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Al-Wandi A, Landén M, Nordenskjöld A. Electroconvulsive therapy in the maintenance phase of psychotic unipolar depression. Acta Psychiatr Scand 2024; 150:148-159. [PMID: 38804530 DOI: 10.1111/acps.13711] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2024] [Revised: 04/12/2024] [Accepted: 05/16/2024] [Indexed: 05/29/2024]
Abstract
OBJECTIVE To determine whether the rates of readmissions and suicide vary in psychotic unipolar depression based on whether patients receive maintenance electroconvulsive therapy (M-ECT) following the initial series of ECT, and to examine if there is an age-dependent association. METHODS We used Swedish national registries to identify hospitalized patients with psychotic unipolar depression, treated 2008-2019 who received ECT during their hospital stay. The patients who received subsequent M-ECT within 14 days after discharge were compared with those who did not. The primary composite outcome was time to readmission due to a psychiatric disorder, suicide attempt, or suicide within 2 years from discharge. Data were analyzed using Cox regression adjusted for previous psychiatric admissions, age, sex, comorbidity, and pharmacological treatment. We also conducted a within-individual analysis using the sign-test, with patients having ≥1 hospital episode followed by M-ECT and ≥1 hospital episode without M-ECT. RESULTS A total of 1873 patients were included, of which 130 received M-ECT. There was no statistically significant group difference regarding the primary outcome in the whole sample. However, when stratified by age, there was a significant difference in favor of M-ECT for patients >65 years (adjusted hazard ratio 0.55, 95% confidence interval 0.35-0.87). The within-individual analysis, including 46 patients, significantly favored M-ECT. CONCLUSION M-ECT was not associated with a differential risk of the composite of readmission and suicide in psychotic depression. Among patients >65 years, M-ECT was significantly associated with a decreased risk of the outcome. The possibility of residual confounding cannot be excluded.
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Affiliation(s)
- Ahmed Al-Wandi
- University Health Care Research Centre, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Mikael Landén
- Institute of Neuroscience and Physiology, The Sahlgrenska Academy at Gothenburg University, Gothenburg, Sweden
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Axel Nordenskjöld
- University Health Care Research Centre, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
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Brooks JO, Kruse JL, Kubicki A, Hellemann G, Espinoza RT, Irwin MR, Narr KL. Structural brain plasticity and inflammation are independently related to changes in depressive symptoms six months after an index ECT course. Psychol Med 2024; 54:108-116. [PMID: 36600668 DOI: 10.1017/s0033291722003555] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
BACKGROUND Electroconvulsive therapy (ECT) is effective for treatment-resistant depression and leads to short-term structural brain changes and decreases in the inflammatory response. However, little is known about how brain structure and inflammation relate to the heterogeneity of treatment response in the months following an index ECT course. METHODS A naturalistic six-month study following an index ECT course included 20 subjects with treatment-resistant depression. Upon conclusion of the index ECT course and again after six months, structural magnetic resonance imaging scans and peripheral inflammation measures [interleukin-6 (IL-6), IL-8, tumor necrosis factor (TNF-α), and C-reactive protein] were obtained. Voxel-based morphometry processed with the CAT-12 Toolbox was used to estimate changes in gray matter volume. RESULTS Between the end of the index ECT course and the end of follow-up, we found four clusters of significant decreases in gray matter volume (p < 0.01, FWE) and no regions of increased volume. Decreased HAM-D scores were significantly related only to reduced IL-8 level. Decreased volume in one cluster, which included the right insula and Brodmann's Area 22, was related to increased HAM-D scores over six months. IL-8 levels did not mediate or moderate the relationship between volumetric change and depression. CONCLUSIONS Six months after an index ECT course, multiple regions of decreased gray matter volume were observed in a naturalistic setting. The independent relations between brain volume and inflammation to depressive symptoms suggest novel explanations of the heterogeneity of longer-term ECT treatment response.
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Affiliation(s)
- John O Brooks
- Department of Psychiatry and Biobehavioral Sciences, Semel Institute for Neuroscience and Human Behavior, University of California, Los Angeles, CA, USA
| | - Jennifer L Kruse
- Department of Psychiatry and Biobehavioral Sciences, Semel Institute for Neuroscience and Human Behavior, University of California, Los Angeles, CA, USA
| | - Antoni Kubicki
- Department of Psychiatry and Biobehavioral Sciences, Semel Institute for Neuroscience and Human Behavior, University of California, Los Angeles, CA, USA
- Department of Neurology, Ahmanson-Lovelace Brain Mapping Center, Geffen School of Medicine at the University of California, Los Angeles, CA, USA
| | | | - Randall T Espinoza
- Department of Psychiatry and Biobehavioral Sciences, Semel Institute for Neuroscience and Human Behavior, University of California, Los Angeles, CA, USA
| | - Michael R Irwin
- Department of Psychiatry and Biobehavioral Sciences, Semel Institute for Neuroscience and Human Behavior, University of California, Los Angeles, CA, USA
| | - Katherine L Narr
- Department of Psychiatry and Biobehavioral Sciences, Semel Institute for Neuroscience and Human Behavior, University of California, Los Angeles, CA, USA
- Department of Neurology, Ahmanson-Lovelace Brain Mapping Center, Geffen School of Medicine at the University of California, Los Angeles, CA, USA
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Koh AHK, Tan XW, Tor PC, Chatterton ML, Martin DM, Loo CK. The association between outpatient continuation/maintenance electroconvulsive therapy, readmission risk and total direct cost in patients with depressive, bipolar and psychotic disorders: A naturalistic retrospective cohort study. J Affect Disord 2023; 338:289-298. [PMID: 37295655 DOI: 10.1016/j.jad.2023.06.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Revised: 05/18/2023] [Accepted: 06/04/2023] [Indexed: 06/12/2023]
Abstract
BACKGROUND The transdiagnostic effect of continuation/maintenance ECT (CM-ECT) across mood and psychotic disorders on hospital psychiatric readmission risk and total direct cost remains unclear. METHODS A naturalistic retrospective analysis of 540 patients who received inpatient acute ECT treatment from May 2017 to Mar 2021 in a tertiary psychiatric institution. Patients were assessed with validated clinical rating scales pre-ECT and after the first 6 treatments of a course of inpatient acute ECT. After discharge, patients who continued with CM-ECT were compared with those not receiving CM-ECT using survival analysis of hospital readmission. Total direct cost (hospitalisation and ECT treatment cost) was also analysed. All patients were subjected to a standard post-discharge monitoring program with case managers checking in on the patients regularly after discharge and ensuring they were given an outpatient appointment within a month of discharge. RESULTS Both cohorts had significant improvement in their rating scales scores after their first six 6 sessions of inpatient acute ECT. Patients who continued with CM-ECT after completing their inpatient acute ECT (mean number of acute ECT: N = 9.9, SD 5.3), had a significantly lower risk of readmission [adjusted hazard ratio of 0.68 (95 % CI: 0.49-0.94, p = 0.020)]. Patients who received CM-ECT also had a significantly lower average total direct cost compared to those who did not (SGD$35,259 vs SGD$61,337). For patients with mood disorders, the CM-ECT group had a significantly lower inpatient ECT cost, hospitalisation cost and total direct costs compared to those without CM-ECT. LIMITATIONS The naturalistic study cannot prove a causal relationship between CM-ECT and reduced readmission and lower healthcare costs. CONCLUSION CM-ECT is associated with lower readmission risks and lower total direct healthcare costs for the treatment of mood and psychotic disorders, especially for mood disorders.
