Clinical Outcome and Memory Function With Maintenance Electroconvulsive Therapy

Effect of Continuation-Maintenance Electroconvulsive Therapy on Hospitalization: A Retrospective Mirror-Image Study

Objective

To examine the effect of continuation-maintenance electroconvulsive therapy (ECT) on psychiatric hospitalization in Thai patients.

Methods

This retrospective mirror-image study reviewed medical records of Thai patients who received continuation-maintenance ECT at Ramathibodi Hospital, Bangkok, between September 2013 and December 2022. The initiation of continuation-maintenance ECT served as the index event, establishing pre-initiation and post-initiation periods. The primary outcome measured the differences in admissions and admission days before and after continuation-maintenance ECT.

Results

Forty-seven patients were included in the study, with diagnoses of schizophrenia (38.3%), schizoaffective disorder (21.3%), and bipolar disorder (19.1%) being the most common. The mean (standard deviation; SD) age was 44.6 (12.2) years. The total duration that patients received continuation-maintenance ECT was 53 ± 38.2 months. Following the initiation of ECT, there was a significant reduction in the median (interquartile range) number of hospitalizations for all patients (2 [2] versus 1 [2], p < 0.001), as well as for the psychotic disorder group (2 [2] versus 1 [2.75], p = 0.006) and the mood disorder group (2 [2] versus 1 [2], p = 0.02). Moreover, there was a significant reduction in the median (interquartile range) length of admission days for all patients after the initiation of continuation-maintenance ECT (66 [69] versus 20 [53], p < 0.001). Specifically, the psychotic disorder group (64.5 [74] versus 15.5 [62], p = 0.02) and mood disorder group (74 [57] versus 20 [54], p = 0.008) demonstrated statistically significant decreases in admission days.

Conclusion

Continuation-maintenance ECT may be an effective treatment option for reducing hospitalizations and admission days in patients with various psychiatric diagnoses. However, the study also highlights the need to carefully consider the potential adverse effects of ECT in clinical decision-making.

Evaluation of cumulative cognitive deficits from electroconvulsive therapy

BACKGROUND

Electroconvulsive therapy (ECT) is the most effective acute treatment for severe depression, but widely held concerns about memory problems may limit its use.

AIMS

To find out whether repeated or maintenance courses of ECT cause cumulative cognitive deterioration.

METHOD

Analysis of the results of 10 years of cognitive performance data collection from patients who have received ECT. The 199 patients had a total of 498 assessments, undertaken after a mean of 15.3 ECT sessions (range 0-186). A linear mixed-effect regression model was used, testing whether an increasing number of ECT sessions leads to deterioration in performance.

RESULTS

The total number of previous ECT sessions had no effect on cognitive performance. The major factors affecting performance were age, followed by the severity of depression at the time of testing and the number of days since the last ECT session.

CONCLUSIONS

Repeated courses of ECT do not lead to cumulative cognitive deficits. This message is reassuring for patients, carers and prescribers who are concerned about memory problems and confusion during ECT.

[The interest of maintenance electroconvulsive therapy in mood disorders]

Maintenance electroconvulsive therapy (M-ECT) is a treatment indicated for the treatment and prevention of recurrent depression in patients who either do not respond or do not tolerate psychotropic medication. We evaluated, retrospectively, clinical response to a 6-month minimum course of M-ECT in 25 patients with a diagnosis of bipolar disorder or schizoaffective disorder according to DSM IV-TR criterion. Our study demonstrated a significant improvement of Global Assessment of functioning (GAF) scores after a six month minimum course of M-ECT (34.8 ± 12.6 vs 65.6 ± 10.8; P<0.05) as well as Brief Psychiatric Rating Scale scores (BPRS): 79.3 ± 12.4 vs 43.4 ± 10.2; P<0.05). We observed a slight increase of Mini Mental State Examination (MMSE) scores after M-ECT; nonetheless, it was not statistically significant (24.2 ± 2.4 vs 26.2 ± 2.4; P=0.2). Regarding the mean duration of hospitalizations, we showed a statistically significant decrease in the median number of days of hospitalization (72 [59-93.50] days before M-ECT vs 43 [25-76] days since the first M-ECT; P=0.017). Maintenance ECT allowed a significant improvement in psychiatric symptoms and global functioning of the patients included in this study, as well as a decrease in the number of days of hospitalization. However, our pattern is limited because of its small size; so, further prospective studies in this field, including larger population is highly recommended.

