Successful maintenance electroconvulsive therapy for more than seven years

The Effects of Maintenance Electroconvulsive Therapy on Hospitalization Rates

ABSTRACT

This study aimed to study the effect of maintenance electroconvulsive therapy (mECT) on hospitalization rates in patients who had been readmitted after acute courses of electroconvulsive therapy (ECT), and determine the most frequently used treatment schedules in mECT. Patients who had undergone mECT treatment for the last 5 years were retrospectively reviewed. Seventy patients were included in the study. The control group of 70 patients was selected from patients who received only acute ECT. Of the patients in the mECT group, 55.8% (39) were female, and 41.4% (29) were diagnosed with major depressive disorder. The mean number of patients hospitalized who received mECT after acute ECT was 0.55 ± 0.87, whereas it was 1.13 ± 1.31 in patients who received only pharmacotherapy after ECT in a covariant analysis adjusted for age and diagnosis. The most commonly used initial treatment protocol of mECT was weekly × 4, biweekly × 2, and monthly × 6. mECT is more effective in reducing hospitalization after acute ECT treatments than using psychotropic drugs alone for maintenance therapy.

First known case of catatonia due to cyclosporine A-related neurotoxicity in a pediatric patient with steroid-resistant nephrotic syndrome

BACKGROUND

Catatonia is a neuropsychiatric syndrome characterized by diverse psychomotor abnormalities, including motor dysregulation and behavioral and affective disturbances. Once thought to occur primarily in the context of schizophrenia, recent data suggest most cases of catatonia develop in individuals with depressive or bipolar disorders. Moreover, catatonia may ensue in general medical and neurological conditions, as well as due to a variety of pharmaceuticals, drugs of abuse, and toxic agents. At one time considered rare in pediatric patients, evidence now suggests catatonia is both underrecognized and undertreated in this population, where it carries an elevated risk of morbidity and mortality. Here we present the case of a child with steroid-resistant nephrotic syndrome who developed catatonia due to cyclosporine A-related neurotoxicity.

CASE PRESENTATION

A 9-year-old African-American boy with no psychiatric history and a 9-month history of nephrotic syndrome due to focal segmental glomerulosclerosis was admitted to the local children's hospital for management of mutism, posturing, insomnia, gait abnormalities, and somatic delusions. Seven days prior to admission, his cyclosporine plasma concentration was elevated at 1224 ng/mL (therapeutic range: 100-200 ng/mL). Upon admission, cyclosporine was discontinued and psychiatry was consulted, diagnosing catatonia. The patient subsequently received propofol 80 mg IV resulting in a transient lysis of catatonia. Over a lengthy hospitalization, the patient's catatonia was initially treated with lorazepam, quetiapine being added later to target psychosis. All signs and symptoms of catatonia resolved, and the patient was eventually tapered off both lorazepam and quetiapine with no return of symptoms more than 6 months later.

CONCLUSIONS

To our knowledge, this case represents the first reported instance of cyclosporine A-induced catatonia in a patient with steroid-resistant nephrotic syndrome. It illustrates the importance of maintaining vigilance for signs and symptoms of cyclosporine A-related neurotoxicity (including catatonia) in patients with steroid-resistant nephrotic syndrome. In addition, it highlights the challenges faced by clinicians in jurisdictions that prohibit the use of electroconvulsive therapy in pediatric patients.

Treatment of catatonia in autism spectrum disorders

OBJECTIVE

To review the treatment courses of 22 autistic patients diagnosed with catatonia over a 12-year period, including treatment with benzodiazepines and electroconvulsive therapy.

METHOD

Retrospective review of inpatient and outpatient records of 22 autistic youth presenting to a neurobehavioral service who were treated for catatonia.

