Electroconvulsive Therapy in Sweden 2013: Data From the National Quality Register for ECT

Electroconvulsive therapy in the maintenance phase of psychotic unipolar depression

OBJECTIVE

To determine whether the rates of readmissions and suicide vary in psychotic unipolar depression based on whether patients receive maintenance electroconvulsive therapy (M-ECT) following the initial series of ECT, and to examine if there is an age-dependent association.

METHODS

We used Swedish national registries to identify hospitalized patients with psychotic unipolar depression, treated 2008-2019 who received ECT during their hospital stay. The patients who received subsequent M-ECT within 14 days after discharge were compared with those who did not. The primary composite outcome was time to readmission due to a psychiatric disorder, suicide attempt, or suicide within 2 years from discharge. Data were analyzed using Cox regression adjusted for previous psychiatric admissions, age, sex, comorbidity, and pharmacological treatment. We also conducted a within-individual analysis using the sign-test, with patients having ≥1 hospital episode followed by M-ECT and ≥1 hospital episode without M-ECT.

RESULTS

A total of 1873 patients were included, of which 130 received M-ECT. There was no statistically significant group difference regarding the primary outcome in the whole sample. However, when stratified by age, there was a significant difference in favor of M-ECT for patients >65 years (adjusted hazard ratio 0.55, 95% confidence interval 0.35-0.87). The within-individual analysis, including 46 patients, significantly favored M-ECT.

CONCLUSION

M-ECT was not associated with a differential risk of the composite of readmission and suicide in psychotic depression. Among patients >65 years, M-ECT was significantly associated with a decreased risk of the outcome. The possibility of residual confounding cannot be excluded.

Bibliometric analysis of research in epilepsy and comorbid depression from 2014 to 2023

BACKGROUND

Epilepsy and depression have complicated bidirectional relationships. Our study aimed to explore the field of epilepsy comorbid with depression in a bibliometric perspective from 2014-2023.

AIM

To improve our understanding of epilepsy and depression by evaluating the relationship between epilepsy and depression, bibliometric analyses were performed.

METHODS

Epilepsy and depression-related publications from the last decade were retrieved from the Web of Science Core Collection. We conducted bibliometric and visual analysis using VOSviewer and CiteSpace, examining authorships, countries, institutions, journals of publication, co-citations of references, connections between keywords, clusters of keywords, and keywords with citation bursts.

RESULTS

Over the past ten years, we collected 1045 research papers focusing on the field of epilepsy and comorbid depression. Publications on epilepsy and depression have shown a general upward trend over time, though with some fluctuations. The United States, with 287 articles, and the University of Melbourne, contributing 34 articles, were the top countries and institutions, respectively. In addition, in the field of epilepsy and depression, Professor Lee, who has published 30 articles, was the most contributing author. The hot topics pay attention to the quality of life in patients with epilepsy and depression.

CONCLUSION

We reported that quality of life and stigma in patients with epilepsy comorbid with depression are possible future hot topics and directions in the field of epilepsy and depression research.

Availability of Electroconvulsive Therapy in Public Health Services in the Last Decade in Brazil

OBJECTIVE

To identify the current treatment options for electroconvulsive therapy (ECT) therapy in public services linked to the Unified Health System in Brazil and compare them with data published in 2012 based on their availability.

METHODS

In this retrospective observational study, we mapped institutions that perform ECT under public health services in Brazil. A questionnaire was administered to active and inactive service centers between August 2022 and June 2023.

RESULTS

We identified 16 institutions that performed ECT, including 12 linked to public universities and 4 with various links. In the last decade, 2 new public services that perform ECT in the country have emerged, whereas 4 services have ceased function. In 2022, the number of individuals treated with ECT per 100,000 population was 1.86, whereas the number of procedures performed per 100,000 people was 6.55.

CONCLUSIONS

Although 2 new public ECT services have been identified, 4 have turned inactive. Most services are linked to public universities, and inactive service points to financial issues as the main factor in service interruption. Brazil has one of the lowest rates of individuals treated with ECT per 100,000 population compared with countries in North America and Europe. Thus, it is essential to raise awareness to improve ECT adoption rates and bring it out of the shadows in Brazil.

Suicidal behavior and all-cause mortality in depressed older adults aged 75+ treated with electroconvulsive therapy: A Swedish register-based comparison study

OBJECTIVES

Electroconvulsive therapy (ECT) is effective in treating late-life depression. There is limited research on suicidal behavior and all-cause mortality in the oldest old after ECT.

METHODS

Older adults aged 75 years and above who had been inpatients for moderate to severe depression between January 1, 2011, and December 31, 2017, were included in the study. We used exact and propensity score matching to balance groups. We compared suicidal behavior (fatal and non-fatal) and all-cause mortality in those who had received ECT and those with other depression treatments.

RESULTS

Of the study population, 1802 persons who received ECT were matched to 4457 persons with other treatments. There were no significant differences in the risk of suicidal behavior between groups, (within 3 months: odds ratio 0.73; 95% confidence intervals (CI), 0.44-1.23, within 4 months to 1 year: aOR 1.34; 95% CI, 0.84-2.13). All-cause mortality was lower among ECT recipients compared to those who had received other treatments, both within 3 months (aOR, 0.35; 95% CI, 0.23-0.52), and within 4 months to 1 year (aOR 0.65; 95% CI, 0.50-0.83).

CONCLUSIONS

Compared to other depression treatments, ECT is not associated with a higher risk of suicidal behavior in patients aged 75 and above. ECT is associated with lower all-cause mortality in this age group, but we advise caution regarding causal inferences.

The ethical imperative of trauma-sensitive care for electroconvulsive therapy (ECT)

BACKGROUND

The empirical literature on the lived experience of electroconvulsive therapy (ECT) is limited, divergent, and largely focused on the experiences of procedures, (adverse) effects, information provision, or decision-making.

AIMS

This study aimed to investigate aspects related to the lived experience and meaning-making of people who have had ECT.

METHOD

In-depth interviews with 21 women (21-65 years old) were analyzed using interpretative phenomenological analysis (IPA).

FINDINGS

A subgroup of nine participants described more negative experiences with ECT. A common factor for these participants was the experience of trauma that remained under-treated. The superordinate themes identified were a lack of trauma-based and recovery-oriented treatment. The rest of the sample (12) expressed more positive experiences with ECT.

CONCLUSIONS

This study suggests that exploring more broadly the impacts of ECT at the long term offers insights that can help design more person-centered services aligned to the needs of the treatment recipients. Educational modules for mental health care staff should include, besides knowledge on the methods' effectiveness, additional evidence about treatment recipients' subjective concerns and the relevance of trauma and recovery-oriented care models.

Association between pulse width and health-related quality of life after electroconvulsive therapy in patients with unipolar or bipolar depression: an observational register-based study

AIMS

To examine the association between pulse width and HRQoL measured within one week after electroconvulsive therapy (ECT) and at six-month follow-up in patients with unipolar or bipolar depression.

METHODS

This was an observational register study using data from the Swedish National Quality Registry for ECT (2011-2019). Inclusion criteria were: age ≥18 years; index treatment for unipolar/bipolar depression; unilateral electrode placement; information on pulse width; EQ-5D measurements before and after ECT. Multiple linear regressions were performed to investigate the association between pulse width (<0.5 ms; 0.5 ms; >0.5 ms) and HRQoL (EQ-5D-3L index; EQ VAS) one week after ECT (primary outcome) and six months after ECT (secondary outcome).

RESULTS

The sample included 5,046 patients with unipolar (82%) or bipolar (18%) depression. At first ECT session, 741 patients (14.7%) had pulse width <0.5 ms, 3,639 (72.1%) had 0.5 ms, and 666 (13.2%) had >0.5 ms. There were no statistically significant associations between pulse width and HRQoL one week after ECT. In the subsample of patients with an EQ-5D index recorded six months after ECT (n = 730), patients receiving 0.5 ms had significantly lower HRQoL (-0.089) compared to <0.5 ms, after adjusting for demographic and clinical characteristics (p = .011). The corresponding analysis for EQ VAS did not show any statistically significant associations.

