Electroconvulsive therapy: Part II: a biopsychosocial perspective

Unmasking patient diversity: Exploring cognitive and antidepressive effects of electroconvulsive therapy

BACKGROUND

Electroconvulsive therapy (ECT) is an established treatment for depression, but more data on effectiveness and safety in clinical practice is needed. The aim of this register-based study was to investigate short-term effectiveness and cognitive safety after ECT, evaluated by clinicians and patients. Secondary, we investigated predictors for remission and cognitive decline.

METHODS

The study included 392 patients from the Regional Register for Neurostimulation Treatment in Western Norway. Depressive symptoms and cognitive function were assessed with Montgomery-Åsberg Depression Rating Scale and Mini-Mental State Examination (clinician-rated) and Beck Depression Inventory and Everyday Memory Questionnaire (patient-rated). Assessments were done prior to ECT-series and a mean of 1.7 days after (range 6 days before and 12 days after) end of ECT-series. Paired samples t-tests were extended by detailed, clinically relevant subgroups. Predictors were examined using logistic regression.

RESULTS

Clinician- and patient-rated remission rates were 49.5 and 41.0%, respectively. There was a large reduction in depressive symptoms and a small improvement in cognition after ECT, but we also identified subgroups with non-response of ECT in combination with cognitive decline (4.6% clinician-rated, 15.7% patient-rated). Positive predictors for patient- and clinician-rated remission were increasing age, shorter duration of depressive episode, and psychotic features. Antipsychotic medication at the commencement of treatment and previous ECT-treatment gave higher odds of clinician-rated remission, whereas higher pretreatment subjective depression level was associated with lower odds for patient-rated remission. Clinician-rated cognitive decline was predicted by higher pretreatment MMSE scores, whereas psychotic features, increasing age, and greater pretreatment subjective memory concerns were associated with lower odds for patient-rated cognitive decline.

CONCLUSIONS

Our study supports ECT as an effective and safe treatment, although subgroups have a less favorable outcome. ECT should be considered at an early stage for older patients suffering from depression with psychotic features. Providing comprehensive and balanced information from clinicians and patients perspectives on effects and side effects, may assist in a joint consent process.

High-Frequency Repetitive Transcranial Magnetic Stimulation (rTMS) in the First Episode of Catatonia: A Series of Four Cases

Four patients with benzodiazepine non-responsive catatonia were administered repetitive transcranial magnetic stimulation (rTMS) at the left dorsolateral prefrontal cortex at 120% of resting motor threshold, frequency of 10Hz, with a total of 3,000 pulses/session. Patients with mood disorders showed good responses. One patient with chronic resistant schizophrenia had worsening catatonic symptoms during rTMS that responded to electroconvulsive therapy. Maximum response was observed between sessions 8 and 12.

Electroconvulsive Therapy: Mechanisms of Action, Clinical Considerations, and Future Directions

LEARNING OBJECTIVES

• Outline and discuss the fundamental physiologic, cellular, and molecular mechanisms of ECT to devise strategies to optimize therapeutic outcomes• Summarize the overview of ECT, its efficacy in treating depression, the known effects on cognition, evidence of mechanisms, and future directions.

ABSTRACT

Electroconvulsive therapy (ECT) is the most effective treatment for a variety of psychiatric illnesses, including treatment-resistant depression, bipolar depression, mania, catatonia, and clozapine-resistant schizophrenia. ECT is a medical and psychiatric procedure whereby electrical current is delivered to the brain under general anesthesia to induce a generalized seizure. ECT has evolved a great deal since the 1930s. Though it has been optimized for safety and to reduce adverse effects on cognition, issues persist. There is a need to understand fundamental physiologic, cellular, and molecular mechanisms of ECT to devise strategies to optimize therapeutic outcomes. Clinical trials that set out to adjust parameters, electrode placement, adjunctive medications, and patient selection are critical steps towards the goal of improving outcomes with ECT. This narrative review provides an overview of ECT, its efficacy in treating depression, its known effects on cognition, evidence of its mechanisms, and future directions.

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.

ECT-related anxiety during maintenance ECT: A prospective study

OBJECTIVE

Despite the established safety of electroconvulsive therapy (ECT), ECT-related anxiety (ERA) remains one of the most distressing complications of ECT. ERA is reported to diminish during an acute course of ECT, but it was never studied during maintenance ECT (M-ECT). Our aim was to study the trajectories of ERA during M-ECT and how they differ from trajectories during the acute course.

METHODS

Thirty-nine patients with unipolar or bipolar depression, retained for M-ECT after an acute ECT course, were included. ERA was assessed the morning before each ECT session using the ECT-related Anxiety Questionnaire (ERAQ).

RESULTS

ERA remained stable during M-ECT (RC = -0.05 (SE = 0.06), t(8.35) = -0.86, p = 0.42), while ERA declined significantly during the acute course (RC = -0.85 (SE = 0.30), t(33.6) = -2.81, p = 0.0082). During the acute course, patients with a psychotic depression were more anxious at baseline (t(32)= -2.42, p = 0.02), and showed a significant decline in ERAQ scores (RC = -1.65 (SE = 0.46), t(31.6) = -3.56, p = 0.0012), whereas patients with a non-psychotic depression were less anxious at baseline and retained stable ERAQ scores during the acute course (RC = -0.06 (SE = 0.41), t(32.1) = -0.14, p = 0.89). Whereas a correlation (r = 0.48) was noticed between the decline of depression severity and ERA during the acute course, this was not the case during M-ECT.

CONCLUSION

ERA runs a stable course during M-ECT, after having decreased during the acute course. During the acute course, ERA trajectories differed significantly between patients with a psychotic and non-psychotic depression. Decline of depression severity and ERA are significantly connected during the acute course of ECT. Both depression severity and ERA remain stable during M-ECT.

