The Prevalence of Electroconvulsive Therapy Use Since 1973: A Meta-analysis

Trends in Electroconvulsive Therapy Utilization in South Korea: Health Insurance Review Data From 2008 to 2018

OBJECTIVE

The study aimed to analyze and clinically correlate 10-year trends in the demographic characteristics of patients receiving electroconvulsive therapy (ECT) to provide an overview of ECT utilization in South Korea.

METHODS

Using health insurance claims data from 2008 to 2018 retrieved from Health Insurance Review and Assessment Service database in South Korea, we identified individuals undergoing ECT based on procedural codes. Descriptive analysis evaluated baseline clinical characteristics, and trend analysis used a linear regression model.

RESULTS

The prevalence of ECT increased by 240.49% (0.405/105 inhabitants in 2008 to 0.974/105 inhabitants in 2018). The increasing trend was more pronounced in younger and older patients. The proportion of women consistently exceeded that of men. A rise in the proportion of patients with affective disorders, and a decrease in the proportion of psychotic disorders was observed. More antidepressants and atypical antipsychotics were prescribed to patients undergoing ECT. The proportion of ECT sessions conducted in large hospital inpatient settings also decreased during the observation period. Despite increasing global trends, ECT prevalence in South Korea remains significantly lower than worldwide rates.

CONCLUSION

This study demonstrated an increasing trend of ECT across a wide range of population demographics and in more accessible settings. The comparatively low prevalence of ECT in Korea compared to other countries might be attributed to insufficient mental health literacy and the stigma associated with ECT. Given the elevated suicide rates in Korea, more extensive adoption of ECT appears imperative.

Understanding the Patient Landscape: A Ten-Year Retrospective Examination of Electroconvulsive Therapy in Romania's Largest Psychiatric Hospital

The aim of this analysis was to investigate the socio-demographic and clinical profile, the effectiveness, and the association of pharmacological treatment in patients who underwent electroconvulsive therapy during the last 10 years in the largest psychiatric hospital in Romania. This study includes 249 patients aged between 18 and 73 years old. Recurrent depression was the most frequent diagnosis for which ECT was performed (T = 96, 38.55%), followed by schizophrenia (T = 72, 28.91%). The most frequent indication for ECT was treatment resistance (T = 154, 61.84%), followed by persistent suicidal ideation (T = 54, 21.68%) and catatonia (T = 42, 16.86%). In 111 (44.60%) cases included in this study, re-hospitalization was required after performing ECT, while 138 (55.40%) participants did not require any further hospital readmissions. Significant differences were found between these groups in terms of socio-demographic data, diagnosis, number of ECT sessions performed, and association of psychotropic medication during and after the procedure, therefore two separate patient profiles were found based on these characteristics. Patients necessitating re-hospitalization post-ECT were mainly males aged 25-44 diagnosed with schizophrenia and underwent a greater number of ECT sessions (7-12), whereas those not requiring re-hospitalization were predominantly females aged 45-64 with recurrent depressive disorder for which 4-6 ECT sessions were performed.

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.

Cerebral and Aortic Aneurysms in Electroconvulsive Therapy Patients: A Systematic Review and Results From 12 Years of Screening

INTRODUCTION

Theoretically, the procedural risk of electroconvulsive therapy (ECT) could be increased in the presence of undetected aneurysms due to the hemodynamic changes associated with ECT. However, empirical evidence is limited to few individual case reports and case series.

METHODS

We performed a systematic review of available evidence on ECT treatment in patients with intracranial aneurysms and untreated aortic aneurysms and we retrospectively analyzed data from 252 consecutive patients referred for ECT at the Department of Psychiatry, Psychotherapy and Psychosomatics of Siegen Hospital, Germany, who received magnetic resonance angiographies and abdominal sonographies as part of their routine pre-ECT workup.