CONCLUSION

No robust associations were observed between pulse width and HRQoL after ECT. On average, significant improvements in HRQoL were observed one week and six months after ECT for patients with unipolar or bipolar disease, independent of the pulse width received.

Antipsychotics in the maintenance phase for psychotic depression

OBJECTIVE

This study aimed to associate antidepressants with versus without antipsychotics with readmission and suicide in patients with psychotic unipolar depression.

METHODS

Swedish national registers were used to identify inpatients with psychotic unipolar depression, treated 2007-2016. The participants collected antidepressants with or without antipsychotics from a pharmacy within 14 days after discharge and were followed up for 2 years. The primary outcome was hospital readmission due to any psychiatric disorder, suicide attempt, or completed suicide. Cox regression was used to analyze the data, which were adjusted for sex, age, prior admissions, comorbidity, electroconvulsive therapy, and other pharmacological treatments.

RESULTS

We identified 4391 patients, of which 2972 were in the antidepressant + antipsychotic combination therapy group, and 1419 were in the antidepressant monotherapy group. After 2 years, 42.3% and 36.6% of patients were readmitted or committed suicide in the combination therapy and monotherapy group, respectively. Monotherapy was significantly associated with a lower risk of reaching the outcome in the main analysis (hazard ratio = 0.86; 95% confidence interval: 0.77-0.95). The results went in the same direction in all sensitivity analyses.

CONCLUSION

Our findings do not indicate any advantage of adding antipsychotics as adjunctive to antidepressants as maintenance treatment. Considering the wide use, known side effects, and the current lack of evidence supporting the benefit, further studies on the effect of antipsychotics in the maintenance phase of psychotic unipolar depression are urgently warranted.

Electroconvulsive therapy in children and adolescents: results from a population‑based study utilising the Swedish National Quality Register

Electroconvulsive therapy (ECT) is effective and safe for adults with severe depression, but less studied in adolescents. Here, we examined the indications, prevalence, practice, response and remission rates, and side effects in young people treated with ECT in Sweden. We also examined the usage of ECT in the transition to adult psychiatry. Using data from national patient registers and the Swedish National Quality Register for ECT (Q-ECT), we identified patients aged up to 19 years treated with ECT over a 5-year study period. Response and remission rates were analysed using the Clinical Global Impression (7-point scale)-Improvement (CGI-I) and Severity (CGI-S). A total of 118 individuals were identified, of which 105 were also enrolled in the Q-ECT. The most common indication for ECT was depression (68%; n = 80). Adolescents aged < 18 years were more severely ill before treatment than those aged 18 years (P < 0.01). Three of the hospitals in Sweden treated the majority of adolescents < 18 years old. The median number of sessions in each ECT series was seven. Unilateral placement of the electrodes was the most common (88%; n = 99). Fifty-seven percent (n = 54) of the patients responded (CGI-I, 1-2) to the treatment; remission (CGI-S, 1-2) was achieved by 32% (n = 30). Psychotic symptoms were associated with a higher response rate in patients with depression (P = 0.038). A deterioration of memory compared to pre-treatment was reported in six patients. ECT was associated with high response and remission rates in adolescents with severe psychiatric disorders after non-response to medication.

What Can We Tell About the Effect of Electroconvulsive Therapy on the Human Hippocampus?

Electroconvulsive therapy (ECT) is the most effective antidepressant treatment, although its mechanisms of action remain unclear. Since 2010, several structural magnetic resonance imaging studies based on a neuroplastic hypothesis have consistently reported increases in the hippocampal volume following ECT. Moreover, volume increases in the human dentate gyrus, where neurogenesis occurs, have also been reported. These results are in line with the preclinical findings of ECT-induced neuroplastic changes, including neurogenesis, gliogenesis, synaptogenesis, and angiogenesis, in rodents and nonhuman primates. Despite this robust evidence of an effect of ECT on hippocampal plasticity, the clinical relevance of these human hippocampal changes continues to be questioned. This narrative review summarizes recent findings regarding ECT-induced hippocampal volume changes. Furthermore, this review also discusses methodological considerations and future directions in this field.

Alterations in the Serum Proteome Following Electroconvulsive Therapy for a Major Depressive Episode: A Longitudinal Multicenter Study

Background

Electroconvulsive therapy (ECT) is the most effective treatment for severe depression, but the biological changes induced by ECT remain poorly understood.

Methods

This study investigated alterations in blood serum proteins in 309 patients receiving ECT for a major depressive episode. We analyzed 201 proteins in samples collected at 3 time points (T): just before the first ECT treatment session (T0), within 30 minutes after the first ECT session (T1), and just before the sixth ECT session (T2).

Results

Using statistical models to account for repeated sampling, we identified 152 and 70 significantly (<5% false discovery rate) altered proteins at T1 and T2, respectively. The most pronounced alterations at T1 were transiently increased levels of prolactin, myoglobin, and kallikrein-6. However, most proteins had decreased levels at T1, with the largest effects observed for pro-epidermal growth factor, proto-oncogene tyrosine-protein kinase Src, tumor necrosis factor ligand superfamily member 14, sulfotransferase 1A1, early activation antigen CD69, and CD40 ligand. The change of several acutely altered proteins correlated with electric current and pulse frequency in a dose-response-like manner. Over a 5-session course of ECT, some acutely altered levels were sustained while others increased, e.g., serine protease 8 and chitinase-3-like protein 1. None of the studied protein biomarkers were associated with clinical response to ECT.

Conclusions

We report experimental data on alterations in the circulating proteome triggered by ECT in a clinical setting. The findings implicate hormonal signaling, immune response, apoptotic processes, and more. None of the findings were associated with clinical response to ECT.

Polygenic risk scores of lithium response and treatment resistance in major depressive disorder

Treatment response and resistance in major depressive disorder (MDD) are suggested to be heritable. Due to significant challenges in defining treatment-related phenotypes, our understanding of their genetic bases is limited. This study aimed to derive a stringent definition of treatment resistance and to investigate the genetic overlap between treatment response and resistance in MDD. Using electronic medical records on the use of antidepressants and electroconvulsive therapy (ECT) from Swedish registers, we derived the phenotype of treatment-resistant depression (TRD) and non-TRD within ~4500 individuals with MDD in three Swedish cohorts. Considering antidepressants and lithium are first-line treatment and augmentation used for MDD, respectively, we generated polygenic risk scores (PRS) of antidepressants and lithium response for individuals with MDD and evaluated their associations with treatment resistance by comparing TRD with non-TRD. Among 1778 ECT-treated MDD cases, nearly all (94%) used antidepressants before their first ECT and the vast majority had at least one (84%) or two (61%) antidepressants of adequate duration, suggesting these MDD cases receiving ECT were resistant to antidepressants. We did not observe a significant difference in the mean PRS of antidepressant response between TRD and non-TRD; however, we found that TRD cases had a significantly higher PRS of lithium response compared to non-TRD cases (OR = 1.10-1.12 under various definitions). The results support the evidence of heritable components in treatment-related phenotypes and highlight the overall genetic profile of lithium-sensitivity in TRD. This finding further provides a genetic explanation for lithium efficacy in treating TRD.

Electroconvulsive Therapy in Switzerland: A Survey on Contemporary Practice in Remembrance of a Historical Meeting

OBJECTIVES

The prevalence and use of electroconvulsive therapy (ECT) varies widely across Europe. Historically, Switzerland played an important role in the worldwide spread of ECT. Nevertheless, an overview of current ECT practice in Switzerland is still lacking. The present study aims to fill this gap.

METHODS

A cross-sectional study was conducted in 2017 using a standardized questionnaire to investigate current ECT practice in Switzerland. Fifty-one Swiss hospitals were contacted by email and followed up by telephone. In early 2022, we updated the list of facilities that offer ECT.

