Electroconvulsive therapy: Part I. A perspective on the evolution and current practice of ECT

Mental health treatments and the influence of culture: portrayals of hypnotherapy and electroconvulsive therapy in Singaporean television dramas

Stigma is one of the chief reasons for treatment-avoidant behaviour among people with mental health conditions. Stigmatising attitudes are spread through multiple determinants, including but not limited to: (i) individual beliefs; (ii) interpersonal influences; (iii) local cultural values and (iv) shared culture such as depictions in television shows. Our research indicates that popular television shows are currently understudied vectors for narratives that alternately reify or debunk assumptions and stereotypes about people with mental health conditions. Although such shows are fictional, they influence perception by normalising 'common sense' assumptions over extended periods of time. Consequently, representations of patients, psychiatrists and treatments influence knowledge and understanding of mental health and treatment-seeking behaviour. While storytelling about sickness can inspire possibilities and bestow meaning on traumatic experiences, fictional narratives written without sufficient care can have the inverse effect of curtailing horizons and limiting expectations. Problematic portrayals of patients, mental health professionals and psychological interventions are often reductive and may increase stigma and prevent treatment-seeking behaviour. This article analyses the representation of hypnotherapy and electroconvulsive therapy (ECT) in Singaporean television dramas that attract a wide, mainstream audience. Our diverse team investigated dramas in all four of the official languages of Singapore: English, Mandarin Chinese, Bahasa Melayu and Tamil. We found that depictions of hypnotherapy tend to produce problematic images of mental health professionals as manipulative, able to read minds, engaging in criminal behaviour, lacking in compassion and self-interested. Meanwhile, representations of ECT typically focus on the fear and distress of the patient, and it is primarily depicted as a disciplinary tool rather than a safe and effective medical procedure for patients whose condition is severe and refractory to pharmacotherapy and behavioural interventions. These depictions have the potential to discourage treatment-seeking behaviour-when early intervention has found to be crucial-among vulnerable populations.

Exploring the Decision-Making Process for Electroconvulsive Therapy in Patients With Major Depressive Disorder and Their Relatives After Treatment

OBJECTIVES

Shared decision making is used for reaching medical decisions, also in the management of major depressive disorder (MDD). Electroconvulsive therapy (ECT) is an effective treatment option for patients with severe MDD. However, the decision-making process, specifically the exchange of evidence-based information, for ECT may be hampered by the controversy and stigma surrounding ECT. We aim to explore the experiences of the decision-making process of patients and their relatives who have chosen to receive ECT in order to guide optimization of shared decision making in ECT.

METHODS

Semistructured interviews were conducted with MDD patients and their relatives who had voluntarily received ECT between 2018-2023 at the Radboud University Medical Center, the Netherlands. The interviews were analyzed by thematic analysis.

RESULTS

Meaning saturation occurred after 16 interviews. The following 3 major themes emerged: 1) information is key, 2) empowering the decision, and 3) lived experiences with ECT. Participants emphasized the importance of accessible information presented in a calm and stepwise manner. They also identified gaps in desired information, particularly regarding memory loss and difficulty in retaining the given information. Factors empowering the decision included support from family, healthcare professionals, peers, and desperation, while negative factors included stigma, negative images, lack of support, and fear. Lived experiences with ECT might influence a future decision. Positive experiences were improved attitudes, treatment effects, and empathic and involved professionals, while negative aspects included cognitive side effects and lack of follow-up.

CONCLUSIONS

This study offers insights into factors influencing the decision-making process in patients with MDD that received ECT. It shows possibilities for improving the decision-making process in clinical practice.

A Retrospective Analysis of the Impact of Electroconvulsive Therapy on Anxiety Symptoms in Patients With Treatment-Resistant Depression

BACKGROUND

Electroconvulsive therapy (ECT) is an effective treatment for treatment-resistant depression (TRD). There are limited data on the improvement of anxiety symptoms in patients receiving ECT for TRD.

OBJECTIVE

The aim of the study was to examine the extent to which anxiety symptom severity improves, relative to improvements in depressive symptoms, in TRD patients receiving an acute course of ECT.

METHODS

A retrospective chart review of 117 TRD patients who received an acute ECT course in a naturalistic outpatient setting was conducted. Symptomatic response was measured using the Beck Depression Inventory II and Generalized Anxiety Disorder 7 Scale. Two generalized estimating equation models assessed the degree of change in anxious symptoms relative to the change in depressive symptoms.

RESULTS

Both depression (-0.09, P < 0.001) and anxiety (-0.08, P < 0.001) improved after ECT treatment, with a greater standardized decrease for symptoms of depression. Higher levels of anxiety over the treatment (-0.42, P < 0.001) were associated with smaller antidepressant improvements.

CONCLUSIONS

ECT may improve symptoms of anxiety in patients with TRD. Anxiety symptoms show a favorable trajectory of improvement, though to a lesser extent, relative to changes in symptoms of depression. Higher symptoms of anxiety throughout the treatment course may be a negative predictor of antidepressant response in ECT.

Role of stimulus dose on neuropsychological functioning after electroconvulsive therapy in patients with major depressive disorder

Introduction

Electroconvulsive therapy (ECT) is the most effective treatment for patients suffering from treatment-resistant depression but its use is often limited by the concern for cognitive side effects. This study examines the effect of ECT on autobiographical and verbal memory compared to a healthy control group and the impact of the mean stimulus dose on cognition after ECT.

Methods

Autobiographical and verbal memory were assessed in depressed patients and healthy controls before the first and within one week after the last ECT treatment. Neuropsychological testing included the Autobiographical Memory Interview, the Verbal Learning and Memory Test and five tests from the Cambridge Neuropsychological Test Automated Battery. The mean charge delivered across the ECT series and the total number of sessions were examined in relationship to cognitive impairment after ECT using a multiple regression model.

Results

Autobiographical memory was significantly impaired after ECT treatment compared to healthy controls. Baseline scores were lower for depressed patients on all cognitive domains. Improvements in performance after ECT were found on tests for executive functions and working memory. Effects of the mean charge delivered on cognitive functioning after ECT were heterogeneous across cognitive domains but significant for verbal retrograde memory.

Conclusion

ECT led to autobiographical memory impairment. The relationship between mean charge delivered and cognitive performance is heterogeneous across different cognitive domains and requires further research. Significant effects of the mean charge delivered were found without a significant difference in cognitive functioning compared to a healthy control group.