RESULTS

Of 252 patients referred for ECT, 5 (2.0%) were found to have an intracerebral aneurysm and 1 (0.4%) was found to have an abdominal aortic aneurysm. These cases are reported in detail together with 2 additional cases of aortic aneurysms from the Central Institute of Mental Health, Mannheim, Germany. Electroconvulsive therapy was performed without complications in all 8 cases.

CONCLUSIONS

Aneurysms might occur in ECT patients at a similar rate as in the general population. The number of ECTs performed annually in mostly unscreened patients suggests that there might be a significant number of patients with undetected aneurysms in whom ECT is performed without reported complications.

Pharmacological prevention of postictal agitation after electroconvulsive therapy-A systematic review and meta-analysis

Background

Postictal agitation (PIA) after electroconvulsive therapy (ECT) is a serious clinical problem estimated to occur in 7-36% of patients and recur in 19-54% of patients. PIA has the potential to cause dangerous situations for the patient and staff members aside from the financial impact. To date, it is unclear which pharmacological interventions should be used in the management of PIA. This study aimed to systematically review the (preventative) pharmacological treatment options for PIA after ECT.

Method

A systematic search was done in PubMed, EMBASE, PsycINFO, and Web of Science from inception until 10 November 2022. We included randomized trials with any pharmacological intervention or comparison and a predefined outcome measure on PIA. Studies that solely included patients with neurodegenerative disorders or stroke were excluded. Data quality was assessed with the RoB2 and GRADE. Meta-analysis was performed if possible. This study was registered on PROSPERO under CRD42021262323.

Results

We screened 2,204 articles and included 14 studies. Dexmedetomidine was investigated in 10 studies. Alfentanil, lignocaine, esmolol, midazolam, propofol, ketamine, haloperidol, and diazepam were each studied in only one study. Meta-analysis revealed an OR of 0.45 (0.32-0.63), a moderate effect size, in favor of dexmedetomidine than placebo to prevent PIA with very low heterogeneity (I² = 0%). The certainty of the evidence was moderate. The other interventions studied were all found to have low certainty of evidence.

Conclusion

For clinical practice, we believe that our results indicate that dexmedetomidine should be considered for the prevention of PIA in patients that have previously experienced PIA.

Knowledge, attitudes and beliefs about electroconvulsive therapy among Polish students

Introduction: Electroconvulsive therapy (ECT) is an effective and safe treatment for many mental disorders. Nevertheless, the attitudes towards ECT are negative and the use of this method in Poland is decreasing.

Aim: The aim of the study was to investigate the general knowledge and attitudes towards electroconvulsive therapy among Polish university students, including students of medicine, psychology and other faculties.

Material and methods: An original online questionnaire containing 39 questions was used, distributed through student groups on social networking sites. A total of 418 questionnaires were completed. The collected data were statistically analyzed.

Results: Significant knowledge gaps and negative beliefs about electroconvulsive therapy were observed among Polish students. Medical and psychology students had more extensive knowledge and more positive beliefs about this method of treatment than students of other faculties. Greater knowledge of the therapy was associated with a more positive attitude towards it. The main source of knowledge about ECT for students of medicine and psychology were lectures and courses, and for students of other faculties – movies. Students, who considered psychiatry as their future specialization, had less knowledge and a more negative attitude towards ECT, relative to the rest of the respondents.

Conclusions: There is a need for educational interventions that will change the way how ECT is perceived both in the public opinion and in the medical community. An effective solution to low levels of knowledge for medical students may be the observation of the procedure included in the study programme.