RESULTS

Thirty eight of the 51 hospitals (74.5%) provided feedback to the questionnaire, 10 of them claimed to offer ECT. They reported 402 treated patients, which corresponds to an ECT-treated person rate of 4.8 persons per 100,000 inhabitants. Depression was the most frequent indication. All hospitals reported an increase in ECT treatments between 2014 and 2017 except for one with constant numbers. The number of facilities offering ECT almost doubled between 2010 and 2022. Most ECT facilities performed the treatment predominantly on an outpatient rather than an inpatient basis.

CONCLUSIONS

Historically, Switzerland relevantly contributed to the worldwide spread of ECT. In an international comparison, the treatment frequency is in the lower middle range. The outpatient treatment rate is high compared with other countries in Europe. The supply and spread of ECT in Switzerland have increased over the past decade.

Investigating genetic overlap between antidepressant and lithium response and treatment resistance in major depressive disorder

Treatment response and resistance in major depressive disorder (MDD) are suggested to be heritable. Due to significant challenges in defining treatment-related phenotypes, our understanding of their genetic bases is limited. This study aimed to derive a stringent definition of treatment resistance and to investigate genetic overlap between treatment response and resistance in MDD. Using electronic medical records on the use of antidepressants and electroconvulsive therapy (ECT) from Swedish registers, we derived the phenotype of treatment-resistant depression (TRD) within ~ 4 500 individuals with MDD in three Swedish cohorts. Considering antidepressants and lithium are first-line treatment and augmentation used for MDD, respectively, we generated polygenic risk scores of antidepressant and lithium response for individuals with MDD, and evaluated their associations with treatment resistance by comparing TRD with non-TRD. Among 1 778 ECT-treated MDD cases, nearly all (94%) used antidepressants before first ECT, and the vast majority had at least one (84%) or two (61%) antidepressants of adequate duration, suggesting these MDD cases receiving ECT were resistant to antidepressants. We found that TRD cases tend to have lower genetic load of antidepressant response than non-TRD, although the difference was not significant; furthermore, TRD cases had significantly higher genetic load of lithium response (OR = 1.10-1.12 under different definitions). The results support evidence of heritable components in treatment-related phenotypes and highlight the overall genetic profile of lithium-sensitivity in TRD. This finding further provides a genetic explanation for lithium efficacy in treating TRD.

Risk factors for mortality of medical causes within 30 days of electroconvulsive therapy

BACKGROUND

Electroconvulsive therapy (ECT) is used to treat severe psychiatric disorders and is associated with reduced risk of suicide and all-cause mortality in patients with severe depression. We investigated the causes of death occurring shortly after ECT and identified potential risk factors for medical causes of death.

METHODS

Patients treated with ECT between 2012 and 2018 were included in this Swedish register-based study. Multivariate binary logistic regression was used to calculate odds ratios for covariates to determine potential predictors of 30-day mortality.

RESULTS

Of the 20,225 included patients, 93 (0.46 %) died of suicide and 123 (0.61 %) died of medical causes after ECT. Cardiovascular disease was the most common medical cause of death (n = 49, 40 %). An older age, a Charlson Comorbidity Index of 1 or more, atrial fibrillation, kidney disease, reflux disease, dementia, and cancer were associated with increased risk of death by medical causes.

LIMITATIONS

Real-life observational studies based on registry data may demonstrate associations, but cannot determine causality. If medical records had been available, we would be better able to determine if deaths were due to the ECT, anesthesia, pre-existing medical conditions, or the mental disorder.

CONCLUSIONS

ECT appears to be a low-risk medical procedure. Older individuals with severe somatic diseases have the highest risk of death and extra measures should be considered to optimize their medical health during the pre-ECT workup, and during and after ECT.

[Health service aspects of electroconvulsive therapy: analysis of external referrals to a university medical center]

BACKGROUND

The application of ECT in Germany varies widely depending on regional availability. This shortfall in ECT supply is partly compensated via referrals to hospitals with ECT services, yet restricted by limited resources in these clinics.

OBJECTIVE

External referrals for ECT were investigated at the University Medical Center Göttingen. We analyzed the referring institutions, patient characteristics, pharmacotherapy according to current guidelines before indications for ECT, and clinical outcome in cases of treatment with ECT.

MATERIAL AND METHODS

All external referrals were systematically recorded and retrospectively evaluated for the time span of 1 year. Besides descriptive presentation of the data, pharmacological pretreatment was compared with the current guideline recommendations. We used overall clinical impression (CGI-I) to determine the treatment response post-ECT.

RESULTS

External referrals were made for N = 52 patients, 82.7% of whom were from the inpatient setting and from a distance of up to 300 km. The most common diagnoses were unipolar depression (57.7%), followed by schizophrenia spectrum (36.5%). Prior to referral, at least one guideline-based pretreatment was given in the majority of cases. ECT was performed in 18 patients in our hospital, of whom 72.7% showed a good to very good response.

CONCLUSION

Both numbers and radius of external referrals indicate a high unmet need for ECT and thus limited access to this evidence-based and guideline-recommended therapy. As treatment close to home should be the goal, more hospitals are needed to establish (or expand) ECT services; however, even with considerable delays which are often associated with external referrals, the response rate is good across all diagnoses.

Electroconvulsive therapy following incident bipolar disorder: When, how, and for whom?

OBJECTIVE

The use of electroconvulsive therapy (ECT) in the treatment of bipolar disorder (BD) remains poorly described. Based on data from Danish registries with complete nationwide coverage, this study of patients with incident BD aimed to describe when, how, and for whom ECT is used in the context of BD.

METHODS

We identified patients receiving their first diagnosis of BD in the period from 2008 to 2018, who subsequently received ECT. Descriptive statistics were used to clarify when, how, and for whom ECT is used.

RESULTS

We identified 1338 patients with incident BD who subsequently received ECT. The median age at the first ECT session was 50.6 years (interquartile range [IQR]: 26.4), and 62% of those treated with ECT were female. The median time from the diagnosis of BD to the first ECT treatment was 0.6 years (IQR: 2.6), and 58% of the patients receiving ECT had the first treatment within the first year after being diagnosed with BD. The most common indication for the first ECT treatment was depression (mainly non-psychotic depression), followed by mania (mainly psychotic mania). The first ECT session was typically provided to inpatients (97%), upon patient consent (98%) and with bilateral electrode placement (60%).

CONCLUSIONS

A substantial proportion of the patients with incident BD who receive ECT require this treatment within the first year after the diagnosis. The most common indication for ECT is depression followed by (psychotic) mania. Inpatient voluntary ECT using bilateral electrode placement is the most common form of administration.

Electroconvulsive Therapy in Children and Adolescents in Germany-A Case Series From 3 University Hospitals

OBJECTIVE

Electroconvulsive therapy (ECT) is a well-established, safe, and efficacious treatment for severe psychiatric disorders. In children and adolescents, it is used much less frequently than in adults, likely because of a lack of knowledge.

METHODS

We retrospectively analyzed all patients aged 12 to 17 years who completed a course of ECT at 3 psychiatric university hospitals in Germany between 2010 and 2020. Clinical Global Impression Severity (CGI-S) scores were assessed based on electronic medical records. Changes in CGI-S scores were assessed using a paired samples t test. Predictors for response and remission were assessed using binomial logistic regression.

RESULTS

We included 32 patients. The CGI-S scores improved significantly from before to after ECT treatment (6.9 vs 3.9, t = 10.0, P < 0.01). A total of 40.6% of patients responded (CGI ≤ 3) and 21.9% remitted (CGI ≤ 2). The number of ineffective medication trials in the 6 months before ECT treatment was significantly associated with response (odds ratio, 0.54; P = 0.028) and remission (odds ratio, 0.31; P = 0.048). Five patients reported subjective cognitive adverse effects, 2 patients exhibited a prolonged seizure, 1 patient reported headaches, and 1 patient experienced a mild allergic reaction after anesthesia with etomidate. A total of 65.6% of patients experienced no adverse effects at all.

CONCLUSIONS

This retrospective analysis found ECT to be effective and safe in children and adolescents irrespective of their main diagnosis. The reported data point to the importance of an early use of ECT for severe psychiatric diseases in child and adolescent psychiatry.