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

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

Assessing and improving public mental health literacy concerning rTMS

BACKGROUND

Repetitive transcranial magnetic stimulation (rTMS) has received empirical support as a viable treatment alternative for treatment-resistant major depressive disorder. Nevertheless, patients and the public-at-large may be hesitant to adopt rTMS. In three studies, we sought to (1) assess and (2) improve public perceptions of rTMS as a treatment for depression.

METHODS

In Study 1 (N = 107), we administered questionnaires on Amazon's Mechanical Turk (MTurk) to individuals from the US and Canada in a cross-sectional design to assess perceptions of rTMS compared to psychopharmacology, electroconvulsive therapy (ECT), and talk therapy. In Study 2 (N = 106), we again used an MTurk sample and a cross-sectional design to assess perceptions of rTMS after providing participants with a relatively long description of rTMS. In Study 3 (N = 308), we conducted an experiment in undergraduate students. Participants were randomized to one of four experimental conditions manipulating participants' understanding of the causal mechanisms of depression prior to assessing their perceptions of rTMS.

RESULTS

Public perceptions of rTMS were more negative than pharmacotherapy and talk therapy but not ECT (Study 1). rTMS perceptions were notably better when participants were given thorough information about rTMS procedures, pain, and side-effects (Study 2), compared to the previous study when they were given a very brief description of rTMS. Finally, perceptions of rTMS were significantly better when participants were given a brain circuitry-based causal explanation of depression compared to when they were given a psychological explanation of the causes of depression (Study 3).

CONCLUSIONS

Public perceptions of rTMS are relatively poor. To improve rTMS acceptability, practitioners should carefully consider patients' prior attitudes and beliefs when explaining rTMS as a treatment alternative. Given that beliefs can have powerful effects on treatment outcome (e.g., placebo, nocebo), future research should explore whether rTMS effects on depression can be improved by facilitating less negative perceptions of rTMS.

The Nomenclature of Electroconvulsive Therapy

ABSTRACT

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

Mental Health Nurse experiences of delivering care to severely depressed adults receiving electroconvulsive therapy

WHAT IS KNOWN ON THE SUBJECT?: ECT is a fast-working and potentially life-saving treatment, but it is still considered a controversial treatment choice. Due to lack of knowledge and public stigma, ECT can be an anxiety-inducing treatment for people experiencing severe depression. The nurse's role is to alleviate this anxiety, aid recovery and minimize the risk of relapse. They manage this onerous task ideally through the therapeutic relationship, and use the skills of assessment and risk identification in order to maximize patient outcomes. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: The views of mental health nurses who provide care for adults receiving treatment of ECT for severe depressive illness are in the main positive. The knowledge of and attitude towards ECT among nurses may reflect on patients and influence treatment choice. If stigma is not addressed, then patients will not be appropriately informed regarding their treatment options. Mental health nurses need to engage in reflective practice to ensure that the dignity of the patient is maintained throughout this treatment. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Mental Health nurses should engage with additional training, formalized clinical supervision and avail of peer support in order to improve confidence, skills and quality of care in the delivery of ECT. Education modules should include a presentation of evidence of effectiveness of ECT as a treatment option. Dialogue among mental healthcare colleagues is important about caring for people presenting for ECT treatment. This will ensure that the mental health nurse can remain cognizant of the potential for patient distress throughout this treatment. ABSTRACT: Background There is a considerable dearth of literature on attitudes towards Electroconvulsive Therapy (ECT) as a treatment for severe depression. Despite being a highly effective treatment, it is still stigmatized even among professionals. Understanding perceptions and knowledge related to ECT treatment among healthcare providers is important for ensuring that treatment can be safely explored as a treatment option with patients. Aim The overall aim of this study is to explore the views of mental health nurses who provide nursing care to people receiving ECT for severe depressive illness in a mental health setting. Methods This is a qualitative study using focus groups (n = 2) with 14 mental health nurses who had a minimum of 3 months experience caring for older adults receiving ECT. Transcripts were subjected to a thematic analysis. Full ethical approval was granted for this study. Results In total, four themes were identified exploring attitudinal changes, managing patient dignity, reflecting changes in practice and managing the unknown. In general, participants experienced ECT as a positive treatment option for adults with severe depressive illness contributing to an enhanced quality of life. Conclusion Findings indicate a desire to improve person-centred care for patients undergoing ECT. Educational support for nurses who work in this area would improve confidence on work practices and lead to improved patient experience. Mental health personnel without direct experience of the treatment should be exposed to educational modules to decrease stigma and to best facilitate informed decision-making among the patient cohort.

Achieving Equity in Informed Consent: A Culturally-Informed Perspective for the Consideration and Consent of Minority Patients for Electroconvulsive Therapy

Electroconvulsive therapy (ECT) is highly efficacious to treat severe depression in older adults. Yet, patients of ethnic and racial minorities are consistently underrepresented amongst those who receive ECT across all age groups. One strong hypothesis to explain this disparity is that minority patients are less likely to trust medical professionals and are therefore less likely to consent for ECT. Increasing participation of depressed, elderly, minority patients is uniquely challenging. Senior minority individuals have survived decades of medical and social injustices that no other demographic, specifically younger minorities or clinically-matched Caucasian peers, can truly comprehend from a first-hand perspective. This article provides a perspective based in cultural translational science to conversations of informed consent for ECT that removes our self-imposed stigma against discussing past and ongoing injustices with minority patients. Reducing disparities to geriatric minorities through equity of informed consent means that clinicians must validate the unique minority experience in medicine as it pertains to agreeing to a treatment modality as emotionally, socially, and historically laden as ECT.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Understanding electroconvulsive therapy-related anxiety: a prospective study

AIMS OF STUDY

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

METHODS

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

RESULTS

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

CONCLUSION

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

A Randomized Controlled Trial of Video Psychoeducation for Electroconvulsive Therapy in the United States

OBJECTIVE

Electroconvulsive therapy (ECT) is a highly effective psychiatric treatment that remains largely underutilized. Patient psychoeducation about ECT may improve uptake of this treatment.