The electro-convulsive therapy story of Africa, a systematic review

Over the years, the use of Electroconvulsive therapy (ECT) has gained increasing acceptance as a viable treatment for managing treatment-resistant mental health conditions, and it is known to deliver more rapid therapeutic benefits than most treatment modalities in psychiatry. However, the practice of ECT exhibits significant variability both within and between countries. This review aimed to shed light on the status of ECT in the African context and its implications for mental health care in the region. In July 2023, databases (Ovid, PubMed, Web of Science, etc.) were searched for articles about ECT in Africa, following the PRISMA guidelines. Eligible studies reporting ECT practices in Africa and those about knowledge, attitudes, and perceptions were excluded. A total of 25 articles met the study criteria. The reviewed studies revealed that unmodified ECT continues to be used in some African countries due to resource limitations, while bilateral ECT is widely practiced across the continent. The primary diagnostic indications for ECT in Africa included severe depression and affective disorders. ECT usage and regulation vary significantly throughout Africa. The studies, primarily observational, detailed numerous challenges in employing the method, particularly concerning resource utilization in healthcare facilities. The review highlights the necessity for adaptable standards and local protocols to enhance ECT practices throughout Africa. It emphasizes the importance of conducting more evidence-based research to develop region-specific guidelines that ensure the safe and effective use of ECT. Policymakers and healthcare practitioners should prioritize resource allocation, training, and standardization to improve ECT delivery and outcomes on the continent.

Amygdala and hippocampal substructure volumes and their association with improvement in mood symptoms in patients with mood disorders undergoing electroconvulsive therapy

Electroconvulsive therapy (ECT) demonstrates favorable outcomes in the management of severe depressive disorders. ECT has been consistently associated with volumetric increases in the amygdala and hippocampus. However, the underlying mechanisms of these structural changes and their association to clinical improvement remains unclear. In this cross-sectional structural MRI study, we assessed the difference in amygdala subnuclei and hippocampus subfields in n = 37 patients with either unipolar or bipolar disorder immediately after eighth ECT sessions compared to (n = 40) demographically matched patients in partial remission who did not receive ECT (NoECT group). Relative to NoECT, the ECT group showed significantly larger bilateral amygdala volumes post-treatment, with the effect originating from the lateral, basal, and paralaminar nuclei and the left corticoamydaloid transition area. No significant group differences were observed for the hippocampal or cortical volumes. ECT was associated with a significant decrease in depressive symptoms. However, there were no significant correlations between amygdala subnuclei volumes and symptom improvement. Our study corroborates previous reports on increased amygdalae volumes following ECT and further identifies the subnuclei driving this effect. However, the therapeutic effect of ECT does not seem to be directly related to structural changes in the amygdala.

Psychodynamically Informed Brain Stimulation: Building a Bridge from Brain to Mind

Since its inception, psychiatry has undergone several periods of radical identity transformation. Initially limited to psychotherapy alone, the advent of medications stimulated an era of biological psychiatry. For years, medications served as the mainstay of biological treatments, paralleled by a rise in treatment resistance. Brain stimulation therapies are psychiatry's newest arm of intervention and represent an area ripe for exploration. These techniques offer new hope to treatment-resistant patients, but in a manner often dissociated from psychoanalytic conceptualization and the practice of psychotherapy. There is growing interest in bridging this divide. In this article, we continue the efforts at interweaving what may seem to be disparate approaches through the topic of treatment resistance. This article aims to engage interventional psychiatrists in considering psychosocial dimensions of their treatments and to provide education for psychoanalytic clinicians on the history, mechanism of action, and applications of brain stimulation technologies.

The Economics of Treatment for Depression

The global prevalence of depression has risen over the past three decades across all socioeconomic groups and geographic regions, with a particularly rapid increase in prevalence among adolescents (aged 12-17 years) in the United States. Depression imposes large health, economic, and societal costs, including reduced life span and quality of life, medical costs, and reduced educational attainment and workplace productivity. A wide range of treatment modalities for depression are available, but socioeconomic disparities in treatment access are driven by treatment costs, lack of culturally tailored options, stigma, and provider shortages, among other barriers. This review highlights the need for comparative research to better understand treatments' relative efficacy, cost-effectiveness, scalability, and potential heterogeneity in efficacy across socioeconomic groups and country and cultural contexts. To address the growing burden of depression, mental health policy could consider reducing restrictions on the supply of providers, implementing digital interventions, reducing stigma, and promoting healthy lifestyles.

Multiomics and blood-based biomarkers of electroconvulsive therapy in severe and treatment-resistant depression: study protocol of the DetECT study

Electroconvulsive therapy (ECT) is commonly used to treat treatment-resistant depression (TRD). However, our knowledge of the ECT-induced molecular mechanisms causing clinical improvement is limited. To address this issue, we developed the single-center, prospective observational DetECT study ("Multimodal Biomarkers of ECT in TRD"; registered 18/07/2022, www.clinicalTrials.gov , NCT05463562). Its objective is to identify molecular, psychological, socioeconomic, and clinical biomarkers of ECT response in TRD. We aim to recruit n = 134 patients in 3 years. Over the course of 12 biweekly ECT sessions (± 7 weeks), participant blood is collected before and 1 h after the first and seventh ECT and within 1 week after the twelfth session. In pilot subjects (first n = 10), additional blood draws are performed 3 and 6 h after the first ECT session to determine the optimal post-ECT blood draw interval. In blood samples, multiomic analyses are performed focusing on genotyping, epigenetics, RNA sequencing, neuron-derived exosomes, purines, and immunometabolics. To determine clinical response and side effects, participants are asked weekly to complete four standardized self-rating questionnaires on depressive and somatic symptoms. Additionally, clinician ratings are obtained three times (weeks 1, 4, and 7) within structured clinical interviews. Medical and sociodemographic data are extracted from patient records. The multimodal data collected are used to perform the conventional statistics as well as mixed linear modeling to identify clusters that link biobehavioural measures to ECT response. The DetECT study can provide important insight into the complex mechanisms of ECT in TRD and a step toward biologically informed and data-driven-based ECT biomarkers.

Exploring New Electroencephalogram Parameters in Electroconvulsive Therapy

OBJECTIVE

This pilot study aims to evaluate a novel metric based on the power spectrum of the EEG recordings from ECT-induced seizures-its association to volume changes in the hippocampus after ECT and improvement in depression rating scores.

METHODS

Depressed patients treated with ECT underwent brain magnetic resonance imaging before and after treatment and the EEG from each seizure was recorded (N = 29). Hippocampal volume changes and EEG parameters were recorded in addition to clinician-rated and self-reported measures of depressive symptoms. The slope of the power law in the power spectral density of the EEG was calculated. Multivariate linear models relating seizure parameters to volume change or clinical outcome were systematically and successively simplified. The best models were selected according to Akaike information criterion.

RESULTS

The slope of the power law was steeper in the right than the left hemisphere (P < 0.001). Electroencephalogram measures were included in the best models of volume change for both hippocampi as well as in the models explaining clinical outcome ( P = 0.014, P = 0.004).

CONCLUSIONS

In this pilot study, novel EEG measures were explored and contributed in models explaining the variation in volume change in the hippocampus and in clinical outcome after ECT.

Attitudes of medical students to electroconvulsive therapy

Purpose

This study aims to explore medical students’ attitudes to electroconvulsive therapy (ECT). The authors sought to determine correlates of baseline attitudes to ECT and whether specific forms of ECT teaching improved attitudes to ECT during students’ psychiatry placement.

Design/methodology/approach

At the beginning of their placement, fourth-year medical students completed a questionnaire capturing background information and baseline attitudes. A second questionnaire, in the second half of the placement, recorded educational and clinical experience gained on ECT during placement, in addition to attitudes at this timepoint. The authors measured attitude using a five-point Likert scale and defined a positive shift in attitude as an improvement of ≥ 1 point between the two time points.