Risk Assessment of Electroconvulsive Therapy in Clinical Routine: A 3-Year Analysis of Life-Threatening Events in More Than 3,000 Treatment Sessions

Background: Extensive research has reported that electroconvulsive therapy (ECT) can be highly effective in approximately 80% of patients suffering from depression. Its clinical use is mainly limited by historical objections and the concern about unwanted adverse effects (AEs), including serious and potentially life-threatening adverse events (pLTAEs), induced either by ECT or by anesthesia. Objective risk estimation is, therefore, a decisive factor in determining an indication for ECT. Methods: This paper presents a retrospective analysis of 3-year safety protocols and patient files of 157 patients who received a total of 3,106 ECT applications in a psychiatric inpatient setting at a psychiatric community hospital. This patient group comprises 5.3% of inpatients admitted with comparable diagnoses. Adverse events were analyzed from standardized safety protocols and patient files with a focus on pLTAEs. Results: Adverse events were reported for 30 (19.1%) of the 157 participants during 39 (6.1%) of 641 hospital stays. Serious pLTAEs occurred during three electroconvulsive stimulations in three patients, who needed action through the administration of medication or mechanical respiration. No patient suffered permanent damage to health, and no patient died. The incidence of these and other AEs was independent of sex, age, and diagnosis of patients, and anesthesia medication. Minor AEs occurred more often with higher stimulus doses and an increasing number of treatments. Conclusion: The low incidence rate of 0.097% of serious pLTAEs that require medical action may allow the conclusion that ECT is a rather safe treatment when performed in a controlled setting. The beneficial risk profile of ECT performed in the standard care of psychiatric hospitals suggests a more generous indication of this treatment method. We recommend that ECT facilities collect individual safety data to allow a reliable judgment of their institutional ECT risk profile.

Autonomy and consent assessment for electroconvulsive therapy (ECT). A retrospective study of medical records

The Norwegian Mental Health Act allows involuntary treatment for patients who lack consent capacity, however it allows only administration of pharmaceutical treatment and nutrition and not ECT. In lack of specific regulations, the legal access to ECT without valid consent has been grounded on the general rule of necessity in the Norwegian Penal code. This restriction and lack of legal regulation has implications for patients' rights and legal security. The study's aim was to assess the documented consent provided by patients for electroconvulsive therapy (ECT), whether ECT was administered without valid consent or under coercion, and the documented reasons, and ultimately compare practice with the legal requirements. We analysed systematically all the relevant medical records for hospitalised patients and outpatients receiving ECT during 2011-2016. We categorized data from these two groups into seven defined categories describing the attitude and quality of the consents to the ECT (or lack thereof). 378 patients received 498 ECT series´. The noted consents varied from treatment based on request (54 treatments), consent upon recommendation (209 treatments), consent after hesitation (88 treatments), consent presumed or noted without specification (114 treatments), to no consent (21 treatments) whereof the majority with documented coercion applied (19 treatments). All cases of ECT without consent referred to a "plea of necessity". The remaining treatments (12) lacked notifications specifying the consent (or attitude) expressed. Specific notes on the patient's capacity to consent for the respective ECT were generally lacking. This study indicates a large spread in patients´ acceptance and valid consent to ECT. The main reason for administering ECT without consent and/or against patients' will was for life-saving reasons. Such treatments were justified legal under a plea of necessity in the Penal Code or lacked noted legal justification. The legal vacuum for ECT without a valid consent needs to be addressed as this kind of disputed treatment is used in some cases.

[Impact of an educational video on the representations of electroconvulsive therapy among psychiatrists in Hauts-de-France and Occitanie]

INTRODUCTION

Despite its effectiveness and good tolerance, electro-convulsive therapy (ECT) is under-used in current clinical practice probably because of stigma and the negative image of this treatment. The main objective of this study was to evaluate the impact of an educational video on the representations of ECT among psychiatrists and psychiatric residents in the North and in Occitanie districts of France.

METHOD

We evaluated the representations of ECT through the Questionnaire on Attitudes and Knowledge of ECT (QuAKE) before (T0) and after (T1) viewing a short educational video. Scores at T0 and T1 were compared with a paired t-test. Factors associated with the improvement of the representations were investigated using a logistic regression model.

RESULTS

In all, 195 responses were obtained. The QuAKE score at T1 was significantly better than at T0 (29.4 at T1 vs. 31.5 at T0, P<0.001). The more negative the representations were at T0, the higher the probability of a decrease in the score at T1 (OR=1.07 [1.02-1.13], P=0.003).