METHODS

This randomized controlled trial compared two forms of psychoeducation about ECT: video psychoeducation and an informational brochure. In 2019, a national sample of 556 U.S. adults who screened positive for depression were recruited and randomly assigned to receive one of these educational interventions online. Participant perceptions, knowledge, and willingness to receive ECT were assessed before and after psychoeducation.

RESULTS

Both the video psychoeducation and brochure groups showed significantly more positive perceptions and knowledge about ECT following the intervention, with no significant differences between groups. The proportion of participants who reported being willing to receive ECT increased significantly after receipt of psychoeducation (from 31% to 63% in the video psychoeducation group and from 29% to 56% in the brochure group). Female gender, severity of depression, and comorbid mental and substance use disorders were associated with positive changes in ECT perceptions and increased willingness to receive ECT.

CONCLUSIONS

These findings suggest brief psychoeducation for ECT is needed and may improve acceptance of this robust treatment.

Antidepressant efficacy and side effect burden: an updated guide for clinicians

Antidepressant treatment has been evolving and changing since the 1950s following the discovery of the classic antidepressant treatments including tricyclic antidepressants and monoamine oxidase inhibitors. The heterogeneity of the disorder became apparent in the beginning when individuals remained symptomatic despite medication compliance. This spurred further research in order to understand the neurobiology underlying the disorder. Subsequently, newer medications were designed to target specific neurotransmitters and areas of the brain involved in symptom development and maintenance. Our original review article looked at both classic and modern antidepressant medications used in the treatment of major depressive disorder. This manuscript is an update to the original review and serves to provide clinicians with information about novel antidepressant medications, augmentation strategies with atypical antipsychotics, over-the-counter medications, as well as nonpharmaceutical treatments that should be considered when treating each individual patient who remains symptomatic despite treatment efforts.

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.

Electroconvulsive Therapy for Patients with Catatonia: Current Perspectives

Catatonia is a serious, common syndrome of motoric and behavioral dysfunction, which carries high morbidity and mortality. Electroconvulsive therapy (ECT) is the definitive treatment for catatonia, but access to ECT for the treatment of catatonia remains inappropriately limited. Catatonia is observable, detectable, and relevant to various medical specialties, but underdiagnosis impedes the delivery of appropriate treatment and heightens risk of serious complications including iatrogenesis. Current understanding of catatonia's pathophysiology links it to the current understanding of ECT's mechanism of action. Definitive catatonia care requires recognition of the syndrome, workup to identify and treat the underlying cause, and effective management including appropriate referral for ECT. Even when all of these conditions are met, and despite well-established data on the safety and efficacy of ECT, stigma surrounding ECT and legal restrictions for its use in catatonia are additional critical barriers. Addressing the underdiagnosis of catatonia and barriers to its treatment with ECT is vital to improving outcomes for patients. While no standardized protocols for treatment of catatonia with ECT exist, a large body of research guides evidence-based care and reveals where additional research is warranted. The authors conducted a review of the literature on ECT as a treatment for catatonia. Based on the review, the authors offer strategies and future directions for improving access to ECT for patients with catatonia, and propose an algorithm for the treatment of catatonia with ECT.

Suicide Prevention Strategies for General Hospital and Psychiatric Inpatients: A Narrative Review

BACKGROUND

In-patient (IP) suicides contribute a small but significant proportion of overall suicides. Despite this, suicide prevention strategies focusing on the general hospital IP population remain relatively underresearched. This paper is intended to provide an overview of various proposed suicide prevention approaches in the general hospital, including psychiatric IP, settings, and their evidence base.

METHODOLOGY

Electronic searches of MEDLINE through PubMed, ScienceDirect, and Google Scholar databases were performed to identify potentially relevant articles from inception till January 2019. The generated abstracts were systematically screened for their eligibility to be included in the review. Included articles were grouped under five broad themes: environmental modification, staff education, pharmacotherapy, psychotherapy, and brain stimulation. Data extraction was done using a structured proforma.

RESULTS

Environmental modifications and educating the health care professionals appear to be the most promising strategies to reduce suicide-related mortality among IPs. Among pharmacological methods, ketamine has shown initial promise in reducing suicidal ideations. Follow-up data are lacking for most of the described methods. Limited but positive evidence exists for cognitive therapies focusing on the immediate postadmission period and brain stimulation techniques, and it warrants further replication.

CONCLUSION

There is a striking paucity of original research on IP suicide prevention. Given the ethical and methodological issues in carrying out studies with IP suicide as the primary outcome, there is a need to focus on intermediate suicide outcome measures, such as knowledge, attitude, and skills among staff handlers of suicidal patients.

Electroconvulsive practice in Singapore: a cross-sectional national survey

INTRODUCTION

The use of electroconvulsive therapy (ECT) in Singapore dates back to 1947. However, there is little local information on the clinical practice of ECT and its standards. We aimed to conduct a comprehensive national survey of ECT practice in Singapore.

METHODS

A cross-sectional structured questionnaire assessing the types of ECT (e.g. electrode placement, stimulus parameters), indications, anaesthetic technique, dosing methods, monitoring of outcomes and credentialing was sent in 2015 to all ECT centres in Singapore via email to collect qualitative and quantitative data regarding ECT.

RESULTS

Data was obtained from all ECT centres (n = 6), which represented that ECT was available in 23.1% of all hospitals and 50.0% of all psychiatric specialist centres. The rate of ECT was 5.89 treatments per 10,000 residents per year, and each patient received an average of 5.4 ECT per course. Only 7.0% of ECT was administered for continuation/maintenance ECT. The most common indication for ECT was depression in 5 (83.3%) out of six centres, with schizophrenia being the second most common. In 5 (83.3%) out of six centres, ECT was brief (0.5 ms) bitemporal ECT with age-based dosing, and 93.0% of the sessions were conducted in an inpatient setting. All ECT was conducted under general anaesthesia, with propofol (66.7%) being the most common type of anaesthetic used.