Findings

At Timepoint 1, 66% reported a positive attitude to ECT. This was associated with having attended a lecture and with having read a professional article on ECT at some time before the psychiatry placement. Attitudes significantly improved during the placement (66% vs 95% positive). Students who attended a lecture on ECT were more likely to have a positive shift in attitude, as were students who experienced three or more teaching modalities.

Practical implications

Personal, social and medical problems arise from treatment-resistant psychiatric disorders. ECT is a safe and effective treatment for such disorders.

Originality/value

It is hoped that this study will contribute to the development of medical education, so that lectures on ECT, and three or more teaching modalities, are incorporated into the undergraduate medical curriculum.

Evaluating the use of electroconvulsive therapy in low-middle income countries: A narrative review

BACKGROUND

Electroconvulsive therapy (ECT) is a well-accepted intervention for treatment-resistant, serious mental illnesses. Its acceptability, efficacy, and tolerability are well documented in high-income settings, but less so in lower- and middle-income countries (LMICs). This report is a narrative review of ECT practice in the latter setting.

METHODS

A literature search was conducted using Medline and PubMed. Initial results yielded 81 publications in English. Following the screening, 19 papers were included to evaluate the information on ECT practice and perceptions.

RESULTS

Reports from LMICs on efficacy, tolerability, and perceptions of ECT were relatively sparse. In general, they confirm its use mostly for treatment-resistant major mental illnesses (i.e., depression, schizophrenia, bipolar disorder). Both modified and unmodified forms of ECT are used and considered equally effective, although the former is better tolerated. Use of unmodified ECT remains significant in LMICs due to its low cost and limited resource requirements. In general, there is satisfaction with ECT and its outcomes. The education of patients and families, content process, and research have been noted as areas to improve.

CONCLUSIONS

ECT is perceived as an effective intervention in LMICs, but use of unmodified ECT remains controversial. There is a need for the development and use of global guidelines to improve clinician training, knowledge sharing with patients and their families, and outcome research.

The use of theta burst stimulation in patients with schizophrenia - A systematic review

Transcranial magnetic stimulation (TMS) can offer therapeutic benefits and provide value in neurophysiological research. One of the newer TMS paradigms is theta burst stimulation (TBS) which can be delivered in two patterns: continuous (cTBS - inducing LTD-like effects) and intermittent (iTBS - inducing LTP-like effects). This review paper aims to explore studies that have utilized TBS protocols over different areas of the cortex to study the neurophysiological functions and treatment of patients with schizophrenia. PubMed was searched using the following keywords "schizophrenia", "schizoaffective", or "psychosis", and "theta burst stimulation". Out of the 90 articles which were found, thirty met review inclusion criteria. The inclusion criteria included studying the reported effect (clinical, physiological, or both) of at least one session of TBS on human subjects, and abstracts (at minimum) must have been in English. The main target areas included prefrontal cortex (12 studies - 10 dorsolateral prefrontal cortex (DLPFC), 2 dorsomedial prefrontal cortex (DMPFC)) vermal cerebellum (5), and temporo-parietal cortex (8). Other target areas included inferior parietal lobe (2), and motor cortex (3). TBS neurophysiological effect was explored in 5 studies using functional magnetic resonance image (fMRI), magnetic resonance spectroscopy (MRS), electroencephalography (EEG), electromyography (EMG) and positron emission topography (PET) scan. Overall, TBS can offer great therapeutic potential as it is well-tolerated, feasible, and has few, if any, adverse effects. TBS may be targeted to treat specific symptomatology, as an augmenting intervention to pharmacotherapy, or even improving patient's insight into their diagnosis.

The Relative Effectiveness of Bilateral and Unilateral Electrode Placement in Electroconvulsive Therapy (ECT) in Patients With Major Depressive Disorder: A Retrospective Cohort Study

Background This study is focused on the comparative efficacy of bilateral and unilateral electroconvulsive therapy (ECT) on depressive symptoms in patients at the Perth Clinic for the period from 2016 to 2021. Methods This was a retrospective cohort study of 485 patients who received ECT treatment. The expected improvements in depressive symptoms were evaluated by the Depression Anxiety Stress Scale (DASS) assessment tool filled out by the patients on admission and discharge from the hospital. Only the depression score of the DASS scale was utilised for this research. Results The results suggested that both electrode placements resulted in a significant improvement in depressive symptoms. The positive response rates for the bilateral and unilateral electrode placements were 78.3% and 71.6%, respectively. There was no difference between males and females in the average DASS score at discharge for bilateral and unilateral electrode placements. Conclusions This study confirmed that the results obtained at the Perth Clinic are similar to the existing international research results on the same topic. Bifrontal and unilateral ECT electrode placements are equally efficacious in improving depressive symptoms in patients suffering from major depressive disorder (MDD).

Neuroimaging study of electroconvulsive therapy for depression

Electroconvulsive therapy (ECT) is an important treatment for depression. Although it is known as the most effective acute treatment for severe mood disorders, its therapeutic mechanism is still unclear. With the rapid development of neuroimaging technology, various neuroimaging techniques have been available to explore the alterations of the brain by ECT, such as structural magnetic resonance imaging, functional magnetic resonance imaging, magnetic resonance spectroscopy, positron emission tomography, single photon emission computed tomography, arterial spin labeling, etc. This article reviews studies in neuroimaging on ECT for depression. These findings suggest that the neurobiological mechanism of ECT may regulate the brain functional activity, and neural structural plasticity, as well as balance the brain's neurotransmitters, which finally achieves a therapeutic effect.

Electroceutical and Bioelectric Therapy: Its Advantages and Limitations

Given the long history, the field of electroceutical and bioelectric therapy has grown impressively, recognized as the main modality of mental health treatments along with psychotherapy and pharmacotherapy. Electroceutical and bioelectric therapy comprises electroconvulsive therapy (ECT), vagus nerve stimulation (VNS), repetitive transcranial magnetic stimulation (rTMS), deep brain stimulation (DBS), transcranial electrical stimulation (tES), and other brain stimulation techniques. Much empirical research has been published regarding the application guidelines, mechanism of action, and efficacy of respective brain stimulation techniques, but no comparative study that delineates the advantages and limitations of each therapy exists for a comprehensive understanding of each technique. This review provides a comparison of existing electroceutical and bioelectric techniques, primarily focusing on the therapeutic advantages and limitations of each therapy in the current electroceutical and bioelectric field.

Turkish Validity and Reliability Study of the ECT Perception and Knowledge Scale

Introduction

Electroconvulsive Therapy (ECT) is an effective and safe treatment method used in the treatment of various psychiatric diseases. However, negative attitudes associated with ECT are common. This causes many negative consequences, from the treatment preference to treatment response and stigma. In this study, we aimed to carry out a validity-reliability analysis of the ECT Perception and Knowledge Scale (ECT-PK), which was developed to determine the perception and knowledge levels related to ECT, and adapt it to Turkish.