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Affiliation(s)
- Azriel H K Koh
- Department of Mood and Anxiety, Institute of Mental Health, Singapore 539747, Singapore
| | - Xiao Wei Tan
- Department of Mood and Anxiety, Institute of Mental Health, Singapore 539747, Singapore
| | - Phern Chern Tor
- Department of Mood and Anxiety, Institute of Mental Health, Singapore 539747, Singapore.
| | - Mary Lou Chatterton
- Public Health and Preventive Medicine, Monash University, Melbourne, VIC 3004, Australia; Deakin Health Economics, Institute for Health Transformation, Deakin University, Geelong, VIC, Australia
| | - Donel M Martin
- Psychiatry and Mental Health, University of New South Wales, Sydney, New South Wales, Australia; Black Dog Institute, Sydney, New South Wales, Australia
| | - Colleen K Loo
- Psychiatry and Mental Health, University of New South Wales, Sydney, New South Wales, Australia; Black Dog Institute, Sydney, New South Wales, Australia
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Rowland T, Mann R, Azeem S. The Efficacy and Tolerability of Continuation and Maintenance Electroconvulsive Therapy for Depression: A Systematic Review of Randomized and Observational Studies. J ECT 2023; 39:141-150. [PMID: 36961277 DOI: 10.1097/yct.0000000000000914] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/25/2023]
Abstract
ABSTRACT Electroconvulsive therapy (ECT) is a highly effective treatment for severe and treatment-resistant depression, but relapse rates remain high despite maintenance pharmacotherapy. Continuation or maintenance ECT (C/M-ECT) offers the potential to prevent relapses in the most unwell patients, but there remains disagreement among guidelines regarding its efficacy and tolerability. This review aims to summarize and assess the current evidence for the efficacy and tolerability of continuation and maintenance ECT for depression, including data from randomized and observational studies, which included an appropriate control group. Twenty studies were found meeting inclusion criteria. There was evidence from 14 studies suggesting that relapse rates are reduced in those receiving C/M-ECT. There was evidence from 6 studies suggesting that C/M-ECT had no effect on global cognitive function. Detailed neuropsychological testing was limited, but within studies that assessed specific cognitive domains, there was not consistent evidence for deficits in C/M-ECT compared with the control group. The certainty of evidence across outcomes was low or very low because of inclusion of observational studies, heterogeneity of study design, and patient populations. The findings add further weight to evidence suggesting that C/M-ECT is a viable treatment option to prevent relapse in severe depression and provides clinicians with further evidence for the benefits and risks of C/M-ECT when discussing treatment options with patients. Future research should focus on randomized or well-designed prospective studies with sufficient follow-up to determine longer-term outcomes, while including a standardized, detailed neurocognitive battery to assess potential adverse effects.
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Affiliation(s)
| | - Roshani Mann
- From the Coventry and Warwickshire NHS Partnership Trust
| | - Samina Azeem
- From the Coventry and Warwickshire NHS Partnership Trust
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Kinoshita M, Kinoshita M, Takahashi R, Mutoh S, Kakuta N, Tanaka K. The Safety and Strategies for Reinitiating Electroconvulsive Therapy After ECT-Induced Takotsubo Cardiomyopathy: A Case Report and Systematic Review. J ECT 2023; 39:185-192. [PMID: 36897138 DOI: 10.1097/yct.0000000000000905] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/11/2023]
Abstract
OBJECTIVES Takotsubo cardiomyopathy (TCM) is a life-threatening complication of electroconvulsive therapy (ECT). We report the case of a 66-year-old woman who was rechallenged with ECT after ECT-induced TCM. Moreover, we have made a systematic review to assess the safety of and strategies for reinitiating ECT after TCM. METHODS We searched for published reports on ECT-induced TCM since 1990 in MEDLINE (PubMed), Scopus, Cochrane Library, ICHUSHI, and CiNii Research. RESULTS A total of 24 ECT-induced TCM cases were identified. Patients who developed ECT-induced TCM were predominantly middle-aged and older women. There was no specific trend in anesthetic agents used. Seventeen (70.8%) cases developed TCM by the third session in the acute ECT course. Eight (33.3%) cases developed ECT-induced TCM despite the use of β-blockers. Ten (41.7%) cases developed cardiogenic shock or abnormal vital signs related to cardiogenic shock. All cases recovered from TCM. Eight (33.3%) cases tried to receive ECT retrial. The duration until ECT retrial was between 3 weeks and 9 months. The most common preventive measures during ECT retrial were related to β-blockers; however, the type, dose, and route of administration of β-blockers varied. In all cases, ECT could be reperformed without TCM recurrence. CONCLUSIONS Electroconvulsive therapy-induced TCM is more likely to cause cardiogenic shock than nonperioperative cases; nevertheless, it has good prognosis. Cautious reinitiation of ECT after TCM recovery is possible. Further studies are required to determine preventive measures for ECT-induced TCM.
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Affiliation(s)
- Michiko Kinoshita
- From the Department of Anesthesiology, Tokushima University Hospital, Tokushima-shi, Tokushima, Japan
| | - Makoto Kinoshita
- Department of Psychiatry, Institute of Biomedical Sciences, Tokushima University Graduate School, Tokushima-shi, Tokushima, Japan
| | - Rikako Takahashi
- From the Department of Anesthesiology, Tokushima University Hospital, Tokushima-shi, Tokushima, Japan
| | - Sarara Mutoh
- From the Department of Anesthesiology, Tokushima University Hospital, Tokushima-shi, Tokushima, Japan
| | - Nami Kakuta
- From the Department of Anesthesiology, Tokushima University Hospital, Tokushima-shi, Tokushima, Japan
| | - Katsuya Tanaka
- From the Department of Anesthesiology, Tokushima University Hospital, Tokushima-shi, Tokushima, Japan
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Sombatcharoen-non N, Yamnim T, Jullagate S, Ittasakul P. Effect of Continuation-Maintenance Electroconvulsive Therapy on Hospitalization: A Retrospective Mirror-Image Study. Neuropsychiatr Dis Treat 2023; 19:1427-1433. [PMID: 37342756 PMCID: PMC10278859 DOI: 10.2147/ndt.s415878] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Accepted: 06/07/2023] [Indexed: 06/23/2023] Open
Abstract
Objective To examine the effect of continuation-maintenance electroconvulsive therapy (ECT) on psychiatric hospitalization in Thai patients. Methods This retrospective mirror-image study reviewed medical records of Thai patients who received continuation-maintenance ECT at Ramathibodi Hospital, Bangkok, between September 2013 and December 2022. The initiation of continuation-maintenance ECT served as the index event, establishing pre-initiation and post-initiation periods. The primary outcome measured the differences in admissions and admission days before and after continuation-maintenance ECT. Results Forty-seven patients were included in the study, with diagnoses of schizophrenia (38.3%), schizoaffective disorder (21.3%), and bipolar disorder (19.1%) being the most common. The mean (standard deviation; SD) age was 44.6 (12.2) years. The total duration that patients received continuation-maintenance ECT was 53 ± 38.2 months. Following the initiation of ECT, there was a significant reduction in the median (interquartile range) number of hospitalizations for all patients (2 [2] versus 1 [2], p < 0.001), as well as for the psychotic disorder group (2 [2] versus 1 [2.75], p = 0.006) and the mood disorder group (2 [2] versus 1 [2], p = 0.02). Moreover, there was a significant reduction in the median (interquartile range) length of admission days for all patients after the initiation of continuation-maintenance ECT (66 [69] versus 20 [53], p < 0.001). Specifically, the psychotic disorder group (64.5 [74] versus 15.5 [62], p = 0.02) and mood disorder group (74 [57] versus 20 [54], p = 0.008) demonstrated statistically significant decreases in admission days. Conclusion Continuation-maintenance ECT may be an effective treatment option for reducing hospitalizations and admission days in patients with various psychiatric diagnoses. However, the study also highlights the need to carefully consider the potential adverse effects of ECT in clinical decision-making.
