Seizure Adequacy Markers and the Prediction of Electroconvulsive Therapy Response

Correlation Between ECT Quality Measures and Likelihood to Transition From Acute to Continuation and Maintenance ECT

OBJECTIVES

To evaluate the association between 3 ECT quality measures (seizure duration, Postictal Suppression Index [PSI], and heart rate response) and therapeutic compliance as indicated by transitioning from acute to continuation to maintenance phases of ECT.

METHODS

This was a retrospective chart review of patients who received ECT between July 2016 and July 2019. ECT quality measures were lagged by 1 ECT session to examine the effect of the prior session's quality measure on progressing to a higher ECT phase at the subsequent ECT session. Associations with therapeutic compliance were analyzed using mixed-effects ordinal regression and mixed-effects partial proportional odds models.

RESULTS

Seizure duration was associated with 8% higher adjusted odds of progressing to out of the acute phase (95% confidence interval [CI]: 2% to 15%, P = 0.007) and 18% higher adjusted odds of progressing to the maintenance phase (95% CI: 10% to 28%, P < 0.001); PSI was associated with 9% higher adjusted odds of progressing out of the acute phase (95% CI: 3% to 16%, P = 0.005), whereas heart rate response was not statistically associated with therapeutic compliance. Greater therapeutic compliance was also associated with bilateral electrode placement and older age.

CONCLUSIONS

Longer seizure duration was associated with greater therapeutic compliance across all ECT phases, PSI was associated with progressing out of the acute phase, and heart rate response was not associated with therapeutic compliance. Our findings assist ECT psychiatrists in optimizing ECT quality measures to promote better compliance with ECT.

The Effect of Remimazolam on Seizure Profile, Hemodynamics, and Recovery in Patients With Electroconvulsive Therapy Comparison With Propofol and Etomidate: A Retrospective Study

OBJECTIVES

To compare seizure-related, hemodynamic, and recovery outcomes when using remimazolam for ECT with those of other anesthetics, specifically propofol and etomidate.

METHODS

A total of 49 patients who underwent 405 ECT treatment sessions under general anesthesia were retrospectively analyzed. Remimazolam, propofol, and etomidate were used for 93, 138, and 174 ECT sessions, respectively. The primary outcome was durations of motor and electroencephalogram (EEG) seizure activity, whereas secondary outcomes included hemodynamics (ie, mean arterial pressure [MAP] and heart rate [HR] at various time points from induction to postanesthesia care unit [PACU] discharge), antihypertensive drugs administration after electrical stimulus, and recovery profiles (ie, length of PACU stay and incidence of postictal confusion).

RESULTS

Durations of motor and EEG seizures were shorter for remimazolam than etomidate (motor, P < 0.001; EEG, P = 0.003) but similar compared with propofol (motor, P = 0.191; EEG, P = 0.850). During seizure, remimazolam showed a comparable MAP and HR to etomidate (MAP: P = 0.806; HR: P = 0.116). The antihypertensive drug use was lowest for remimazolam (6.8%), followed by propofol (35.6%) and etomidate (65.6%), and the mean length of PACU stay was comparable for remimazolam (19.7 min), propofol (22.8 min), and etomidate (24.5 min). The occurrence of postictal confusion did not differ among the 3 agents (P > 0.050).

CONCLUSIONS

Remimazolam is a promising anesthetic option for ECT because of its comparable seizure profiles, stable hemodynamics, and comparable PACU stay when compared with propofol and etomidate without additional adverse events.

Behavioral and transcriptional effects of repeated electroconvulsive seizures in the neonatal MK-801-treated rat model of schizophrenia

RATIONALE

Electroconvulsive therapy (ECT) is an effective treatment modality for schizophrenia. However, its antipsychotic-like mechanism remains unclear.

OBJECTIVES

To gain insight into the antipsychotic-like actions of ECT, this study investigated how repeated treatments of electroconvulsive seizure (ECS), an animal model for ECT, affect the behavioral and transcriptomic profile of a neurodevelopmental animal model of schizophrenia.

METHODS

Two injections of MK-801 or saline were administered to rats on postnatal day 7 (PN7), and either repeated ECS treatments (E10X) or sham shock was conducted daily from PN50 to PN59. Ultimately, the rats were divided into vehicle/sham (V/S), MK-801/sham (M/S), vehicle/ECS (V/E), and MK-801/ECS (M/E) groups. On PN59, prepulse inhibition and locomotor activity were tested. Prefrontal cortex transcriptomes were analyzed with mRNA sequencing and network and pathway analyses, and quantitative real-time polymerase chain reaction (qPCR) analyses were subsequently conducted.

RESULTS

Prepulse inhibition deficit was induced by MK-801 and normalized by E10X. In M/S vs. M/E model, Egr1, Mmp9, and S100a6 were identified as center genes, and interleukin-17 (IL-17), nuclear factor kappa B (NF-κB), and tumor necrosis factor (TNF) signaling pathways were identified as the three most relevant pathways. In the V/E vs. V/S model, mitophagy, NF-κB, and receptor for advanced glycation end products (RAGE) pathways were identified. qPCR analyses demonstrated that Igfbp6, Btf3, Cox6a2, and H2az1 were downregulated in M/S and upregulated in M/E.

CONCLUSIONS

E10X reverses the behavioral changes induced by MK-801 and produces transcriptional changes in inflammatory, insulin, and mitophagy pathways, which provide mechanistic insight into the antipsychotic-like mechanism of ECT.

Association between postictal suppression and the therapeutic effects of electroconvulsive therapy: A systematic review

Electroconvulsive therapy (ECT) is an effective and safe medical treatment for patients with severe mood and neuropsychiatric disorders. Since the advent of ECT, extensive research has been performed to identify the predictive factors for response to ECT. In recent decades, postictal suppression on an electroencephalogram (EEG) has been considered a potential predictor of response to ECT. We aimed to investigate the direct association between postictal suppression and the therapeutic effects of ECT. In this systematic review, all articles in the field of the association between postictal suppression and the therapeutic effects of ECT published between 1990 and 2021 were identified. The full texts of these articles, which include clinical trials and retrospective and cross-sectional studies, are available in scholarly research databases and search engines, including PubMed, Google Scholar, OVID, Web of Science, and Scopus. Of all retrieved articles, eight studies, including four retrospective cohort articles and four clinical trials, met the inclusion criteria for further analyses. The findings of this study showed a significant association between postictal suppression and the therapeutic efficacy of ECT. Factors such as electrode placement, tachycardia, type of anesthetic agent, and EEG amplitude were also directly related to postictal suppression and the efficacy of ECT. Postictal suppression on EEG can be considered a predictor of response to ECT. To increase the effectiveness of treatment with ECT and increase postictal suppression, factors including electrode placement, tachycardia, type of anesthesia, and EEG amplitude should be considered, which highlights the need for further research.