Method

The Turkish adaptation of the ECT-PK was made using the translation-retranslation method. Our study included 50 patients with schizophrenia, 50 patients with bipolar disorder, 50 patients with major depression who met the remission criteria determined separately for each disorder, and 150 healthy controls.. To measure test-retest reliability, the scale was re-applied to 30 patients randomly selected from the patient group 14-21 days after the first application of the scale.

Results

In our study, a significant difference was found in both the patient and control groups in terms of the history of ECT application in the past and the status of accepting ECT application when recommended, and the perception and knowledge subscales of the ECT-PK. These results support the construct and criterion validity of the ECT-PK. Cronbach's alpha coefficient was found to be 0.85 for the perception subscale and 0.78 for the knowledge subscale. The intra-class correlation coefficient used to evaluate the test-retest reliability was 0.86 for the perception scale and 0.83 for the knowledge subscale.

Conclusion

It has been shown that the ECT-PK is a valid and reliable measurement tool that can be used to measure the perception and knowledge levels related to ECT in both clinical and non-clinical groups.

Prolonged neurologic deficits with brain MRI changes following ECT in an adolescent with a CACNA1a-related disorder; a case report

BACKGROUND

Electroconvulsive therapy is used to treat depression and schizophrenia with infrequent use in pediatric patients. We report a case of an adolescent with autism spectrum disorder and acute catatonia that presented with status epilepticus (SE) and prolonged neurologic deficits with unilateral left cerebral edema on imaging following unilateral electroconvulsive therapy (ECT) on the right side, subsequently found to have a CACNA1a pathogenic variant. This case highlights a potential adverse effect of ECT in patients with CACNA1a related disorders.

CASE

The patient received unilateral ECT to the right side and subsequently had an episode of SE with right-sided hemiplegia for 72 h prior to regaining some function with persistent mild right-hand weakness that persisted for at least 1-2 weeks. A brain MRI 2 days after ECT was unremarkable, but a repeat MRI on day four of admission showed left hemisphere cortical diffusion restriction, increased perfusion and T2 prolongation suggestive of cortical edema. They had whole exome genetic testing sent after discharge that showed a known pathogenic CACNA1a variant (p.I1709T). CACNA1a encodes the P/Q type calcium channels and deleterious variants in this gene result in a channelopathy associated with a spectrum of neurodevelopmental disorders that include autism spectrum disorder, hemiplegic migraine with unilateral cerebral edema, epileptic encephalopathies, or episodic ataxia syndromes.

CONCLUSION

A literature review of ECT and neurologic deficits showed that most neurologic deficits resolve within 30 min of ECT. Case reports of prolonged deficits are rare and there are no prior reports of acute MRI changes related to ECT. Thus, the acute deterioration and MRI findings in this patient are likely related to the underlying CACNA1a channelopathy disorder with ECT as a precipitating event. This case report suggests care should be taken when using ECT in patients with pathogenic variants in CACNA1a. Furthermore, it reinforces the utility and importance of expanded genetic testing in patients with neurodevelopmental disorders as findings can provide valuable information that can guide treatment decisions.

Investigating the efficacy of Ginkgo biloba on the cognitive function of patients undergoing treatment with electric shock: a double-blind clinical trial

Cognitive impairment is common in patients undergoing electroconvulsive therapy (ECT). Researchers are seeking pharmaceutical compounds with low side effects to decrease these outcomes. This study aimed to investigate the effectiveness of Ginkgo biloba therapy on the cognitive function of patients treated with electroshock. In a double-blinded clinical trial, 80 patients with psychiatric disorders who were candidates for ECT in 2019 were randomly assigned to two groups: the intervention group (receiving Ginkgo biloba drug) and the control group (receiving placebo). We used the Mini-Mental State Examination (MMSE) and Wechsler Memory Scale Recipe III (WMS-III) questionnaires to evaluate the efficacy of the drug on the cognitive function at time 0, after 4 sessions and 72 hours post-final session of ECT. The data were analyzed by SPSS version 22, with a significance level of 0.05. Patients' assessment after the intervention showed that the average MMSE scores in the intervention group (28.92±1.04) were statistically higher than in the control group (27.85±1.56). The average scores of the WMS-III in the intervention group and the control group were 97.45±8.04 and 92.00±4.45 after 4 sessions of ECT, and 100.26±8.33 and 92.40±3.92 after the intervention (p=0.001). According to the findings, Gingko biloba increased MMSE and WMS-III scores in older patients (patients over 40 had better scores in both questionnaires, the drug was more effective, and with no side effects).

Vagally Mediated Heart Rate Variability Is Associated With Executive Function Changes in Patients With Treatment-Resistant Depression Following Magnetic Seizure Therapy

OBJECTIVES

Magnetic seizure therapy (MST) is a novel investigational brain stimulation modality for patients with treatment-resistant depression (TRD). MST is a potential alternative seizure-based treatment to electroconvulsive therapy (ECT), given that it may offer equivalent antidepressant efficacy, yet with a relative sparing of cognitive functioning. Heart rate variability (HRV) is a marker of central autonomic functioning. We aimed to explore the relationships among baseline HRV, age, clinical outcome, and executive function following MST, in patients with TRD.

MATERIALS AND METHODS

Eighty-eight TRD patients (55 females; 18-70 years) were enrolled and 48 patients completed a course of MST in an open-label study. Patients received MST treatments two to three times per week, using one of three stimulation frequencies (ie, 100 Hz, 50 Hz, or 25 Hz) at 100% stimulator output. Root mean square of the successive R-R differences (RMSSD), an index of HRV, was computed from a baseline electrocardiogram (ECG) recording. Clinical symptoms were assessed using the Hamilton Depression Rating Scale (HAM-D₂₄) and the Quick Inventory of Depressive Symptomatology (QIDS₁₆). Executive function was assessed using the Trail Making Test and the Mazes Test from the MATRICS battery.

RESULTS

Baseline RMSSD was correlated with baseline HAM-D₂₄ (r = -0.340, p = 0.001) and baseline Mazes Test (r = 0.417, p = 0.0007) but not with baseline Trail Making Test. Furthermore, baseline RMSSD was not correlated with changes on the HAM-D₂₄, QIDS₁₆, or total scores on the Trail Making Test. However, there was a significant correlation between baseline RMSSD and improvement on the Mazes Test following MST (r = 0.502, p = 0.0004).

CONCLUSIONS

Since this is an open-label trial, the influence of the placebo effect cannot be excluded. However, our results suggest that baseline RMSSD may be a state-biomarker of depression and executive function impairment. Additionally, while baseline vagally mediated resting cardiac activity did not predict the outcome of depression, it may mediate executive function improvements following MST.

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.

A case of negative-pressure pulmonary oedema after first-time electroconvulsive therapy

Electroconvulsive therapy (ECT) has been used for many years as an important treatment modality in patients with schizophrenia. Recently, many new oral medications have become available to treat schizophrenia. However, ECT remains a valuable therapy for patients who are resistant to oral medications. A 16-year-old girl with schizophrenia was admitted to our hospital with hypoxaemia due to negative-pressure pulmonary oedema (NPPE) after her first ECT. NPPE is an exceedingly rare complication after ECT. However, it can result in serious morbidity if not immediately recognized and treated. This case illustrates the importance of recognizing this rare complication.

