case report and review of the literature

We report the safe administration of a course of electroconvulsive therapy (ECT) in a 96-year-old woman with severe aortic stenosis. The patient experienced a relapse of her severe depression when ECT had been withheld because of increased concerns regarding medical risk given her age and degree of aortic stenosis. Reassessment of the case confirmed severe stenosis with a valve area of 0.5 cm2 and a peak pressure gradient across the valve of 110 mm Hg. The ventricular ejection was normal at 70% however, and after a careful weighing of the risk of ECT treatment versus the risk of withholding ECT, it was decided to proceed with ECT in this case. In the event, ECT was very well tolerated by the patient, and she experienced a full remission of symptoms. She continues to receive maintenance ECT successfully at a once-per-month frequency. This case illustrates that neither age nor aortic stenosis by itself precludes ECT in the setting of severe depression. Rather, in each case, a careful weighing of the risks both of proceeding with and withholding ECT is warranted.

A review of the cognitive effects of electroconvulsive therapy in older adults

OBJECTIVE

To review studies that examined the impact of electroconvulsive therapy (ECT) on cognitive functioning in depressed older people.

METHODS

Studies were systematically retrieved using PsychINFO and MEDLINE, with additional articles sourced from lists of references. Given our aged-care focus, study participants had a minimum mean age of 60 years, with no single participant younger than 50 years.

RESULTS

Twenty-seven studies met our criteria. Apart from evidence of interictal slowing of information processing speed, there were mixed results with regard to the impact of ECT on other cognitive domains. Factors contributing to this variability in results include the lack of discrimination between unilateral, bilateral, or mixed electrode placement; the inclusion of patients with dementia; the small sample sizes; and the use of tests insensitive to subtle cognitive changes.

CONCLUSIONS

The effect of ECT in elderly recipients' cognition remains unclear, and further research with more critically selected methods is required. In the meantime, we recommend that clinicians regularly administer brief focused cognitive tests before, during, and after treatment to monitor progress.

Age-related cognitive effects of ECT and ECT-induced mood improvement in depressive patients

This explorative study investigated the interaction between electroconvulsive therapy (ECT) treatment-effect, reduced depression, and neuropsychological outcome in relation to age. Follow-up neuropsychological assessment was conducted with depressive patients treated with ECT. From a potential sample of 45 patients, the neuropsychological measures (pre-ECT, three times post-ECT, up to 12 months) and clinical data from the remaining 21 patients who completed all assessments were evaluated (mean age=56.76; SD=14.12; range, 33-79). ECT resulted in a decrease in the depression scores. A distinct impact of ECT and depression decrease on cognitive domains was found. Depression alleviation was mainly associated with improvement in cognitive domains such as memory, information processing, and executive function. ECT improved cognitive domains such as information processing and perception. Short-term cognitive improvement was greater in older patients but showed an increase similar to that at long-term follow-up in younger patients (<60). Current findings provide evidence that ECT may improve cognitive functioning in nondemented elderly, which has strong clinical relevance concerning the use of ECT.

Fixed high-dose electroconvulsive therapy in the elderly with depression: a double-blind, randomized comparison of efficacy and tolerability between unilateral and bilateral electrode placement

OBJECTIVE

To evaluate efficacy and tolerability of unilateral (RUL) and bilateral (BL) electroconvulsive therapy (ECT) in the elderly with depression.

METHODS

Thirty-nine elderly inpatients with major depression referred to ECT were randomized into RUL or BL ECT, using high, fixed electrical doses. Cognition and depression severity were assessed before, during, and 1 month after treatment. Adverse effects were assessed after each session.

RESULTS

Remission rates for RUL ECT (88.2%) and BL ECT (68.2%) were similar (P = 0.25). Reduction rates of depressive symptoms were also similar. There were no serious adverse events. There were more adverse effects in the BL ECT group (P = 0.05). BL ECT showed more short-term cognitive impairment, whereas improvements in neuropsychological scores were seen in both groups.

CONCLUSION

In elderly depressive subjects, high-dose RUL ECT is as effective as BL ECT yet produces less adverse effects and less cognitive impairment.

Course and outcomes of depression in the elderly

Major depressive disorder is a potentially debilitating condition that often is unrecognized or undertreated in the elderly. Even when aggressively treated, the course of geriatric depression can be severe. There is growing evidence that suggests that late-life depression may carry a higher illness burden than depression with onset earlier in life, and that severity is linked to medical and psychiatric comorbidity. Data continue to accumulate in support of various treatment modalities, including medication, electroconvulsive therapy, and psychotherapy. Given the increased risk of adverse outcomes associated with geriatric depression, such as dementia and suicide, it is essential that future investigations continue to build on the evidence base supporting improved diagnosis and treatment of this complex disorder.