Adequacy of Children's Psychopharmacology Services: Variations by Race and Clinical Characteristics

OBJECTIVE

An expert consensus approach was used to determine the adequacy of children's psychopharmacology and to examine whether adequacy varied by demographic or clinical characteristics.

METHODS

Data were from the baseline interview of 601 children, ages 6-12 years, who had visited one of nine outpatient mental health clinics and participated in the Longitudinal Assessment of Manic Symptoms study. Children and parents were interviewed with the Kiddie Schedule for Affective Disorders and Schizophrenia and the Service Assessment for Children and Adolescents to assess the child's psychiatric symptoms and lifetime mental health services use, respectively. An expert consensus approach informed by published treatment guidelines was used to determine the adequacy of children's psychotropic medication treatment.

RESULTS

Black children (compared with White children; OR=1.84, 95% CI=1.53-2.23) and those with anxiety disorders (vs. no anxiety disorder; OR=1.55, 95% CI=1.08-2.20) were more likely to receive inadequate pharmacotherapy; those whose caregivers had a bachelor's degree or more education (vs. those who had a high school education, general equivalency diploma, or less than high school education; OR=0.74, 95% CI=0.61-0.89) were less likely to receive inadequate pharmacotherapy.

CONCLUSIONS

The consensus rater approach permitted use of published treatment efficacy data and patient characteristics (e.g., age, diagnoses, history of recent hospitalizations, and psychotherapy) to assess adequacy of pharmacotherapy. These results replicate findings of racial disparities reported in previous research using traditional methods to determine treatment adequacy (e.g., with a minimum number of treatment sessions) and highlight the continued need for research on racial disparities and strategies to improve access to high-quality care.

Irremediability in psychiatric euthanasia: examining the objective standard

BACKGROUND

Irremediability is a key requirement for euthanasia and assisted suicide for psychiatric disorders (psychiatric EAS). Countries like the Netherlands and Belgium ask clinicians to assess irremediability in light of the patient's diagnosis and prognosis and 'according to current medical understanding'. Clarifying the relevance of a default objective standard for irremediability when applied to psychiatric EAS is crucial for solid policymaking. Yet so far, a thorough examination of this standard is lacking.

METHODS

Using treatment-resistant depression (TRD) as a test case, through a scoping review in PubMed, we analyzed the state-of-the-art evidence for whether clinicians can accurately predict individual long-term outcome and single out irremediable cases, by examining the following questions: (1) What is the definition of TRD; (2) What are group-level long-term outcomes of TRD; and (3) Can clinicians make accurate individual outcome predictions in TRD?

RESULTS

A uniform definition of TRD is lacking, with over 150 existing definitions, mostly focused on psychopharmacological research. Available yet limited studies about long-term outcomes indicate that a majority of patients with long-term TRD show significant improvement over time. Finally, evidence about individual predictions in TRD using precision medicine is growing, but methodological shortcomings and varying predictive accuracies pose important challenges for its implementation in clinical practice.

CONCLUSION

Our findings support the claim that, as per available evidence, clinicians cannot accurately predict long-term chances of recovery in a particular patient with TRD. This means that the objective standard for irremediability cannot be met, with implications for policy and practice of psychiatric EAS.

Effects of electroconvulsive therapy on cerebral A1 adenosine receptor availability: a PET study in patients suffering from treatment-resistant major depressive disorder

Introduction

Sleep deprivation and electroconvulsive therapy (ECT) effectively ameliorate symptoms in major depressive disorder (MDD). In rodents, both are associated with an enhancement of cerebral adenosine levels, which in turn likely influence adenosinergic receptor expression. The aim of the current study was to investigate cerebral A1 adenosine receptor (A1AR) availability in patients with MDD as a potential mediating factor of antidepressant effects of ECT using [18F]CPFPX and positron emission tomography (PET).

Methods

Regional A1AR availability was determined before and after a series of ECT applications (mean number ± SD 10.4 ± 1.2) in 14 subjects (4 males, mean age 49.5 ± 11.8 years). Clinical outcome, measured by neuropsychological testing, and ECT parameters were correlated with changes in A1AR availability.

Results

ECT had a strong antidepressive effect (p < 0.01) while on average cerebral A1AR availability remained unaltered between pre-and post-ECT conditions (F = 0.65, p = 0.42, mean difference ± SD 3.93% ± 22.7%). There was no correlation between changes in clinical outcome parameters and regional A1AR availability, although individual patients showed striking bidirectional alterations of up to 30-40% in A1AR availability after ECT. Solely, for the mean seizure quality index of the applied ECTs a significant association with changes in A1AR availability was found (rs = -0.6, p = 0.02).

Discussion

In the present study, therapeutically effective ECT treatment did not result in coherent changes of A1AR availability after a series of ECT treatments. These findings do not exclude a potential role for cerebral A1ARs in ECT, but shift attention to rather short-termed and adaptive mechanisms during ECT-related convulsive effects.

Seizure EEG Quality in Right Unilateral Ultrabrief ECT

OBJECTIVE

The aims of this study were to compare threshold and suprathreshold ictal electroencephalograms (EEGs) in right unilateral (RUL) ultrabrief (UB) electroconvulsive therapy (ECT) and to identify the differences between these EEGs.

METHODS

This study is a retrospective review of 125 pairs EEGs from titration and subsequent sessions across a 2-year period. All EEGs were independently rated for by 2 assessors using a scale based on qualities of an EEG used to guide ECT treatment dose adequacy, for example, midictal amplitude, regularity, interhemispheric coherence, seizure end point, and postictal suppression. The scores of threshold and suprathreshold EEGs were compared within and between groups based on 2 ECT types, that is, RUL UB ECT and RUL brief pulse (BP) ECT.

RESULTS

Paired t tests showed a statistically significant difference in between threshold and suprathreshold EEG scores in RUL UB ECT. There were no statistically significant differences between corresponding scores for RUL UB ECT and RUL BP ECT threshold and suprathreshold EEGs.