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Affiliation(s)
- Nujaree Sombatcharoen-non
- Department of Psychiatry, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Thidarat Yamnim
- Department of Psychiatry, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Sudawan Jullagate
- Department of Psychiatry, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Pichai Ittasakul
- Department of Psychiatry, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
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Grover S, Kathiravan S, Chakrabarti S. The clinical profile and outcome of patients receiving continuation electroconvulsive therapy (C-ECT): A retrospective study. Indian J Psychiatry 2023; 65:647-654. [PMID: 37485402 PMCID: PMC10358809 DOI: 10.4103/indianjpsychiatry.indianjpsychiatry_169_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Revised: 04/23/2023] [Accepted: 05/23/2023] [Indexed: 07/25/2023] Open
Abstract
Background There is a lack of data on the use of continuation electroconvulsive therapy (C-ECT) from India. Objectives This study aimed to evaluate the clinical profile and outcome of patients receiving C-ECT. Materials and Methods The ECT register was used to identify patients receiving C-ECT (ECT after completion of an acute course, to maintain remission or prevent relapse) from 2011 to July 2022. Socio-demographic, clinical, and treatment outcome details were extracted from their treatment records. Results A total of 72 C-ECT courses were identified that were used in 60 patients. Out of all the patients receiving ECT, only 3.25% of patients receive C-ECT. The majority of the patients were male (60%). The mean age of the patients at the time of starting ECT was around 39 years. The most common diagnosis was schizophrenia (73.3%), followed by recurrent depressive disorder (21.6%). The most common indication was persistent psychotic symptoms poorly responding to multiple antipsychotic trials of 3.09 (SD: 1.39), including clozapine. These patients received a mean of 22.58 (SD: 8.05; range: 10 to 46) ECTs, with 10.0 (SD: 4.83) ECTs for the management of the acute phase of illness and 12.57 (SD: 6.20) ECTs as part of continuation treatment. The majority (61.1%) of the patients received four (once weekly) C-ECTs in the first month, followed by three more in the next month. However, 16 patients received weekly ECTs during the second month too, as symptoms worsened with the lowering of frequencies. Twelve patients received more than one C-ECT course. The majority of the patients maintained the improvement gained during the acute phase or showed further improvement with C-ECT along with ongoing pharmacotherapy as rated on appropriate scales. The Clinical Global Impressions-Severity (CGI-S) difference before and after C-ECTs was 2.94 (SD: 0.88). Conclusions C-ECT is considered in only in a small proportion of patients. However, when used, it is effective in maintaining the benefits gained during the acute course of ECT and preventing relapse.
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Affiliation(s)
- Sandeep Grover
- Department of Psychiatry, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Sanjana Kathiravan
- Department of Psychiatry, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Subho Chakrabarti
- Department of Psychiatry, Post Graduate Institute of Medical Education and Research, Chandigarh, India
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Kudo S, Uchida T, Nishida H, Takamiya A, Kikuchi T, Yamagata B, Mimura M, Hirano J. Clinical characteristics and potential association to Parkinson's disease and dementia with Lewy bodies in patients with major depressive disorder who received maintenance electroconvulsive therapy: a retrospective chart review study. BMC Psychiatry 2023; 23:243. [PMID: 37041471 PMCID: PMC10091570 DOI: 10.1186/s12888-023-04743-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Accepted: 04/03/2023] [Indexed: 04/13/2023] Open
Abstract
BACKGROUND Maintaining remission after electroconvulsive therapy (ECT) is clinically relevant in patients with depression, and maintenance ECT has been introduced in patients who fail to maintain remission after ECT. However, the clinical characteristics and biological background of patients who receive maintenance ECT are poorly understood. Thus, this study aimed to examine the clinical background of patients who underwent maintenance ECT. METHODS Patients with major depressive disorder who underwent ECT followed by maintenance ECT (mECT group) and those who did not (acute ECT [aECT] group) were included. Clinical characteristics, including the results of neuroimaging examinations for Parkinson's disease (PD) and dementia with Levy body (DLB) such as myocardial 123I-metaiodobenzylguanidine (MIBG) scintigraphy and dopamine transporter imaging single-photon emission computerized tomography (DaT-SPECT), were compared between the groups. RESULTS In total, 13 and 146 patients were included in the mECT and aECT groups, respectively. Compared to the aECT group, the mECT group showed a significantly higher prevalence of melancholic features (92.3% vs. 27.4%, p < 0.001) and catatonic features (46.2% vs. 9.6%, p = 0.002). Overall, 8 of the 13 patients in the mECT group and 22 of the 146 patients in the aECT group underwent neuroimaging examinations for PD/DLB. The rate of patients examined is significantly higher in the mECT group than in the aECT group (61.5% vs. 11.2%, p < 0.001). Among the groups examined, 7/8 patients in the mECT group and 16/22 patients in the aECT group showed relevant neuroimaging findings for PD/DLB; the positive rate was not significantly different between the two groups (87.5% vs. 72.7%, p = 0.638). CONCLUSIONS Patients who receive acute and maintenance ECT may have underlying neurodegenerative diseases, including PD/DLB. Investigating the neurobiology of patients who receive maintenance ECT is important for developing appropriate treatments for depression.
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Affiliation(s)
- Shun Kudo
- Department of Neuropsychiatry, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-Ku, Tokyo, 160-8582, Japan
- Department of Psychiatry, Saitama City Hospital, Saitama, Japan
| | - Takahito Uchida
- Department of Neuropsychiatry, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-Ku, Tokyo, 160-8582, Japan.
- Department of Psychiatry, Melbourne Neuropsychiatry Centre, The University of Melbourne, Victoria, Australia.
| | - Hana Nishida
- Department of Neuropsychiatry, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-Ku, Tokyo, 160-8582, Japan
| | - Akihiro Takamiya
- Department of Neuropsychiatry, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-Ku, Tokyo, 160-8582, Japan
| | - Toshiaki Kikuchi
- Department of Neuropsychiatry, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-Ku, Tokyo, 160-8582, Japan
| | - Bun Yamagata
- Department of Neuropsychiatry, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-Ku, Tokyo, 160-8582, Japan
| | - Masaru Mimura
- Department of Neuropsychiatry, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-Ku, Tokyo, 160-8582, Japan
| | - Jinichi Hirano
- Department of Neuropsychiatry, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-Ku, Tokyo, 160-8582, Japan
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Dar H, Vuthaluru K, Folajimi A, Maheshwari L, Shah J, Senaratne M, Pizzorno G, Ali N. Effectiveness of Electroconvulsive Therapy for Preventing Relapse and Recurrence of Depression in Adults With Major Depressive Disorder: An Updated Meta-Analysis of Randomized Clinical Trials. Cureus 2023; 15:e35683. [PMID: 37012942 PMCID: PMC10066659 DOI: 10.7759/cureus.35683] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/01/2023] [Indexed: 03/06/2023] Open
Abstract
The present meta-analysis aimed to assess the impact of electroconvulsive therapy (ECT) in preventing the relapse and recurrence of depression in adults with major depressive disorders. The study was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Two authors conducted a systematic search of online databases, such as PubMed, PsycINFO, and EMBASE, using keywords, such as "electroconvulsive therapy," "depressive disorders," and "recurrence." The primary outcome measure was the incidence of relapse and recurrence in adults with major depressive disorder who received ECT alone or in combination with an antidepressant medication compared to those who received antidepressant medication alone. The secondary outcome measure was the change in the Mini-Mental State Examination score from baseline to the end of the trial in both groups. A total of six articles were included in the meta-analysis. The pooled rate of recurrence in the ECT group was 28.4% compared to 30.6% in the antidepressant group, with no significant difference between the two groups (risk ratio (RR) = 0.84, 95% confidence interval (CI) = 0.65-1.10, p = 0.21). However, subgroup analysis showed that the risk of recurrence was significantly lower in patients receiving ECT with antidepressant therapy compared to the antidepressant group alone (RR = 0.65, 95% CI = 0.45-0.93, p = 0.02). On the other hand, when ECT was given alone, the risk was higher in the ECT group compared to the antidepressant group; however, the difference was not statistically significant (RR = 1.17, 95% CI = 0.79-1.75). In conclusion, the results of this meta-analysis suggest that ECT alone or in combination with an antidepressant medication does not significantly impact the incidence of recurrence in adults with major depressive disorder when compared to antidepressant medication alone.