Association Between Polygenic Risk Scores and Outcome of ECT

OBJECTIVE

Identifying biomarkers associated with response to electroconvulsive therapy (ECT) may aid clinical decisions. The authors examined whether greater polygenic liabilities for major depressive disorder, bipolar disorder, and schizophrenia are associated with improvement following ECT for a major depressive episode.

METHODS

Between 2013 and 2017, patients who had at least one treatment series recorded in the Swedish National Quality Register for ECT were invited to provide a blood sample for genotyping. The present study included 2,320 participants (median age, 51 years; 62.8% women) who had received an ECT series for a major depressive episode (77.1% unipolar depression), who had a registered treatment outcome, and whose polygenic risk scores (PRSs) could be calculated. Ordinal logistic regression was used to estimate the effect of PRS on Clinical Global Impressions improvement scale (CGI-I) score after each ECT series.

RESULTS

Greater PRS for major depressive disorder was significantly associated with less improvement on the CGI-I (odds ratio per standard deviation, 0.89, 95% CI=0.82, 0.96; R²=0.004), and greater PRS for bipolar disorder was associated with greater improvement on the CGI-I (odds ratio per standard deviation, 1.14, 95% CI=1.05, 1.23; R²=0.005) after ECT. PRS for schizophrenia was not associated with improvement. In an overlapping sample (N=1,207) with data on response and remission derived from the self-rated version of the Montgomery-Åsberg Depression Rating Scale, results were similar except that schizophrenia PRS was also associated with remission.

CONCLUSIONS

Improvement after ECT is associated with polygenic liability for major depressive disorder and bipolar disorder, providing evidence of a genetic component for ECT clinical response. These liabilities may be considered along with clinical predictors in future prediction models of ECT outcomes.

National Network of Depression Centers' Recommendations on Harmonizing Clinical Documentation of Electroconvulsive Therapy

ABSTRACT

Electroconvulsive therapy (ECT) is a highly therapeutic and cost-effective treatment for severe and/or treatment-resistant major depression. However, because of the varied clinical practices, there is a great deal of heterogeneity in how ECT is delivered and documented. This represents both an opportunity to study how differences in implementation influence clinical outcomes and a challenge for carrying out coordinated quality improvement and research efforts across multiple ECT centers. The National Network of Depression Centers, a consortium of 26+ US academic medical centers of excellence providing care for patients with mood disorders, formed a task group with the goals of promoting best clinical practices for the delivery of ECT and to facilitate large-scale, multisite quality improvement and research to advance more effective and safe use of this treatment modality. The National Network of Depression Centers Task Group on ECT set out to define best practices for harmonizing the clinical documentation of ECT across treatment centers to promote clinical interoperability and facilitate a nationwide collaboration that would enable multisite quality improvement and longitudinal research in real-world settings. This article reports on the work of this effort. It focuses on the use of ECT for major depressive disorder, which accounts for the majority of ECT referrals in most countries. However, most of the recommendations on clinical documentation proposed herein will be applicable to the use of ECT for any of its indications.

ECT on a world map - a narrative review of the use of electroconvulsive therapy and its frequency in the world

Introduction: Since implementation, electroconvulsive therapy has remained very effective treatment in psychiatry. The aim of this study is to present the differences in its use in medical practice around the world. The range of diseases in which ECT is most commonly used and the frequency of its use in different countries were compared with special attention to the differences between highly and poorly developed countries.

Material and method: Review of literature by searching PubMed and Google Scholar databases using the keywords: indications of ECT, frequency of ECT use for papers published from 1991 to 2021.

Results: Among the diseases for which electroconvulsive therapy is used worldwide, major depression dominates, while in Asia and Africa this therapy is used in schizophrenia. In Latin America it is used primarily for schizophrenia and bipolar disorder. In Poland, it is used for depression, bipolar disorder, and fewer for schizophrenia. The highest rate of people treated with therapy per 100,000 population is found in countries such as the USA (51), Canada (23.2-25.6), Australia (37.85), Sweden (41), Finland (23), Slovakia (29.2), Estonia (27.8) and Belgium (47).

Conclusions: There is a relationship between the range of diseases most frequently treated with ECT, the frequency of use and the level of country development. In the high developed countries, ECT is used mainly in major depression, in less developed countries more frequent treatment of schizophrenia may be determined by the high cost of medications and limited availability of hospital beds. The highest rates of use of this therapy are found in more developed countries.

Suicidal ideation and ECT, ECT and suicidal ideation: A register study

OBJECTIVE

Although electroconvulsive therapy (ECT) is anti-suicidal, it is not known whether the presence of suicidal ideation (SI) at baseline predicts response and remission after ECT. The aim of the study was to analyze the impact of baseline SI on response and remission following ECT treatment in a large sample of patients with depression and to assess SI before and after ECT.

METHODS

This population-based register study used data from the Swedish National Quality Register for ECT and the Swedish Patient Register. Patients aged 18 years or older who had received ECT for a unipolar or bipolar depressive episode between 2011 and 2018 were included in the study. SI was defined as a score of ≥4 on the last item of the Montgomery-Åsberg Depression Rating Scale - Self Assessment (MADRS-S). Using a logistic regression model, SI at baseline was used to predict response and remission following ECT, while controlling for depression severity, psychotic symptoms, presence of a comorbid personality disorder, age, sex, electrode position, unipolar or bipolar disorder, and number of previous suicide attempts at baseline.

RESULTS

In patients who exhibited SI at baseline, 53.7% (N = 632) of cases showed a response to ECT, whereas 68.4% (N = 690) of patients without SI showed a response. In addition, 27.2% (N = 320) of cases with SI achieved remission, whereas 48.5% (N = 489) of cases without SI achieved remission. The odds of achieving response and remission for patients with SI were 0.75 and 0.58 times, respectively, those for patients without SI. Of the 1178 patients with pre-treatment SI, 75.64% (N = 891) exhibited no SI at the end of treatment. Moreover, in this subgroup, the presence of a personality disorder, higher MADRS-S-score, and younger age were associated with persistent SI.

CONCLUSION

The presence of SI was associated with lower ECT response and remission rates. Nevertheless, depressive symptoms and SI were reduced in a large proportion of patients across both patient groups. Clinicians should be aware of the lower likelihood of achieving a successful outcome following ECT in younger patients who present with a non-psychotic depressive episode, SI, and (suspected) personality disorders. More research is warranted regarding if these patients can achieve similar or better results with other treatments.

Electroconvulsive therapy and psychiatric readmission in major depressive disorder - A population-based register study

OBJECTIVE

The primary aim was to determine whether electroconvulsive therapy (ECT) is associated with reduced risk of psychiatric readmission in major depressive disorder (MDD).

METHODS

This study was based on data from multiple Swedish population-based registries. All adult patients admitted to any Swedish hospital for moderate-to-severe MDD between 2012 and 2018 were included. Participants were divided into two groups depending on whether they received ECT during inpatient care. Follow-up was set at 30 and 90 days from discharge. Data were analyzed using logistic regression, and matching was conducted.

RESULTS

A total of 27,851 unique patients contributed to 41,916 admissions. ECT was used in 26.8% of admissions. In the main multivariate analysis, the risk of both 30- and 90-day readmission was lower in the ECT group than in the non-ECT group. In a matched sensitivity model, the results pointed in the same direction for readmission risk within 30 days, but statistical significance was not reached. ECT-treated subgroups with superior outcomes on readmission risk compared with non-ECT treatment were older, unemployed, married, or widowed patients, those treated with antipsychotics or benzodiazepines before admission, with psychotic features, prior psychiatric hospitalizations, or family history of suicide. However, in patients below 35 years of age, ECT was associated with increased readmission risk.

CONCLUSION

This study suggests that ECT reduces the risk of psychiatric readmission in certain subgroups of patients with MDD. Since patients receiving ECT tend to be more difficult to treat, there is a risk of residual confounding.