CONCLUSIONS

There is a significant difference between the quality of threshold and suprathreshold EEGs in RUL UB ECT when measured with an EEG rating scale. Visual rating of ictal EEGs is as reliable in discriminating between threshold and suprathreshold seizure in RUL UB ECT as it is in RUL BP ECT.

Information flow and dynamic functional connectivity during electroconvulsive therapy in patients with depression

BACKGROUND

Electroconvulsive therapy is effectively used for treatment-resistant depression; however, its neural mechanism is largely unknown. Resting-state functional magnetic resonance imaging is promising for monitoring outcomes of electroconvulsive therapy for depression. This study aimed to explore the imaging correlates of the electroconvulsive therapy effects on depression using Granger causality analysis and dynamic functional connectivity analyses.

METHODS

We performed advanced analyses of resting-state functional magnetic resonance imaging data at the beginning and intermediate stages and end of the therapeutic course to identify neural markers that reflect or predict the therapeutic effects of electroconvulsive therapy on depression.

RESULTS

We demonstrated that information flow between the functional networks analyzed by Granger causality changes during electroconvulsive therapy, and this change was correlated with the therapeutic outcome. Information flow and the dwell time (an index reflecting the temporal stability of functional connectivity) before electroconvulsive therapy are correlated with depressive symptoms during and after treatment.

LIMITATIONS

First, the sample size was small. A larger group is needed to confirm our findings. Second, the influence of concomitant pharmacotherapy on our results was not fully addressed, although we expected it to be minimal because only minor changes in pharmacotherapy occurred during electroconvulsive therapy. Third, different scanners were used the groups, although the acquisition parameters were the same; a direct comparison between patient and healthy participant data was not possible. Thus, we presented the data of the healthy participants separately from that of the patients as a reference.

CONCLUSIONS

These results show the specific properties of functional brain connectivity.

Effects of Anesthesia Changes During Maintenance ECT: A Longitudinal Comparison of Seizure Quality Under Anesthesia Using Propofol/Esketamine Versus Methohexital

INTRODUCTION

The effectiveness of ECT relies on the induction of a generalized cerebral seizure. Among others, seizure quality (SQ) is potentially influenced by the anesthetic drug used. Commonly used anesthetics comprise barbiturates, etomidate, propofol, and esketamine, with different characteristics and impacts on seizure parameters. So far, no studies have compared the influence of methohexital vs. a combination of propofol/esketamine on established SQ parameters.

METHODS

This retrospective longitudinal study compared eight established SQ parameters (PSI, ASEI, MSC, midictal amplitude, motor and electroencephalography (EEG) seizure duration, concordance, PHR) before and after the change from propofol/esketamine to methohexital in 34 patients under maintenance ECT. Each patient contributed four measurements, two before and two after the anesthesia change. Anesthesia dose, stimulus dose, electrode placement, and concomitant medication remained unchanged throughout the analyzed treatments.

RESULTS

Under methohexital (M=88.97 mg), ASEI (p=0.039 to 0.013) and midictal amplitude (p=0.022 to<0.001) were significantly lower, whereas seizure duration (motor and EEG) was significantly longer when compared to propofol/esketamine (M=64.26 mg/51.18 mg; p=0.012 to<0.001). PSI, MSC, seizure concordance, and PHR were not affected by the anesthetic used.

DISCUSSION

Although to what extent these parameters correlate with the therapeutic effectiveness remains ambiguous, a decision for or against a particular anesthetic could be considered if a specific SQ parameter needs optimization. However, no general superiority for one specific substance or combination was found in this study. In the next step, anesthetic effects on treatment response and tolerability should be focused on.

Comparison of etomidate and methohexital as anesthetic agents for continuation and maintenance electroconvulsive therapy: A retrospective analysis of seizure quality and safety

BACKGROUND

The ideal hypnotic agent for electroconvulsive therapy (ECT) is still under debate and previous studies comparing etomidate and methohexital have produced conflicting results. This retrospective study compares etomidate and methohexital as anesthetic agents in continuation and maintenance (m)ECT with regard to seizure quality and anesthetic outcomes.

METHODS

All subjects undergoing mECT at our department between October 1st, 2014 and February 28th, 2022 were included in this retrospective analysis. Data for each ECT session were obtained from the electronic health records. Anesthesia was performed with either methohexital/succinylcholine or etomidate/succinylcholine. Standard seizure quality parameters, anesthesiological monitoring data, pharmacological interventions and side-effects were recorded.

RESULTS

573 mECT treatments in 88 patients were included (methohexital n = 458, etomidate n = 115). Seizures lasted significantly longer after using etomidate (electroencephalography: +12.80 s [95 %-CI:8.64-16.95]; electromyogram +6.59 s [95 %-CI:4.14-9.04]). Time to maximum coherence was significantly longer with etomidate (+7.34 s [95 %-CI:3.97-10.71]. Use of etomidate was associated with longer procedure duration (+6.51 min [95 %-CI:4.84-8.17]) and higher maximum postictal systolic blood pressure (+13.64 mmHg [95 %-CI:9.33-17.94]). Postictal systolic blood pressure > 180 mmHg, the use of antihypertensives, benzodiazepines and clonidine (for postictal agitation), as well as the occurrence of myoclonus was significantly more common under etomidate.

CONCLUSIONS

Due to longer procedure duration and an unfavorable side effect profile, etomidate appears inferior to methohexital as an anesthetic agent in mECT despite longer seizure durations.

Cerebral oxygen saturation in the prefrontal cortex during electroconvulsive therapy and its relation with the postictal reorientation time

The therapeutic effect of Electroconvulsive Therapy (ECT) has been attributed to generalised seizure. Although patients are well oxygenated prior to and during treatment, critics have associated ECT with brain tissue hypoxemia. In this study, the regional oxygen saturation (rSO₂) was measured continuously during ECT in the prefrontal cortex (PFC) of both hemispheres using 2-channel Near Infrared Spectroscopy (NIRS). Additionally, the postictal reorientation time (PRT) was determined and related to the rSO₂ course. We evaluated 72 ECT treatments in 22 adult patients who were treated for a therapy-resistant depressive syndrome. The therapy was performed according to our standard clinical procedures deploying right unilateral (RUL) and left anterior versus right temporal (LART) electrode placements. According to our results, the rSO₂ courses showed an increase during hyperventilation, a sharp drop immediately after the stimulus, and a long recovery period with values far exceeding the baseline. In 55,6% of treatments the rSO₂ course stayed above the baseline. In the others, the drop fell below it for an average of 12.6 s. According to a cardio surgical standard no signs of hypoxemia occurred during ECT treatments. The rSO₂ drop at seizure onset was the only parameter of the oxygen course related to the PRT in the multivariate analysis and might therefore be a characteristic feature of the seizure. It could reflect its physiological intensity and thereby be involved in the mechanism of action of ECT. NIRS seems to be an interesting non-invasive tool for monitoring and studying ECT.