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Methfessel I, Belz M, Bühler F, Zilles-Wegner D. [Health service aspects of electroconvulsive therapy: analysis of external referrals to a university medical center]. DER NERVENARZT 2023; 94:8-17. [PMID: 35951050 PMCID: PMC9859897 DOI: 10.1007/s00115-022-01360-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Accepted: 06/21/2022] [Indexed: 01/25/2023]
Abstract
BACKGROUND The application of ECT in Germany varies widely depending on regional availability. This shortfall in ECT supply is partly compensated via referrals to hospitals with ECT services, yet restricted by limited resources in these clinics. OBJECTIVE External referrals for ECT were investigated at the University Medical Center Göttingen. We analyzed the referring institutions, patient characteristics, pharmacotherapy according to current guidelines before indications for ECT, and clinical outcome in cases of treatment with ECT. MATERIAL AND METHODS All external referrals were systematically recorded and retrospectively evaluated for the time span of 1 year. Besides descriptive presentation of the data, pharmacological pretreatment was compared with the current guideline recommendations. We used overall clinical impression (CGI-I) to determine the treatment response post-ECT. RESULTS External referrals were made for N = 52 patients, 82.7% of whom were from the inpatient setting and from a distance of up to 300 km. The most common diagnoses were unipolar depression (57.7%), followed by schizophrenia spectrum (36.5%). Prior to referral, at least one guideline-based pretreatment was given in the majority of cases. ECT was performed in 18 patients in our hospital, of whom 72.7% showed a good to very good response. CONCLUSION Both numbers and radius of external referrals indicate a high unmet need for ECT and thus limited access to this evidence-based and guideline-recommended therapy. As treatment close to home should be the goal, more hospitals are needed to establish (or expand) ECT services; however, even with considerable delays which are often associated with external referrals, the response rate is good across all diagnoses.
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Affiliation(s)
- Isabel Methfessel
- grid.411984.10000 0001 0482 5331Klinik für Psychiatrie und Psychotherapie, Universitätsmedizin Göttingen, Von-Siebold-Str. 5, 37075 Göttingen, Deutschland
| | - Michael Belz
- grid.411984.10000 0001 0482 5331Klinik für Psychiatrie und Psychotherapie, Universitätsmedizin Göttingen, Von-Siebold-Str. 5, 37075 Göttingen, Deutschland
| | - Fabienne Bühler
- grid.411984.10000 0001 0482 5331Klinik für Psychiatrie und Psychotherapie, Universitätsmedizin Göttingen, Von-Siebold-Str. 5, 37075 Göttingen, Deutschland
| | - David Zilles-Wegner
- grid.411984.10000 0001 0482 5331Klinik für Psychiatrie und Psychotherapie, Universitätsmedizin Göttingen, Von-Siebold-Str. 5, 37075 Göttingen, Deutschland
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Yoldi-Negrete M, Gill LN, Olivares S, Lauzière A, Désilets M, Tourjman SV. The effect of continuation and maintenance electroconvulsive therapy on cognition: A systematic review of the literature and meta-analysis. J Affect Disord 2022; 316:148-160. [PMID: 35952935 DOI: 10.1016/j.jad.2022.08.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Revised: 07/18/2022] [Accepted: 08/01/2022] [Indexed: 10/31/2022]
Abstract
BACKGROUND Electroconvulsive therapy (ECT) is an effective treatment for depression, mania, and refractory schizophrenia. Its tolerability profile is established for acute treatment, but less is known regarding the effects of longer treatment courses, particularly on cognitive performance. OBJECTIVES To assess the effect of the long-term ECT on cognition. METHODS We searched CINAHL, EMBASE, PsychInfo and Pubmed, for the period between January 1, 2010, and June 30, 2022, in English or French, for randomized controlled trials, prospective or retrospective studies of ECT continued for at least 2 months for the treatment of mood or schizophrenic disorders and which measured cognition before and at the end of treatment. Non-peer reviewed records were excluded. The Cochrane Risk of Bias tool was used to assess study quality. Classical meta-analyses, with heterogeneity statistics (tau2, I2) were complemented with three level-meta-analysis and Bayesian Meta-analyses. RESULTS Nine studies were included in the narrative and quantitative review. Controlled comparison at 6 months (k = 6, n = 334) and at 12 months (k = 3, n = 56), within-subject comparisons at 6 (k = 6, n = 218) and 12 months (k = 4, n = 147) showed no detrimental effect of maintenance or continuation ECT on cognition, with little to no heterogeneity. Bayesian analysis further confirmed that data better supported the no effects hypothesis. LIMITATIONS Insufficient data resulted in imprecision in estimates. CONCLUSIONS Continuation and maintenance ECT do not appear detrimental for cognitive performance. However, the low number of studies limit the interpretation of the results.
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Affiliation(s)
- María Yoldi-Negrete
- Laboratorio de Epidemiología Clínica, Subdirección de Investigaciones Clínicas, Instituto Nacional de Psiquiatría Ramón de la Fuente Muñiz, Ciudad de México, Mexico
| | - Louis-Nascan Gill
- Institut Universitaire en Santé Mentale de Montréal, Montreal, Canada; Université du Québec à Montréal, Canada
| | - Scarlett Olivares
- Institut Universitaire en Santé Mentale de Montréal, Montreal, Canada
| | - Anabel Lauzière
- Institut Universitaire en Santé Mentale de Montréal, Montreal, Canada
| | - Marie Désilets
- Institut Universitaire en Santé Mentale de Montréal, Montreal, Canada
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Joung KW, Park DH, Jeong CY, Yang HS. Anesthetic care for electroconvulsive therapy. Anesth Pain Med (Seoul) 2022; 17:145-156. [PMID: 35538655 PMCID: PMC9091667 DOI: 10.17085/apm.22145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Accepted: 03/18/2022] [Indexed: 11/17/2022] Open
Abstract
Counselling and medication are often thought of as the only interventions for psychiatric disorders, but electroconvulsive therapy (ECT) has also been applied in clinical practice for over 80 years. ECT refers to the application of an electric stimulus through the patient’s scalp to treat psychiatric disorders such as treatment-resistant depression, catatonia, and schizophrenia. It is a safe, effective, and evidence-based therapy performed under general anesthesia with muscle relaxation. An appropriate level of anesthesia is essential for safe and successful ECT; however, little is known about this because of the limited interest from anesthesiologists. As the incidence of ECT increases, more anesthesiologists will be required to better understand the physiological changes, complications, and pharmacological actions of anesthetics and adjuvant drugs. Therefore, this review focuses on the fundamental physiological changes, management, and pharmacological actions associated with various drugs, such as anesthetics and neuromuscular blocking agents, as well as the comorbidities, indications, contraindications, and complications of using these agents as part of an ECT procedure through a literature review and our own experiences.