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.

Effectiveness of aromatherapy with inhaled lavender essential oil and breathing exercises on ECT-related anxiety in depressed patients

Background and aims Electroconvulsive therapy (ECT) is considered a safe, effective, and significant treatment in patients suffering from a major depressive disorder. Anxiety caused by this invasive treatment may impose several side effects on patients. The purpose of this study was to evaluate the effectiveness of aromatherapy with inhaled lavender essential oil and breathing exercises on ECT-related anxiety in depressed patients. Methods In this randomized controlled clinical trial, 90 depressed patients were selected and divided into three groups: aromatherapy, breathing exercise, and routine care using a random allocation method. Before undergoing ECT, the aromatherapy group was exposed to the inhaled lavender essential oil (n = 30), the breathing exercise group performed the breathing exercises (n = 30), and the routine care group received routine care (n = 30). Before (20 min) and after the intervention (30 min later), patients' anxiety was assessed using Beck Anxiety Inventory. Results After the intervention, the results revealed that anxiety score changes were statistically significant among the three groups (p < 0.001). In addition, it was found that the patients' mean anxiety scores significantly decreased in the aromatherapy and breathing exercise groups compared to with the pre-intervention scores (p < 0.001). Conclusion Aromatherapy with inhaled lavender essential oil and breathing exercises can be considered by clinical nurses as simple, applicable, and effective interventions to reduce ECT-related anxiety in depressed patients.

One century of healing currents into the brain from the scalp: From electroconvulsive therapy to repetitive transcranial magnetic stimulation for neuropsychiatric disorders

Electroconvulsive therapy (ECT) was applied for the first time in humans in 1938: after 80 years, it remains conceptually similar today except for modifications of the original protocol aimed to reduce adverse effects (as persistent memory deficits) without losing clinical efficacy. We illustrate the stages of development as well as ups and downs of ECT use in the last eighty years, and the impact that it still maintains for treatment of certain psychiatric conditions. Targeted, individualized and safe noninvasive neuromodulatory interventions are now possible for many neuropsychiatric disorders thanks to repetitive transcranial magnetic stimulation (rTMS) that injects currents in the brain through electromagnetic induction, powerful enough to depolarize cortical neurons and related networks. Although ECT and rTMS differ in basic concepts, mechanisms, tolerability, side effects and acceptability, and beyond their conceptual remoteness (ECT) or proximity (rTMS) to "precision medicine" approaches, the two brain stimulation techniques may be considered as complementary rather than competing in the current treatment of certain neuropsychiatric disorders.

Right Unilateral Versus Bilateral Electroconvulsive Therapy in Patients With Clinical Depression

Introduction Electroconvulsive therapy (ECT) is a functional treatment for a significant mental illness that involves a momentary application of electrical stimulation to induce generalized seizures. The use of right unilateral (RUL) and bilateral (BL) ECT has been controversial. Thus, the study aimed at comparing the effectiveness of RUL ECT and BL ECT in treating depression. Methodology A longitudinal study was conducted between September 2016 and January 2021 at a tertiary care hospital in Sindh, Pakistan. All patients over the age of 18 with clinically diagnosed depression in the last month were included in the study. Baseline depression scores and post-treatment scores were determined using Hamilton Depression Rating Scale (HDRS). All patients were assigned to each treatment group. Group A was administered right unilateral electroconvulsive therapy, while group B was administered bilateral electroconvulsive therapy. Adverse effects were documented right after treatment, at four hours, and then one day after therapy. Depression severity was determined after each ECT session using the HDRS scale. Electroconvulsive therapy was discontinued when an HDRS score of 10 was achieved.  Results  The mean HDRS score at baseline in the bilateral ECT group was 24.99 ± 3.938, which lowered to 17.56 ± 2.65 by the 3rd session, 12.45 ± 3.76 by the 6th session, and to 11.86 ± 2.3 by the end of treatment (p<0.0001). Similarly, the right unilateral ECT was equally effective in improving the depressive symptoms (p<0.0001). There was no significant difference between the efficacy of bilateral and unilateral placements of electrodes in electroconvulsive therapy (p=0.116).

Electroconvulsive therapy for negative symptoms in schizophrenia: a literature review from 2000 to 2021

Negative symptoms in schizophrenia remain a clinical challenge with small effect sizes and evidence for pharmacological or psychotherapeutic treatment approaches. Studies suggest that electroconvulsive therapy (ECT) holds some promise as a treatment option of often persistent negative symptoms with clinically meaningful effects. This review summarizes the existing evidence on the efficacy of ECT on negative symptoms in patients with schizophrenia. Thirty-five publications were included in this literature review comprising 21 studies, two meta-analyses, eight reviews and four case reports. Conclusions should be interpreted cautiously, given the small number and methodological shortcomings of the included publications with a variation of study designs and missing standardized protocols. Implications for future research and practice are critically discussed. Recommendations are given to provide more evidence that will meet the clinical challenge of reducing the negative symptoms in schizophrenia. Study designs that focus explicitly on negative symptoms and assess patients over longer follow up periods could be helpful. Future research should include control groups, and possibly establish international multicentered studies to get a sufficient study population. Findings suggest that patients with schizophrenia resistant to pharmacological treatment might benefit from ECT. A risk and benefit assessment speaks in favour of the ECT treatment. Future practice of ECT should include a combination treatment with antipsychotics. Whereas the use of anaesthetics and electrode placement does not seem to play a role, the recommendation regarding frequency of ECT treatments is currently three times a week, For the assessment of negative symptoms the assessment tool should be chosen carefully.

Electroconvulsive Therapy and Movement Disorders. New Perspectives on A Time-Tested Therapy

Electroconvulsive therapy (ECT) has been a very well known therapy in Psychiatry for over 80 years. ECT is considered useful in treating acute mania, severe depression and other psychiatric conditions. Over time, this therapy has also been used in several movement disorders including Parkinson disease (PD) and Huntington disease (HD). In this brief review, I summarize the recent History and evolution of ECT, its proven and potential applications in movement disorders as well as its potential mechanisms.