Intercorrelation of physiological seizure parameters and hormonal changes in electroconvulsive therapy

OBJECTIVE

Physiological parameters that predict electroconvulsive therapy (ECT) effectiveness may reflect propagation of the induced epileptic seizure. As an indication of seizure propagation to the diencephalon, we here examined the correlation between prolactin increase after ECT and clinical seizure evaluation parameters, focusing on peak heart rate. As a proxy for peripheral endocrine stress response, we examined the correlation to postictal cortisol increase.

METHODS

Participants were consecutively recruited from clinical ECT patients (n = 131, age 18-85 years). The first ECT session in a series was examined. For each participant, blood serum concentrations of prolactin and cortisol were measured immediately before and within 30 min after the seizure. Physiological parameters were extracted from clinical records: peak heart rate (HR) during seizure, electroencephalography (EEG) seizure duration, and motor seizure duration. Correlations were calculated using non-parametric tests.

RESULTS

Serum prolactin increased after ECT and correlated with peak HR, EEG seizure duration, and motor seizure duration. Peak HR during seizure also correlated positively with both EEG seizure duration and motor seizure duration. Correlations were unaffected by age, sex, baseline prolactin levels, antipsychotics, or beta-blocking agents. Serum cortisol increased after ECT but did not correlate with the seizure evaluation parameters, nor with prolactin concentrations.

CONCLUSIONS

Our findings of a positive correlation between peak HR and prolactin that was independent from the peripheral endocrine stress response might be in line with the idea that tachycardia during ECT seizures reflects seizure propagation to the diencephalon. This supports the practice of monitoring cardiovascular response for ECT seizure evaluation.

Increased Stimulation Intensity Helped to Cope with Prolonged Seizures During the Next Round of Modified Electroconvulsive Therapy: A Case Report

Background

Case Presentation

Conclusion

Investigating the Role of Leukocyte Telomere Length in Treatment-Resistant Depression and in Response to Electroconvulsive Therapy

Psychiatric disorders seem to be characterized by premature cell senescence. However, controversial results have also been reported. In addition, the relationship between accelerated aging and treatment-resistance has scarcely been investigated. In the current study, we measured leukocyte telomere length (LTL) in 148 patients with treatment-resistant depression (TRD, 125 with major depressive disorder, MDD, and 23 with bipolar disorder, BD) treated with electroconvulsive therapy (ECT) and analyzed whether LTL was associated with different response profiles. We also compared LTL between patients with TRD and 335 non-psychiatric controls. For 107 patients for which genome-wide association data were available, we evaluated whether a significant overlap among genetic variants or genes associated with LTL and with response to ECT could be observed. LTL was negatively correlated with age (Spearman’s correlation coefficient = −0.25, p < 0.0001) and significantly shorter in patients with treatment-resistant MDD (Quade’s F = 35.18, p < 0.0001) or BD (Quade’s F = 20.84, p < 0.0001) compared to controls. Conversely, baseline LTL was not associated with response to ECT or remission. We did not detect any significant overlap between genetic variants or genes associated with LTL and response to ECT. Our results support previous findings suggesting premature cell senescence in patients with severe psychiatric disorders and suggest that LTL could not be a predictive biomarker of response to ECT.

Challenges during Electroconvulsive Therapy—A Review

Electroconvulsive therapy (ECT) is one of the most successful treatment techniques employed in psychiatric practice. ECT is usually administered as a last resort to a patient who fails to respond to medical management or on an urgent basis as a life-saving procedure when immediate response is desired. It is performed under general anesthesia and is often associated with autonomic changes. All attempts should be made to minimize the resulting hemodynamic disturbances in all the patients using various pharmacological methods. Anesthesiologists providing anesthesia for ECT frequently encounter patients with diverse risk factors. Concurrent cardiovascular, neurological, respiratory, and endocrine disorders may require modification of anesthetic technique. It is ideal to optimize patients before ECT. In this review, the authors discuss the optimization, management, and modification of anesthesia care for patients with various cardiac, neurological, respiratory, and endocrine disorders presenting for ECT to improve the safety of the procedure. It is not infrequent that an anesthesiologist also plays an important role in inducing a seizure. Proconvulsants such as caffeine, adjuvants like opioids, hyperventilation, and appropriate choice of anesthetic agent for induction such as etomidate or ketamine can help. The use of BIS monitoring to guide the timing of electric stimulation is also elaborated in this review.

Factors Predicting Ictal Quality in Bilateral Electroconvulsive Therapy Sessions

In electroconvulsive therapy (ECT), ictal characteristics predict treatment response and can be modified by changes in seizure threshold and in the ECT technique. We aimed to study the impact of ECT procedure-related variables that interact during each session and might influence the seizure results. Two hundred and fifty sessions of bilateral ECT in forty-seven subjects were included. Seizure results were evaluated by two different scales of combined ictal EEG parameters (seizure quality index (SQI) and seizure adequacy markers sum (SAMS) scores) and postictal suppression rating. Repeated measurement regression analyses were performed to identify predictors of each session’s three outcome variables. Univariate models identified age, physical status, hyperventilation, basal oxygen saturation, days between sessions, benzodiazepines, lithium, and tricyclic antidepressants as predictors of seizure quality. Days elapsed between sessions, higher oxygen saturation and protocolized hyperventilation application were significant predictors of better seizure quality in both scales used in multivariate models. Additionally, lower ASA classification influenced SQI scores as well as benzodiazepine use and lithium daily doses were predictors of SAMS scores. Higher muscle relaxant doses and lower applied stimulus intensities significantly influenced the postictal suppression rating. The study found several modifiable procedural factors that impacted the obtained seizure characteristics; they could be adjusted to optimize ECT session results.