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Affiliation(s)
- Kyoung-Woon Joung
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Dong Ho Park
- Department of Anesthesiology and Pain Medicine, Daejeon Eulji Medical Center, Eulji University School of Medicine, Daejeon, Korea
| | - Chang Young Jeong
- Department of Anesthesiology and Pain Medicine, Daejeon Eulji Medical Center, Eulji University School of Medicine, Daejeon, Korea
| | - Hong Seuk Yang
- Department of Anesthesiology and Pain Medicine, Daejeon Eulji Medical Center, Eulji University School of Medicine, Daejeon, Korea
- Corresponding author Hong Seuk Yang, M.D., Ph.D. Department of Anesthesiology and Pain Medicine, Daejeon Eulji Medical Center, Eulji University School of Medicine, 95 Dunsanseo-ro, Seo-gu, Daejeon 35233, Korea Tel: 82-42-611-3881, Fax: 82-42-259-1111 E-mail:
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13
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Madero S, Anmella G, Sagué-Vilavella M, Pons MT, Giménez A, Murru A, Gómez-Ramiro M, Gil-Badenes J, Rios J, Bioque M, Vieta E, Benabarre A. Evaluating maintenance electroconvulsive therapy in Bipolar Disorders: 3-year mirror-image study. J Affect Disord 2022; 298:58-64. [PMID: 34715196 DOI: 10.1016/j.jad.2021.10.052] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Revised: 10/01/2021] [Accepted: 10/23/2021] [Indexed: 11/16/2022]
Abstract
BACKGORUND Maintenance electroconvulsive therapy (mECT) is underused in the treatment of bipolar disorder (BD). We aimed to study the real-life effectiveness of mECT in BD. METHODS Naturalistic 3-year mirror-image study in individuals diagnosed with BD who underwent mECT at a tertiary hospital. Intra-subject comparisons of psychiatric hospitalization were performed using McNemar test. Days and number of psychiatric hospitalizations before and during mECT were compared through wilcoxon signed-rank test. Mean annual days and mean annual number of psychiatric hospitalizations per patient were compared by means of the rate ratio (RR) estimation through a generalized estimating equation (GEE) model. RESULTS A total of 43 patients were included and 37 required psychiatric hospitalization during the study. The use of mECT showed an effectiveness of 62.2% for preventing psychiatric hospitalizations (p<0.01). We found significant reduction in days and number of psychiatric hospitalizations during mECT compared to before mECT (p<0.01). Comparison of the 3-year period before/during mECT showed a reduction in mean annual days (RR=0.14; 95%CI: 0.07-0.29) and mean annual number (RR=0.24; 95%CI: 0.13-0.43) of psychiatric hospitalizations, without substantial changes for adjusted models for gender and age of onset of the illness. LIMITATIONS The main limitations of this study consisted of the mirror-image retrospective naturalistic study design, the relatively small sample size, and possibly patient selection bias. CONCLUSIONS mECT reduced the number of psychiatric hospitalizations and hospitalization days in BD. The use of mECT outlines a mood stabilizing effect in BD. This naturalistic study supports the effectiveness of mECT in BD across several mood states.
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Affiliation(s)
- Santiago Madero
- Department of Psychiatry, Clinical Institute of Neuroscience, Hospital Clínic de Barcelona, Barcelona, Spain; Barcelona Clínic Schizophrenia Unit (BCSU), Institute of Neuroscience, Hospital Cliníc de Barcelona, Barcelona, Catalonia, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain; Centro de investigación biomédica en Red en Salud Mental (CIBERSAM), Barcelona, Spain
| | - Gerard Anmella
- Department of Psychiatry, Clinical Institute of Neuroscience, Hospital Clínic de Barcelona, Barcelona, Spain; Bipolar and Depressive Disorders Unit, Institute of Neuroscience, Hospital Cliníc de Barcelona, Barcelona, Catalonia, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain; Centro de investigación biomédica en Red en Salud Mental (CIBERSAM), Barcelona, Spain; Universitat de Barcelona, Spain
| | - Maria Sagué-Vilavella
- Department of Psychiatry, Clinical Institute of Neuroscience, Hospital Clínic de Barcelona, Barcelona, Spain; Bipolar and Depressive Disorders Unit, Institute of Neuroscience, Hospital Cliníc de Barcelona, Barcelona, Catalonia, Spain
| | - Maria Teresa Pons
- Department of Psychiatry, Clinical Institute of Neuroscience, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Anna Giménez
- Department of Psychiatry, Clinical Institute of Neuroscience, Hospital Clínic de Barcelona, Barcelona, Spain; Bipolar and Depressive Disorders Unit, Institute of Neuroscience, Hospital Cliníc de Barcelona, Barcelona, Catalonia, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain; Centro de investigación biomédica en Red en Salud Mental (CIBERSAM), Barcelona, Spain; Universitat de Barcelona, Spain
| | - Andrea Murru
- Department of Psychiatry, Clinical Institute of Neuroscience, Hospital Clínic de Barcelona, Barcelona, Spain; Bipolar and Depressive Disorders Unit, Institute of Neuroscience, Hospital Cliníc de Barcelona, Barcelona, Catalonia, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain; Centro de investigación biomédica en Red en Salud Mental (CIBERSAM), Barcelona, Spain; Universitat de Barcelona, Spain
| | - Marta Gómez-Ramiro
- Department of Psychiatry, Clinical Institute of Neuroscience, Hospital Clínic de Barcelona, Barcelona, Spain; Barcelona Clínic Schizophrenia Unit (BCSU), Institute of Neuroscience, Hospital Cliníc de Barcelona, Barcelona, Catalonia, Spain
| | - Joaquín Gil-Badenes
- Department of Psychiatry, Clinical Institute of Neuroscience, Hospital Clínic de Barcelona, Barcelona, Spain; Barcelona Clínic Schizophrenia Unit (BCSU), Institute of Neuroscience, Hospital Cliníc de Barcelona, Barcelona, Catalonia, Spain
| | - José Rios
- Medical Statistics Core Facility, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS) and Hospital Clinic, Barcelona, Spain; Biostatistics Unit, Faculty of Medicine, Universitat Autònoma de Barcelona, Spain
| | - Miquel Bioque
- Department of Psychiatry, Clinical Institute of Neuroscience, Hospital Clínic de Barcelona, Barcelona, Spain; Barcelona Clínic Schizophrenia Unit (BCSU), Institute of Neuroscience, Hospital Cliníc de Barcelona, Barcelona, Catalonia, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain; Centro de investigación biomédica en Red en Salud Mental (CIBERSAM), Barcelona, Spain; Universitat de Barcelona, Spain
| | - Eduard Vieta
- Department of Psychiatry, Clinical Institute of Neuroscience, Hospital Clínic de Barcelona, Barcelona, Spain; Bipolar and Depressive Disorders Unit, Institute of Neuroscience, Hospital Cliníc de Barcelona, Barcelona, Catalonia, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain; Centro de investigación biomédica en Red en Salud Mental (CIBERSAM), Barcelona, Spain; Universitat de Barcelona, Spain.
| | - Antonio Benabarre
- Department of Psychiatry, Clinical Institute of Neuroscience, Hospital Clínic de Barcelona, Barcelona, Spain; Bipolar and Depressive Disorders Unit, Institute of Neuroscience, Hospital Cliníc de Barcelona, Barcelona, Catalonia, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain; Centro de investigación biomédica en Red en Salud Mental (CIBERSAM), Barcelona, Spain; Universitat de Barcelona, Spain
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14
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Munkholm K, Jørgensen KJ, Paludan-Müller AS. Electroconvulsive therapy for preventing relapse and recurrence in people with depression. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2022. [DOI: 10.1002/14651858.cd015164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Affiliation(s)
- Klaus Munkholm
- Centre for Evidence-Based Medicine Odense (CEBMO) and Cochrane Denmark; Department of Clinical Research, University of Southern Denmark; Odense Denmark
- Open Patient data Exploratory Network (OPEN); Odense University Hospital; Odense Denmark
| | - Karsten Juhl Jørgensen
- Centre for Evidence-Based Medicine Odense (CEBMO) and Cochrane Denmark; Department of Clinical Research, University of Southern Denmark; Odense Denmark
- Open Patient data Exploratory Network (OPEN); Odense University Hospital; Odense Denmark
| | - Asger Sand Paludan-Müller
- Centre for Evidence-Based Medicine Odense (CEBMO) and Cochrane Denmark; Department of Clinical Research, University of Southern Denmark; Odense Denmark
- Open Patient data Exploratory Network (OPEN); Odense University Hospital; Odense Denmark
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Abstract
BACKGROUND There are limited studies examining mortality associated with electroconvulsive therapy (ECT), and many studies do not include a control group or method to identify all patient deaths. AIMS We aimed to evaluate the risk of death associated with ECT treatments over 30 days and 1 year. METHOD We conducted a study analysing electronic medical record data from the Department of Veterans Affairs healthcare system between 2000 and 2017. We compared mortality among patients who received ECT with a matched group of patients created through propensity score matching. RESULTS Our sample included 123 479 individual ECT treatments provided to 8720 patients (including 5157 initial index courses of ECT). Mortality associated with individual ECT treatments was 3.08 per 10 000 treatments over the first 7 days after treatment. When comparing patients who received ECT with a matched group of mental health patients, those receiving ECT had a relative odds of all-cause mortality in the year after their index course of 0.87 (95% CI 0.79-1.11; P = 0.10), and a relative risk of death from causes other than suicide of 0.79 (95% CI 0.66-0.95; P < 0.01). The similar relative odds of all-cause mortality in the first 30 days after ECT was 1.06 (95% CI 0.65-1.73) for all-cause mortality, and 1.02 (95% CI 0.58-1.8) for all-cause mortality excluding suicide deaths. CONCLUSIONS There was no evidence of elevated or excess mortality after ECT. There was some indication that mortality may be reduced in patients receiving ECT compared with similar patients who do not receive ECT.