Electroconvulsive Therapy in Children and Adolescents: A Systematic Review of Current Literature and Guidelines

ABSTRACT

There is a lack of studies regarding the efficacy of electroconvulsive therapy (ECT) in children and adolescents. In this study, we aimed to assess benefits and harms of ECT in children and adolescents with major psychiatric diseases. We conducted a systematic search in PubMed, EMBASE, and PsycINFO for peer-reviewed articles written in English regarding the use of ECT as treatment for major psychiatric diseases in children and adolescents. This study consists of 192 articles, mostly case studies (n = 50), reviews and overview articles (n = 52), and retrospective studies (n = 30). We present an overview of evidence for ECT in children and adolescents with mood disorders, catatonia, schizophrenia, intellectual disability, self-injurious behavior, and other indications. This article is also a summary of international guidelines regarding the use of ECT in children and adolescents. We evaluated the overall quality of evidence by using Grading of Recommendations, Assessment, Development and Evaluations and found the overall level of evidence to be of low quality. There are no absolute contra indications for ECT in children and adolescents. Fears regarding cognitive dysfunction have not been reproduced in studies. Electroconvulsive therapy should be considered in severe, treatment-resistant mood disorders, catatonia, and schizophrenia, especially in older adolescents. High-quality studies are warranted to assess the efficacy of ECT, especially in these potentially life-threatening diseases.

Willingness to pay for a quality-adjusted life year for depressive disorders compared to heart disease based on population preferences

PURPOSE

According to estimations of the World Health Organization, depressive disorders, and cardiovascular disease will be the leading causes for global burden of disease in 2030. The aim of the present study was to estimate the value a representative sample of the German population places on quality-adjusted life years (QALYs) for depressive disorders compared to heart disease.

METHODS

A representative sample of N = 967 of the German general public was randomly presented with one of two hypothetical health-loss scenarios: One version of the questionnaire presented respondents with health loss due to depression, while the other version dealt with health loss due to experiencing a heart disease. Respondents were asked to indicate their willingness to pay (WTP) for four hypothetical health-gain scenarios with different treatment options.

RESULTS

In the depression questionnaire median WTP values ranged from 1000 to 1500 EUR; in the heart disease questionnaire from 1000 to 2000 EUR. Results of the Mann-Whitney U-Test and Median Test indicate higher WTP values for heart disease compared to depressive disorders when QALY gains were minor and stretched over a long period of time, and when treatment with bypass operation (rather than treatment with ECT) was offered. Zero WTP was significantly higher in all scenarios of the depression questionnaire in comparison to the hearth disease questionnaire.

CONCLUSION

Results indicate that respondents valued the necessity of paying for treatment higher when presented with heart disease compared to depression.

Electroconvulsive Therapy and the Risk of Suicide in Hospitalized Patients With Major Depressive Disorder

Importance

Electroconvulsive therapy (ECT) is indicated for severe depression, including depression with psychosis, catatonia, and/or an elevated suicide risk. However, the association of ECT with suicide risk is uncertain.

Objective

To determine the association between ECT and the risk of suicide in patients with unipolar major depressive disorder.

Design, Setting, and Participants

This registry-based cohort study used patient data from Swedish national registers. Patients with a record of inpatient care between January 1, 2012, and October 31, 2018, for moderate depression, severe depression, or severe depression with psychosis were included in the study. Propensity score matching (1:1) was used to balance risk factors for suicide at baseline between patients treated with and without ECT during the inpatient episode.

Exposures

Data from the Swedish National Quality Register for ECT and the Swedish National Inpatient Register were combined to identify patients who had received ECT during the inpatient episode. National registers were used to identify risk factors for suicide.

Main Outcomes and Measures

Suicide within 3 and 12 months of admission to inpatient care was analyzed. Cox regression analyses were used to adjust for confounders.

Results

The study included 28 557 patients (mean [SD] age, ECT group, 55.9 [18.4] years; non-ECT group, 45.2 [19.2] years; 15 856 women [55.5%]). In the matched sample of 5525 patients in each group, 62 patients (1.1%) in the ECT group and 90 patients (1.6%) in the non-ECT group died of suicide within 12 months (hazard ratio [HR], 0.72; 95% CI, 0.52-0.99). Electroconvulsive therapy was significantly associated with a decreased risk of suicide in patients with psychotic features (HR, 0.20; 95% CI, 0.08-0.54) and those aged 45 to 64 years (HR, 0.54; 95% CI, 0.30-0.99) or 65 years or older (HR, 0.30; 95% CI, 0.15-0.59), but not in patients aged 44 years or younger (HR, 1.22; 95% CI, 0.68-2.16).

Conclusions and Relevance

The results of this cohort study support the continued use of ECT to reduce suicide risk in hospitalized patients who are severely depressed, especially those who are older than 45 years and those with a psychotic subtype.

[Use of electroconvulsive therapy in adolescents - A retrospective survey on 12- to 17-year-old patients at three university hospitals in Germany]

Use of electroconvulsive therapy in adolescents - A retrospective survey on 12- to 17-year-old patients at three university hospitals in Germany Abstract. Abstract. Background: Electroconvulsive therapy (ECT) is a highly effective and well-researched therapy in adult psychiatry and has been successfully used especially as a treatment for severe depressive, catatonic, and psychotic disorders. Although severe disease progressions also occur in child and adolescent psychiatry, ECT is used much less frequently there. This may be because hardly any data have been collected on the use, effectiveness, and tolerability of ECT in child and adolescent psychiatric patients. This article outlines the application, effectiveness, and tolerability of ECT when applied to young adolescents in Germany. Methods: A retrospective survey on ECT in 29 patients under 18 years of age was conducted at three German university centers. All documented cases were recorded and evaluated for effectiveness and tolerability. In addition, a comprehensive PubMed-based database search was carried out. Results and conclusions: Internationally, there are no meta-analyses or randomized controlled studies and hardly any published cases on electroconvulsive therapy in German child and adolescent psychiatry. Our data on ECT show high efficacy in previously treatment-resistant and severely ill patients. Side effects occurred rarely. There was no evidence of differences between adults and adolescents in indication (depression, catatonia, schizophrenia), effectiveness, tolerability, and negative predictors of response to ECT. The results also suggest that the use of ECT in adolescents should be considered earlier in the treatment course.

Value of Electroconvulsive Therapy in the General Public: A Willingness to Pay Study in Germany

OBJECTIVE

The aims of this study were to estimate the value a population-representative sample places on electroconvulsive therapy (ECT) through willingness to pay (WTP) and to assess the effects of individual characteristics on WTP for ECT.

METHODS

A German population-representative sample of 518 was presented with a hypothetical health loss scenario of depression and was asked to indicate WTP for ECT. Probit and quantile regression were used to estimate the effects of individual characteristics on the probability of stating a positive WTP and on the amount of money respondents were willing to pay.

RESULTS

Two thirds of respondents stated that they had no knowledge about ECT. Most (56.5%) respondents indicated zero WTP for health gains through ECT treatment. Mean WTP was €5201 ($5612); median WTP was €1000 ($1079). Respondents' monthly household income had a significant effect on the probability of stating a positive WTP. Assessing WTP above zero, income showed a significant positive effect, whereas a higher score of depressive complaints showed a significant negative effect on the amount respondents were willing to pay.

CONCLUSION

Knowledge about ECT treatment is particularly low in the German public.

A Survey of Electroconvulsive Therapy in Finland

OBJECTIVES

The purpose of this study was to explore the use of electroconvulsive therapy (ECT) in Finland in 2013. This included the rate of use, patient ages, sex, number of treatments, patient diagnoses, regional distribution, and availability of ECT.

METHODS

A structured electronic questionnaire was used to collect data regarding the use of ECT from 21 Finnish hospital districts' 29 psychiatric ECT units. Data for comparison were collected from scientific publications concerning the use of ECT in Sweden, Norway, Denmark, and Estonia.