An Observational Retrospective Study Investigating Changes in Seizure Adequacy Parameters of Electroconvulsive Therapy and Their Relationships to Clinical Outcome in Schizophrenia and Schizoaffective Disorder

The aim of the current study was to investigate a possible relationship between electroconvulsive therapy (ECT) seizure adequacy parameters and clinical outcome as well as differences between ECT responders and nonresponders in terms of ECT seizure parameters in patients diagnosed with schizophrenia and schizoaffective disorder. First and last ECT records data, sociodemographic variables, and baseline and post ECT Positive and Negative Syndrome Scale scores were obtained. Maximum sustained power was higher in last ECT in favor of responders while peak heart rate was higher in ECT nonresponders than responders in first ECT. Stimulus doses were higher in last ECT than in the first ECT in both groups. No predictor variable was observed among baseline ECT seizure parameters for clinical improvement. Study was insufficient to yield a precise finding pointing a relationship between electrophysiological seizure parameters and clinical outcome in schizophrenia and schizoaffective disorder.

The novel seizure quality index for the antidepressant outcome prediction in electroconvulsive therapy: association with biomarkers in the cerebrospinal fluid

For patients with depression treated with electroconvulsive therapy (ECT), the novel seizure quality index (SQI) can predict the risk of non-response (and non-remission)-as early as after the second ECT session-based the extent of several ictal parameters of the seizure. We aim to test several CSF markers on their ability to predict the degree of seizure quality, measured by the SQI to identify possible factors, that could explain some variability of the seizure quality. Baseline CSF levels of metabolites from the kynurenine pathway, markers of neurodegeneration (tau proteins, β-amyloids and neurogranin), elements of the innate immune system, endocannabinoids, sphingolipids, neurotrophic factors (VEGF) and Klotho were measured before ECT in patients with depression (n = 12) to identify possible correlations with the SQI by Pearson's partial correlation. Negative, linear relationships with the SQI for response were observed for CSF levels of T-tau (r_partial = - 0.69, p = 0.019), phosphatidylcholines (r_partial = - 0.52, p = 0.038) and IL-8 (r_partial = - 0.67, p = 0.047). Regarding the SQI for remission, a negative, linear relationship was noted with CSF levels of the endocannabinoid AEA (r_partial = - 0.70, p = 0.024) and CD163 (r_partial = - 0.68, p = 0.029). In sum, CSF Markers for the innate immune system, for neurodegeneration and from lipids were found to be associated with the SQI for response and remission after adjusting for age. Consistently, higher CSF levels of the markers were always associated with lower seizure quality. Based on these results, further research regarding the mechanism of seizure quality in ECT is suggested.

Psychotropic Medication Effects on Seizure Threshold and Seizure Duration During Electroconvulsive Therapy Stimulus Titration

OBJECTIVES

Decisions about psychotropic medication administration before electroconvulsive therapy (ECT) are central to management of a very psychiatrically ill patient population. Given that many psychotropic medications are thought to either promote or prevent seizures, there is ongoing concern about concurrent psychotropic medication and ECT administration. This study examined the effect of psychotropic medications on seizure threshold and duration during ECT stimulus titration.

METHODS

The study sample consisted of 550 patients receiving ECT stimulus titration at a single site during a 27-month period. Systematic chart review provided clinical data, including patients' demographics, psychiatric diagnoses, medications administered in the 48 hours before ECT, and information on the ECT procedure. Referring psychiatrists were advised to discontinue lithium before ECT but otherwise managed psychotropic medications as clinically indicated. A fixed charge titration schedule was used to estimate seizure threshold. Electroconvulsive therapy motor seizure duration was estimated by the cuff method, and electroencephalogram seizure duration was estimated by review of a 2-lead strip.

RESULTS

Administration of psychotropic medications, including benzodiazepines, antiepileptics, selective serotonin reuptake inhibitors, tricyclic and tetracyclic antidepressants, bupropion, and stimulants, was not associated with seizure threshold as estimated by electrical charge eliciting a generalized seizure or duration during the initial ECT titration. Tricyclic and tetracyclic antidepressant dosage was associated with seizure threshold.

CONCLUSIONS

Psychotropic medications may have little effect on seizure threshold and duration during titration of electrical dose at ECT initiation. Integrating this work with other literature supports making recommendations for medication discontinuation before ECT on an individual basis.

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.

Influence of electroconvulsive therapy on white matter structure in a diffusion tensor imaging study

BACKGROUND

Electroconvulsive therapy (ECT) is a fast-acting intervention for major depressive disorder. Previous studies indicated neurotrophic effects following ECT that might contribute to changes in white matter brain structure. We investigated the influence of ECT in a non-randomized prospective study focusing on white matter changes over time.

METHODS

Twenty-nine severely depressed patients receiving ECT in addition to inpatient treatment, 69 severely depressed patients with inpatient treatment (NON-ECT) and 52 healthy controls (HC) took part in a non-randomized prospective study. Participants were scanned twice, approximately 6 weeks apart, using diffusion tensor imaging, applying tract-based spatial statistics. Additional correlational analyses were conducted in the ECT subsample to investigate the effects of seizure duration and therapeutic response.

RESULTS

Mean diffusivity (MD) increased after ECT in the right hemisphere, which was an ECT-group-specific effect. Seizure duration was associated with decreased fractional anisotropy (FA) following ECT. Longitudinal changes in ECT were not associated with therapy response. However, within the ECT group only, baseline FA was positively and MD negatively associated with post-ECT symptomatology.

CONCLUSION

Our data suggest that ECT changes white matter integrity, possibly reflecting increased permeability of the blood-brain barrier, resulting in disturbed communication of fibers. Further, baseline diffusion metrics were associated with therapy response. Coherent fiber structure could be a prerequisite for a generalized seizure and inhibitory brain signaling necessary to successfully inhibit increased seizure activity.

Overlooking the obvious? Influence of electrolyte concentrations on seizure quality parameters in electroconvulsive therapy

Clinical response to electroconvulsive therapy (ECT) depends on eliciting a generalized seizure. Though there are multiple ictal and other parameters to assess seizure quality, factors that influence these parameters have only been identified to a limited extend in antecedent studies (e.g., stimulus dosage, age). In the context of ECT, electrolyte concentrations have hardly been investigated so far-although hyponatremia is one well-known clinical factor to increase the risk of spontaneous seizures. In 31 patients with unipolar or bipolar depressive disorder, blood concentrations of sodium (Na), potassium (K), and calcium (Ca) were measured immediately prior to repeated sessions of maintenance ECT. Generalized linear mixed models were used to analyze the influence of Na, K, and Ca on seven seizure quality parameters: postictal suppression index (PSI), maximum sustained coherence (MSC), midictal amplitude, average seizure energy index, seizure duration (EEG/motor), and peak heart rate. Results show a statistically significant relationship between the serum sodium level and MSC: in the model, a reduction of 1 mmol/l led to an increase in interhemispheric coherence of 0.678%. The further markers remained unaffected by changes in electrolyte concentrations. This finding provides first evidence that a lower blood concentration of sodium could enhance the quality of ECT-induced seizures in terms of higher interhemispheric coherence.