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Affiliation(s)
- Bradley V Watts
- Department of Mental Health Services, White River Junction VA Medical Center, Vermont, USA; Department of Psychiatry, Geisel School of Medicine at Dartmouth College, New Hampshire, USA; and VA Office of Systems Redesign and Improvement, Department of Veterans Affairs, Washington, DC, USA
| | - Talya Peltzman
- Department of Mental Health Services, White River Junction VA Medical Center, Vermont, USA
| | - Brian Shiner
- Department of Mental Health Services, White River Junction VA Medical Center, Vermont, USA; and Department of Psychiatry, Geisel School of Medicine at Dartmouth College, New Hampshire, USA
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16
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Martínez-Amorós E, Cardoner N, Gálvez V, de Arriba-Arnau A, Soria V, Palao DJ, Menchón JM, Urretavizcaya M. Can the Addition of Maintenance Electroconvulsive Therapy to Pharmacotherapy Improve Relapse Prevention in Severe Major Depressive Disorder? A Randomized Controlled Trial. Brain Sci 2021; 11:brainsci11101340. [PMID: 34679404 PMCID: PMC8534103 DOI: 10.3390/brainsci11101340] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Accepted: 10/03/2021] [Indexed: 12/22/2022] Open
Abstract
Few systematic evaluations have been performed of the efficacy of electroconvulsive therapy (ECT) as a relapse prevention strategy in major depressive disorder (MDD). This is a single-blind, multicenter, randomized controlled trial to compare the efficacy and tolerability of pharmacotherapy plus maintenance ECT (M-Pharm/ECT) versus pharmacotherapy alone (M-Pharm) in the prevention of MDD relapse. Subjects with MDD who had remitted with bilateral acute ECT (n = 37) were randomly assigned to receive M-Pharm/ECT (n = 19, 14 treatments) or M-Pharm (n = 18) for nine months. The subjects were followed up for 15 months. The main outcome was relapse of depression, defined as a score of 18 or more on the Hamilton Depression Rating Scale. At nine months, 35% of the subjects treated with M-Pharm/ECT relapsed as compared with 61% of the patients treated with M-Pharm. No statistically significant differences between groups were indicated by either Kaplan–Meier or Cox proportional hazards regression analyses. The subjects without psychotic features were at higher risk of relapse. There were no statistically significant differences in the MMSE scores of the two groups at the end of the study. Further studies are needed to better define the indications for M-ECT in order to improve its efficacy as a relapse prevention strategy.
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Affiliation(s)
- Erika Martínez-Amorós
- Department of Mental Health, Parc Taulí University Hospital, Institut d’Investigació i Innovació Sanitària Parc Taulí (I3PT), 08208 Sabadell, Spain; (E.M.-A.); (V.G.); (D.J.P.)
- Department of Psychiatry and Forensic Medicine, Universitat Autònoma de Barcelona, 08193 Bellaterra, Spain
- Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Carlos III Health Institute, 28029 Madrid, Spain; (V.S.); (J.M.M.)
| | - Narcís Cardoner
- Department of Mental Health, Parc Taulí University Hospital, Institut d’Investigació i Innovació Sanitària Parc Taulí (I3PT), 08208 Sabadell, Spain; (E.M.-A.); (V.G.); (D.J.P.)
- Department of Psychiatry and Forensic Medicine, Universitat Autònoma de Barcelona, 08193 Bellaterra, Spain
- Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Carlos III Health Institute, 28029 Madrid, Spain; (V.S.); (J.M.M.)
- Correspondence: (N.C.); (M.U.)
| | - Verònica Gálvez
- Department of Mental Health, Parc Taulí University Hospital, Institut d’Investigació i Innovació Sanitària Parc Taulí (I3PT), 08208 Sabadell, Spain; (E.M.-A.); (V.G.); (D.J.P.)
- Department of Psychiatry and Forensic Medicine, Universitat Autònoma de Barcelona, 08193 Bellaterra, Spain
| | - Aida de Arriba-Arnau
- Department of Psychiatry, Bellvitge University Hospital, Bellvitge Biomedical Research Institute (IDIBELL), Neurosciences Group—Psychiatry and Mental Health, 08907 L’Hospitalet de Llobregat, Spain;
- Department of Clinical Sciences, School of Medicine, Universitat de Barcelona, 08007 Barcelona, Spain
| | - Virginia Soria
- Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Carlos III Health Institute, 28029 Madrid, Spain; (V.S.); (J.M.M.)
- Department of Psychiatry, Bellvitge University Hospital, Bellvitge Biomedical Research Institute (IDIBELL), Neurosciences Group—Psychiatry and Mental Health, 08907 L’Hospitalet de Llobregat, Spain;
- Department of Clinical Sciences, School of Medicine, Universitat de Barcelona, 08007 Barcelona, Spain
| | - Diego J. Palao
- Department of Mental Health, Parc Taulí University Hospital, Institut d’Investigació i Innovació Sanitària Parc Taulí (I3PT), 08208 Sabadell, Spain; (E.M.-A.); (V.G.); (D.J.P.)
- Department of Psychiatry and Forensic Medicine, Universitat Autònoma de Barcelona, 08193 Bellaterra, Spain
- Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Carlos III Health Institute, 28029 Madrid, Spain; (V.S.); (J.M.M.)
| | - José M. Menchón
- Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Carlos III Health Institute, 28029 Madrid, Spain; (V.S.); (J.M.M.)
- Department of Psychiatry, Bellvitge University Hospital, Bellvitge Biomedical Research Institute (IDIBELL), Neurosciences Group—Psychiatry and Mental Health, 08907 L’Hospitalet de Llobregat, Spain;
- Department of Clinical Sciences, School of Medicine, Universitat de Barcelona, 08007 Barcelona, Spain
| | - Mikel Urretavizcaya
- Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Carlos III Health Institute, 28029 Madrid, Spain; (V.S.); (J.M.M.)
- Department of Psychiatry, Bellvitge University Hospital, Bellvitge Biomedical Research Institute (IDIBELL), Neurosciences Group—Psychiatry and Mental Health, 08907 L’Hospitalet de Llobregat, Spain;
- Department of Clinical Sciences, School of Medicine, Universitat de Barcelona, 08007 Barcelona, Spain
- Correspondence: (N.C.); (M.U.)
