Concurrent Electroconvulsive Therapy and Bupropion Treatment

A Retrospective Matched Comparison Study of Prolonged Seizures in ECT

OBJECTIVE

This study assessed the incidence of and risk factors for prolonged seizures (>180 sec) in electroconvulsive therapy (ECT).

METHOD

In 611 adult patients undergoing 6697 ECT treatments administered over a 2.5-year study period, 29 individuals experienced 42 prolonged seizures. A comparison sample (n = 29) was matched on sex, age, and treatment, and compared on psychiatric and medical diagnoses, as well as current medications. To examine the association between the characteristics and prolonged seizure, conditional logistic regression models or exact McNemar tests were conducted.

RESULTS

Prolonged seizures occurred on average in 1 of every 167 treatments. No specific psychiatric disorders or medical conditions were associated with the prolonged seizure group. Antipsychotic drugs were used in a higher proportion of the comparison group than in the prolonged seizure group, suggesting a protective effect. Atropine was used in a lower proportion of the long seizure group than in the comparison group. No untoward sequelae occurred, and no progression to status epilepticus was observed.

CONCLUSIONS

Prolonged seizures appear to be an uncommon complication of ECT in adults. The characteristics examined in this study suggest limited association of psychotropic medications with prolonged seizures. Treatment of prolonged seizures was straightforward. Prolonged seizures had no impact on the course of treatment. Further exploration of prolonged seizures would enhance the generalizability of the findings from this single site study.

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.

Ketamine treatment protects against oxidative damage and the immunological response induced by electroconvulsive therapy

BACKGROUND

Electroconvulsive therapy (ECT) is often recommended for major depressive disorder (MDD) for those who do not respond to the first and second antidepressant trials. A combination of two therapies could improve antidepressant efficacy. Thus, this study aimed to investigate the synergistic effects of ECT combined to antidepressants with a different mechanism of action.

METHODS

Rats were treated once a day, for five days with ketamine (5 mg/kg), fluoxetine (1 mg/kg), and bupropion (4 mg/kg) alone or in combination with ECT (1 mA; 100 V). After, oxidative damage and antioxidant capacity were assessed in the prefrontal cortex (PFC) and hippocampus, and pro-inflammatory cytokines levels were evaluated in the serum.

RESULTS

ECT alone increased lipid peroxidation in the PFC and hippocampus. In the PFC of rats treated with ECT in combination with fluoxetine and bupropion, and in the hippocampus of rats treated with ECT combined with ketamine and bupropion there was a reduction in the lipid peroxidation. The nitrite/nitrate was increased by ECT alone but reverted by combination with ketamine in the hippocampus. Superoxide dismutase (SOD) was increased by ECT and maintained by fluoxetine and bupropion in the PFC. ECT alone increased interleukin-1β (IL-1β) and the administration of ketamine was able to revert this increase showing a neuroprotective effect of this drug when in combination with ECT.

CONCLUSION

The treatment with ECT leads to an increase in oxidative damage and alters the immunological system. The combination with ketamine was able to protect against oxidative damage and the immunological response induced by ECT.

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.

The Efficacy and Safety of Concomitant Psychotropic Medication and Electroconvulsive Therapy (ECT)

Electroconvulsive therapy (ECT) is an effective treatment for severe psychiatric disorders. Patients referred to ECT are often taking multiple medications, many of which can potentially affect the safety and efficacy of their course of ECT. This review evaluates the impact of a variety of psychotropic medications often used in conjunction with ECT and examines strategies to optimize their management. The review encompasses mood stabilizers, antidepressants, benzodiazepines, antiepileptics, antipsychotics, and other commonly used psychotropics.

[Electroconvulsive therapy in combination with psychotropic and non-psychotropic pharmacological treatments: Review of the literature and practical recommendations]

CONTEXT

Electro-convulsive therapy (ECT) is the most effective treatment for treatment resistant mood disorders and catatonia. ECT also appears to be an effective treatment in combination with clozapine in the context of treatment resistant schizophrenia spectrum disorders. Although increasingly codified (guidelines on indications, contraindications, methods of implementation), the practice of ECT still lacks consensual protocols. The concomitant use of psychotropic and/or non-psychotropic medication is a common situation when ECT treatment is considered. To our knowledge, there is to date no summary of studies or case reports in France, nor any proposal for guidelines concerning the management of medication of the patient to whom ECT sessions are offered. Indeed, several particularities must be considered. This article proposes to specify for each pharmacological class the possible interaction between ECT and medication. A first section of this article will be devoted to non-psychotropic treatments, and a second section to psychotropic treatments. A practical summary table is also provided.

METHOD

A review of the literature was conducted including all articles published prior to January 2019 referenced in Pub Med database, combining research with Medical Subject Headings "Electroconvulsive Therapy" and each following pharmacological class: "Cardiovascular Agents" "Bronchodilator Agents" "Bronchoconstrictor Agents" "Theophylline" "Anticoagulants" "Hypoglycemic Agents" "Insulin" "Potassium" "Benzodiazepines" "Valproic Acid" "Carbamazepine" "Lamotrigine" "Lithium" "Antidepressive Agents" "Antipsychotic Agents".

RESULTS

After reading the titles, abstracts and whole articles, then searching for additional articles in the references, 50 articles were selected. A summary table summarizing the main risks and proposing a course of action has been produced.

DISCUSSION

It is essential to take into account the specificity and the different physiological mechanisms involved in the ECT treatment in order to adjust the associated pharmacological treatments. The prescription for each molecule should be reviewed when ECT treatment is initiated.

Caffeine Sodium Benzoate for Electroconvulsive Therapy Augmentation

OBJECTIVES

Because of an ongoing manufacturer shortage of injectable caffeine sodium benzoate (CSB), patients at our health system were given CSB compounded in-house to increase seizure response during electroconvulsive therapy (ECT). Therefore, we aimed to evaluate its effectiveness and safety as an ECT augmentation agent.

METHODS

Medical records of patients who received compounded CSB at Virginia Commonwealth University Health System were reviewed to identify adults receiving it as part of an index ECT treatment course between June 2012 and December 2016. The primary outcome was change in electroencephalogram seizure duration from pre-caffeine session to initial caffeine session. Data were also collected on demographics, motor seizure duration, maximum heart rate, mean arterial pressure, and concurrent medication use for these sessions and the last caffeine session.

RESULTS

Seven-one patients were included in the study, predominantly white females with a mean age of 58.6 years. The most common indication for ECT was major depressive disorder resistant to pharmacotherapy (71.8%), followed by catatonia associated with another mental disorder (19.7%). Electroencephalogram seizure duration increased by 24.1 seconds on average with first CSB use (P < 0.0001), allowing 24 more patients overall to achieve goal of at least 30 seconds (P < 0.0001). No clinically significant changes in maximum heart rate or mean arterial pressure were observed, nor did any patients require an abortive agent for prolonged seizure. Five patients (7%) discontinued CSB prematurely: 4 related to adverse effects and 1 secondary to ineffectiveness.

CONCLUSIONS

We confirm results of prior studies of the utility of CSB and add that compounded CSB is effective for ECT augmentation, maintaining effectiveness throughout the index course with minimal safety concerns.