Effectiveness of Electroconvulsive Therapy and Associated Cognitive Change in Schizophrenia: A Naturalistic, Comparative Study of Treating Schizophrenia With Electroconvulsive Therapy

Predictors of cognitive changes in patients with schizophrenia undergoing electroconvulsive therapy

INTRODUCTION

Previous studies on the effects of electroconvulsive therapy (ECT) on cognition in schizophrenia have been inconclusive. This study aimed to identify factors that may predict cognitive improvement or deterioration in patients with schizophrenia after-ECT.

MATERIALS & METHODS

Patients with schizophrenia or schizoaffective disorder with predominantly positive psychotic symptoms, who were treated with ECT at the Institute of Mental Health (IMH), Singapore, between January 2016 and January 2018, were assessed. Montreal Cognitive Assessment (MoCA), Brief Psychiatric Rating Scale (BPRS) and Global Assessment of Function (GAF) were performed before and after ECT. Patients with clinically significant improvement, deterioration or no change in MoCA scores were compared on demographics, concurrent clinical treatment and ECT parameters.

RESULTS

Of the 125 patients analysed, 57 (45.6%), 36 (28.8%) and 32 (25.6%) showed improvements, deterioration and no change in cognition respectively. Age and voluntary admission predicted MoCA deterioration. Lower pre-ECT MoCA and female sex predicted MoCA improvement. Patients showed improvements in GAF, BPRS and BPRS subscale scores on average, except for the MoCA deterioration group, who did not show statistically significant improvement in negative symptom scores. Sensitivity analysis showed that nearly half the patients (48.3%) who were initially unable to complete MoCA pre-ECT were able to complete MoCA post-ECT.

CONCLUSIONS

The majority of patients with schizophrenia demonstrate improved cognition with ECT. Patients with poor cognition pre-ECT are more likely to see improvement post-ECT. Advanced age may be a risk factor for cognitive deterioration. Finally, improvements in cognition may be associated with improvements in negative symptoms.

Can brain stimulation enhance cognition in clinical populations? A critical review

Many psychiatric and neurological conditions are associated with cognitive impairment for which there are very limited treatment options. Brain stimulation methodologies show promise as novel therapeutics and have cognitive effects. Electroconvulsive therapy (ECT), known more for its related transient adverse cognitive effects, can produce significant cognitive improvement in the weeks following acute treatment. Transcranial magnetic stimulation (TMS) is increasingly used as a treatment for major depression and has acute cognitive effects. Emerging research from controlled studies suggests that repeated TMS treatments may additionally have cognitive benefit. ECT and TMS treatment cause neurotrophic changes, although whether these are associated with cognitive effects remains unclear. Transcranial electrical stimulation methods including transcranial direct current stimulation (tDCS) and transcranial alternating current stimulation (tACS) are in development as novel treatments for multiple psychiatric conditions. These treatments may also produce cognitive enhancement particularly when stimulation occurs concurrently with a cognitive task. This review summarizes the current clinical evidence for these brain stimulation treatments as therapeutics for enhancing cognition. Acute, or short-lasting, effects as well as longer-term effects from repeated treatments are reviewed, together with potential putative neural mechanisms. Areas of future research are highlighted to assist with optimization of these approaches for enhancing cognition.

Effects of electroconvulsive therapy on cognition and quality of life in schizophrenia

INTRODUCTION

The effects of electroconvulsive therapy (ECT) on quality of life (QoL), and its relationship with symptom and cognitive change remains unclear. We aim to examine the association of QoL changes with psychiatric symptom and cognitive changes among patients with schizophrenia who underwent ECT.

METHODS

This is a retrospective cohort study of 132 patients who received ECT from July 2017 to December 2019. Sociodemographic and clinical characteristics were obtained from medical records. Changes in QoL, psychiatric symptoms and cognition function were examined after 6 sessions of ECT. Generalised linear regression was used to examine the associations of Brief Psychiatric Rating Scale (BPRS) scores and Montreal Cognitive Assessment (MoCA) scores with QoL as measured by EQ-5D scores.