CONCLUSION

The practice of ECT in Singapore was highly uniform. The rates and indications for ECT were consistent with those of other developed countries, with greater use of ECT for schizophrenia. Future advances for ECT in Singapore include the use of individualised dosing based on empirical seizure threshold titration, expanded electrode placements and increased utilisation of continuation/maintenance ECT.

Family Presence During Electroconvulsive Therapy

BACKGROUND

The practice of electroconvulsive therapy (ECT) is often hampered by stigma and myths prevailing among patients and families. Family attendance at ECT has not been systematically studied.

METHODS

From January 2017 to May 2018, 69 consecutive patients were approached for family attendance at ECT. The inclusion criteria for entry to the ECT suite were consent from families and patients, age older than 18 years, and 1 family member at a time. After watching ECT, family members completed a multiple-choice questionnaire regarding their experience.

RESULTS

Twenty-one family members watched ECT. A majority viewed the idea of attendance at ECT as reassuring, and a few indicated that it was anxiety provoking. Five participants (24%) felt distressed while watching the procedure, whereas 16 family members rated their experience as comfortable or rewarding (76%). In terms of the outcome, a clear majority have responded that watching the procedure alleviated their fears of ECT or provided transformative knowledge, whereas others felt no change in their attitude toward ECT (71% vs 29%). Most of the participants recommended watching ECT to other family members, whereas a minority was uncertain about their opinion (62% vs 38%). There were no adverse effects, premature exit from the ECT suite, interferences with treatment, or litigations.

CONCLUSIONS

A clear majority of families viewed their attendance at ECT as a beneficial experience. Family presence during ECT may have the potential to promulgate its practice by reducing stigma and misconceptions.

Racial/Ethnic Disparities in Receipt of Electroconvulsive Therapy for Elderly Patients With a Principal Diagnosis of Depression in Inpatient Settings

OBJECTIVE

Electroconvulsive therapy (ECT) is underused despite being among the most effective treatments for older adults with severe, pharmacotherapy-resistant mood disorders. Furthermore, those in minority groups are even less likely to receive ECT. The objective of this study was to examine racial and ethnic disparities in the receipt of ECT in older adults.

METHODS

We used survey-weighted log-binomial regression to generate adjusted prevalence ratios (aPRs) and 95% confidence intervals (CIs) that represented the associations between race/ethnicity and receipt of ECT during hospitalization at an ECT-available hospital. We used data from the 2002-2015 National Inpatient Sample, the largest all-payer inpatient database in the United States. The analysis was restricted to hospitalizations of adults aged 65-95 with depression as a principal diagnostic code. The primary exposure was patient race/ethnicity, and the primary outcome was receipt of ECT during hospitalization, restricted to ECT-available hospitals.

RESULTS

Among the 685,939 patients included in the analysis, 45% received care at an ECT-available hospital, and among those, 17% received ECT. Non-Hispanic (NH) blacks were nearly half as likely to receive ECT as NH whites (aPR: 0.56 [0.47-0.81]; t: -6.42; df: 1,327; p < 0.001). Hispanics were nearly half as likely to receive ECT as NH whites (aPR: 0.57 [0.44-0.72]; t: -4.59; df: 1,327; p < 0.001).

CONCLUSION

This national cross-sectional study of racial/ethnic disparities in receipt of ECT among depressed elderly patients confirms prior literature and reveals the potential worsening of disparities for racial/ethnic minorities blacks.

Clinical Predictors of Response to Magnetic Seizure Therapy in Depression: A Preliminary Report

OBJECTIVES

Magnetic seizure therapy (MST) is a novel convulsive brain stimulation method in clinical testing, which is used as an alternative for electroconvulsive therapy in patients with treatment-resistant depression (TRD). Preliminary studies have suggested that MST leads to fewer cognitive adverse effects than electroconvulsive therapy but has similar efficacy. However, the clinical predictors of response to MST have not been evaluated yet. This study aimed to investigate whether these predictors can be identified in patients with TRD.

METHODS

Thirty-eight patients with TRD were included. As clinical predictors for treatment response, we used the diagnosis, sex, age, family history, and severity of depression, as well as the melancholic, psychotic, anxiety, and atypical depression symptoms. A response was defined as an improvement higher than 50% on the 28-item Hamilton Rating Scale for Depression. The binary logistic regression, stepwise linear regression, and effect sizes were calculated.

RESULTS

We found that 68.4% of the patients responded to MST. The responders had significantly fewer previous depressive episodes, less severe depression, and fewer melancholic (anhedonia) and anxiety symptoms than the nonresponders. In addition, responders were more likely to have a positive family history of depression than nonresponders. In particular, the number of previous episodes and a family history of depression were significant predictors of the response to MST.

CONCLUSIONS

We demonstrate that the chronicity, severity, and family history of depression, as well as the presence of melancholic and anxiety symptoms, can serve as clinical predictors of the response to MST. Further research with a larger sample size will be required to verify these preliminary findings.

Therapeutic Uses of Seizures in Neuropsychiatry

Although seizures typically indicate a state of brain dysfunction, there are circumstances in which the biological effects of a seizure may exert therapeutic benefits. The standard technique for inducing controlled therapeutic seizures in humans is electroconvulsive therapy (ECT), a treatment that involves the application of an electrical stimulus to the scalp of a patient under general anesthesia and muscle relaxation. This review discusses the contemporary use of ECT for treating certain mental and neurologic disorders and previews two experimental forms of seizure therapy that are related to ECT and may hold promise for the future: focal electrically administered seizure therapy and magnetic seizure therapy.