DISCUSSION

Our study showed a beneficial effect of a short educational video on psychiatrists' representations of ECT. The wide use of this type of media, allowing information and destigmatization, could considerably optimize access to ECT for patients.

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

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

Current Practices of Electroconvulsive Therapy in Mental Disorders: A Systematic Review and Meta-Analysis of Short and Long-Term Cognitive Effects

ABSTRACT

Electroconvulsive therapy (ECT) remains one of the most effective treatments for major depressive disorder, but uncertainties persist regarding the cognitive tests to include in ECT follow-up. The current study is a systematic review and meta-analysis of the most frequent cognitive side effects after ECT. We also discuss the most common cognitive tests in ECT follow-up. We searched studies published from 2000 to 2017 in English and French language in Pubmed, EBM Reviews, EMBASE, and PsycINFO. Standardized cognitive tests were separated into 11 cognitive domains. Comparisons between cognitive measures included pre-ECT baseline with post-ECT measures at 3 times: PO1, immediately post-ECT (within 24 hours after last ECT); PO2, short term (1-28 days); and PO3, long term (more than 1 month). A total of 91 studies were included, with an aggregated sample of 3762 individuals. We found no significant changes in global cognition with Mini-Mental State Examination at PO1. Hedges g revealed small to medium effect sizes at PO2, with individuals presenting a decrease in autobiographical memory, verbal fluency, and verbal memory. Verbal fluency problems showed an inverse correlation with age, with younger adults showing greater deficits. At PO3, there is an improvement on almost all cognitive domains, including verbal fluency and verbal memory. There is a lack of standardization in the choice of cognitive tests and optimal cognitive timing. The Mini-Mental State Examination is the most common screening test used in ECT, but its clinical utility is extremely limited to track post-ECT cognitive changes. Cognitive assessment for ECT purposes should include autobiographical memory, verbal fluency, and verbal memory.

Changes in the Practice of Electroconvulsive Therapy in Poland: A Nationwide Survey Comparing Data Between 2005 and 2020

BACKGROUND

The use and the characteristics of the practice of electroconvulsive therapy (ECT) in Poland have not been evaluated since 2005, when a nationwide survey revealed its rare utilization (0.11 patients/10,000 inhabitants/year). The aims of this study were to determine the current use of ECT and to compare the findings with those of the previous survey.

METHODS

Two questionnaires were sent to all 48 inpatient psychiatric centers in Poland. The first one - to units providing ECT to explore its practice, and the second - to units not performing ECT to explore the reasons for not using this treatment.

RESULTS

Nineteen (39.6%) of all psychiatric inpatient centers confirmed the use of ECT. The utilization rate was 0.13 patients/10,000 inhabitants. Similar to the findings from 2005, the main indications were affective disorders, and bitemporal electrode placement was the dominant method used for the delivery of ECT. Age-based and titration-based methods were applied exclusively in 50% and 25% of the centers, respectively (compared with 15% and 35% in 2005, respectively), while both methods were used in the remaining 25%. Improvements in safety were reflected by the use of comprehensive pre-ECT evaluation and treatment monitoring. None of the centers used sine-wave devices; this contrasts with their use by 29% of the centers in 2005. The main reasons for not using ECT were insufficient funding and a lack of experienced staff.

CONCLUSION

The frequency of ECT use in Poland remains very low. In view of the improvement in the quality of health services in the past decade, such a markedly rare use of an effective treatment was unexpected. There is an urgent need of education to create more positive attitude towards ECT among health professionals and among public, and to increase the training of mental health professionals in ECT.

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.