RESULTS

The mean (standard error) improvements after ECT were statistically significant for the assessment scales of EQ-5D utility score: 0.77 (0.02) to 0.89 (0.02), P<0.001; EuroQol-5-Dimension (EQ-5D) visual analogue scale score: 66.82 (2.61) to 73.05 (1.93), P=0.012; and EQ-5D subdomain scores. Both improvement in BPRS (adjusted β coefficient -0.446, 95% confidence interval [CI] -0.840 to -0.052) and MoCA (adjusted β 12.068, 95% CI 0.865 to 12.271) scores were significantly associated with improvement in EQ-5D utility scores after adjustment for sociodemographic and clinical characteristics. Improvement of BPRS scores (psychiatric symptoms) was significantly associated with improvement of the patients' mental health that was assessed by EQ-5D subdomain scores of pain (adjusted β coefficient 0.012, 95% CI 0.004 to 0.021) and anxiety (adjusted β coefficient 0.013, 95% CI 0.002 to 0.024). Improvement of MoCA scores (cognitive function) was significantly associated with patients' physical health as assessed by EQ-5D subdomain score of usual activity (adjusted β coefficient -0.349, 95% CI -0.607 to -0.09).

CONCLUSION

ECT was associated with an overall improvement of QoL among patients with schizophrenia. The improvement of psychiatric symptoms was found to be significantly associated with better mental health while the improvement of cognitive function was associated with better physical health.

Dopaminergic dysfunction and excitatory/inhibitory imbalance in treatment-resistant schizophrenia and novel neuromodulatory treatment

Antipsychotic drugs are the mainstay in the treatment of schizophrenia. However, one-third of patients do not show adequate improvement in positive symptoms with non-clozapine antipsychotics. Additionally, approximately half of them show poor response to clozapine, electroconvulsive therapy, or other augmentation strategies. However, the development of novel treatment for these conditions is difficult due to the complex and heterogenous pathophysiology of treatment-resistant schizophrenia (TRS). Therefore, this review provides key findings, potential treatments, and a roadmap for future research in this area. First, we review the neurobiological pathophysiology of TRS, particularly the dopaminergic, glutamatergic, and GABAergic pathways. Next, the limitations of existing and promising treatments are presented. Specifically, this article focuses on the therapeutic potential of neuromodulation, including electroconvulsive therapy, repetitive transcranial magnetic stimulation, transcranial direct current stimulation, and deep brain stimulation. Finally, we propose multivariate analyses that integrate various perspectives of the pathogenesis, such as dopaminergic dysfunction and excitatory/inhibitory imbalance, thereby elucidating the heterogeneity of TRS that could not be obtained by conventional statistics. These analyses can in turn lead to a precision medicine approach with closed-loop neuromodulation targeting the detected pathophysiology of TRS.

Comparison of Acute Followed by Maintenance ECT vs Clozapine on Psychopathology and Regional Cerebral Blood Flow in Treatment-Resistant Schizophrenia: A Randomized Controlled Trial

BACKGROUND AND HYPOTHESIS

In treatment-resistant schizophrenia (TRS), Clozapine is only approved treatment with undesirable side-effects, warranting better alternatives. Our hypothesis is acute followed by maintenance Electroconvulsive Therapy (M-ECT) will be comparable in efficacy and safety to Clozapine in TRS.

STUDY DESIGN

In this open-label trial, 60 TRS patients were randomized equally to M-ECT (following an acute-course) or Clozapine. Positive and Negative Syndrome Scale (PANSS), Clinical Global Impression Schizophrenia Scale (CGI-SCH), Montreal Cognitive Assessment (MoCA), and Global assessment of functioning (GAF) were measured and compared within and between the groups at baseline, 6 weeks, 12 weeks, and 24 weeks. SPECT-CT brain was done at baseline and 24 weeks to compare the changes in regional cerebral perfusion between the groups and correlate with the changes in the outcome-measures.