RESULTS

Six girls and 16 boys ranging from ages 8 to 26 years old presenting for neurobehavioral assessment were found to meet criteria for catatonia according to the DSM5 and were treated for such. All but one patient was initially unsuccessfully treated with benzodiazepines in dosages ranging from 1 to 27 mg daily, and all patients underwent electroconvulsive therapy. Mean age of ECT start was 15.6 years old, and the total number of ECT received ranged from 16 to 688, with 13 patients still receiving maintenance ECT at the end of the study period. ECT conferred prominent patient benefit in terms of catatonic symptom reduction, including alleviation of incapacitating, treatment-resistant self-injury.

CONCLUSION

Myriad symptoms of catatonia were seen in this sample of 22 autistic youth. Implementation of anti-catatonic paradigms, particularly electroconvulsive therapy, conferred vast patient benefit.

Evaluation of cumulative cognitive deficits from electroconvulsive therapy

BACKGROUND

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

AIMS

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

METHOD

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

RESULTS

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

CONCLUSIONS

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

Electroconvulsive therapy: a life course approach for recurrent depressive disorder

We describe the case of an 89-year-old woman (deceased) with a 60-year history of recurrent depressive disorder treated with electroconvulsive therapy (ECT). It is estimated that she received up to 400 ECTs over her life course as her symptoms would not respond to oral medication. Despite extensive exposure to ECT, there was only minimal cognitive impairment and an excellent safety record, even in later life, as she became increasingly frail from multiple comorbidities. Over the years, there has been a drive to reduce the frequency of ECT administration. However, this case illustrates how in some patients ECT may be vital for acute episodes of severe depression as well as for maintenance therapy. This case report adds to observational evidence that maintenance ECT may be an underused treatment for recurrent depression and also recommends that greater emphasis be given to incorporating carers' views when planning individualised treatment approaches.

Drug therapy versus electroconvulsive therapy for refractory schizophrenia: report of a case with 14 years of follow-up

The long-term efficacy and safety of electroconvulsive therapy (ECT) for refractory schizophrenia is rarely reported. We report the case of a 38-year-old female patient with refractory schizophrenia who was treated with ECT for 14 years (from 24 years of age). Case records of clinical treatment and laboratory tests are described and analyzed. During the first 11 years, the patient was treated with ECT as an adjunct to antipsychotic drugs, but the effectiveness was unstable. For the remaining 3 years she was treated with antipsychotic drugs as an adjunct to ECT and her condition stabilized as she gradually recovered social function. We summarize the clinical characteristics, therapy regimen, long-term effectiveness, and safety of this interesting case.

[The interest of maintenance electroconvulsive therapy in mood disorders]

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

Effectiveness and pattern of use of continuation and maintenance electroconvulsive therapy

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

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

Maintenance electroconvulsive therapy in autistic catatonia: a case series review

The usage of electroconvulsive therapy for the acute resolution of catatonia in autistic children and adults is a novel area that has received increased attention over the past few years. Reported length of the acute ECT course varies among these patients, and there is no current literature on maintenance ECT in autism. The maintenance ECT courses of three patients with autism who developed catatonia are presented. Clinical, research, legal, and administrative implications for ECT treatment in this special population are discussed.

Electroconvulsive therapy, brain-derived neurotrophic factor, and possible neurorestorative benefit of the clinical application of electroconvulsive therapy

Treatment-resistant depression (TRD) is a growing problem in psychiatry. A recent meta-analysis has estimated TRD to be as high as 40%. Just over a decade ago, TRD was estimated to be as low as 10% to 15%. The causes of TRD are not fully understood. Finding ways to bring patients to remission faster may be part of the solution, but increasing our understanding of how depression works and how the brain responds to treatment may shed some light on this growing problem. Patients with TRD have been shown to have decreased volumes in gray matter structures, particularly in the hippocampus. Hippocampal volumes are correlated with decreased expression of neurotrophic factors (most notably, brain-derived neurotrophic factor [BDNF]), and decreased expression of BDNF correlates with the presence of depression. Increased expression of BDNF has a strong association with increased volumes in the hippocampus. Electroconvulsive therapy (ECT), a safe and effective treatment of severe depression, has been shown to be effective in TRD. Patients who undergo ECT have also had measurable increases in BDNF, indicating that ECT may be modulating intracellular processes in the patients with depression. Taken together, ECT may have a positive effect on restoring gray matter volume in patients with depression and especially TRD.