RESULTS

Of 29 psychiatric ECT units, 25 (86%) responded. Electroconvulsive therapy was available in all except 1 hospital district, which used the services of another hospital district. Electroconvulsive therapy was administered to 1023 patients in total. The mean number of treatments per patient was 9.7. Twenty-three persons per 100,000 inhabitants received ECT. The ECT rate between hospital districts varied from 7.5 to 53.0 per 100,000 inhabitants. The mean number and median were 24.9 and 21.7 per 100,000 inhabitants, respectively. Maintenance therapy was administered to 27.1% of patients. Most (75%) of the ECT units indicated the capability to administer ECT to all patients who required it. The most common indications for ECT were major depression (38.4%), psychotic depression (30.9%), and bipolar disorder with depressive episodes (14.2%).

CONCLUSIONS

Electroconvulsive therapy was available in every hospital district in Finland. In Finland, ECT was administered at approximately the same level as in Norway, Denmark, and Estonia (24, 32, and 28 per 100,000 inhabitants, respectively), but less than in Sweden (41 per 100,000 inhabitants).

Neurocognitive functioning after electroconvulsive therapy in late-life depression: A 4-year prospective study

OBJECTIVE

Despite the proven efficacy and safety of ECT, there is still concern about the possible cognitive side effects of ECT in older patients. In this study, we aimed to characterize the long-term cognitive effects of ECT in patients with late-life depression (LLD) from before the start until 4 years after the index ECT course.

METHODS

Fourty one patients aged 55 years and older with a unipolar depression, referred for ECT, were included. The neuropsychological test battery was assessed prior to ECT, 6 months, 1 year, 2 years, 3 years, and 4 years after the last ECT session.

RESULTS

We did not find any statistically significant cognitive changes from before the start to 4 years after ending the ECT course. Although we could not detect cognitive changes at group level, we found clinically important differences on an individual level.

CONCLUSION

Cognitive performance in patients with LLD runs a stable course from before the start of ECT until 4 years after the index course. At an individual level, however, both cognitive decline and improvement can be witnessed. Older patients can tolerate ECT and most of them will not experience long-term cognitive side effects.

Genome-wide association study of patients with a severe major depressive episode treated with electroconvulsive therapy

Although large genome-wide association studies (GWAS) of major depressive disorder (MDD) have identified many significant loci, the SNP-based heritability remains notably low, which might be due to etiological heterogeneity in existing samples. Here, we test the utility of targeting the severe end of the MDD spectrum through genome-wide SNP genotyping of 2725 cases who received electroconvulsive therapy (ECT) for a major depressive episode (MDE) and 4035 controls. A subset of cases (n = 1796) met a narrow case definition (MDE occurring in the context of MDD). Standard GWAS quality control procedures and imputation were conducted. SNP heritability and genetic correlations with other traits were estimated using linkage disequilibrium score regression. Results were compared with MDD cases of mild-moderate severity receiving internet-based cognitive behavioral therapy (iCBT) and summary results from the Psychiatric Genomics Consortium (PGC). The SNP-based heritability was estimated at 29-34% (SE: 6%) for the narrow case definition, considerably higher than the 6.5-8.0% estimate in the most recent PGC MDD study. Our severe MDE cases had smaller genetic correlations with neurodevelopmental disorders and neuroticism than PGC MDD cases but higher genetic risk scores for bipolar disorder than iCBT MDD cases. One genome-wide significant locus was identified (rs114583506, P = 5e-8) in an intron of HLA-B in the major histocompatibility locus on chr6. These results indicate that individuals receiving ECT for an MDE have higher burden of common variant risk loci than individuals with mild-moderate MDD. Furthermore, severe MDE shows stronger relations with other severe adult-onset psychiatric disorders but weaker relations with personality and stress-related traits than mild-moderate MDD. These findings suggest a different genetic architecture at the severest end of the spectrum, and support further study of the severest MDD cases as an extreme phenotype approach to understand the etiology of MDD.

Electroconvulsive Therapy in Italy-Current Dissemination of Treatment and Determining Factors of the Past

OBJECTIVES

The history of electroconvulsive therapy (ECT) spans eight decades, over which period this method of treatment has been modernized. At the same time, however, the conflict between acceptance and rejection of ECT therapy remains unresolved today. This ambivalence is particularly noticeable in Italy, where the number of uses of ECT has been declining for several years. The aim of the present study is to examine the distribution and use of ECT in Italy today in comparison to 2009 and to analyze the factors that have influenced this downward development.

METHODS

A cross-sectional study using a standardized Italian-language questionnaire was conducted in 2017 to investigate the dissemination and practice of ECT in Italy. The study was addressed to all public and private hospitals providing ECT as a treatment.

RESULTS

Of the 145 mental health facilities in Italy, only 9 offered ECT. A total of 293 patients were treated with ECT within 1 year (mainly for depression). Rates for 3-year treatments in the centers yielded an uneven picture: 4 centers showed an increase in cases and just as many a decline. A north-south divide existed in terms of geographical distribution: centers were mainly located in the north in 2017.

CONCLUSIONS

The study shows that the dissemination and use of ECT have reached a historical low in Italy. It further documents the extent to which the use of ECT declined after 2009. Three factors that have accompanied this development are discussed. If this downward trend is to be reversed, it will be necessary to develop a new approach so as to engender a perception of ECT as a viable treatment option.

Electroconvulsive Therapy in Depression: Improvement in Quality of Life Depending on Age and Sex

OBJECTIVES

It is uncertain if there are variations in the improvement of quality in life between sexes and age groups after electroconvulsive therapy (ECT). The aim of this study was to investigate how health-related quality of life changed after treatment and to examine differences in the results between sex and age groups.

METHODS

This register-based study used data from the Swedish national quality register for ECT. The study population was patients diagnosed with depression who had received ECT. Health-related quality of life was quantified using the 3-level version the EuroQol 5-dimensional questionnaire (EQ-5D 3 L). Analysis of variance was used to compare change in EQ-5D score from pretreatment to posttreatment between sex and age groups.

RESULTS

There was a statistically significant improvement in EQ-5D index score and EQ visual analog scale (VAS) score in all patient groups after ECT. The mean improvement in EQ-5D index score and EQ-VAS score ranged from 0.31 to 0.46 and 28.29 to 39.79, respectively. Elderly patients had greater improvement in EQ-5D index score and EQ-VAS score than younger patients. There was no significant difference in improvement between the sexes. The mean improvement in EQ-5D index score was 0.40 for male patients and 0.41 for female patients.

CONCLUSIONS

Electroconvulsive therapy had a considerable effect on health-related quality of life in patients with depression of both sexes and all age groups. The improvement was greatest in elderly patients, who more often had psychotic features. More studies are needed to investigate the long-term effects of ECT and to further explain the varying treatment results between elderly and younger patients.

The Incidence of Dental Fracturing in Electroconvulsive Therapy in Sweden

OBJECTIVES

One adverse effect of electroconvulsive therapy (ECT) is dental fracture; thus, a bite guard and muscle relaxants are used to prevent it. Earlier research reported varying rates of dental fracture, but there is no large-scale study on the incidence of dental fracture during ECT. This study aimed to examine the incidence of dental fracture during ECT and to investigate whether the incidence differs between different sexes, age groups, diagnosis groups, electrode placements, or number of treatment sessions.

METHODS

This register-based study used data from the Swedish national quality register for ECT. All hospitals offering ECT report to this register, and the coverage ratio is about 90%. All registered patients who started an ECT series between January 2012 and January 2019 were included in this study, with the data representing 16,681 individuals, 38,862 series, and 254,906 sessions.

RESULTS

Forty-six dental fractures were identified, giving an incidence of dental fracture of 0.2% per series, 0.02% per session, and 0.3% per individual. We did not find any significant associations between dental fracture rates and male or female populations, age, or different diagnosis groups, nor was there any significant difference between dental fracture rates and electrode placement. The mean number of treatments was significantly higher in the dental fracture group than in patients without dental fracture.

CONCLUSIONS

There is a minimal risk of dental fracture during ECT. Our findings, together with those of other studies, provide further motivation for the use of a bite guard and muscle relaxant.