STUDY RESULTS

The PANSS-T scores changes from baseline over the observation-points were significant in both M-ECT and clozapine groups (P < .001), with comparatively better reduction with M-ECT (P < .001). Similar trends were observed in PANSS subscales, CGI-SCH and GAF in both groups, with significantly better improvement with M-ECT over the study-period. After 24 weeks, there was significantly better perfusion with M-ECT in bilateral prefrontal and temporal cortices (P < .05). With M-ECT, a positive correlation was found between changes in PANSS-P scores and left-lateral Temporal cortical perfusion (r = .465, P = .017).

CONCLUSIONS

Acute followed by M-ECT was more effective than clozapine over 6 months in reducing the positive and negative symptoms, general psychopathology, illness-severity, and improving the global functionality in TRS [clinicaltrials.gov: NCT03807882].

The Impact of Electroconvulsive Therapy on Negative Symptoms in Schizophrenia and Their Association with Clinical Outcomes

OBJECTIVE

The treatment efficacy of electroconvulsive therapy (ECT) for negative symptoms amongst patients with schizophrenia remains unclear. In this study, we aim to examine the effects of ECT on negative symptoms in schizophrenia and their association with other clinical outcomes, including cognition and function.

METHODS

This is a retrospective data analysis of patients with schizophrenia/schizoaffective disorder treated with ECT at the Institute of Mental Health (IMH), Singapore, between January 2016 and December 2019. Clinical outcomes were assessed by the Brief Psychiatric Rating Scale (BPRS), the Montreal Cognitive Assessment (MoCA), and Global Assessment of Function (GAF). Changes in scores were compared with repeated measures analysis of variance. Sequential structural modelling was utilized to examine the pathway relationships between changes in negative symptoms, global functioning, and cognition functioning after ECT.

RESULTS

A total of 340 patients were analysed. Hence, 196 (57.6%), 53 (15.5%), and 91 (26.7%) showed improvements, no change, and deterioration in negative symptoms, respectively. ECT-induced improvement of negative symptoms was significantly associated with improvement of global functioning (direct effect correlation coefficient (r): -0.496; se: 0.152; p = 0.001) and cognition function (indirect effect r: -0.077; se: 0.037; p = 0.035). Moreover, having capacity to consent, more severe baseline negative symptoms, lithium prescription, and an indirect effect of voluntary admission status via consent capacity predicted ECT associated negative symptoms improvement.

CONCLUSION

ECT is generally associated with improvements of negative symptoms in people with schizophrenia, which correlate with improvements of overall function. Possible novel clinical predictors of negative symptom improvement have been identified and will require further research and validation.

A Systematic Review on Cognitive Effects of Electroconvulsive Therapy in Asian Patients

Objective

Electroconvulsive therapy (ECT) is the most efficacious treatment for many major mental illnesses but is limited by cognitive side effects. However, research on the pattern and severity of ECT-related cognitive side effects is inconsistent. Furthermore, little is known about the cognitive effects of ECT in Asian populations. A systematic review was conducted to examine objective cognitive performance following ECT in the Asian context.

Methods

This review systematically identified studies assessing ECT-related cognitive effects in PubMED, PsychINFO, The Cochrane Library, Journal of ECT and major databases in Asian countries. The search included publications from peer-reviewed journals of languages other than English.

Results

A total of 6,322 studies were identified; 823 were assessed for eligibility, of which 16 studies met the search criteria and were included in this review. Majority used high dose Bitemporal ECT for Depression and/or Schizophrenia. Cognitive impairment, which could occur immediate to the first ECT session, was reported in only 9 out of the 16 studies. However, deficits were observed to resolve as early as 3 weeks after the initiation of ECT. The remaining studies reported no impairment or even improvement after ECT.

Conclusion

There is no consistent evidence that suggests ECT causes cognitive deficits in patients, despite the widespread use of high dose Bitemporal ECT. This review suggests that Asian patients, presenting with a different psychiatric profile, may respond to high-dose Bitemporal ECT differently from Western samples.