Long-term follow-up in depressed patients treated with electroconvulsive therapy

DESIGN

Our aim was to study the long-term effects of electroconvulsive therapy (ECT) in depression. A total of 55 patients were followed-up 20 to 24 years after an ECT series; 13 patients were still alive, and 10 agreed to participate in the study. All 55 patients had been investigated with clinical and neuropsychological assessment and with neurophysiological measurements and with regional cerebral blood flow (rCBF) and EEG before the first ECT, 6 months later, and after approximately 1 year. These investigations were repeated in the 10 patients.

RESULTS

Before the original ECT series, all patients had suffered from severe mood disorder. At follow-up, the 10 patients showed no clear signs of mood disorder or cognitive impairment. There was a slightly subnormal performance in working memory and in verbal as well as visual episodic memory on all 3 occasions after the ECT series. The rCBF measurement showed a significant average CBF decrease from the first to the last measurement. There was, moreover, a significant rCBF decrease in frontal areas at the last measurement compared with the 3 previous assessments.

CONCLUSION

All ten patients followed-up 20 to 24 years after an ECT series were mentally healthy and thus besides a moderate visual memory dysfunction, no severe side effects were observed with clinical and neuroimaging techniques.

Does electrode placement predict time to rehospitalization?

We sought to determine whether electrode placement influenced time to rehospitalization. A retrospective review of an elderly, depressed population that had received bitemporal, bifrontal or 6 x RUL ECT was examined to determine time to rehospitalization. Bitemporal ECT was associated with a statistically significant reduction in the number of (P = 0.026) and time to (P = 0.025), rehospitalization. Bitemporal ECT may be a preferred electrode placement, not only because of its demonstrated effectiveness across a range of diagnoses, but for its previously undocumented capacity to delay rehospitalization.

The efficacy and safety of ECT in depressed older adults: a literature review

BACKGROUND

Although little doubt exists among practising clinicians in old age psychiatry about the efficacy and safety of ECT in depression, opinions about acceptability differ widely. The objectives of this review were to determine the efficacy and safety of ECT based on both randomised and non-randomised evidence in elderly with a major depressive disorder.

METHODS

Randomised and non-randomised studies on efficacy and safety of ECT in elderly with and without concomitant disorders such as cerebrovascular disorders, Alzheimer's dementia, vascular dementia and Parkinson's disease were selected. Literature was systematically searched in a number of electronic databases.

RESULTS

Although 121 studies were included in the review process, only four provided randomised evidence. No negative studies with respect to efficacy were found. ECT is effective in the acute treatment of late life depression. ECT is generally safe, although a number of serious complications possibly related to ECT have been described. Most of the objectives of this review could not be answered or refuted with certainty, because firm randomised evidence on the efficacy and safety of ECT in the depressed elderly is missing.

CONCLUSIONS

ECT is effective in the acute treatment of late life depression and is generally safe. Important questions such as the relative efficacy of ECT over antidepressants, the long-term efficacy of ECT, morbidity and mortality related to ECT, cost-effectiveness and the efficacy of ECT in subgroups of patients cannot be answered and need to be studied further.

Effects of maintenance electroconvulsive therapy on cognitive functions

BACKGROUND

This study examined cognitive side effects of maintenance electroconvulsive (ECT) in comparison with maintenance pharmacotherapy after index ECT.

METHOD

Clinical outcome data and neuropsychological measurements were compared in 11 maintenance ECT patients and 13 control patients treated with maintenance pharmacotherapy after index ECT. Data were gathered in a prospective naturalistic study during follow-up.

RESULTS

There were no significant differences in patient characteristics and effects of index ECT between groups. In control patients treated with maintenance pharmacotherapy, cognitive function as well as depression ratings remained stable. During maintenance ECT neuropsychological test performance and depression ratings improved slightly but not significantly.

CONCLUSIONS

Neuropsychological functioning during the maintenance phase of treatment did not differ between the two treatment groups. Cognitive function remained stable during maintenance ECT.

Perceptions of outcome from electroconvulsive therapy by depressed patients and psychiatrists

OBJECTIVE

To determine (i) patients' expectations before and attitudes after a course of electroconvulsive therapy (ECT); (ii) the concordance between the perceptions of patients and their psychiatrists; and (iii) whether patients and psychiatrists are accurate in predicting a positive outcome with ECT.