Long-term weekly continuation electroconvulsive therapy: a case series

Despite best efforts with continuation pharmacotherapy, many patients relapse after a successful course of electroconvulsive therapy (ECT). Although maintenance ECT can be a useful and cost-effective treatment modality, there is considerable heterogeneity on how it is used. The authors report a case series of 3 patients ages 68, 43, and 81 years with diagnosis of schizoaffective disorder, bipolar disorder, and major depression with psychotic features who required weekly ECT treatments for several years. All attempts to space treatments led to rapid decompensation. None of the patients experienced clinical evidence of any treatment related cognitive or physical morbidity.

Acute and maintenance electroconvulsive therapy for treatment of psychotic depression in a pregnant patient

Depression may relapse during pregnancy in women with a history of depression. Treatments which may be effective for mothers may be harmful to the fetus. Electroconvulsive therapy (ECT) has been widely used in patients with different medical illnesses. It is safe, and its efficacy is well established. In our example, the patient was a 34-year-old white woman who was at 13 weeks' gestation at the time of admission to our hospital. Over a 1-month period, the patient underwent a total of 13 ECTs (3 times a week) and 3 more ECTs monthly until the birth of her child. After 10th ECT, the Hamilton Depression Rating Scale score was reduced from 33 before ECT to 7. After 3 more weekly ECTs, the patient was discharged from the hospital with a Hamilton Depression Rating Scale score of 3. The patient was instructed to continue maintenance treatment with ECT sessions monthly. Except for pelvic pain and transient fetal arrhythmias, no complications were reported. Thus, acute and maintenance ECT may be the choice of treatment in severely depressed or psychotic pregnant patients.

Effects of maintenance electroshock on the oxidative damage parameters in the rat brain

Although several advances have occurred over the past 20 years concerning refining the use and administration of electroconvulsive therapy to minimize side effects of this treatment, little progress has been made in understanding the mechanisms underlying its therapeutic or adverse effects. This work was performed in order to determine the level of oxidative damage at different times after the maintenance electroconvulsive shock (ECS). Male Wistar rats (250-300 g) received a protocol mimicking therapeutic of maintenance or simulated ECS (Sham) and were subsequently sacrificed immediately after, 48 h and 7 days after the last maintenance electroconvulsive shock. We measured oxidative damage parameters (thiobarbituric acid reactive species for lipid peroxidation and protein carbonyls for protein damage, respectively) in hippocampus, cortex, cerebellum and striatum. We demonstrated no alteration in the lipid peroxidation and protein damage in the four structures studied immediately after, 48 h and 7 days after a last maintenance electroconvulsive shock. Our findings, for the first time, demonstrated that after ECS maintenance we did protocol minimal oxidative damage in the brain regions, predominating absence of damage on the findings.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Continuation and maintenance electroconvulsive therapy for the treatment of depressive illness: a response to the National Institute for Clinical Excellence report

Continuation and maintenance electroconvulsive therapy (ECT) is used to prevent relapse and recurrence of depressive episodes in those patients who have failed previous continuation and/or maintenance pharmacotherapy and who have also responded to an acute course of ECT. These patients frequently have histories of medication-resistant depression, medication intolerance, and/or comorbid medical conditions that complicate the management of their psychiatric illness. Previous studies of continuation and maintenance ECT, mostly consisting of case reports and retrospective chart reviews, as well as several prospective studies, support the practice of continuation and maintenance ECT as a viable treatment option for these difficult-to-treat patients. However, continuation and maintenance ECT have come under fire recently because of concerns of insufficient controlled studies demonstrating its efficacy, its long-term benefits, and its risks. This article thus reviews the most recent data available on the use of continuation and maintenance ECT in the treatment of depressive disorders. Although few new prospective controlled studies exist in the literature, published and emerging data continue to support the use of continuation and maintenance ECT, particularly in those individuals with medication-refractory, ECT-responsive, and relapse-prone depression.