Comparative outcomes in electroconvulsive therapy (ECT): A naturalistic comparison between outcomes in psychosis, mania, depression, psychotic depression and catatonia

Electroconvulsive Therapy's (ECT) use and place in treatment guidelines varies worldwide with a primary indication of depression in Western countries and acute psychosis in Asian countries. There is sparse evidence about the relative effectiveness of ECT among different indications that may account for this discrepancy. We aimed to compare the clinical global impression of disease severity, cognitive change, subjective quality of life (QoL) and global functioning after ECT given for treatment of the indications of acute psychosis, mania, depression, psychotic depression and catatonia. We conducted a retrospective naturalistic cohort study with post-hoc analyses of patients' ECT registry data from 2017 to 2019. 691 patients were assessed before and after 6 sessions of ECT treatment, using the Clinical Global Impression-Improvement and Severity (CGI-I and CGI-S) scale, Montreal Cognitive Assessment (MoCA), Quality of Life Enjoyment and Satisfaction Questionnaire Short Form (Q-LES-Q-SF), EQ-5D utility score and Global Assessment of Functioning (GAF) scale. The pre-ECT vs post-ECT clinical assessment change scores were compared within and across the five indications. For each indication, there were large improvements in clinical global impression of disease severity, QoL and global functioning. There were no significant changes in MoCA score for most indications except for an improvement in patients with schizophrenia. ECT is a rapidly acting and effective acute treatment across several severe mental illnesses with large improvements in symptoms, QoL and global functioning.

A Pilot Study of Switching Electroconvulsive Therapy for Patients With Treatment Resistant Schizophrenia or Mood Disorder

OBJECTIVES

Switching of ECT electrode modality is commonly done in clinical practice but outcomes are unclear. We aimed to compare the clinical outcomes between ECT modality switchers and nonswitchers in a large tertiary psychiatric institution over 1 year.

METHODS

Brief Psychiatric Rating Scale (BPRS), Montgomery-Åsberg Depression Rating Scale (MADRS) and Montreal Cognitive Assessment (MoCA) were used to assess symptoms and cognition. General linear regression was utilized to compare the change of BPRS or MADRS and MoCA score among switchers vs nonswitchers.

RESULTS

21.5% of 209 patients switched ECT. Baseline BPRS scores were lower among nonswitchers. Response rate in schizophrenia, depression and mania were higher for nonswitchers (69.6%, 81.35% and 84.8% respectively / 9.2 (SD 3.3) sessions) compared to switchers (53.8%, 0% and 66.7% respectively / 10.6 (SD 4.5) sessions). Most common ECT switches were Bifrontal (BF) to Bitemporal (BT) (schizophrenia), UB RUL (ultrabrief right unilateral) to BT (depression), and UB RUL to BT / BF (mania). There was no significant difference in the change of BPRS and MoCA scores between nonswitchers and switchers. However, there was significantly more improvement of MADRS scores among nonswitchers [adjusted mean ± SE: (-26.4 ± 2.8)] compared with switchers (-10.6) ±6.6).

CONCLUSIONS

ECT switching was commonly done and may result in better or worse outcomes than not switching depending on diagnosis. Controlled trials are required to address this urgent clinical issue.

Is There Evidence That Stimulus Parameters and Electrode Placement Affect the Cognitive Side Effects of Electroconvulsive Therapy in Patients With Schizophrenia and Schizoaffective Disorder?: A Systematic Review