Auricular Vagus Neuromodulation-A Systematic Review on Quality of Evidence and Clinical Effects

Background: The auricular branch of the vagus nerve runs superficially, which makes it a favorable target for non-invasive stimulation techniques to modulate vagal activity. For this reason, there have been many early-stage clinical trials on a diverse range of conditions. These trials often report conflicting results for the same indication. Methods: Using the Cochrane Risk of Bias tool we conducted a systematic review of auricular vagus nerve stimulation (aVNS) randomized controlled trials (RCTs) to identify the factors that led to these conflicting results. The majority of aVNS studies were assessed as having "some" or "high" risk of bias, which makes it difficult to interpret their results in a broader context. Results: There is evidence of a modest decrease in heart rate during higher stimulation dosages, sometimes at above the level of sensory discomfort. Findings on heart rate variability conflict between studies and are hindered by trial design, including inappropriate washout periods, and multiple methods used to quantify heart rate variability. There is early-stage evidence to suggest aVNS may reduce circulating levels and endotoxin-induced levels of inflammatory markers. Studies on epilepsy reached primary endpoints similar to previous RCTs testing implantable vagus nerve stimulation therapy. Preliminary evidence shows that aVNS ameliorated pathological pain but not evoked pain. Discussion: Based on results of the Cochrane analysis we list common improvements for the reporting of results, which can be implemented immediately to improve the quality of evidence. In the long term, existing data from aVNS studies and salient lessons from drug development highlight the need for direct measures of local neural target engagement. Direct measures of neural activity around the electrode will provide data for the optimization of electrode design, placement, and stimulation waveform parameters to improve on-target engagement and minimize off-target activation. Furthermore, direct measures of target engagement, along with consistent evaluation of blinding success, must be used to improve the design of controls-a major source of concern identified in the Cochrane analysis. The need for direct measures of neural target engagement and consistent evaluation of blinding success is applicable to the development of other paresthesia-inducing neuromodulation therapies and their control designs.

Treatment Capacity and Clinical Outcomes for Patients With Schizophrenia Who Were Treated With Electroconvulsive Therapy: A Retrospective Cohort Study

BACKGROUND

Patients with schizophrenia are often found incapable to consent to psychiatric treatment. We evaluated clinical outcomes for incapable and capable patients with schizophrenia treated with electroconvulsive therapy (ECT).

METHODS

We conducted a chart review of all inpatients treated with an acute course of ECT between 2010 and 2018 at the Centre for Addiction and Mental Health, Toronto, Canada. Short-term outcomes included treatment response and cognitive impairment. We assessed whether incapable patients regained the capacity to consent to treatment. Long-term outcomes included readmissions and subsequent courses of acute or maintenance ECT.

RESULTS

A total of 159 (67%) incapable and 79 (33%) capable patients were included. Patients experienced treatment response (incapable, n = 108, 67.9%; capable, n = 52, 65.8%; P = .771) and few experienced cognitive impairment (incapable, n = 21, 13.2%; capable, n = 19, 24.1%; P = .043). A minority of patients were treated with a subsequent course of acute ECT (incapable, n = 46, 28.9%; capable, n = 16, 20.3%; P = .162). Incapable patients were more likely to be treated with maintenance ECT for at least 6 months (incapable, n = 46, 28.9%; capable, n = 13, 16.5%; P = .039). Both groups had similar readmission rates (incapable, n = 70, 44.0%; capable, n = 35, 44.3%; P = 1.000). Eight (5.0%) incapable patients regained capacity and 7 consented to further treatment.

CONCLUSIONS

Irrespective of treatment capacity, the majority of patients demonstrated clinical improvement. Incapable patients experienced less cognitive side effects when compared with capable patients, though they had fewer treatments overall. This study informs clinicians, patients, and substitute decision-makers about the outcomes and challenges of ECT in patients with schizophrenia.

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.

Outcomes in patients with and without capacity in electroconvulsive therapy

BACKGROUND

Electroconvulsive therapy (ECT) is an effective treatment for severe mental illness but access is limited for patients lacking consent capacity. We aimed to compare the symptomatic, cognitive, quality of life (QOL) and functional outcomes of patients with and without capacity receiving ECT for schizophrenia, depression or mania.

METHODS

Patients prescribed ECT in a single center had their clinical outcomes pre and post ECT compared with repeated measures ANOVAs. Differences in demographic, clinical characteristics and ECT treatment between the group lacking and having capacity were examined using independent t-tests for continuous variables and chi-squared tests for categorical variables.

RESULTS

75.1% of 175 patients lacked capacity. The group lacking capacity had overall poorer cognitive and global functioning pre ECT but higher QOL. Objective psychiatric symptom ratings after ECT improved similarly between groups. Mood, cognition, QOL and function improved in both groups, with more improvement in mood and function in the group lacking capacity and a trend towards greater cognitive improvement (p = 0.051).

LIMITATIONS

Subgroup analysis by diagnosis was not done due to smaller sample sizes in each group. Cognition was assessed with a general screening instrument not a full neuropsychological assessment.

CONCLUSIONS

ECT is a safe and effective treatment for schizophrenia, bipolar mania and depression, and may provide similar or greater benefits in patients lacking capacity to consent, compared to those with capacity. These results support the provision of a framework for substitute decision making in the patients' best interests for ECT in patients unable to provide their own consent.

The Care of Patients With Complex Mood Disorders

This article focuses on some common dilemmas facing clinicians, patients, and families in managing the treatment of complicated mood disorders. Specifically, this article reviews the interaction of depressive states, including unipolar, bipolar, and mixed, with other adversities, including comorbid physical and psychological disorders, personality vulnerabilities, misuse of drugs and alcohol, and social and family problems. These issues are not always clearly differentiated from the depressive illness. Each of these adversities can worsen an existing mood disorder and influence the patient's resolve to persist with a treatment plan. Although this article is not focused strictly on treatment-resistant depression, these coexisting issues make depressive states harder to manage therapeutically. For brevity, the aim of this article has been limited to discussion of some complex situations that psychiatrists in general practice may encounter.

Is There a Change in Electroconvulsive Therapy Practice Following the New Mental Health Act 2014 in Victoria?: A Study at a Metropolitan Mental Health Service

OBJECTIVES

The main objective of our study was to examine whether there has been any change to electroconvulsive therapy (ECT) practice since the new Mental Health Act 2014 (MHA) in a public metropolitan mental health service in Victoria.

METHODS

This retrospective study examined any change in ECT rate following the new MHA. We compared sociodemographic, clinical, and ECT-related variables for patients treated before (July 1, 2013, and June 30, 2014) and after (1st July 2014 and the 30th June 2015) the new MHA.

RESULTS

A reduction of 11.15% in ECT use per 1000 admissions and 16.4% in ECT use per 100,000 persons was observed subsequent to the new MHA. Hospital legal status at admission positively predicted the chance of starting ECT treatment under involuntary consent. Hospital legal status at admission and discharge, history of involuntary ECT, and final Clinical Global Impression-Severity scores positively predicted, but the year of treatment negatively predicted the chance of completing ECT treatment under involuntary consent.

CONCLUSIONS

The new MHA appeared to have been associated with reduced ECT use and lower rate of completing ECT under involuntary consent.