Current clinical practice of electroconvulsive therapy and repetitive transcranial magnetic stimulation in psychiatry, a German sample

The purpose of the study was to evaluate the current clinical practice of Electroconvulsive Therapy and Repetitive Transcranial Magnetic Stimulation in German psychiatry. Case-based data (> 1.000.000 cases) were collected according to §21 of the German hospital remuneration law from January 2015 to December 2017. The study cohort comprises approximately 35-40% of the annual psychiatric cases and hospitals in Germany. Frequency of ECT and rTMS cases were investigated considering main diagnoses according to ICD-10 and treatment settings (inpatient vs. day-care). ECT cases with short-term hospitalization (≤ 4 days) were supposed to be maintenance ECT cases. A linear regression analysis was conducted to estimate trends in the use of ECT and rTMS. Different groups were compared using Chi-square tests. ECT and rTMS cases appear to increase in total during the observation period possibly due to facilities newly introducing ECT and rTMS but also to increased frequency of treatments. Both treatments were rarely performed in day-care settings (0.89% and 11.25%). ECT was performed in 1.72% of all cases with affective disorders and in 1.48% with major depressions, respectively. Age ≥ 65 years, females, severe and psychotic depression were significantly associated with a higher rate of ECT cases. > 40% of all ECT cases were possibly maintenance ECT cases. Only 0.60% of these were performed in day- care settings. rTMS was primarily performed in major depression (86,7% of all rTMS cases). This study suggests a growing demand for ECT and rTMS. Nevertheless, the use of ECT is still low compared to the high prevalence of treatment resistant depression. The use of rTMS is even lower and seems to be restricted to specialized institutions. Maintenance ECT is frequently carried out in an inpatient setting. Limitations of this study are the case- and group-based analysis, missing data on outpatient services and treatment sessions per case. Therefore, the database is not necessarily representative for the entire German healthcare system. Further studies are needed to verify the presented findings and should address the feasibility of ambulatory and day-care ECT services.

Developing Precision Invasive Neuromodulation for Psychiatry

Psychiatric conditions are common and often disabling. Although great strides have been made in alleviating symptoms with pharmacotherapy and psychotherapeutic approaches, many patients continue to have severe disease burden despite the best therapies available. One of the pervasive challenges to improving treatment is that present diagnostic and therapeutic strategies lag behind our modern conceptualization of the pathophysiology of these disorders. Psychiatric symptoms manifest through activity in specific neural circuits; thus, therapies capable of modulating these circuits are attractive. The investigators reviewed recent advances that facilitate treating medically refractory psychiatric disorders with intracranial neuromodulation in a way that intervenes more directly with the underlying pathophysiology. Specifically, they reviewed the prospects for using intracranial multielectrode arrays to record brain activity with high spatiotemporal resolution and identify circuit-level electrophysiological correlates of symptoms. A causal relationship of circuit electrophysiology to symptoms could then be established by modulating the circuits to disrupt the symptoms. Personalized therapeutic neuromodulation strategies can then proceed in a rational manner with stimulation protocols informed by the underlying circuit-based pathophysiology of the most bothersome symptoms. This strategy would enhance current methods in neurotherapeutics by identifying individualized anatomical targets with symptom-specific precision, circumventing many of the limitations inherent in modern psychiatric nosology and treatment.

Demographics of Patients Receiving Electroconvulsive Therapy Based on State-Mandated Reporting Data

OBJECTIVES

Electroconvulsive therapy (ECT) is an effective treatment of depression and other psychiatric conditions. There are few comprehensive data on how many patients receive ECT in the United States or about the demographics of ECT recipients. This study characterizes the demographics of those receiving ECT and how these demographics may have changed with time.

METHODS

Freedom of information requests for all data from record keeping inception to January 2019 were sent to the Department of Health or equivalent agency of states that mandate reporting of ECT. Information on demographics and the number of treating facilities was extracted.

RESULTS

Data on 62,602 patients receiving treatment in 3 states (California, Illinois, Vermont) were obtained. Overall, 62.3% were women. Fewer than 1% of patients treated were younger than 18 years, whereas 30.3% were 65 years or older. White patients received a disproportionate proportion of treatments, with all other races underrepresented. The total number of facilities offering ECT in the 3 states declined over the study period.