ABSTRACT

Seventy percent of patients with treatment-resistant schizophrenia do not respond to clozapine. Electroconvulsive therapy (ECT) can potentially offer significant benefit in clozapine-resistant patients. However, cognitive side effects can occur with ECT and are a function of stimulus parameters and electrode placements. Thus, the objective of this article is to systematically review published clinical trials related to the effect of ECT stimulus parameters and electrode placements on cognitive side effects. We performed a systematic review of the literature up to July of 2020 for clinical studies published in English or German examining the effect of ECT stimulus parameters and/or electrode placement on cognitive side effects in patients with schizophrenia or schizoaffective disorder. The literature search generated 3 randomized, double-blind, clinical trials, 1 randomized, nonblinded trial, and 1 retrospective study. There are mixed findings regarding whether pulse width and stimulus dose impact on cognitive side effects. One study showed less cognitive side effect for right unilateral (RUL) than bitemporal (BT) electrode placement, and 2 studies showed a cognitive advantage for bifrontal (BF) compared with BT ECT. Only 1 retrospective study measured global cognition and showed post-ECT cognitive improvement with all treatment modalities using Montreal Cognitive Assessment in comparison to pre-ECT Montreal Cognitive Assessment scores. Current data are limited, but evolving. The evidence suggests that RUL or BF ECT have more favorable cognitive outcomes than BT ECT. Definitive larger clinical trials are needed to optimize parameter and electrode placement selection to minimize adverse cognitive effects.

Cognitive change after electroconvulsive therapy in mood disorders measured with the Montreal Cognitive Assessment

OBJECTIVE

The Montreal Cognitive Assessment (MoCA) is a sensitive and clinically practical test but its usefulness in measuring long-term cognitive effects of ECT is unclear. Using the MoCA, we investigated short- and long-term global cognitive change in ECT-treated patients with a Major Depressive Episode (MDE).

METHOD

We included 65 consecutive ECT-treated patients with MDE, in whom global cognitive functioning was assessed at baseline (T0); during ECT (before the third session; T1); and 1 week (T2), 3 months (T3), and 6 months (T4) after completion of the index course. Changes in MoCA (sub)scores were analyzed using linear mixed models and reliable change indices were computed to investigate individual changes in MoCA total scores.

RESULTS

There was a significant effect of time on MoCA scores (F(4, 230.5) = 4.14, P = 0.003), with an improvement in global cognitive functioning from T3 compared to T1 and T2. At the individual level, 26% (n = 17) of patients showed a significantly worse cognitive functioning at T2 and 12% (n = 8) an improved cognitive functioning compared to T0. For T4, these percentages ameliorated to 8% and 18% respectively.

CONCLUSION

No persistent global cognitive impairment induced by ECT was found at the group level using the MoCA. At the individual level, however, there was clear heterogeneity in the effects of ECT on cognitive functioning. The MoCA is a suitable tool to monitor short- and long-term global cognitive functioning in ECT-treated patients with MDE but in younger patients, potential ceiling effects must be taken into account.

Outcomes in patients with and without capacity in electroconvulsive therapy

BACKGROUND

Electroconvulsive therapy (ECT) is an effective treatment for severe mental illness but access is limited for patients lacking consent capacity. We aimed to compare the symptomatic, cognitive, quality of life (QOL) and functional outcomes of patients with and without capacity receiving ECT for schizophrenia, depression or mania.

METHODS

Patients prescribed ECT in a single center had their clinical outcomes pre and post ECT compared with repeated measures ANOVAs. Differences in demographic, clinical characteristics and ECT treatment between the group lacking and having capacity were examined using independent t-tests for continuous variables and chi-squared tests for categorical variables.

RESULTS

75.1% of 175 patients lacked capacity. The group lacking capacity had overall poorer cognitive and global functioning pre ECT but higher QOL. Objective psychiatric symptom ratings after ECT improved similarly between groups. Mood, cognition, QOL and function improved in both groups, with more improvement in mood and function in the group lacking capacity and a trend towards greater cognitive improvement (p = 0.051).

LIMITATIONS

Subgroup analysis by diagnosis was not done due to smaller sample sizes in each group. Cognition was assessed with a general screening instrument not a full neuropsychological assessment.

CONCLUSIONS

ECT is a safe and effective treatment for schizophrenia, bipolar mania and depression, and may provide similar or greater benefits in patients lacking capacity to consent, compared to those with capacity. These results support the provision of a framework for substitute decision making in the patients' best interests for ECT in patients unable to provide their own consent.