METHOD

Eighty-one inpatients (mean 67.2 years, median 70 years) with major depression were assessed before and after receiving a course of ECT. On both occasions, patients were administered the Hamilton Rating Scale for Depression (HRSD) and the Global Assessment of Functioning Scale (GAF). Patients and two research psychiatrists rated their expectancy of treatment outcome before ECT and their impression of outcome after ECT was completed.

RESULTS

Both HRSD and GAF scores improved with treatment. Before treatment, 39.7% of patients believed ECT would improve their condition. Following treatment, 68.8% of patients thought their condition had improved as a result of ECT. There was only slight agreement between patients' and psychiatrists' expectations before and ratings of efficacy after treatment. The psychiatrists', but not the patients', pretreatment expectations of ECT efficacy were significantly associated with improvement in depression as measured by the effect size change in HRSD score from pre- to post-ECT.

CONCLUSIONS

Patients were poor judges of ECT outcome and, in this sample, less positive than previous reports had suggested. Psychiatrists' expectations however, were generally accurate indicating good clinical selection.

Clinical outcome and adverse effects of electroconvulsive therapy in elderly psychiatric patients

We evaluated the short-term outcome and side effects of electroconvulsive treatment (ECT) in a population of elderly psychiatric patients. The material included patients consecutively hospitalized at a psychogeriatric department within a period of 5 years. From a total number of 239 patients, we included 52 treated with ECT (22%). Altogether, 41 patients (79%) improved clinically. Of them, 21 (40%) of the patients went home after the treatment. Twenty patients (38%) developed adverse reactions from the ECT treatment. Impaired memory (14%), confusion (6%), and hypertension (6%) represented the most commonly reported negative reactions secondary to the treatment. The findings from the study support previous assumptions that ECT is effective in the treatment of serious psychiatric disorders in elderly patients. Because of the relative high frequency of side effects, the patients should be selected

Electroconvulsive therapy for the depressed elderly

BACKGROUND

Depressive disorder is a common mental disorder in old age, with serious health consequences such as increased morbidity, disability, and mortality. The frailty of elderly may seriously hamper the efficacy and safety of pharmacotherapy in depressed elderly. Electroconvulsive therapy (ECT) in depressed elderly therefore may be an alternative to treatment with antidepressants.

OBJECTIVES

To assess the efficacy and safety of ECT (compared to simulated ECT or antidepressants) in depressed elderly.

SEARCH STRATEGY

We searched the CCDANCTR database, Medline 1966-2000, EMBase 1980-2000, Biological abstracts 1985-2000, Cinahl 1982-2000, Lilacs from 1982 onwards, Psyclit 1887-2000, Sigle 1980-2000. The reference lists of relevant papers were scanned for published reports. Hand searching of the Journal of ECT and the Journal of Geriatric Psychiatry was done. Based on the title of the publication and its abstract, non-eligible citations were excluded.

SELECTION CRITERIA

Data were independently extracted by at least two reviewers. Randomised, controlled trials on depressed elderly (> 60 years) with or without concomitant with conditions like cerebrovascular disease, dementia of the Alzheimer's type, vascular dementia or Parkinson's disease were included.

DATA COLLECTION AND ANALYSIS

Data were independently extracted by at least two reviewers. For continuous data weighted mean differences (WMD) between groups were calculated.

MAIN RESULTS

Randomised evidence is sparse. Only three trials could be included, one on the efficacy of real ECT versus simulated ECT (O'Leary et al 1994), one on the efficacy of unilateral versus bilateral ECT (Fraser 1980) and the other comparing the efficacy of ECT once a week with ECT three times weekly (Kellner 1992). All had major methodological shortcomings; data were mostly lacking essential information to perform a quantitative analysis. Although the O'Leary study concluded that real ECT was superior over simulated ECT, these conclusions need to be interpreted cautiously. Only results from the second trial (unilateral versus bilateral ECT) could be analysed, not convincingly showing efficacy of unilateral ECT over bilateral ECT, WMD 6.06 (CI -5.20,17.32). Randomised evidence on the efficacy and safety of ECT in depressed elderly with concomitant dementia, cerebrovascular disorders or Parkinson's disease is completely lacking. Possible side-effects could not be adequately examined because the lack of randomised evidence and the methodological shortcomings.

REVIEWER'S CONCLUSIONS

None of the objectives of this review could be adequately tested because of the lack of firm, randomised evidence. Given the specific problems in the treatment of depressed elderly, it is of importance to conduct a well designed randomised controlled trial in which the efficacy of ECT is compared to one or more antidepressants.