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Lambrichts S, Vansteelandt K, Crauwels B, Obbels J, Pilato E, Denduyver J, Ernes K, Maebe P, Migchels C, Roosen L, Buggenhout S, Bouckaert F, Schrijvers D, Sienaert P. Relapse after abrupt discontinuation of maintenance electroconvulsive therapy during the COVID-19 pandemic. Acta Psychiatr Scand 2021; 144:230-237. [PMID: 34086984 PMCID: PMC8212096 DOI: 10.1111/acps.13334] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2021] [Accepted: 05/31/2021] [Indexed: 12/15/2022]
Abstract
OBJECTIVE Maintenance electroconvulsive therapy (M-ECT) is considered an effective relapse prevention strategy in severe mood and psychotic disorders. How long M-ECT should be continued, and what the outcome is after its discontinuation has not been adequately studied. In our tertiary psychiatric hospital, M-ECT treatments were suspended at the start of the COVID-19 pandemic. We aimed to determine the 6-month relapse rate and time to relapse after abrupt discontinuation of M-ECT and to assess the impact of patient and treatment characteristics on the risk of relapse. METHODS Eighty-one patients whose M-ECT was discontinued abruptly were followed up prospectively for 6 months, or until relapse (i.e., hospital admission, restart of ECT, change of pharmacotherapy, or suicide (attempt)). We used multivariable Cox proportional hazards models to assess the impact of patient and treatment characteristics on the risk of relapse. RESULTS Thirty-six patients (44.44%) relapsed within 6 months following abrupt discontinuation of M-ECT. A greater number of previous acute ECT courses, a diagnosis of psychotic disorder (compared with major depressive disorder or bipolar disorder), and a shorter interval between M-ECT treatments at the time of discontinuation were significantly associated with increased risk of relapse. CONCLUSION Almost half of the patients relapsed, similar to the relapse rate after a successful acute course of ECT. Patients with a shorter interval between M-ECT treatments at the time of discontinuation seem to be at increased risk, as well as patients with a diagnosis of psychotic disorder, compared to patients with mood disorders.
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Affiliation(s)
- Simon Lambrichts
- KU LeuvenDepartment of NeurosciencesResearch Group PsychiatryNeuropsychiatryAcademic Center for ECT and Neuromodulation (AcCENT)University Psychiatric Center KU Leuven (UPC KU LeuvenKortenbergBelgium
| | - Kristof Vansteelandt
- KU LeuvenDepartment of NeurosciencesResearch Group PsychiatryNeuropsychiatryAcademic Center for ECT and Neuromodulation (AcCENT)University Psychiatric Center KU Leuven (UPC KU LeuvenKortenbergBelgium
| | - Bo Crauwels
- KU LeuvenDepartment of NeurosciencesResearch Group PsychiatryNeuropsychiatryAcademic Center for ECT and Neuromodulation (AcCENT)University Psychiatric Center KU Leuven (UPC KU LeuvenKortenbergBelgium
| | - Jasmien Obbels
- KU LeuvenDepartment of NeurosciencesResearch Group PsychiatryNeuropsychiatryAcademic Center for ECT and Neuromodulation (AcCENT)University Psychiatric Center KU Leuven (UPC KU LeuvenKortenbergBelgium
| | - Eva Pilato
- KU LeuvenDepartment of NeurosciencesResearch Group PsychiatryNeuropsychiatryAcademic Center for ECT and Neuromodulation (AcCENT)University Psychiatric Center KU Leuven (UPC KU LeuvenKortenbergBelgium
| | - Jonas Denduyver
- KU LeuvenUniversity Psychiatric Center KU Leuven (UPC KU LeuvenKortenbergBelgium
| | - Katrien Ernes
- KU LeuvenUniversity Psychiatric Center KU Leuven (UPC KU LeuvenKortenbergBelgium
| | - Pieter‐Paul Maebe
- KU LeuvenUniversity Psychiatric Center KU Leuven (UPC KU LeuvenKortenbergBelgium
| | - Charlotte Migchels
- KU LeuvenUniversity Psychiatric Center KU Leuven (UPC KU LeuvenKortenbergBelgium
| | - Lore Roosen
- KU LeuvenUniversity Psychiatric Center KU Leuven (UPC KU LeuvenKortenbergBelgium
| | - Satya Buggenhout
- KU LeuvenUniversity Psychiatric Center KU Leuven (UPC KU LeuvenKortenbergBelgium
| | - Filip Bouckaert
- KU LeuvenUniversity Psychiatric Center KU Leuven (UPC KU LeuvenKortenbergBelgium
| | - Didier Schrijvers
- Collaborative Antwerp Psychiatric Research Institute (CAPRI)UAntwerpAntwerpBelgium
| | - Pascal Sienaert
- KU LeuvenDepartment of NeurosciencesResearch Group PsychiatryNeuropsychiatryAcademic Center for ECT and Neuromodulation (AcCENT)University Psychiatric Center KU Leuven (UPC KU LeuvenKortenbergBelgium
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18
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Kellner CH. Electroconvulsive Therapy: Stayin' Alive, Stayin' Well. Acta Psychiatr Scand 2021; 144:215-217. [PMID: 34397107 DOI: 10.1111/acps.13352] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Revised: 07/24/2021] [Indexed: 01/05/2023]
Affiliation(s)
- Charles H Kellner
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, South Carolina, USA
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Methfessel I, Besse M, Belz M, Zilles‐Wegner D. Effectiveness of maintenance electroconvulsive therapy-Evidence from modifications due to the COVID-19 pandemic. Acta Psychiatr Scand 2021; 144:238-245. [PMID: 33960406 PMCID: PMC8212113 DOI: 10.1111/acps.13314] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Revised: 04/20/2021] [Accepted: 05/03/2021] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Continuation and maintenance ECT (c-/m-ECT) are effective in the prevention of relapse and recurrence of both affective and psychotic disorders. However, data are scarce concerning the trajectories of severe mental disorders after the end of c-/m-ECT. This prospective study investigates the clinical outcome of patients with versus without modifications of their c-/m-ECT schedules. METHODS In the context of the COVID-19 pandemic, ECT capacities were restricted at many clinics in early 2020. All patients receiving c-/m-ECT in March and April 2020 at our department (n = 53, unipolar depression, bipolar disorder, schizophrenia) were followed up for six months to investigate the impact of treatment modifications imposed by the pandemic. Based on individual decisions, c-/m-ECT was either (a) continued without modification, (b) continued with reduced frequency, or (c) discontinued. RESULTS Both reduced frequency and discontinuation of c-/m-ECT were associated with significant clinical deterioration as measured by CGI-I (Clinical Global Impression Scale - Global Improvement) during the six-month follow-up when compared to the subgroup of patients without any treatment modification (p = 0.005, p = 0.011). Furthermore, patients with discontinued or reduced c-/m-ECT showed significantly higher rates of rehospitalizations (p = 0.028) and new acute courses of ECT (p = 0.018). CONCLUSION Despite the limitations of a heterogeneous and relatively small sample, our study strongly corroborates the effectiveness of c-/m-ECT in a real-world population. Especially, patients with shorter time since index ECT seem to be at high risk for severe clinical deterioration in the case of treatment discontinuation or reduction.
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Affiliation(s)
- Isabel Methfessel
- Department of Psychiatry and PsychotherapyUniversity Medical Center GöttingenGöttingenGermany
| | - Matthias Besse
- Department of Psychiatry and PsychotherapyUniversity Medical Center GöttingenGöttingenGermany
| | - Michael Belz
- Department of Psychiatry and PsychotherapyUniversity Medical Center GöttingenGöttingenGermany
| | - David Zilles‐Wegner
- Department of Psychiatry and PsychotherapyUniversity Medical Center GöttingenGöttingenGermany
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Pharmacotherapy Prescriptions for Relapse Prevention of Psychotic Depression After Electroconvulsive Therapy. J Clin Psychopharmacol 2021; 41:196-199. [PMID: 33587400 DOI: 10.1097/jcp.0000000000001354] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE/BACKGROUND Electroconvulsive therapy (ECT) is effective in the treatment of acute episodes of psychotic depression. However, no adequately powered studies have directly investigated the efficacy of antipsychotic pharmacotherapy in relapse prevention of psychotic depression after ECT. In the absence of such literature, we reviewed the clinical practice of 4 academic medical centers that have made research contributions in the treatment of psychotic depression over the past 20 years. METHODS/PROCEDURES We reviewed medical records of patients with a diagnosis of psychotic depression who received 1 or more acute courses of ECT over the span of 3 years. Chi-square tests were used to compare pharmacotherapy prescribed at the time of completion of ECT. FINDINGS/RESULTS A total of 163 patients received 176 courses of ECT for separate episodes of psychotic depression. The combination of an antidepressant plus an antipsychotic was the most common regimen, ranging from 61.9% to 85.5% of all prescriptions. One center added lithium in 45.5% of cases treated with the combination of an antidepressant plus an antipsychotic. An antipsychotic alone was prescribed in less than 10% of cases. An antidepressant alone or other drug combinations were rare. IMPLICATIONS/CONCLUSIONS The combination of an antidepressant plus an antipsychotic was the most commonly prescribed regimen at the completion of ECT for relapse prevention in patients with psychotic depression acutely treated with ECT. Although this report offers a view of the clinical practice of 4 academic medical centers, it also points to the need of randomized controlled trials on continuation pharmacotherapy after treatment of psychotic depression with ECT.