Relief of expressed suicidality in schizophrenia after electroconvulsive therapy: A naturalistic cohort study

Suicide risk in schizophrenia is a significant treatment challenge but there are few approved treatments. Electroconvulsive therapy (ECT) is a highly effective treatment for suicidality in depression but its effect on suicidality in schizophrenia is unclear. We conducted a retrospective naturalistic study of the real-world effect of ECT on expressed suicidality as assessed by item 4 of the 24-item Brief Psychiatric Rating Scale in 113 patients with treatment resistant schizophrenia receiving ECT. 19.5% of patients expressed suicidal ideation pre-ECT of which 86.4% experienced an improvement in expressed suicidality after an average of 10.2 (SD 2.7) sessions of ECT. Changes in suicide scores before and after ECT was examined using a generalized estimating equation (GEE) model which showed that the effect of ECT on suicide was significantly mediated by depression and explained 72.2% of the decreased in expressed suicidality. ECT is effective in decreasing depression and expressed suicidality in patients with schizophrenia and should be considered as a treatment option for managing suicidality and psychosis in patients with treatment resistant schizophrenia.

Acute electroconvulsive therapy in the elderly with schizophrenia and schizoaffective disorder: A case series

INTRODUCTION

There is a paucity of evidence regarding the use of electroconvulsive therapy (ECT) in the elderly with primary psychotic conditions, such as schizophrenia and schizoaffective disorder. This study examined the efficacy and safety of acute ECT treatment in late-life patients with primary psychotic conditions.

METHODS

A retrospective chart review was conducted on all patients aged 60 and above, who received ECT within a large metropolitan psychiatric facility in Australia between 2012 and 2018, and who were diagnosed with a primary psychotic condition. Information regarding demographic data, illness correlates, ECT treatment, treatment outcomes, and adverse effects was collected.

RESULTS

A total of 20 patients met inclusion into the study, 35% of whom were diagnosed with schizophrenia and 65% with schizoaffective disorder. The average age was 69 years. Patients had been trialed on an average of seven distinct antipsychotic agents prior to acute ECT treatment; 50% had been trialed on clozapine. ECT was associated with full (60%) or partial remission (35%) of psychotic illness in 95% (n = 19) of patients. No ECT-related fatalities were encountered. Adverse effects were experienced in 20% of patients, although none precluded the continuation of treatment.

DISCUSSION

This study found ECT to be a highly effective and safe treatment in the elderly with schizophrenia and schizoaffective disorder, who had not responded adequately to psychotropic medications.

Acute electroconvulsive therapy in the elderly with schizophrenia and schizoaffective disorder: a literature review

OBJECTIVES

This study reviewed the evidence regarding the efficacy of acute electroconvulsive therapy for primary psychotic conditions in the elderly.

METHODS

A literature search was performed using the Medline, Embase and Cochrane databases.

RESULTS

Acute electroconvulsive therapy resulted in an improvement of psychotic symptoms in almost all elderly patients, a large proportion of whom had treatment-resistant conditions. No electroconvulsive therapy related fatalities or severe medical complications were encountered.

CONCLUSIONS

Acute electroconvulsive therapy may present a valuable treatment modality for elderly patients with primary psychotic conditions who do not respond adequately to antipsychotic medications.

A Retrospective Study of Cognitive Improvement Following Electroconvulsive Therapy in Schizophrenia Inpatients

OBJECTIVES

Findings on the cognitive effect of electroconvulsive therapy (ECT) in individuals with schizophrenia have brought mixed results, with few recent studies beginning to report cognitive improvements after treatment. Cognitive change in inpatients with schizophrenia who were referred for an acute course of ECT was examined in the current study. Furthermore, the study aimed to determine the profile of patients who experience cognitive improvement and the potential use of a brief cognitive battery to detect this positive cognitive change, if any.

METHODS

Montreal Cognitive Assessment (MoCA) was conducted at baseline and posttreatment after 6 sessions of ECT. The Brief ECT Cognitive Screen was also administered to determine its predictive ability on cognitive gain of 2 points or higher in MoCA total scores for the 2 consecutive time points.

RESULTS

A total of 81 inpatients were included in the study. Retrospective analysis revealed significant improvements in MoCA total score and domains of visuospatial/executive function and attention. Cognitive improvement was more pronounced among those who had worse pre-MoCA score before ECT.