Effectiveness and pattern of use of continuation and maintenance electroconvulsive therapy

Patients with major depressive disorder (MDD) who require an acute course of electroconvulsive therapy (ECT) have high relapse rates. Therefore, an effective maintenance treatment strategy needs to be established. Continuation and maintenance ECT (C/M-ECT) could be an adequate treatment option, although the lack of controlled studies has led to its usefulness being questioned. This review includes a detailed description of studies on the effectiveness/efficacy of ECT in MDD. Despite their methodological limitations, the results appear to support the idea that C/M-ECT would be a safe and effective alternative, especially in patients with severe and recurrent disease. Nevertheless, more controlled studies are needed to provide new evidence and allow a more accurate assessment of the efficacy, safety and pattern of use of C/M-ECT.

Continuation and maintenance electroconvulsive therapy for mood disorders: review of the literature

BACKGROUND

Electroconvulsive therapy (ECT) is a highly effective treatment for mood disorders. Continuation ECT (C-ECT) and maintenance ECT (M-ECT) are required for many patients suffering from severe and recurrent forms of mood disorders. This is a review of the literature regarding C- and M-ECT.

METHODS

We conducted a computerized search using the words continuation ECT, maintenance ECT, depression, mania, bipolar disorder and mood disorders. We report on all articles published in the English language from 1998 to 2009.

RESULTS

We identified 32 reports. There were 24 case reports and retrospective reviews on 284 patients. Two of these reports included comparison groups, and 1 had a prospective follow-up in a subset of subjects. There were 6 prospective naturalistic studies and 2 randomized controlled trials.

CONCLUSIONS

C-ECT and M-ECT are valuable treatment modalities to prevent relapse and recurrence of mood disorders in patients who have responded to an index course of ECT. C-ECT and M-ECT are underused and insufficiently studied despite positive clinical experience of more than 70 years. Studies which are currently under way should allow more definitive recommendations regarding the choice, frequency and duration of C-ECT and M-ECT following acute ECT.

Use of continuation or maintenance electroconvulsive therapy in adolescents with severe treatment-resistant depression

Retrospective data are presented for 6 adolescents ranging in age from 14 to 17 years, who were diagnosed with severe treatment-resistant major depression (TRD). Subjects were treated with one or more index courses of electroconvulsive therapy (ECT) followed by continuation ECT (C-ECT, up to 6 months of ECT) or maintenance ECT (M-ECT; ECT beyond 6 months) when necessary. Electroconvulsive therapy was continued until remission or until minimal residual symptoms were evident. Pharmacotherapy and psychotherapy were reintroduced during C-ECT or M-ECT. Premorbid functioning was achieved by 5 of 6 cases. Cognitive deficits were not evident. In fact, comparison of pre-ECT and post-ECT neuropsychological functioning revealed a trend toward improved auditory and verbal memory on most of the results. We concluded that C-ECT and M-ECT are useful and safe treatment strategies for selected adolescents with severe treatment-resistant depression, and symptom remission may be achieved without experiencing cognitive impairment.

A review of continuation electroconvulsive therapy: application, safety, and efficacy