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.

Performance of the Psychotic Depression Assessment Scale as a Predictor of ECT Outcome

OBJECTIVES

The presence of psychotic symptoms is an important predictor of responsiveness to electroconvulsive therapy (ECT). This study investigates whether a continuous severity measure, the Psychotic Depression Assessment Scale (PDAS), is a more accurate predictor.

METHODS

Depression severity was assessed before and after the ECT course using the Montgomery-Asberg Depression Rating Scale (MADRS) in 31 patients with psychotic depression and 34 depressed patients without psychotic symptoms. Logistic regression models for MADRS response and remission were fitted, with either the PDAS total score or the dichotomous predictors "absence/presence of psychotic symptoms" as the independent variables. Age, episode duration, and treatment resistance were added as covariates.

RESULTS

Both the asserted presence of psychotic symptoms and a higher PDAS total score reflected MADRS response (areas under the curve, 0.83 and 0.85, respectively), with MADRS remission also being predicted by the presence of psychotic symptoms and higher PDAS scores (areas under the curves, 0.86 and 0.84, respectively). Age was a contributor to these prediction models, with response and remission rates being highest in the older patients. Psychotic Depression Assessment Scale scores decreased significantly during ECT: at end point, 81.5% of the patients showed significant response and 63.9% had achieved remission.

CONCLUSIONS

The PDAS indeed accurately predicts response to and remission after ECT in (psychotic) depression and most pronouncedly so in older patients but seems to have no clear advantage over simply verifying the presence of psychotic symptoms. This could be the consequence of a ceiling effect, as ECT was extremely effective in patients with psychotic depression.ClinicalTrials.gov: Identifier: NCT02562846.

A novel seizure quality index based on ictal parameters for optimizing clinical decision-making in electroconvulsive therapy. Part 2: Validation

Early identification of patients who are at a high risk for an unfavorable outcome to ECT during the treatment course might be beneficial because it provides an opportunity for timely intensification or optimization of stimulus conditions. We aimed to validate a previously developed seizure quality index (SQI) that delivers a clinically relevant outcome prediction early in the treatment course and can be used within common clinical setting. Therefore, a prospective study was conducted. Patients (n = 26) below the age of 65 years with a depressive episode and the clinical decision for ECT (right unilateral, brief pulse) were included and several ictal parameters, the SQI for non-response and non-remission, and the clinical outcome of the patients were documented. Logistic regression analysis revealed a statistically significant association between the SQI and non-response (p = 0.035). A significant association between the clinical outcome of non-response and the classified outcome of non-response was detected (p = 0.041). The overall classification accuracy regarding response/non-response was 71.3%, and the model revealed a sensitivity of 84.6% and a specificity of 61.5% for non-response. In this study, we could validate the SQI for the clinical outcome of non-response, but not for non-remission. Based on our data, the SQI might become an interesting clinical tool for early outcome prediction for ECT in patients with depression.

Thalamic volume, resting-state activity, and their association with the efficacy of electroconvulsive therapy

Electroconvulsive therapy (ECT) is the most effective antidepressant treatment. Biological predictors of clinical outcome to ECT are valuable. We aimed to examine multimodal magnetic resonance imaging (MRI) data that correlates to the efficacy of ECT. Structural and resting-state functional MRI data were acquired from 46 individuals (25 depressed individuals who received ECT, and 21 healthy controls). Whole-brain grey matter volume (GMV) and fractional amplitude of low frequency fluctuations (fALFF) were investigated to identify brain regions associated with post-ECT Hamilton Depression Rating Scale (HAM-D) total scores. GMV and fALFF values were compared with those in healthy controls using analysis of covariance (ANCOVA). Remission was defined by HAM-D ≤7. A multiple regression analysis revealed that pretreatment smaller GMV in the left thalamus was associated with worse response to ECT (i.e. higher post-ECT HAM-D). Pretreatment higher fALFF in the right anterior insula, and lower fALFF in the left thalamus and the cerebellum were associated with worse outcomes. The left thalamus was identified in both GMV and fALFF analyses. Nonremitters showed significantly smaller thalamic GMV compared to remitters and controls. We found that pretreatment thalamic volume and resting-state activity were associated with the efficacy of ECT. Our results highlight the importance of the thalamus as a possible biological predictor and its role in the underlying mechanisms of ECT action.

An Electrophysiological Biomarker That May Predict Treatment Response to ECT

OBJECTIVE

Electroconvulsive therapy (ECT) is the most effective treatment for major depression but also carries risk of cognitive side effects. The ability to predict whether treatment will be effective before initiation of treatment could significantly improve quality of care, reduce suffering, and diminish costs. We sought to carry out a comprehensive and definitive study of the relationship between the background electroencephalography (EEG) and therapeutic response to ECT.

METHODS

Twenty-one channel resting EEG was collected pre-ECT and 2 to 3 days after ECT course from 2 separate data sets, one to develop an EEG model of therapeutic response (n = 30) and a second to test this model (n = 40). A 3-way principal components analysis was applied and coherence and spectral amplitude across 6 frequency bands were examined. The primary outcome measure was the Montgomery-Asberg Rating Scale (MADRS).

RESULTS

Four patterns of amplitude and coherence along with baseline MADRS score accounted for 85% of the variance in posttreatment course MADRS score in study 1 (R = 0.85, F = 11.7, P < 0.0002) and 53% of the variance in MADRS score in study 2 (R = 0.53, F = 5.5, P < 0.003). Greater pre-ECT course anterior delta coherence accounted for the majority of variance in therapeutic response (study 1: R = 0.44, P = 0.01; study 2: R = 0.16, P = 0.008).

CONCLUSIONS

These results suggest a putative electrophysiological biomarker that can predict therapeutic response before a course of ECT. Greater baseline anterior delta coherence is significantly associated with a better subsequent therapeutic response and could be indicative of intact circuitry allowing for improved seizure propagation.