CONCLUSIONS

The study provided support to the existing literature where cognitive improvement has been reported among individuals with schizophrenia after ECT. Future studies should consider the use of randomized controlled trials to examine the possible cognitive benefits of ECT. In a setting where there is a high volume of patients receiving ECT, the monitoring of patients' cognitive status through the course of ECT continues to be warranted and the Brief ECT Cognitive Screen may be useful as a quick measure to detect such ECT-related cognitive change.

Clinical effectiveness and speed of response of electroconvulsive therapy in treatment-resistant schizophrenia

AIM

Although electroconvulsive therapy (ECT) has been shown to be efficacious for patients with treatment-resistant schizophrenia, there has been limited evidence on the rate of response, cognition, and quality-of-life outcomes. The primary aims of the present study were thus to examine the effectiveness and speed of response to ECT in a naturalistic retrospective cohort in patients with treatment-resistant schizophrenia.

METHODS

We performed a retrospective database analysis. The primary effectiveness outcome was defined as an improvement of ≥40% from pretreatment scores based on the Brief Psychiatric Rating Scale (BPRS) Psychotic Symptom subscale. Data were included for analysis for all patients with a primary DSM-5 diagnosis of schizophrenia that was treatment-resistant and who had had an acute course of ECT initiated for the treatment of schizophrenia between 1 July 2016 and 1 December 2016.

RESULTS

A total of 50 inpatients were included for analysis. The present study revealed that 50% of patients showed at least a 40% reduction in BPRS Psychotic Symptom subscale scores after completion of ECT and that 16.7% of patients responded after the first three sessions, 39.3% after six sessions, 46.4% after nine sessions, and 50% after 12 sessions. The greatest improvement in BPRS scores was between the third and sixth ECT sessions. BPRS scores, Clinical Global Impression, Montreal Cognitive Assessment, and Global Assessment of Functioning showed significant improvement. There was no significant difference in quality-of-life outcomes.

CONCLUSION

Utilizing modern techniques in treatment-resistant schizophrenia, this study demonstrates the real-world effectiveness and rate of response of patients receiving ECT.

Electroconvulsive practice in Singapore: a cross-sectional national survey

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

Electroconvulsive Therapy and Schizophrenia: A Systematic Review

Electroconvulsive therapy (ECT) is a remarkably effective treatment for major depressive disorder, but is less commonly utilized for treatment of psychotic disorders. Recent literature indicates that ECT can be a useful strategy for a wide range of psychotic disorders, including treatment-resistant schizophrenia. The purpose of this review is to examine the extant literature on ECT in schizophrenia with a primary focus on its efficacy, its impact on cognitive function, the role of maintenance ECT, and the potential role of neuroimaging biomarkers to provide more precise ECT treatment strategies. We evaluated the available literature, with a particular focus on prospective, randomized trials. Our review suggests that ECT can be an effective treatment strategy in this severely ill patient population. Studies suggest that while ECT in schizophrenia is a safe treatment modality, the potential for cognitive impairment must always be carefully weighed. The use and investigation of new biomarker strategies for the pharmacological treatment of schizophrenia, and the extension of these approaches to ECT are also discussed.

Effectiveness and Cognitive Changes With Ultrabrief Right Unilateral and Other Forms of Electroconvulsive Therapy in the Treatment of Mania

OBJECTIVE

Electroconvulsive therapy (ECT) is an effective treatment in mania. However, there is little evidence regarding the use of ultrabrief right unilateral (RUL-UB) ECT in treatment of acute manic episodes. The aim of this study was to report on the effectiveness and cognitive profile of ECT in bipolar mania, including a sample who received RUL-UB ECT.

METHODS

This naturalistic study retrospectively collected data in 33 patients who received ECT with concurrent antipsychotics for mania between October 1, 2014, and July 30, 2016. Electroconvulsive therapy was given using RUL-UB, brief-pulse right unilateral, or brief-pulse bitemporal approaches, dosed according to the patient's seizure threshold. The Brief Psychiatric Rating Scale (BPRS), Young Mania Rating Scale (YMRS) score, and the Montreal Cognitive Assessment (MoCA) were administered to patients before and after the ECT course.