Drug and ECT treatment of depression in the elderly, 1996-2001: a literature review

A computer-based literature search of all antidepressant and electroconvulsive therapy (ECT) treatment studies published between 1995 and September 2001 was conducted. In addition, a review of published chapters, review articles, and metaanalyses was also conducted. Articles were categorized into those reporting comparative studies, those in which the therapeutic agent was not compared with another, articles about ECT, and review articles. These recent publications support the conclusions from prior reviews that antidepressants and ECT are effective and safe treatments for depressed elderly patients. Differences in efficacy and side effects appear to be slight among the various types of antidepressants. Research studies of depressed elderly increased markedly since 1995 compared with all previous years although more studies are still necessary.

Differential response to right unilateral ECT in depressed patients: impact of comorbidity and severity of illness [ISRCTN39974945]

BACKGROUND

Recent electroconvulsive therapy (ECT) efficacy studies of right unilateral (RUL) ECT may not apply to real life clinics with a wide range of patients with major depressive episodes.

METHODS

The study included two groups of patients. In addition to a homogeneous group of patients with major depression according to DSM-IV criteria with severity of the major depressive episode > 16 scores on 17-item Hamilton Rating Scale for Depression (HDRS) (Group 1, n = 16), we included a heterogeneous group of patients with less severe major depressive episodes or with a variety of comorbid conditions (Group 2, n = 24). We randomly assigned the patients to an RUL ECT treatment dosed at 5 or 2.5 times seizure threshold with an intent-to-treat design. The outcomes measured blindly were HDRS, number of treatments, and Mini-Mental State Examination (MMSE). The patients were considered to have responded to treatment if the improvement in HDRS score was at least 60% and they had a total score of less than ten.

RESULTS

The Group 2 patients responded poorer (8% vs. 63%), and had more often simultaneous worsening in their MMSE scores than Group 1 patients. The differences in the outcomes between the two different doses of RUL ECT treatment were not statistically significant.

CONCLUSIONS

ECT effectiveness seems to be lower in real-life heterogeneous patient groups than in homogeneous patient samples used in experimental efficacy trials.

Der Beitrag der Neuropsychologie zum Problem der Differentialdiagnose Depression versus Demenz

Zusammenfassung: Die Differentialdiagnose Depression versus Demenz ist für den Kliniker eine schwierige und für Betroffene und Angehörige folgenreiche Entscheidung. Viele ältere depressive Patientinnen und Patienten haben kognitive Defizite, die auf den ersten Blick den Symptomen einer beginnenden Demenz ähneln, beispielsweise Beeinträchtigungen mnestischer und exekutiver Funktionen. Diese Beeinträchtigungen sind keineswegs immer reversibel, wie der häufig verwendete, jedoch problematische Begriff “Pseudodemenz” suggeriert. Für die Differentialdiagnose ist ein multidisziplinärer Ansatz erforderlich, der psychopathologische, neurologische, neuroradiologische, labormedizinische und neuropsychologische Befunde integriert. In unserer Übersicht referieren wir Ergebnisse von Metaanalysen, ausgewählte neuere Untersuchungsbefunde und eigene klinischen Erfahrungen im Hinblick auf die Frage, welche kognitiven Funktionen in der neuropsychologischen Diagnostik berücksichtigt werden sollten, um die Validität differentialdiagnostischer Entscheidungen zu verbessern.

"Side effects" of ECT are mainly depressive phenomena and are independent of age

BACKGROUND

The aetiology of reported side effects of electroconvulsive therapy (ECT) is unclear. We examined the interaction of depression and age on adverse neuropsychological and putative side effects of ECT.

METHOD

Inpatients (N=81; median age 70 years) with major depression were assessed prospectively pre-ECT, immediately post-ECT and 1-3 years later. Patients were administered the Hamilton Rating Scale for Depression (HRSD), the Global Assessment of Functioning scale (GAF) and neuropsychological tests from the Wechsler Memory Scale. Side effects and total burden scores were rated pre- and post-treatment.

RESULTS

HRSD and GAF scores improved with treatment after ECT, but the prevalence and total burden of side effects were unchanged. Side effect burden was related to depression level before and after ECT. Improvement in depression correlated with reduction in side effect burden. There was a significant decline in side effect burden after controlling for change in depression. Patients' scores on neuropsychological measures did not appear to change after ECT or between pre-ECT and follow-up. Re-analysis, allowing for age, chronicity of depression, medication use and development of dementia, did not alter the findings.

LIMITATIONS

lack of a control group, lack of information on ECT technique, incomplete data sets and limited neuropsychological testing.

CONCLUSIONS

ECT, an effective treatment for depression, does not cause significant side effects or neuropsychological impairment, which are more likely to be depressive phenomena. ECT appears to be safe for old (> or =65 years) and very old (> or =75 years) patients, who do not appear to be more susceptible to adverse effects.