CONCLUSIONS

Recipients of ECT are more likely to be female, more likely to be elderly, and more likely to be white than the average person in their state.

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.

Current challenges and possible future developments in personalized psychiatry with an emphasis on psychotic disorders

A personalized medicine approach seems to be particularly applicable to psychiatry. Indeed, considering mental illness as deregulation, unique to each patient, of molecular pathways, governing the development and functioning of the brain, seems to be the most justified way to understand and treat disorders of this medical category. In order to extract correct information about the implicated molecular pathways, data can be drawn from sampling phenotypic and genetic biomarkers and then analyzed by a machine learning algorithm. This review describes current difficulties in the field of personalized psychiatry and gives several examples of possibly actionable biomarkers of psychotic and other psychiatric disorders, including several examples of genetic studies relevant to personalized psychiatry. Most of these biomarkers are not yet ready to be introduced in clinical practice. In a next step, a perspective on the path personalized psychiatry may take in the future is given, paying particular attention to machine learning algorithms that can be used with the goal of handling multidimensional datasets.

A Measure to Assess Perceptions and Knowledge About Electroconvulsive Therapy: Development and Psychometric Properties

OBJECTIVES

Although electroconvulsive therapy (ECT) has been found to be one of the most robust and rapid treatments for severe depression, it is widely underused partly because of negative perceptions and inaccurate knowledge about the treatment.

METHODS

The 18-item ECT Perception and Knowledge (ECT-PK) measure was developed through a systematic review of the literature, subject matter expert ratings, and examination of content validity. The ECT-PK consists of Perception and Knowledge subscales, which were tested on a national sample of 1091 US adults who screened positive for depression in 2018 through Amazon's Mechanical Turk platform.

RESULTS

Evaluation of the ECT-PK subscales found that both subscales demonstrated good construct validity, criterion validity, and internal consistency reliability. Participants who had higher Perception and Knowledge subscale scores were significantly more likely to report that they were willing to try ECT. The ECT-PK revealed that many participants reported fears about pain, brain damage, and memory loss resulting from ECT, and had inaccurate knowledge about ECT being outdated or lacking scientific evidence.

CONCLUSIONS

Together, these results showed that the ECT-PK is an efficient and effective contemporary tool to measure the perception and knowledge of ECT, and highlights areas in need of psychoeducation.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Mental health professionals' attitudes toward and knowledge about electroconvulsive therapy at Weskoppies Hospital, South Africa

PURPOSE

To investigate the attitudes toward and knowledge of electroconvulsive therapy (ECT) among mental health practitioners.

DESIGN AND METHODS

One hundred and eighty-three participants from five groups of mental health practitioners were included. Anonymous questionnaires were used.

FINDINGS

Data were analyzed using SPSS version 24.0. Most of the questionnaires were completed by nurses (N = 142; 77.5%). Mean positive attitude scores were statistically different between the five groups, F(4, 178) = 2.63, P = 0.036). Mean knowledge scores between the five groups were statistically significant, H(4) = 30.0, P < 0.0001. Greater knowledge about ECT was associated with more positive attitude toward ECT, r(183) = 0.290, P = 0.01.

PRACTICE IMPLICATIONS

ECT educational programs need to be provided to all mental health practitioners and the resulting effects on knowledge and attitudes studied.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Geographical access to electroconvulsive therapy services in Texas

AIMS

Electroconvulsive Therapy (ECT) is a well-established and effective treatment in mood disorders but the use of ECT in Texas is much lower than the general average among the United States. Our goal is to explore the geographical accessibility of Electroconvulsive Services in Texas.