Magnetic Seizure Therapy: Towards Personalized Seizure Therapy for Major Depression

Magnetic seizure therapy (MST) is a noninvasive neuromodulation therapy under investigation for the treatment of severe neuropsychiatric disorders. MST involves inducing a therapeutic seizure under anesthesia in a setting similar to electroconvulsive therapy (ECT). To date, randomized controlled trials suggest that MST has similar antidepressant efficacy as ECT, but without significant cognitive adverse effects. Large scale clinical trials are currently underway to confirm these preliminary findings. So far, there has only been one study evaluating the clinical predictors of response to MST and more research is needed. This study found that patients with fewer episodes of depression and a positive family history of depression had a better response to MST. Overall, the ability of MST to focus the delivery of the electric field and the resultant seizure makes targeting seizure therapy to specific brain regions possible, and further research will be helpful in identifying personalized targets to maximize clinical benefit. In this review, we describe MST methodology and how it could be individualized to each patient. We also summarize the clinical and cognitive effects of MST and provide indications of which patients may be most likely to benefit. Finally, we summarize the studied neurophysiological predictors of response.

Predicting postictal suppression in electroconvulsive therapy using analysis of heart rate variability

BACKGROUND

Postictal suppression on an electroencephalogram (EEG) represents electrical silence during electroconvulsive therapy (ECT) and has been considered as a key feature associated with the efficacy of treatment. The present study aimed to predict postictal suppression using heart rate variability (HRV).

METHODS

Participants comprised 21 consecutive patients with depression who underwent bilateral pulse wave ECT. We analyzed the frequency domains of resting HRV before ECT. HRV indices such as the high-frequency component (HF) reflecting parasympathetic activity and the ratio of low-frequency component (LF)/HF reflecting sympathetic activity were natural log transformed for analysis. We evaluated ictal and peri-ictal EEG parameters and investigated their associations with HRV indices.

RESULTS

Postictal suppression and regularity were positively associated with ln[HF]. Postictal suppression remained significantly associated with ln[HF] after adjusting for age in multiple regression analysis of patients with depression.

LIMITATIONS

The present study could not examine the influence of diabetes mellitus, hypertension and polarity on HRV. In addition, the small sample size resulted in low statistical power.

CONCLUSIONS

These results suggested that ln[HF] before ECT could be utilized as a predictor of postictal suppression on EEG during ECT.

Reconsidering the seizure threshold? A retrospective study about seizure quality among patients with maintenance ECT

OBJECTIVES

Electroconvulsive therapy (ECT) is a safe and validated technique used to treat various psychiatric conditions. It triggers an artificially-induced seizure. This seizure is defined using several parameters such as the amount of energy, duration, frequency, pulse width and intensity. Efficacy and adverse events depend on the amount of energy delivered. Due to technical control, the amount of energy delivered by our unit's ECT device was limited to 614 mC, 60% of the maximum possible output of the device. We wondered if lowering the dose would lead to better seizure quality among maintenance ECT patients.

METHODS

We assessed seizure quality based on the EEG, using a validated tool created by MacPherson. Two evaluators independently rated the seizures. Pre- and post-control scores were compared using Student's t-test for paired samples.

RESULTS

We analysed data from 15 patients. Mean age was 65 years old. Twelve had depressive disorder, two had schizophrenia and one had schizo-affective disorder. Mean duration of seizure before control was 41.1 s [95% confidence interval (95CI)=26.1, 51.1]. The mean MacPherson's score was 20.3 (95CI=16.2, 24.4). After control, the mean MacPherson's score was 28.2 (23.1, 33.3), showing a significant difference with the pre-control dataset (p=0.032; t=-2.4; df=14). Specifically, peak mid-ictal amplitude increased from 6.9 (95CI=5.1, 8.7) to 10.0 (95CI=7.2, 12.8). Other sub-scores remained unchanged.

CONCLUSION

Lowering the energy delivered led to an overall increase of seizure quality among our sample. This highlights the necessity and utility of retitration during ECT maintenance, possibly leading to better management of our patients.

Therapeutic Uses of Seizures in Neuropsychiatry

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

Electro convulsive therapy: Modification of its effect on the autonomic nervous system using anti-cholinergic drugs

The antidepressant efficacy of electroconvulsive therapy (ECT) is correlated to the quality of the seizure as measured by EEG but has also been linked to the magnitude of changes in hemodynamic variables. Muscarinic receptor antagonists are frequently used in the treatment, and are known to affect the hemodynamic response. We hypothesized that atropine and glycopyrrolate alter the hemodynamic and autonomic hormonal response to ECT. In a randomized, cross-over study design 23 patients received either atropine, glycopyrrolate or placebo before ECT. Hemodynamic variable, EEG and EMG, and blood adrenaline, noradrenaline and pancreatic polypeptide was determined. No geriatric patients were included. Hemodynamic changes with ECT can be divided into three phases: Drop in blood pressure and pulse rate in 1st post-stimulus phase was less when using 1 mg atropine. In 2nd post-stimulus phase atropine gave a higher systolic blood pressure. No differences were seen in hormone levels after ECT in the three interventions. A significant longer tonic clonic seizure was seen in the glycopyrrolate group and a tendency of the same was seen with atropine. The study found that the changes in hemodynamic variables induced by ECT can be altered by concomitant administration of muscarinic receptor antagonist.

Brief vs. ultrabrief pulse ECT: focus on seizure quality

The effect of electroconvulsive therapy (ECT) performed with ultrabrief pulse (UBP) stimulation has been found inferior to brief pulse (BP) ECT in various studies. We reinvestigated this issue using a new dosing strategy that is based on seizure quality instead of seizure threshold. There is a long history of studies associating ictal characteristics of ECT with the clinical outcome. Accordingly, we used the clinical status of the patient and the quality of the prior seizure to determine the dosage for the upcoming treatment-referred to as Clinical and Seizure Based Stimulation (CASBAS). This approach aims at continuously providing high-quality seizures to optimize the outcome. While this dosing strategy was applied in our department, the pulse width was changed for a period of time from BP to UBP. It was hypothesized that the procedure would: (1) maintain seizure quality and clinical outcome under both conditions and would; and (2) compensate the lesser clinical efficacy of UBP by an increase in stimulus intensity. 245 patients received an ECT course according to the dosing strategy described, 162 with brief pulse (BP) and 83 with ultrabrief pulse ECT (UBP). In a retrospective evaluation, seizure quality and clinical outcome (available in a 20% subgroup of patients) did not differ between both groups in most of the examined parameters, while stimulus intensity was found to be significantly higher in the UBP group. As hypothesized, UBP was less efficient than BP in providing comparable ictal quality and clinical outcome. In a first test of concept the dosing strategy CASBAS seemed suitable to continuously adjust the stimulus intensity in ECT and maintain the seizure quality.