A Qualitative Exploration of Gaps and Challenges in Knowledge and Practices of Electroconvulsive Therapy by Key Personnel in Public and Private Mental Health Units in Kenya

Background: Evidence-based research for electroconvulsive therapy (ECT) practice in Kenya is scarce. This has seemingly stifled knowledge with regard to ECT practice among key personnel in the country. Research shows that evidence-based guidelines not only harmonize clinical practice in a certain region but also improve health outcomes and quality of clinical decisions made by key personnel. This study aimed at assessing knowledge and administration of ECT by key personnel in psychiatric units in Kenya. Method: This is a qualitative study targeting multiple stakeholders in mental health facilities. The study was undertaken in three counties: Nairobi, Nakuru and Eldoret. Snowballing sampling method was used to interview 33 targeted respondents who work in ECT departments or actively interacted with the procedure in both private and public facilities. Researcher-designed respondent profile questionnaire and interview guides focusing on knowledge, practice and barriers in delivery of ECT were used as tools. Data collected were transcribed from the audio recordings. Thematic and content analyses of these semi-structured interviews were carried out based on the patterns that were noted across the data collected. The interviews were read by the research team and re-read to highlight the core ideas. Findings were presented in form of themes, which were illustrated along with representative verbatim quotations. Results: Overall, the key personnel were knowledgeable about ECT in different stages of the procedure, but we noticed methodological incongruence in their practice with regard to the pre-ECT preparation, stimulus dose calculation adequacy of seizure and in the procedure for dose adjustment of psychotropic medication before and after ECT sessions. The identified barriers to the uptake of evidence-based practice were lack of infrastructure, inadequate funding, lack of adequate training and negative perception by patients, relatives and even some participants. Conclusion: Though key personnel in this study showed that they had knowledge on ECT administration, lack of standard guidelines on ECT practice led to lack of standardized training on the procedure hence the methodological incongruence. Inadequate infrastructure, knowledge and negative perception towards the procedure seemed to interfere with uptake of ECT as an intervention. Recommendations: The study makes the following recommendations: adoption of a guideline by psychiatrists, intense training on ECT, specialized training for nurses in ECT and dose calculation for psychiatrists and registrars. Funding should be made available for new ECT machines. Lastly, education and awareness creation should be done about ECT to help deal with negative perception towards the intervention.

From cells to sensations: A window to the physics of mind

Principles of methods for studying particles and fields that cannot be sensed by third-person observers by routine methods can be used to understand the physics of first-person properties of mind. Accordingly, whenever a system exhibits disparate features at multiple levels, unique combination of constraints offered by them direct us towards a solution that will be the first principle of that system. Using this method, it was possible to arrive at a third-person observable solution-point of brain-mind interface. Examination of this location identified a set of unique features that can allow an associatively learned (cue) stimulus to spark hallucinations that form units of first-person internal (inner) sensations reminiscent of stimuli from the associatively learned second item in timescales of milliseconds. It allows us to peep into a virtual space of mind where different modifications and integrations of units of internal sensations generate their different net conformations ranging from perception to an inner sense of hidden relationships that form a hypothesis. Since sparking of inner sensations of the late arriving (when far away) or non-arriving (when hidden) features of items started providing survival advantage, the focus of evolution might have been to optimize this property. Hence, the circuity that generates it can be considered as the primary circuitry of the system. The solution provides several testable predictions. By taking readers through the process of deriving the solution and by explaining how it interconnects disparate findings, it is hoped that the factors determining the physics of mind will become evident.

Clinical effectiveness and speed of response of electroconvulsive therapy in treatment-resistant schizophrenia

AIM

Although electroconvulsive therapy (ECT) has been shown to be efficacious for patients with treatment-resistant schizophrenia, there has been limited evidence on the rate of response, cognition, and quality-of-life outcomes. The primary aims of the present study were thus to examine the effectiveness and speed of response to ECT in a naturalistic retrospective cohort in patients with treatment-resistant schizophrenia.

METHODS

We performed a retrospective database analysis. The primary effectiveness outcome was defined as an improvement of ≥40% from pretreatment scores based on the Brief Psychiatric Rating Scale (BPRS) Psychotic Symptom subscale. Data were included for analysis for all patients with a primary DSM-5 diagnosis of schizophrenia that was treatment-resistant and who had had an acute course of ECT initiated for the treatment of schizophrenia between 1 July 2016 and 1 December 2016.

RESULTS

A total of 50 inpatients were included for analysis. The present study revealed that 50% of patients showed at least a 40% reduction in BPRS Psychotic Symptom subscale scores after completion of ECT and that 16.7% of patients responded after the first three sessions, 39.3% after six sessions, 46.4% after nine sessions, and 50% after 12 sessions. The greatest improvement in BPRS scores was between the third and sixth ECT sessions. BPRS scores, Clinical Global Impression, Montreal Cognitive Assessment, and Global Assessment of Functioning showed significant improvement. There was no significant difference in quality-of-life outcomes.

CONCLUSION

Utilizing modern techniques in treatment-resistant schizophrenia, this study demonstrates the real-world effectiveness and rate of response of patients receiving ECT.

[Electroconvulsive therapy in treatment of resistant schizophrenia: biological markers of efficacy and safety]

AIM

To evaluate clinical and biological efficacy and safety of electroconvulsive therapy (ECT) in patients with treatment-resistant paranoid schizophrenia.

MATERIAL AND METHODS

Determination of CNS specific biological markers (BDNF, NSE, S100B), together with markers of inflammation and CNS alteration (IL-2, CPK, CPK-MB), and clinical evaluation were performed in two groups of patients: the ECT + antipsychotic treatment group (n=66) and the antipsychotic treatment group (n=32).

RESULTS AND CONCLUSION

In the ECT + antipsychotic treatment group, the more pronounced reduction of psychotic symptoms has been revealed compared with subjects on antipsychotic treatment as monotherapy. Patients receiving ECT showed no increase in plasma levels of inflammation and CNS alteration biomarkers (NSE, S100B, CPK, CPK-MB, IL-2). The plasma level of BDNF, capable to characterize both the efficacy and safety of antipsychotic therapy, had a more pronounced upward trend in subjects with combined electroconvulsive and antipsychotic treatment, which may indicate good tolerability and high effectiveness of ECT.

Cognitive effects of non-surgical brain stimulation for major depressive disorder: protocol for a systematic review and meta-analysis

INTRODUCTION

Non-surgical brain stimulation techniques may be considered as alternative or add-on treatments for patients with major depressive disorder who failed to respond to pharmacological interventions. Electroconvulsive therapy has been shown to be highly effective in reducing depressive symptoms but stakeholders remain concerned about adverse cognitive effects. Repetitive transcranial magnetic stimulation and transcranial direct current stimulation may be associated with more benign adverse effect profiles and may indeed improve certain cognitive functions such as memory and attention. To guide clinical decision-making, we will carry out a systematic review and meta-analysis of the cognitive effects of eight non-surgical brain stimulation techniques.

METHODS AND ANALYSIS

A systematic literature search of the Embase, PubMed/MEDLINE and PsycINFO databases, the Cochrane Central Register of Controlled Trials, ClinicalTrials.gov and OpenGrey will be performed. We will include both randomised clinical trials which report on at least one cognitive measure post treatment as well as non-randomised trials and pre-post intervention studies. There are no restrictions to the type of cognitive outcome measures, except that the tests are standardised and psychometrically validated. The Revised Cochrane tool for assessing risk of bias in randomised trials (RoB 2.0) will be used to evaluate included trials. Pre-post studies will be evaluated using the quality assessment tool developed by the US National Heart, Lung and Blood Institute. Meta-analysis, meta-regression, subgroup and sensitivity analyses will be conducted where sufficient data are available.