METHODS

22 ECT Centers in Texas listed in State's 2016 annual ECT report were enrolled and georeferenced. We used Esri's StreetMap Premium Network release 1 network dataset to generate 1-hour drive time service areas for these ECTs. We estimated populations within these service areas based on US Census Tract level population-weighted centroids; generated from the 2015, American Community Survey (ACS) estimates at the US Census Block Group level.

RESULTS

About 75% (19,851,802 of 26,538,614) of Texas total population is within a 1-hour drive time to any ECT Services location. When focusing on population below the poverty level from 2015 Block Group level ACS data: 68% (3,046,141 of 4,472,451) are within a 1-hour drive time.

CONCLUSIONS

ECT services are geographically accessible in Texas. Other barriers may contribute to lower use of ECT.

Pertinence of Titration and Age-Based Dosing Methods for Electroconvulsive Therapy: An International Retrospective Multicenter Study

BACKGROUND

Although the dosage of electroconvulsive therapy (ECT) stimulus has a major impact on the efficacy and safety of this treatment, the method used to determine an optimal dosage remains a matter of debate.

OBJECTIVE

We investigated factors influencing the seizure threshold (ST) in a large-sample study and compared age-based and titration dosing methods in terms of charge.

METHODS

A retrospective study examined data from 503 patients across France and Canada. The patients underwent right unilateral (RUL) or bitemporal (BT) ECT during a titration session before undergoing ECT. Seizure threshold and charge differences between age-based and titration-predicted methods were derived for each RUL and BT patient and compared according to sex, age, and anesthetic agents.

RESULTS

Based on our results, ST is a function of electrode placement, sex, age, and anesthetic agents. Titration and age-based methods led to completely different patterns of charges for the same electrode placement, especially in elderly and in women in the RUL group. Regression models showed that differences between the age-based and titration methods varied with respect to age, sex, and anesthetic agent. Specifically, significant effects of sex and age were observed for RUL ECT and of sex and anesthetics for BT ECT.

CONCLUSIONS

This study revealed that several factors significantly influence the prediction of ECT dose, depending on individuals and treatment modalities. Caution should be exercised when using nonindividualized methods to calculate ST.

Electroconvulsive Therapy Practice in the Province of Quebec: Linked Health Administrative Data Study from 1996 to 2013

OBJECTIVE

As part of a quality improvement process, we propose a model of routinely monitoring electroconvulsive therapy (ECT) in Canadian provinces using linked health administrative databases to generate provincial periodic reports, influence policy, and standardise ECT practices.

METHODS

ECT practice in Quebec was studied from 1996 to 2013, using longitudinal data from the Quebec Integrated Chronic Disease Surveillance System of the Institut National de Santé Publique du Québec, which links 5 health administrative databases. The population included all persons, aged 18 y and over, eligible for the health insurance registry, who received an ECT treatment at least once during the year.

RESULTS

Among recorded cases, 75% were identified by physician claims and hospitalisation files, 19% exclusively by physician claims, and 6% by hospitalisation files. From 1996 to 2013, 8,149 persons in Quebec received ECT with an annual prevalence rate of 13 per 100,000. A decline was observed, which was more pronounced in women and in older persons. On average, each patient received 9.7 treatments of ECT annually. The proportion of acute ECT decreased whereas maintenance treatment proportions increased. A wide variation in the use of ECT was observed among regions and psychiatrists.

CONCLUSION

This study demonstrates the profitable use of administrative data to monitor ECT use in Quebec, and provides a reliable method that could be replicated in other Canadian provinces. Although Quebec has one of the lowest utilisation rates reported in industrialized countries, regional disparities highlighted the need for a deeper examination of the quality and monitoring of ECT care and services.

Electroconvulsive Therapy in the Czech Republic

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Identifying Recipients of Electroconvulsive Therapy: Data From Privately Insured Americans

OBJECTIVE

Despite the effectiveness of electroconvulsive therapy (ECT), limited epidemiologic research has been conducted to identify rates of ECT use and characteristics of patients who receive ECT. Sociodemographic and clinical characteristics associated with ECT use were examined among patients with mood disorders in the MarketScan commercial insurance claims database.