Electroconvulsive Therapy as a Safe, Effective Treatment for Catatonia in an Adolescent with a Nasogastric Tube: A Case Report

This case provides support for electroconvulsive therapy as a safe treatment in adolescents with a feeding tube. The patient presented to our hospital with symptoms of catatonia with minimal oral intake. She had stopped eating, had minimal interaction with her environment, and spent weeks with a nasogastric tube for nutritional support. She had been referred for electroconvulsive therapy but was unable to find a local provider who would perform it on an adolescent with a nasogastric tube. She came to our hospital and received 9 rounds of electroconvulsive therapy with improvement of her catatonia and no aspiration or adverse events.

The Effect of Counseling on Stigma in Psychiatric Patients Receiving Electroconvulsive Therapy: A Clinical Trial Study

PURPOSE

Despite its efficacy and safety, electroconvulsive therapy (ECT) is underutilized, in part, due to the stigma associated with the treatment. This study aimed to evaluate the effect of counseling on stigma in patients with psychiatric disorders receiving ECT.

PATIENTS AND METHODS

A total of 114 patients with psychiatric disorders undergoing ECT were randomly divided into two groups. Both the groups received routine care and treatment, but the intervention group (n=57) received four counseling sessions. At the beginning and end of the study (6 weeks, post-treatment), patients completed the Internalized Stigma of Mental Illness scale. The data were analyzed using independent and paired sample t-tests.

RESULTS

There was no significant difference in the mean stigma scores of participants in the control and intervention groups before counseling (P>0.08). However, post-intervention, there was a significant difference in the mean stigma scores between both the groups (P<0.001).

CONCLUSION

The findings demonstrate that the counseling intervention is effective in decreasing stigma in patients undergoing ECT. Therefore, it is recommended to use this therapeutic method in such patients.

[Effectiveness and tolerability of electroconvulsive therapy : Influence of clinical response from the patient's point of view]

BACKGROUND

Electroconvulsive therapy (ECT) is a highly effective, yet still controversial therapy for both the general public and psychiatrists. In this study, we investigated the patients’ view regarding effectiveness and tolerability of electroconvulsive therapy under consideration of individual clinical response.

MATERIAL AND METHODS

In 31 patients with major depression, subjective effectiveness and tolerability were assessed via a differentiated questionnaire prior to, during, and after ECT. Symptoms were rated using the Montgomery-Åsberg depression rating scale (MADRS) and the Beck depression inventory II (BDI-II).

RESULTS

Patients assessed ECT to be generally effective both before and after the treatment. This view was independent of their individual treatment success. In contrast, patients’ rating of individual effectiveness depended on the objective improvement of their symptoms. Side effects were rated to be generally slight to moderate.

CONCLUSION

Against the background of persisting criticism towards ECT, the viewpoint of involved patients provides us with important references for an appropriate judgement of this therapy. The results suggest a good benefit-risk ratio for ECT from the patients’ perspective.

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.

Ketamine Use for Suicidal Ideation in the General Hospital: Case Report and Short Review

Low-dose infusion of ketamine may have rapid antisuicide properties. Such a treatment may therefore be useful in the general hospital to prevent suicide in an environment that cannot be made safe enough. We report on the use of ketamine as an efficient, well-tolerated treatment for persistent suicidal ideation in a patient hospitalized in a general hospital after a severe suicide attempt. Based on data in the literature, we suggest that the benefit-risk ratio for ketamine use in such a context is highly favorable.

Electroconvulsive Therapy: The Impact of a Brief Educational Intervention on Public Knowledge and Attitudes

The safety and efficacy of electroconvulsive therapy (ECT) are well established, yet efforts to educate the public about ECT advancements are lagging. The purpose of this study was to experimentally examine the impact of a brief educational intervention on public knowledge of, and attitudes toward, ECT. Participants ( n = 91) from a private liberal arts university in the upper Midwestern region of the United States were randomly assigned to either an educational intervention or a control group. The educational intervention group read a brief informational pamphlet about ECT. Both groups completed a 24-item ECT knowledge and attitude measure. Participants who read the ECT pamphlet demonstrated significantly higher levels of ECT knowledge and reported more favorable attitudes toward ECT than did the control group. Furthermore, knowledge of ECT significantly predicted attitudes toward the treatment. Educating the public about available medical treatments not only facilitates help-seeking behavior among prospective patients and their families, but also it hallmarks the informed consent process once help is sought.

ECT-Related Anxiety: A Systematic Review

BACKGROUND

A significant proportion of electroconvulsive therapy (ECT)-treated patients experience anxiety anticipating the treatment, often to such an extent that they refuse or discontinue a much-needed treatment. Despite its great impact on treatment adherence, anxiety in patients receiving ECT is underexposed in the scientific literature.

OBJECTIVES

We aimed to review the prevalence and specific subjects of ECT-related anxiety and therapeutic interventions to reduce it.

METHODS

We performed a computerized search (EMBASE, MEDLINE, and PsycINFO) for articles meeting the following inclusion criteria: (1) qualitative (interview) studies, quantitative (questionnaire) studies, or experimental (interventional) studies that (2) report on anxiety that is related to a planned, ongoing, or past ECT treatment.

RESULTS

Of 1160 search results, 31 articles were included. Electroconvulsive therapy-related anxiety is estimated to be present in 14% to 75% of patients and is most often linked to worries about memory impairment or brain damage. Only a few interventions (chlorpromazine, meprobamate, propofol, a talking-through technique, an information leaflet, and animal-assisted therapy) have been proposed to reduce patients' ECT-related anxiety.

CONCLUSIONS

Electroconvulsive therapy-related anxiety is a highly prevalent phenomenon, and the literature provides little guidance for its clinical management. Most studies are of a low methodological quality and suffer from significant limitations, thereby hampering generalized conclusions. Given the clinical importance of ECT-related anxiety, further study on its nature and evolution through the course of treatment and on anxiety-reducing interventions is warranted.