A novel Seizure Quality Index based on ictal parameters for optimizing clinical decision making in electroconvulsive therapy. Part 1: development

Early identification of patients at high risk for an unfavorable outcome to ECT during the course might be beneficial because it provides an opportunity for timely intensification or optimization of stimulus conditions. We aimed to develop a new Seizure Quality Index (SQI) that delivers a clinical relevant outcome prediction early in the treatment course and can be used within common clinical setting. An observational study was conducted. Patients (n = 86) with a depressive episode and the clinical decision for ECT (right unilateral, brief pulse) were included, and several ictal parameters derived from the second ECT session and the clinical outcome of the patients were documented. Optimal cut-off points for five different domains of ictal adequacy for younger and older patients for the prediction of "non-response" and "non-remission" based on seizure quality was determined by the Youden Index and a sum score was built. Logistic regression analyses tested the predictive power of derived models. For both outcome variables "non-response" and "non-remission", the logistic regression models were statistically significant, albeit for remission only for subjects below the age of 65 years (χ² = 17.9, p = 0.001) and (χ² = 6.4, p = 0.020), respectively. The models correctly classified 87.2% (non-response) and 50.0% (non-remission) of the cases. ROC curve analysis showed an AUC of 0.87 (non-response) and 0.70 (non-remission). In elderly patients (> 65), no such model could be established due to a response rate of 100%. Our data provide promising, clinically relevant results about the prediction of response to ECT at an early stage for patients with depression.

Characteristics of ictal EEG in Magnetic Seizure Therapy at various stimulation frequencies

OBJECTIVES

The first objective of this study aimed to elucidate the relationship between seizure characteristics and Magnetic Seizure Therapy (MST) treatment outcome. The second objective was to determine the effect of stimulation frequency on seizure characteristics.

METHODS

Using a between-subjects design, we compared the seizures of patients with unipolar depression receiving MST at three separate stimulation frequencies: 25 Hz (n = 34), 50 Hz (n = 16) and 100 Hz (n = 11). Seizures were rated for overall seizure adequacy on a scale of 0-6, with one point given for each measure that was considered to be adequate according to the ECT literature: (1) seizure EEG duration (2) motor duration, (3) post-ictal suppression, (4) ictal EEG maximum amplitude, (5) Global Seizure Strength, and (6) Symmetry. Mixed-effect models were used to evaluate the effect of frequency on seizure characteristics and the relationships between seizure characteristics and clinical outcome.

RESULTS

(1) 100 Hz induced seizures that were less adequate than seizures induced with 50 Hz and 25 Hz stimulations. Seizures induced by 50 Hz stimulations had longer slow-wave phase durations and total EEG durations than the 100 Hz and 25 Hz groups. Global seizure strength was less robust in seizures induced by 100 Hz MST compared to the other stimulation frequencies. (2) Shorter polyspike durations and smaller slow-wave amplitude predicted reductions in overall symptoms of depression as measured by the 24-item Hamilton Depression Scale.

CONCLUSION

Analysis of our first objective revealed stimulation frequency significantly influences measures of overall seizure adequacy. However, our results also revealed these descriptions of seizure adequacy based on ECT literature may not be useful for MST-induced seizures, as the characteristics of MST-induced seizure characteristics may predict clinical response in a different manner.

SIGNIFICANCE

These results may help to distinguish the biological processes impacted by stimulation frequency and may suggest different mechanisms of action between convulsive therapies and challenge the current understanding of seizure adequacy for MST.

The influence of the anesthesia-to-stimulation time interval on seizure quality parameters in electroconvulsive therapy

BACKGROUND

Electroconvulsive therapy (ECT) continues to be the most efficacious treatment for severe depression and other life-threatening acute psychiatric conditions. Treatment efficacy is dependent upon the induced seizure quality, which may be influenced by a range of treatment related factors. Recently, the time interval from anesthesia to the electrical stimulation (ASTI) has been suggested to be an important determinant of seizure quality.

METHODS

We measured ASTI in 73 ECT sessions given to 22 individual patients, and analyzed its influence on five seizure quality parameters (EEG seizure time, power, coherence, postictal suppression, and peak heart rate).

RESULTS

Longer ASTI was significantly associated with higher peak heart rate during the seizure (p = .003). After adjustment for confounders, the association continued to be significant, even after Bonferroni correction for multiple comparisons (p = .005). ASTI was not significantly associated with other seizure parameters.

LIMITATIONS

The relatively low number of sessions may lead to false negative findings. The study did not include clinical outcomes.

CONCLUSIONS

Longer ASTI is associated with higher peak heart rate; a phenomenon which is thought to reflect better seizure propagation to subcortical areas of the brain. The finding indicates that delay of stimulation after anesthesia could be a simple way of improving seizure quality and thereby the clinical effect of ECT.

Electroconvulsive Therapy in a Patient With Chronic Catatonia: Clinical Outcomes and Cerebral 18[F]Fludeoxyglucose Positron Emission Tomography Findings

Catatonia is a psychomotor syndrome that can be associated with both psychiatric diseases (mainly mood disorders, but also psychotic disorders) and medical conditions. Lorazepam (6-21 mg/day, occasionally up to 30 md/day) is the first choice treatment and electroconvulsive therapy (ECT) is the second line, regardless of the underlying clinical condition. There are some evidences also for effectiveness of other medications. Patients treated acutely usually show rapid and full therapeutic response but even longstanding catatonia can improve. However, some authors suggested that chronic catatonia in the context of schizophrenia is phenomenologically different and less responsive to lorazepam and ECT, especially if associated with echophenomena. We present here the case of a patient with longstanding catatonic schizophrenia treated with antipsychotics who significantly improved after ECT. Improvement regarded mainly catatonia, but also negative symptoms, cognition and psychosocial functioning. A slight amelioration in prefrontal metabolism (Brain[F]FDG PET) one month following the ECT course was also noted.