RESULTS

For the whole sample, there was a significant improvement in BPRS (total score and manic subscale), YMRS, and MoCA total scores across the ECT treatment course. The overall BPRS response rate was 84%, and mean scores decreased from 42.1 (SD, 12.0) to 26.0 (SD, 4.0). The 13 patients who received RUL-UB ECT also showed significant improvement in BPRS, YMRS, and MoCA scores over the treatment course.

CONCLUSIONS

Electroconvulsive therapy in general and also specifically RUL-UB ECT were effective in treating mania and also led to global cognitive improvement.

Low-charge electrotherapy for patients with schizophrenia: A double-blind, randomised controlled pilot clinical trial

A double-blind, randomised controlled pilot clinical trial was conducted to assess the potential effectiveness and safety of low-charge electrotherapy (LCE) for patients with schizophrenia. Bitemporal LCE (approximately 2.8 Joules) was administered three times a week. The Positive and Negative Syndrome Scale score was set as the outcome measure. Any adverse event (AE) was recorded. Three visits occurred at baseline, post-treatment, and after one month of follow-up. Twelve patients were randomised to the electroconvulsive therapy (ECT) group or LCE group (6 patients in each group). No patient withdrew during the study. The LCE group did not experience seizures during the trial. Patients in both groups showed significant improvements in clinical measures after treatment, and the reduction of all scale scores between the two groups was nonsignificant. The LCE group experienced significantly fewer AEs than the ECT group. Compared with ECT, LCE exerts similar antipsychotic effects while causing fewer AEs. Thus, LCE has the potential to be a safe and effective treatment for patients with schizophrenia, but further research is needed.

Maintenance ECT in schizophrenia: A systematic review

Relapse after discontinuation of ECT is significant in patients with schizophrenia. The purpose of this systematic review was to examine use of M-ECT in schizophrenia to guide clinical decision making for relapse prevention in schizophrenia. We reviewed studies examining the role of continuation (C-ECT) and maintenance electroconvulsive therapy (M-ECT) in schizophrenia. Following PRISMA guidelines, we included randomized controlled trials, open label trials, retrospective chart reviews, case reports, and case series in this review. We evaluated adjunctive pharmacological regimens; ECT treatment parameters, including frequency, duration of continued treatment, electrode placement; clinical outcomes including cognitive side effects and relapse rates from included studies. Our findings suggest M-ECT could provide an effective form of relapse prevention in these patients and persistent cognitive side effects are minimal.

Electroconvulsive therapy (ECT) in schizophrenia: a review of recent literature

PURPOSE OF REVIEW

ECT remains an important, yet underutilized, treatment for schizophrenia. Recent research shows that medication-resistant patients with schizophrenia, including those resistant to clozapine, respond well to ECT augmentation. The purpose of this article is to review recent studies of the use of ECT in the treatment of schizophrenia.

RECENT FINDINGS

We performed an electronic database search for articles on ECT and schizophrenia, published in 2017. The main themes of these articles are: epidemiological data on ECT use from various countries; retrospective studies, prospective studies and meta-analyses focusing on efficacy and cognitive side-effects of ECT in schizophrenia; ECT technical parameters and potential biomarkers.

SUMMARY

There is growing evidence to support the use of ECT for augmentation of antipsychotic response in the treatment of schizophrenia. Cognitive side-effects are generally mild and transient. In fact, many studies show improvement in cognition, possibly related to the improvement in symptoms. There is wide variation among countries in the use of ECT for the treatment of schizophrenia. There are also variations in the choice of ECT electrode placement, parameters and schedules. These technical differences are likely minor and should not interfere with the treatment being offered to patients. Further, long-term studies are needed to optimize ECT treatment parameters, to examine the effect of maintenance ECT and to investigate neuroimaging/biomarkers to understand the mechanism of action and identify potential response predictors to ECT.