ETHICS AND DISSEMINATION

No ethical approval is needed to conduct this work. The findings will be submitted for publication in peer-reviewed journals and presented at scientific meetings.

PROSPERO REGISTRATION NUMBER

CRD42018118850.

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.

Immediate and long-term effects of bilateral electroconvulsive therapy on cognitive functioning in patients with a depressive disorder

BACKGROUND

Electroconvulsive therapy (ECT) is the most effective treatment for patients suffering from major depression. However, its use is limited due to concerns about negative effects on cognition. Unilateral ECT is associated with transient cognitive side-effects, while case-controlled studies investigating the effect of bilateral ECT on cognition remain scarce. We investigate the effects of bilateral ECT on cognition in depression in a longitudinal case-controlled study. We hypothesize that adverse cognitive effects of bilateral ECT are transient rather than long-term.

METHODS

A total of 48 depressed patients and 19 controls were included in the study and assessed with a battery of cognitive tests, including tests of: working memory, verbal fluency, visuospatial abilities, verbal/visual memory and learning, processing speed, inhibition, attention and task-switching, and premorbid IQ. Patients underwent three cognitive assessments: at baseline (n = 43), after ten ECT sessions (post-treatment; n = 39) and six months after the tenth ECT session (follow-up; n = 25). Healthy controls underwent the same cognitive assessment at baseline and after five-weeks.

RESULTS

Within the patient group, transient adverse cognitive side-effects were observed for verbal memory and learning, and verbal fluency. None of the cognitive domains tested in this study showed persisting impairments.

LIMITATIONS

A relatively high attrition rate is observed and autobiographical memory was not assessed.

CONCLUSION

This study shows that bilateral ECT has negative cognitive effects on short-term. These effects could be explained by a decrease in cognitive performance, a lack of learning effects or a combination. However, the decrease in cognitive functioning appears to recover after six months.

Electroconvulsive Therapy in the Czech Republic

OBJECTIVES

Electroconvulsive therapy (ECT) is effective in the treatment of severe psychiatric disorders. Electroconvulsive therapy is applied to almost 1 million patients every year around the world. The aim of this study was to monitor the use of ECT in psychiatric facilities for adults in the Czech Republic (CR) in 2014 and to describe the national practice.

METHODS

A 14-item questionnaire was sent to all Czech inpatient psychiatric facilities that provide ECT, with the aim of getting a detailed picture of the use of ECT in the CR. The questionnaire assessed the technical background for using ECT in each center, along with indications for the treatment, the procedure, and the manner of documenting and monitoring adverse effects. The data obtained were supplemented with information about national legal and ethical regulations as well as historical background.

RESULTS

Electroconvulsive therapy is used in 26 centers across the CR. More than 1000 patients were treated with ECT in 2014. All centers use instruments delivering brief pulse stimuli, monitoring electroencephalogram and electrocardiogram. All patients have to be indicated for this treatment, which is a decision the patient's psychiatrist makes. All patients have to sign an informed consent form, excluding a situation where the patient's life is endangered. Somatic state is assessed in all patients. Bitemporal electrode placement is the preferred option in all centers.

CONCLUSIONS

This article covers detailed information about the use of ECT in the CR. The results will be used to harmonize national practice and reduce the stigma associated with this method in the CR.

When Can We Predict the Outcome of an Electroconvulsive Therapy Course in Adolescents?: A Retrospective Study

OBJECTIVE

There is a dearth of up-to-date literature regarding electroconvulsive therapy (ECT) in adolescents, and the question of when to pronounce course failure has not been properly addressed. The current study aims to evaluate trajectories of clinical status throughout ECT courses in adolescent patients.

METHODS

We retrieved detailed data of 36 patients who received ECT in our treatment center. Clinical records were retrospectively assessed and evaluated every 6 ECT sessions to quantify Clinical Global Impressions-Improvement (CGI-I) scores.

RESULTS

The mean number of sessions per course was 24.4 ± 14.2. The mean CGI-I score at the conclusion of the ECT courses was 2.47 ± 1.19. At the end of the acute treatment stage, 26 patients (72.2%) were much or very much improved, based on CGI-I scores. Only 5 patients exhibited a significant response after 6 sessions or fewer, whereas 21 patients (56.6%) improved after 12 sessions. Pearson correlations between CGI-I scores throughout the course of ECT showed no significant correlation between CGI-I scores after 6 sessions and the final CGI-I scores. However, a significant correlation was found between CGI-I scores after 12 sessions and the final CGI-I score.

CONCLUSIONS

An improvement in the clinical status of adolescents treated by ECT might occur only after a substantial number of sessions. An early lack of response does not necessarily predict a failed ECT course.

The perspectives of former recipients and experts on stigmatization related to electroconvulsive therapy in Denmark: A focus group study

WHAT IS KNOWN ON THE SUBJECT?: Electroconvulsive therapy (ECT) has existed worldwide for nearly 80 years. ECT is a fast-working and potentially life-saving treatment, but it is considered controversial. Although frequently mentioned, stigmatization in relation to ECT has not been systematically explored so far. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: This paper provides new insight into both recipient and expert perspectives on ECT. It identifies several issues of stigmatization related to ECT and suggests that full recovery following ECT might be jeopardized due to both stigmatization and self-stigmatization. The study suggests that most of the stigmatizing behaviors can be ascribed to (a lack of) available knowledge of and experience with ECT. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Being aware of and listening to the needs of former ECT-recipients seems essential to increase their treatment options and support care as well as a will to prioritize this patient group. For example, by addressing the potential stigma issues in follow-up groups and helping to distribute sober, factual information about ECT in society. Providing written information and psychoeducation for patients and relatives before, during, and after ECT, in addition to supporting active use of diaries, might be valuable remedies for helping patients feel adequately informed and able to accept the pros and cons of ECT during and after treatment period. ABSTRACT: Introduction Electroconvulsive therapy (ECT) has existed worldwide for nearly 80 years. Although fast-working and potentially life-saving treatment, ECT is regarded as a strongly controversial treatment and stigmatization is frequently mentioned in relation to it. However, no systematic research in this area has taken place so far. Aim The aim of this qualitative study was to explore the experiences and attitudes of former recipients of ECT and of experts professionally involved with ECT to identify potential stigmatization. Method Two focus groups, one comprising four recipients of ECT and the other seven professional experts, were conducted. Data from each focus group were analyzed separately using a framework-analysis. Results The analysis yielded three major themes for the first focus group interview: ambivalent attitudes, discrediting and exclusion, and survival strategies and three major themes for the second focus group interview: dramatic depictions of ECT, an overlooked and rare treatment, and anti-stigmatization strategies. Discussion and implications for practice Stigmatizing attitudes and behaviors in relation to ECT are closely related to one's personal and factual knowledge, and there is a great need for multi-facetted approaches if social acceptance and recognition are to be achieved. This study provides new knowledge on a scarcely examined area while also introducing suitable methods for anti-stigmatization and empowerment.