A randomized, double-blind, placebo-controlled trial on the role of preemptive analgesia with acetaminophen [paracetamol] in reducing headache following electroconvulsive therapy [ECT]

BACKGROUND

Electroconvulsive therapy (ECT) is a safe and efficient treatment for several severe psychiatric disorders, but its use is limited by side effects. Post-ECT headache is one of the commonest side effects. Preemptive analgesia is effective in post-surgical pain management. The most commonly used analgesic is acetaminophen (paracetamol). However, acetaminophen as a preemptive analgesic for post-ECT headache has not been studied adequately. This study was conducted to compare the incidence and severity of post-ECT headache in patients who were administered acetaminophen pre-ECT with a placebo group.

METHODS

This study was a randomised, double-blind, placebo-controlled trial. Sixty-three patients received 1 g acetaminophen and 63 patients received a placebo identical to acetaminophen. The incidence and severity of headache 2 h before and after ECT were compared between placebo and acetaminophen groups. The severity was measured using a visual analog scale. Generalised linear models were used to evaluate variables associated with post ECT headache.

RESULTS

Demographic and clinical variables of placebo and acetaminophen groups were comparable except for the energy level used to induce a seizure. Higher proportion of the placebo group (71.4%) experienced post-ECT headache when compared to the acetaminophen group (p < 0.001). The median pain score for headache was 0 (Inter quartile range: 0-2) in acetaminophen group whereas the score was 2 (IQR: 0-4) in placebo group (P < 0.001). Model fitting showed that the administration of acetaminophen is associated with less post-ECT headache (odds ratio = 0.23, 95% CI: 0.11-0.48, P < 0.001).

CONCLUSION

A significant reduction was seen in both the incidence and severity of post-ECT headache with preemptive analgesia with acetaminophen.

TRIAL REGISTRATION

Ethical approval was granted by an Ethic review committee, University of Kelaniya, Sri Lanka (P/166/10/2015) and the trial was registered in the Sri Lanka Clinical Trials Registry ( SLCTR/2015/27 ).

Junior medical students' knowledge about and attitudes towards electroconvulsive therapy in a South African setting

Background

Although electroconvulsive therapy (ECT) is a safe and effective treatment modality with a long history of use in psychiatry, it remains controversial owing to misconceptions and negative attitudes among the public and medical profession. The aim of this study was to explore the state of knowledge and attitudes towards ECT among a sample of South African medical students.

Method

Prior to their theoretical psychiatry module, 131 second-year medical students responded to an anonymous online survey designed to assess the source and extent of their ECT knowledge as well as their attitude towards ECT and psychiatry in general.

Results

The Internet (46.6%) and TV and/or movies (30.5%) were the principal sources of knowledge of ECT while ‘professional publication’ was the least common (0%). The students’ attitudes towards psychiatry were generally positive and nearly one-third (29.8%) would consider specialising in the field. Overall, perception towards ECT was mixed, with many respondents approving of its use albeit only as a last resort. Notably, low ECT knowledge scores were associated with more negative attitudes towards this treatment modality and a lower perception of psychiatry as a medical speciality.

Conclusion

The findings indicate that for these students, media is the main source of ECT knowledge. While they are generally knowledgeable about ECT, they still harbour some misconceptions and negative attitudes about the treatment. Knowledge appears able to amend these attitudes, thus underlining the importance of integrating accurate information about ECT into the preclinical medical curriculum rather than leaving it to mass media to forge warped perceptions and attitudes for these future clinicians.

In-hospital mortality among electroconvulsive therapy recipients: A 17-year nationwide population-based retrospective study

BACKGROUND

Electroconvulsive therapy (ECT) remains irreplaceable in the treatment of several psychiatric conditions. However, evidence derived using data from a national database to support its safety is limited. The aim of this study was to investigate in-hospital mortality among patients with psychiatric conditions treated with and without ECT.

METHODS

Using data from the Taiwan National Health Insurance Research Database from 1997 to 2013, we identified 828,899 inpatients with psychiatric conditions, among whom 0.19% (n=1571) were treated with ECT.

RESULTS

We found that ECT recipients were more frequently women, were younger and physically healthier, lived in more urbanized areas, were treated in medical centers, and had longer hospital stays. ECT recipients had lower odds of in-hospital mortality than did those who did not receive ECT. Moreover, no factor was identified as being able to predict mortality in patients who underwent ECT. Among all patients, ECT was not associated with in-hospital mortality after controlling for potential confounders.

CONCLUSION

ECT was indicated to be safe and did not increase the odds of in-hospital mortality. However, ECT appeared to be administered only on physically healthy but psychiatrically compromised patients, a pattern that is in opposition with the scientific evidence supporting its safety. Moreover, our data suggest that ECT is still used as a treatment of last resort in the era of modern psychiatry.

The experience of electroconvulsive therapy and its impact on associated stigma: A meta-analysis

BACKGROUND

Despite its efficacy and safety, electroconvulsive therapy (ECT) is underutilized, in part due to stigma associated with the treatment.

AIMS

The aim of this study was to test the hypothesis that experiencing ECT has an impact on associated stigma, as measured by patient and family knowledge of and attitudes toward ECT.

METHODS

A comprehensive literature search was conducted using MEDLINE, EMBASE and PsycINFO. Studies with cross-sectional and/or longitudinal designs were identified. Studies were further categorized into subcategories based on participant type (patients or patient family members) and outcome domain (knowledge or attitudes). Effect size (Cohen's d) was calculated for each study and then integrated into each subcategory (participant type by outcome domain) using a random effect model.