METHODS

Among individuals with major depressive disorder or bipolar disorder, sociodemographic and clinical characteristics of those who received ECT and those who did not were compared by using bivariate effect size comparisons and multivariate logistic regression.

RESULTS

Among unique individuals in the 2014 MarketScan database (N=47,258,528), the ECT utilization rate was 5.56 ECT patients per 100,000 in the population. Of the 969,277 patients with a mood disorder, 2,471 (.25%) received ECT. Those who received ECT had substantially higher rates of additional comorbid psychiatric disorders (risk ratio [RR]=5.70 for any additional psychiatric disorder), numbers of prescription fills for any psychotropic medication (Cohen's d=.77), rates of any substance use disorder (RR=1.97), and total outpatient psychotherapy visits (Cohen's d=.49). The proportion of patients with a mood disorder who received ECT in the West (.19%) was substantially lower than in other U.S. regions (.28%). This difference was almost entirely accounted for by one western state comprising 59.1% of patients in that region.

CONCLUSIONS

Use of ECT is exceptionally uncommon and limited to patients with extensive multimorbidity and high levels of service use. ECT utilization is most limited in areas of the country where regulatory restrictions are greatest.

Electroconvulsive Therapy at a Veterans Health Administration Medical Center

OBJECTIVES

Little epidemiologic research has examined the practice of electroconvulsive therapy (ECT). We investigated sociodemographic and clinical characteristics, service use, and psychotropic medication prescription patterns associated with ECT use at a Veterans Health Administration Medical Center.

METHODS

Among veterans receiving specialty mental health services, we compared those who received ECT with those who did not using bivariate χ and t tests and multivariate logistic regression.

RESULTS

In fiscal year 2012, 11,117 veterans received specialty mental health services, of whom 50 received ECT (0.45%) in FY2012 or FY2013. Those who received ECT were more likely to be diagnosed with major depressive or bipolar disorders and had substantially higher levels of mental health service usage (Cohen d > 0.75) and psychotropic prescription fills, including antidepressants (Cohen d = 2.66), antipsychotics (Cohen d = 2.15), lithium (Cohen d = 1.34), mood stabilizers (Cohen d = 1.30), and anxiolytic/sedative/hypnotics (Cohen d = 1.34).

CONCLUSIONS

Our findings suggest that ECT is used as a treatment of last resort, although available evidence and guidelines recommend wider use.

General Anaesthesia Protocols for Patients Undergoing Electroconvulsive Therapy: Retrospective analysis of 504 sessions over a five-year period at a tertiary care hospital in Oman

OBJECTIVES

This study aimed to review general anaesthesia protocols for patients undergoing electroconvulsive therapy (ECT) at a tertiary care hospital in Oman, particularly with regards to clinical profile, potential drug interactions and patient outcomes.

METHODS

This retrospective study took place at the Sultan Qaboos University Hospital (SQUH), Muscat, Oman. The electronic medical records of patients undergoing ECT at SQUH between January 2010 and December 2014 were reviewed for demographic characteristics and therapy details.

RESULTS

A total of 504 modified ECT sessions were performed on 57 patients during the study period. All of the patients underwent a uniform general anaesthetic regimen consisting of propofol and succinylcholine; however, they received different doses between sessions, as determined by the treating anaesthesiologist. Variations in drug doses between sessions in the same patient could not be attributed to any particular factor. Self-limiting tachycardia and hypertension were periprocedural complications noted among all patients. One patient developed aspiration pneumonitis (1.8%).

CONCLUSION

All patients undergoing ECT received a general anaesthetic regimen including propofol and succinylcholine. However, the interplay of anaesthetic drugs with ECT efficacy could not be established due to a lack of comprehensive data, particularly with respect to seizure duration. In addition, the impact of concurrent antipsychotic therapy on anaesthetic dose and subsequent complications could not be determined.