Electroconvulsive therapy (ECT) is a neurostimulation therapeutic intervention that is highly effective and frequently used to treat certain psychiatric conditions, particularly major depressive disorder. Despite its high efficacy, a major limitation of ECT is the significant rate at which patients relapse after treatment. Providing additional ECT treatments after completion of a short-term course of ECT, referred to as continuation ECT (C-ECT), is a strategy used to reduce the risk of relapse. Specifically, C-ECT involves the administration of additional ECT treatments during the 6-month period after remission. This article summarizes the available literature regarding C-ECT including indication for use, patient selection, treatment guidelines/parameters, and safety. The efficacy of C-ECT is also discussed, with a focus on major depressive disorder and schizophrenia. On the basis of the current literature, indications for use and patient selection for C-ECT are predominately similar to those for a short-term ECT course. The treatment guidelines/parameters for C-ECT are recommended to be consistent with the parameters used to achieve remission, with the exception of greater intertreatment intervals during C-ECT. Although adverse cognitive effects can occur during C-ECT, the risk and severity of cognitive impairment are generally low, possibly because of the greater intertreatment intervals. Most research supports the use of C-ECT to prolong remission; however, methodologic limitations mitigate firm conclusions and generalizability of these findings. Nonetheless, the available evidence supports the use of C-ECT as a safe and effective method in relapse prevention.

Neuropsychological effects and attitudes in patients following electroconvulsive therapy

The current study examined the effects of electroconvulsive therapy (ECT) on neuropsychological test performance. Forty-six patients completed brief neuropsychological and psychological testing before and after receiving ECT for the treatment of recalcitrant and severe depression. Neuropsychological testing consisted of the Levin Selective Reminding Test (Levin) and Wechsler Memory Scale-Revised Edition (WMS-R). Self-report measures included the Beck Depression Inventory (BDI), the Short-Term Memory Questionnaire (STMQ), and several other measures of emotional functioning and patient attitudes toward ECT. The mean number of days between pre-ECT and post-ECT testing was 24. T-test revealed a significant decrease in subjective ratings of depression as rated by the BDI, t(45) = 9.82, P < 0.0001 (Pre-BDI = 27.9 +/- 20.2; post-BDI = 13.5 +/- 9.7). Objective ratings of memory appeared impaired following treatment, and patients' self-report measures of memory confirmed this decline. More specifically, repeated measures MANOVA [Wilks Lambda F(11,30) = 4.3, p < 0.001] indicated significant decreases for measures of immediate recognition memory (p < 0.005), long-term storage (p < 0.05), delayed prose passage recall (p < 0.0001), percent retained of prose passages (p < 0.0001), and percent retained of visual designs (p < 0.0001). In addition, the number of double mentions on the Levin increased (p < 0.02). This study suggests that there may be a greater need to discuss the intermittent cognitive risks associated with ECT when obtaining informed consent prior to treatment. Further that self-reports of cognitive difficulties may persist even when depression has remitted. However, patients may not acknowledge or be aware of changes in their memory functioning, and post-ECT self-reports may not be reliable.

Introduction of vagus nerve stimulation into a maintenance electroconvulsive therapy regimen: a case study and cost analysis

OBJECTIVE

This case report describes the outcome of a patient implanted with the vagus nerve stimulation (VNS) device while receiving maintenance electroconvulsive treatment (M-ECT) and compares the costs of treatment options for treatment-resistant depression.

METHODS

The patient, a male, aged 47 years with bipolar I disorder, treatment-resistant depression, and a 13-year history of depressions, was receiving M-ECT at 2-week intervals as well as antidepressant medications when he was implanted with the VNS device. His depression was assessed with the Montgomery-Asberg Depression Rating Scale. The cost analysis of treatment modalities placed M-ECT at $800 to $1000 per treatment and VNS at approximately $3900 annually (surgery, device, and office visits, approximately $31,300, was prorated over 8 years).

RESULTS

Antidepressants and other medications were used in combination and were gradually changed while the patient was receiving electroconvulsive therapy. The patient improved with VNS and was able to discontinue M-ECT. His Montgomery-Asberg Depression Rating Scale scores had fluctuated between 2 and 56, but, after VNS, the scores decreased to a level consistent with remission and have remained at those levels. The patient reported feeling as well as he had felt at any time he could remember, began an exercise program, and lost 30 lbs. During the 10 months before implantation, 14 electroconvulsive therapy treatments cost $11,200 to $14,000. For 10 months after implantation, 7 M-ECT treatments ($5600-$7000) plus prorated VNS ($3250) equaled $8850 to $10,250, $2350 to $3750 less than before implantation.

CONCLUSIONS

This patient improved with VNS and was able to discontinue M-ECT. Introducing VNS effected a cost savings over M-ECT.