RESULTS

Eight studies were identified as being eligible for analysis. Two studies were cross-sectional, five were longitudinal and one incorporated both designs. Analysis of the longitudinal studies indicated that experiencing ECT both increased knowledge of and improved attitudes toward ECT in patients; in family members of patients, analysis showed significant positive change in knowledge of ECT, but no significant change in attitudes toward ECT.

CONCLUSION

Experience with ECT may have a positive impact on knowledge of and attitudes toward ECT. However, the quality of evidence of included studies was low; further research is required in order to clarify the relationship and to identify information of use to individuals considering ECT as a treatment option.

An Investigation of Patient Preferences for Music Played Before Electroconvulsive Therapy

OBJECTIVE

Patients often feel anxious before electroconvulsive therapy (ECT), which can lead to avoidance of treatments. Music is a noninvasive safe option to reduce anxiety in the preoperative setting. Therefore, we examined patients' preferences of listening to music while receiving ECT by providing music-by way of headphones or speakers-to participants before treatment.

METHODS

Patients receiving ECT were recruited for this study. Patients served as their own controls in 3 separate music intervention sessions: 1) randomization to music via headphones or speakers, 2) no music, 3) the remaining music intervention. Patients completed a questionnaire related to satisfaction and preferences of music being played before ECT. Patients received a final questionnaire at the end of the study asking which intervention they preferred.

RESULTS

Thirty patients completed the study. Ninety percent enjoyed listening to music through speakers. Eighty percent liked listening to music through headphones. Seventeen percent preferred not having any music. The difference in preference between speakers and headphones was not significant (P = 0.563; McNemar-Bowker test). There was no association between preference at the end of the study and the initial assignment of speakers or headphones (P = 0.542 and P = 0.752, respectively; Pearson χ tests). No adverse events were reported.

CONCLUSIONS

Music is a low-cost intervention with virtually no side effects that could be offered as an adjunctive therapy for patients receiving ECT. A significant proportion of patients liked hearing music before treatment.

[Electroconvulsive therapy for the treatment of major depression]

BACKGROUND

Depressive disorders are common and lead to both individual suffering and high socioeconomic costs. Despite the fact that several effective therapies are available, remission is often not achieved. Electroconvulsive therapy (ECT) can be a therapeutic option in these cases.

OBJECTIVES

This review outlines the current evidence for the efficacy, safety and tolerability of ECT for depressive disorders.

MATERIAL AND METHODS

A selective literature search was carried out with particular consideration of meta-analyses, systematic reviews, and recommendations of national and international therapy guidelines.

RESULTS

For the majority of patients ECT is an effective, safe and well-tolerated therapy for the treatment of depressive disorders. There are relatively high remission rates even in patients with pharmacoresistant depression. There is evidence for a particularly high responsiveness in specific populations. In contrast to the proven effectiveness in the acute treatment of depressive disorders, there is a relative lack of data concerning maintenance therapy. Side effects including cognitive deficits are mostly transient. Modifications in the ECT technique have an impact on effectiveness and tolerability.

CONCLUSION

When administered correctly ECT is a highly effective therapy for the treatment of depressive disorders. In the light of the abundance of depressive disorders and lack of remission despite adequate pharmacological treatment, a broader availability and application of ECT would be desirable. The same is true for a more intensive research into the mechanisms of action and response predictors of ECT.

Update on Neuromodulation for Treatment-Resistant Depression

About 30% of patients suffering from a major depressive disorder do not respond sufficiently to established pharmacological, psychotherapeutic, or somatic treatments. Advances in technology and emerging knowledge about the dysfunctional brain circuits underlying depression have led to the development of different neuromodulation techniques. The aim of the present review is to give an update on noninvasive techniques, such as electroconvulsive therapy (ECT), magnetic seizure therapy (MST), transcranial magnetic stimulation (TMS), and invasive techniques requiring brain surgery, such as vagus nerve stimulation (VNS) and deep brain stimulation (DBS). First, the clinical relevance for therapy-resistant depression, including the current level of evidence, are presented. Neuroethics is concerned with the ethical, legal and social policy implications of neuroscience. A second focus of the review is the application of fundamental ethical principles, such as patient autonomy, patient well-being and justice to neuromodulation therapies. Due to reduced availability and lacking long-term efficacy data, most patients with treatment-resistant depression face a trial-and-error approach to therapeutics. This contravenes the ethical criteria of patient autonomy and justice. In order to raise the level of evidence, financial support of long-term studies, including large samples and randomized control trials, are necessary.

Supportive Nursing Care and Satisfaction of Patients Receiving Electroconvulsive Therapy: A Randomized Controlled Clinical Trial

Background:

Patient satisfaction is the most important criterion in evaluating the quality of care. Besides, its assessment in patients with severe mental disorder treated by electroconvulsive therapy (ECT) is highly appropriate. The ECT is accompanied by lower satisfaction and may exacerbate the patients’ condition.

Objectives:

The current study aimed to determine the effect of supportive nursing care on the satisfaction of patients receiving ECT.

Patients and Methods:

This randomized controlled trial was conducted in the education center of Baharan psychiatric hospital, Zahedan, Iran. Seventy hospitalized patients receiving ECT were randomly divided into two groups of control (n = 35) and intervention (n = 35).The socio-personal and Webster Satisfaction Questionnaire were used as data collection tools. The intervention group received supportive nursing care by nurses trained in informational, emotional, and physical aspects. The control group received only regular nursing care. The levels of satisfaction were measured and compared between groups, before and after the intervention. Data were analyzed using the SPSS software, and Chi-square, independent and paired t tests, as well as covariance analysis were performed.

Results:

The results showed similarities in socio-personal characteristics of both groups. However, there was a significant difference (P < 0.001) between the means of satisfaction in the groups, predominantly for the intervention group. In other words, a significant difference (P < 0.001) was observed between the means of satisfaction of the intervention (54.71 ± 5.27) and control (36.28 ± 7.00) groups after intervention by controlling the effect of socio-personal variables.