Electroconvulsive Therapy in Veterans Health Administration Hospitals: Prevalence, Patterns of Use, and Patient Characteristics

OBJECTIVES

The body of large-scale, epidemiological research on electroconvulsive therapy (ECT) in the United States is limited. To address this gap, we assessed demographic, clinical, pharmacological, and mental health treatment history as well as 2-year mortality outcomes associated with ECT use in the largest U.S. health care system.

METHODS

Among all patients who sought mental health care at Veterans Health Administration (VHA) hospitals in 2012, we used bivariate analyses to compare patients who did and not receive ECT during 2 years of follow-up. Among the population who received ECT, descriptive statistics were calculated to characterize prior mental health treatment patterns and ECT receipt.

RESULTS

0.11% (N = 1616) of all VHA mental health patients in 2012 (N = 1,457,053) received ECT in 2 years of follow-up. There was significant regional variation in provision of ECT. Those who received ECT were more likely to have diagnoses of major depressive, bipolar, and personality disorders and were significantly more likely to have had a recent mental health inpatient stay (risk ratio, 6.94). Receipt of ECT was not associated with a difference in all-cause mortality (risk ratio, 0.88). Thirty-two percent of those who received ECT had no substantial antidepressant or therapy trial in the year before index mental health encounter.

CONCLUSIONS

Use of ECT in the VHA is rare. Patients who receive ECT have a complex and high-risk profile, not necessarily consistent with the most common indications for ECT.

Physician estimated vs. self-reported subjective memory in depressed patients treated with electroconvulsive therapy

Background: Subjective memory deficits are common in depression and during series of treatment with electroconvulsive therapy (ECT). There is a need for feasible assessment of memory deficit. In the Swedish National Quality Register for ECT, patients' subjective memory function is rated by a clinician. Self-ratings would be easier to administer.Objectives: The aim of this study was to analyze the consistency between self-reported and physician estimated subjective memory in depressed patients treated with ECT.Methods: Fifty-two inpatients treated with ECT for major- or bipolar depression were recruited and 41 of them completed the study protocol. Each patient rated their own subjective memory and had it rated in an interview by a physician both before/in the beginning of the ECT series and after the ECT series. The patients' memory was rated and self-rated with the memory item in the Comprehensive Psychopathological Rating Scale (CPRS). We then analyzed correlations, and differences in distributions, between self-reported assessment and physician estimates of patients' subjective memory.Results: The correlations between the self-reported and the physician estimated ratings of subjective memory were 0.699 (p < .01) in baseline ratings and 0.651 (p < .01) in post-treatment ratings. These correlations were relatively high compared to a previous study on self-reported vs. physician estimated CPRS ratings.Conclusions: Based on the results in this study, we propose that patients' self-ratings of subjective memory in association with ECT can be used instead of a physician's rating of patients' subjective memory.

[11 C]raclopride positron emission tomography study of dopamine-D2/3 receptor binding in patients with severe major depressive episodes before and after electroconvulsive therapy and compared to control subjects

AIM

The aim of the study was to test: (i) if D₂ /D₃ binding in three functional subsections of striatum is different in patients with severe major depressive episodes than in controls; and (ii) if this difference is normalized after electroconvulsive therapy (ECT).

METHODS

Nine inpatients were examined with positron emission tomography (PET) and the radioligand [¹¹ C]raclopride before and after an average of 8.4 ECT sessions. Treatment response was assessed using the Montgomery-Åsberg Depression Rating Scale. Nine age- and sex-matched controls were examined twice with PET and [¹¹ C]raclopride.

RESULTS

[¹¹ C]raclopride binding was significantly lower in all three subsections of striatum in patients compared to controls (Cohen's d_z , 1.14-1.68; P = 0.003-0.027). Montgomery-Åsberg Depression Ratings decreased significantly after ECT (P < 0.001; Cohen's d_z , 2.9). ECT had no statistically significant effect on [¹¹ C]raclopride binding, although post-ECT binding estimates were more similar to those obtained in controls in all subsections of striatum.

CONCLUSION

Using PET and [¹¹ C]raclopride, we found support for the notion that severe major depressive episodes are associated with significantly lower dopamine D₂ /D₃ binding in all three subsections of striatum compared to controls. We noted no significant effect on D₂ /D₃ binding in the patient group after response to ECT.

When to consider electroconvulsive therapy (ECT)

OBJECTIVE

To familiarize the reader with the role of electroconvulsive therapy (ECT) in current psychiatric medicine.

METHOD

We review clinical indications for ECT, patient selection, contemporary ECT practice, maintenance treatment and ECT in major treatment guidelines.

RESULTS

ECT is underutilized largely due to persisting stigma and lack of knowledge about modern ECT technique.

CONCLUSION

ECT remains a vital treatment for patients with severe mood disorders, psychotic illness and catatonia.

Long-term subjective memory after electroconvulsive therapy

BACKGROUND

There have been reports of long-term subjective memory worsening after electroconvulsive therapy (ECT).

AIMS

To study the prevalence and risk factors of long-term subjective memory worsening among patients receiving ECT in routine clinical practice.

METHOD

Patients (n = 535, of whom 277 were included in the final analysis) were recruited from eight Swedish hospitals. Participants' subjective memory impairment was assessed before ECT and a median of 73 days after ECT using the memory item from the Comprehensive Psychopathological Rating Scale. Participants also rated their pre-ECT expectations and post-ECT evaluations of the effect of ECT on memory on a 7-point scale. We used ordinal regression to identify variables associated with subjective memory worsening and negative evaluations of the effect of ECT on memory.

RESULTS

Comparisons of pre- and post-ECT assessments showed that subjective memory worsened in 16.2% of participants, remained unchanged in 52.3% and improved in 31.4%. By contrast, when asked to evaluate the effect of ECT on memory after treatment 54.6% reported a negative effect. Subjective memory worsening was associated with negative expectations before ECT, younger age and shorter duration of follow-up.

CONCLUSIONS

Although subjective memory improved more often than it worsened when assessed before and after ECT, a majority of patients reported that ECT had negative effects on their memory when retrospectively asked how ECT had affected it. This might suggest that some patients attribute pre-existing subjective memory impairment to ECT. Clinicians should be aware that negative expectations are associated with subjective worsening of memory after ECT.

A Descriptive Study of Data Collection Systems Used in Electroconvulsive Therapy Units in the Province of Quebec, Canada

OBJECTIVES

This study aimed to describe the data collection systems routinely used by electroconvulsive therapy (ECT) units across the province of Quebec, Canada.

METHODS

We conducted a descriptive, cross-sectional study. Using an online survey, 31 ECT units delivering inpatient or outpatient ECT treatments in the province of Quebec provided information on the data collection systems used, data recorded, data collection strategies, indicators of satisfaction, limitations of the current data collection systems, and expectations toward the improvement of ECT data collection.

RESULTS

Most units routinely collected information on individuals receiving ECT treatments, mainly on the medical chart (80%) and in paper format (71%). Most units (88.9%) collected ECT data manually. Electroconvulsive therapy parameters are collected by 66% to 80% of units, but only 16% of them have computerized records. The main limitations of the current systems are as follows: (a) the low frequency of computerization, (b) the underutilization of data, and (c) difficulties in the integration of information from different ECT units. Although 83.3% were satisfied with the current data collection strategies, 80% had a very positive opinion about the development and implementation of an innovative ECT provincial data collection registry.

CONCLUSIONS

An integrated ECT provincial data collection system could overcome the variability documented in existing strategies and respond to the current provincial needs and expectations. Also, an integrated ECT provincial data collection system could support both clinical research and quality assurance necessary to inform standards of ECT practice in Quebec.

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.

Less memory complaints with reduced stimulus dose during electroconvulsive therapy for depression

BACKGROUND

Electroconvulsive therapy (ECT) is an effective treatment for depression, but there is risk of cognitive adverse events. This risk has been partially attributed to electrical charge, thus the optimal electrical stimulus dose is still under discussion. The aim of this study was to evaluate how the risk of subjective memory worsening was changed after lowering stimulus dose during ECT for patients with major depression.