Conclusions:

Results of the current study confirmed the effect of supportive nursing care on increasing the level of satisfaction in ECT receiving patients, recommending the use of this therapeutic method.

Working alliances not loggerheads: understanding and addressing dissonance between families and treating teams in older people's mental health

OBJECTIVES

To identify and describe common sources of dissonance which arise for treating teams in older person's mental health and the strategies for addressing them.

METHODS

A literature review was conducted with the terms: 'family conflict and treatment team', 'family therapy and old age' and 'family caregiver'.

RESULTS

We discuss the importance of an alliance with families regarding older people's mental health, and the contribution of engagement, attachment and family dynamics to dissonance. We offer strategies to prevent and address dissonance.

CONCLUSIONS

To prevent and manage dissonance, its causes need to be identified and understood. Routinely 'thinking family' first, then 'knowing' and 'hearing' the family are crucial steps to enhancing communication with families.

Effects of ECT in treatment of depression: study protocol for a prospective neuroradiological study of acute and longitudinal effects on brain structure and function

BACKGROUND

Major depression can be a serious and debilitating condition. For some patients in a treatment resistant depressive episode, electroconvulsive treatment (ECT) is the only treatment that is effective. Although ECT has shown efficacy in randomized controlled trials, the treatment is still controversial and stigmatized. This can in part be attributed to our lack of knowledge of the mechanisms of action. Some reports also suggest potential harmful effects of ECT treatment and memory related side effects have been documented.

METHODS/DESIGN

The present study will apply state of the art radiology through advanced magnetic resonance imaging (MRI) techniques to investigate structural and functional brain effects of ECT. As a multi-disciplinary collaboration, imaging findings will be correlated to psychiatric response parameters, neuropsychological functioning as well as neurochemical and genetic biomarkers that can elucidate the underlying mechanisms. The aim is to document both treatment effects and potential harmful effects of ECT.

SAMPLE

n = 40 patients in a major depressive episode (bipolar and major depressive disorder). Two control groups with n = 15 in each group: age and gender matched healthy volunteers not receiving ECT and patients undergoing electrical cardioversion (ECV) for atrial fibrillation (AF). Observation time: six months.

DISCUSSION

The study will contribute to our understanding of the pathophysiology of major depression as well as mechanisms of action for the most effective treatment for the disorder; ECT.

Effect of supportive nursing care on self esteem of patients receiving electroconvulsive therapy: a randomized controlled clinical trial

INTRODUCTION

Self-esteem is an important potential indicator in etiology, diagnosis and treatment of patients with severe mental illness. ECT is a popular treatment for these patients that can effect on their self-esteem and reinforce their problems. The purpose of this study is to determine the effect of supportive nursing care in increasing self esteem of patients receiving ECT.

METHODS

This clinical trial was conducted in the Baharan psychiatric hospital of Zahedan. A total of 70 cases of patients who received ECT were randomly allocated to control (n=35) and intervention (n=35) groups. The data were collected by demographic characteristics questionnaire and Rosenberg Self Esteem Scale (RSES). Intervention group received the supportive nursing care. The control group received only routine treatment. Self esteem level was measured and compared before and after intervention for two groups. The data was analyzed by SPSS using the χ(2), t-test and ANCOVA.

RESULTS

RESULTS showed that both groups were homogeneous on the socio- demographic characteristics. The mean self esteem in the intervention group compared with the control group was significantly increased. While controlling the effects of individual and social variables, the result shows significant differences between two groups in the mean scores of self esteem after the intervention.

CONCLUSION

The results suggest that supportive nursing care can have positive effect on self esteem of patients receiving ECT. It is recommended to use this method for increasing self esteem of these patients.

Brain stimulation in posttraumatic stress disorder

Posttraumatic stress disorder (PTSD) is a complex, heterogeneous disorder that develops following trauma and often includes perceptual, cognitive, affective, physiological, and psychological features. PTSD is characterized by hyperarousal, intrusive thoughts, exaggerated startle response, flashbacks, nightmares, sleep disturbances, emotional numbness, and persistent avoidance of trauma-associated stimuli. The efficacy of available treatments for PTSD may result in part from relief of associated depressive and anxiety-related symptoms in addition to treatment of core symptoms that derive from reexperiencing, numbing, and hyperarousal. Diverse, heterogeneous mechanisms of action and the ability to act broadly or very locally may enable brain stimulation devices to address PTSD core symptoms in more targeted ways. To achieve this goal, specific theoretical bases derived from novel, well-designed research protocols will be necessary. Brain stimulation devices include both long-used and new electrical and magnetic devices. Electroconvulsive therapy (ECT) and Cranial electrotherapy stimulation (CES) have both been in use for decades; transcranial magnetic stimulation (TMS), magnetic seizure therapy (MST), deep brain stimulation (DBS), transcranial Direct Current Stimulation (tDCS), and vagus nerve stimulation (VNS) have been developed recently, over approximately the past twenty years. The efficacy of brain stimulation has been demonstrated as a treatment for psychiatric and neurological disorders such as anxiety (CES), depression (ECT, CES, rTMS, VNS, DBS), obsessive-compulsive disorder (OCD) (DBS), essential tremor, dystonia (DBS), epilepsy (DBS, VNS), Parkinson Disease (DBS), pain (CES), and insomnia (CES). To date, limited data on brain stimulation for PTSD offer only modest guidance. ECT has shown some efficacy in reducing comorbid depression in PTSD patients but has not been demonstrated to improve most core PTSD symptoms. CES and VNS have shown some efficacy in reducing anxiety, findings that may suggest possible utility in relieving PTSD-associated anxiety. Treatment of animal models of PTSD with DBS suggests potential human benefit. Additional research and novel treatment options for PTSD are urgently needed. The potential usefulness of brain stimulation in treating PTSD deserves further exploration.