METHOD

A retrospective register-based intervention study of the effects of reduced electrical charges for patients receiving ECT for depression was conducted. The primary outcome was subjective memory worsening and the secondary outcome change in effect on depressive symptoms.

RESULTS

A total of 154 patients were enrolled in the study (High dosage group: n = 57; Lower dosage group: n = 97). Subjective memory worsening after ECT occurred in 44% of patients in the high dosage group and in 25% of patients in the lower dosage group(p = 0.014). There was no significant between-group difference in the anti-depressive effect of ECT.

LIMITATIONS

The study was register-based and the two groups were not randomized. A large portion of patients were initially excluded due to missing data in the register. The study lacks a long-term follow up.

CONCLUSION

After implementing a change of treatment protocol, that lowered ECT stimulus doses from high to moderate, the occurrence of subjective memory worsening was significantly reduced without compromising treatment results.

Electroconvulsive Therapy Practice in the Kingdom of Denmark: A Nationwide Register- and Questionnaire-Based Study

OBJECTIVES

The aim of this study was to survey and describe the contemporary practice of electroconvulsive therapy (ECT) in the Kingdom of Denmark (Denmark, Greenland, and the Faroe Islands).

METHODS

Data regarding number of ECTs and number of patients with different diagnoses treated with ECT were retrieved from the Danish National Patient Registry. In addition, a 45-item questionnaire was sent to all psychiatric departments practicing ECT in Denmark (n = 26), Greenland (n = 1), and the Faroe Islands (n = 1).

RESULTS

According to the Danish National Patient Registry, a total of 21,730 ECTs were administered to 1891 unique patients in 2017. All departments responded to the survey. The psychiatric departments' attitude toward ECT was generally favorable and in accord with official guidelines. Maintenance ECT was used in all departments but one. Bilateral electrode placement was preferred. All departments used a preselected age-based dosing strategy. Involuntary ECT was performed in 96% of the psychiatric departments, but infrequently (3% of all treatments). All departments used a Thymatron (brief pulse) device, and in 71% of the departments, ECT was given in a specialized ECT unit and preanesthetic evaluation was carried out in all departments. The departments reported several different practices regarding documentation and monitoring of treatment effect, patient consent, screening for side effects (including cognitive side effects), and guidelines for the discharge of ECT patients.

CONCLUSIONS

Electroconvulsive therapy is frequently used in Denmark, Greenland, and the Faroe Islands in a relatively uniform way in adherence with clinical guidelines.

A systematic review and computational modelling analysis of unilateral montages in electroconvulsive therapy

OBJECTIVE

To examine the clinical outcomes of ECT unilateral placements compared in prior studies and apply insights from computational modelling to understand differences between placements.

METHODS

PubMed, Embase, Scopus and PsycINFO and reference lists were systematically searched for studies of depressed patients where two unilateral placements were compared and clinical outcomes were reported. Computational modelling was done to generate electric field maps for each unilateral placement identified in the systematic review.

RESULTS

A total of 29 studies met criteria for inclusion. Eight studies reported efficacy outcomes and 23 studies reported cognitive outcomes. Most studies found no significant difference in efficacy between right unilateral (RUL) and left unilateral (LUL) ECT, and no difference was found between temporo-parietal and fronto-temporal ECT. For the majority of studies, RUL placements had better verbal anterograde memory outcomes compared with the LUL placements. There was some evidence suggestive of cognitive advantages for fronto-frontal and fronto-parietal placements relative to temporo-parietal ECT.

CONCLUSIONS

For efficacy, studies mainly focused on the comparison of right vs. left hemispheric stimulation, with the available evidence suggesting no substantive difference. RUL placements tended to have better verbal anterograde memory outcomes relative to LUL placements, though limited differences were found between the RUL placements.

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

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

Factors Influencing Staff's Attitude Toward Electroconvulsive Therapy: A Comparison of New Versus Experienced Electroconvulsive Therapy Clinics

OBJECTIVES

Despite being a highly effective treatment, electroconvulsive therapy (ECT) is still stigmatized even among professionals. The aim of this study was to identify factors associated with a positive attitude toward ECT among health care workers.

METHODS

We investigated staff's attitude and their self-assessment of knowledge while introducing ECT in 3 German psychiatric clinics. Furthermore, we compared this data to that of a clinic where ECT has been applied with a long tradition. An anonymous questionnaire was answered by n = 182 employees in the ECT-introducing clinics (novices) and n = 68 employees in the clinic with a long history of ECT (experts).

RESULTS

Irrespective of the clinical history, the majority of participants approved the application of ECT in their clinic. Factors associated with a positive attitude were (a) profession (physicians presented a more positive mindset about ECT than nursing staff), (b) subjective feeling of being adequately informed, and (c) having had contact to patients undergoing ECT. Interestingly, the general attitude toward ECT did not differ between subjects who reported to have seen an ECT and those who had not.

CONCLUSIONS

When introducing ECT as a new treatment into a clinic, formal information should be adapted to the needs of each profession with a special emphasis on nurses. To further increase acceptance, contact to ECT-experienced patients (professionals taught by patients) might result in a more positive attitude toward ECT than participation in an ECT treatment itself.

Lithium for suicide and readmission prevention after electroconvulsive therapy for unipolar depression: population-based register study

BACKGROUND

Electroconvulsive therapy (ECT) is effective for unipolar depression but relapse and suicide are significant challenges. Lithium could potentially lower these risks, but is used only in a minority of patients.AimsThis study quantifies the effect of lithium on risk of suicide and readmission and identifies factors that are associate with readmission and suicide.

METHOD

This population-based register study used data from the Swedish National Quality Register for ECT and other Swedish national registers. Patients who have received ECT for unipolar depression as in-patients between 2011 and 2016 were followed until death, readmission to hospital or the termination of the study at the end of 2016. Cox regression was used to estimate hazard ratios (HR) of readmission and suicide in adjusted models.

RESULTS

Out of 7350 patients, 56 died by suicide and 4203 were readmitted. Lithium was prescribed to 638 (9%) patients. Mean follow-up was 1.4 years. Lithium was significantly associated with lower risk of suicide (P = 0.014) and readmission (HR 0.84 95% CI 0.75-0.93). The number needed to be treated with lithium to prevent one readmission was 16. In addition, the following factors were statistically associated with suicide: male gender, being a widow, substance use disorder and a history of suicide attempts. Readmission was associated with young age, being divorced or unemployed, comorbid anxiety disorder, nonpsychotic depression, more severe symptoms before ECT, no improvement with ECT, not receiving continuation ECT or antidepressants, usage of antipsychotics, anxiolytics or benzodiazepines, severity of medication resistance and number of previous admissions.

CONCLUSIONS

More patients could benefit from lithium treatment.Declaration of interestNone.

Electroconvulsive therapy: 80 years old and still going strong

Electroconvulsive therapy (ECT), which is among the oldest and most controversial treatments in the field of psychiatry, has its 80^th birthday this year. In this brief historical overview, the discovery of the therapeutic effects of convulsive therapy by Laszló Meduna, and the circumstances that motivated Ugo Cerletti and Lucio Bini to use electricity as a means of seizure induction are described. Meduna’s original theory about the antagonism between epilepsy and schizophrenia has been replaced by hypotheses on the mechanism of action of ECT. The position of ECT in modern psychiatry is also discussed with special attention to its most important clinical indications, including catatonia, and pre- and postpartum affective and psychotic states that are responsive to ECT and in which ECT may even be lifesaving. Adverse effects and comparison of ECT with recently developed brain stimulation methods are also reviewed. The negative media portrayal of ECT and its earlier misuse may have contributed to its negative professional and public perceptions indicated repeatedly in attitude surveys. This negative attitude has played an important role in the decreasing use of ECT in the developed world and a reduction in access to ECT, which constitutes a violation of psychiatric patients’ right to an effective treatment.