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Kocamer Şahin Ş, Demir B, Elboğa G, Altındağ A, Elmalı E. The Effects of Maintenance Electroconvulsive Therapy on Hospitalization Rates. J Nerv Ment Dis 2021; 209:155-158. [PMID: 33273396 DOI: 10.1097/nmd.0000000000001278] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
ABSTRACT This study aimed to study the effect of maintenance electroconvulsive therapy (mECT) on hospitalization rates in patients who had been readmitted after acute courses of electroconvulsive therapy (ECT), and determine the most frequently used treatment schedules in mECT. Patients who had undergone mECT treatment for the last 5 years were retrospectively reviewed. Seventy patients were included in the study. The control group of 70 patients was selected from patients who received only acute ECT. Of the patients in the mECT group, 55.8% (39) were female, and 41.4% (29) were diagnosed with major depressive disorder. The mean number of patients hospitalized who received mECT after acute ECT was 0.55 ± 0.87, whereas it was 1.13 ± 1.31 in patients who received only pharmacotherapy after ECT in a covariant analysis adjusted for age and diagnosis. The most commonly used initial treatment protocol of mECT was weekly × 4, biweekly × 2, and monthly × 6. mECT is more effective in reducing hospitalization after acute ECT treatments than using psychotropic drugs alone for maintenance therapy.
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Affiliation(s)
- Şengül Kocamer Şahin
- Faculty of Medicine, Department of Psychiatry, Gaziantep University, Gaziantep, Turkey
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Li Z, Ruan M, Chen J, Fang Y. Major Depressive Disorder: Advances in Neuroscience Research and Translational Applications. Neurosci Bull 2021; 37:863-880. [PMID: 33582959 PMCID: PMC8192601 DOI: 10.1007/s12264-021-00638-3] [Citation(s) in RCA: 105] [Impact Index Per Article: 35.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2020] [Accepted: 09/30/2020] [Indexed: 02/07/2023] Open
Abstract
Major depressive disorder (MDD), also referred to as depression, is one of the most common psychiatric disorders with a high economic burden. The etiology of depression is still not clear, but it is generally believed that MDD is a multifactorial disease caused by the interaction of social, psychological, and biological aspects. Therefore, there is no exact pathological theory that can independently explain its pathogenesis, involving genetics, neurobiology, and neuroimaging. At present, there are many treatment measures for patients with depression, including drug therapy, psychotherapy, and neuromodulation technology. In recent years, great progress has been made in the development of new antidepressants, some of which have been applied in the clinic. This article mainly reviews the research progress, pathogenesis, and treatment of MDD.
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Affiliation(s)
- Zezhi Li
- Clinical Research Center and Division of Mood Disorders of Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai, 200030, China.,Department of Neurology, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200127, China
| | - Meihua Ruan
- Shanghai Institute of Nutrition and Health, Shanghai Information Center for Life Sciences, Chinese Academy of Science, Shanghai, 200031, China
| | - Jun Chen
- Clinical Research Center and Division of Mood Disorders of Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai, 200030, China.,Shanghai Key Laboratory of Psychotic Disorders, Shanghai, 201108, China
| | - Yiru Fang
- Clinical Research Center and Division of Mood Disorders of Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai, 200030, China. .,Center for Excellence in Brain Science and Intelligence Technology, Chinese Academy of Science, Shanghai, 200031, China. .,Shanghai Key Laboratory of Psychotic Disorders, Shanghai, 201108, China.
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Abstract
OBJECTIVES Relapses and recurrence remain the greatest risks posed by patients with severe mood disorders after discontinuation of electroconvulsive therapy (ECT). To date, despite a wide range of literature on ECT, little is known about the rate of recurrence of depression after maintenance ECT (mECT) discontinuation specifically. This study sought to address this lacuna, confronting literature data to the results of a retrospective case study. METHODS A comprehensive review was conducted, followed by a retrospective analysis of 18 cases of mECT discontinuation between January 2011 and June 2016 involving patients with affective disorders. RESULTS The comprehensive review revealed that only 3 studies have assessed recurrence rate after c/mECT discontinuation. In our retrospective analysis, mean (SD) mECT duration was 12.69 (12.16) months. A new mood event (usually a depressive state) was observed in 50% of the cases, and 44% of those recurrences occurred during the first 6 months after discontinuation. DISCUSSION Given that high recurrence rates are observed after mECT discontinuation, the authors discuss the advantages of long-term mECT and the choice of concomitant pharmacotherapy for severe and complex affective disorders.
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Atashnama A, Aly H, Krishnan V, Howari R, Mayur P. Naturalistic outcomes of continuation right unilateral ultrabrief ECT in major depression: a retrospective chart review. Australas Psychiatry 2020; 28:286-290. [PMID: 32391725 DOI: 10.1177/1039856220917070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE Continuation treatment of major depression following an acute course of electroconvulsive treatment (ECT) may be often required to prevent relapse. Data on continuation phase of right unilateral ultrabrief ECT are sparse and there are doubts if it is inherently capable of relapse prevention. METHODS All consecutive adult patients with major depression who received the first 'run' of continuation phase of right unilateral ultrabrief ECT over a 10-year period were routinely followed up. ECT frequency varied from weekly to up to once every 4 weeks for a maximum period of 6 months. The data were extracted from a retrospective chart review. RESULTS 20 out of 22 patients persisted with ultrabrief pulses (0.3 ms) with two needing 0.5 ms pulse widths. The median duration of continuation treatment was 51 days (range: 14-460). At the end of 1 month (n = 17), treatment gap in days mean (SD): 10.18 (7.08), widening to mean (SD): 20.11 (16.85) at 4 months (n = 9). Stimulus dose increased throughout the continuation phase: p = 0.026. In 16 out of 22 patients, more than 70% of the visits were charted as being 'in remission'. CONCLUSION As most patients receiving ultrabrief ECT remained well, this study suggests that ultrabrief ECT can be used effectively in continuation therapy.
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Affiliation(s)
| | - Husayn Aly
- Western Sydney Local Health District, Australia
| | | | | | - Prashanth Mayur
- Cumberland Hospital, Australia.,University of Sydney, Australia
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Kellner CH, Obbels J, Sienaert P. When to consider electroconvulsive therapy (ECT). Acta Psychiatr Scand 2020; 141:304-315. [PMID: 31774547 DOI: 10.1111/acps.13134] [Citation(s) in RCA: 95] [Impact Index Per Article: 23.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/21/2019] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To familiarize the reader with the role of electroconvulsive therapy (ECT) in current psychiatric medicine. METHOD We review clinical indications for ECT, patient selection, contemporary ECT practice, maintenance treatment and ECT in major treatment guidelines. RESULTS ECT is underutilized largely due to persisting stigma and lack of knowledge about modern ECT technique. CONCLUSION ECT remains a vital treatment for patients with severe mood disorders, psychotic illness and catatonia.
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Affiliation(s)
- C H Kellner
- New York Community Hospital, Brooklyn, NY, USA.,Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - J Obbels
- Academic Center for ECT and Neuromodulation (AcCENT), University Psychiatric Center, KU Leuven (Catholic University of Leuven), Kortenberg, Belgium
| | - P Sienaert
- Academic Center for ECT and Neuromodulation (AcCENT), University Psychiatric Center, KU Leuven (Catholic University of Leuven), Kortenberg, Belgium
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Parker G, Loo C. Temporal effects of bitemporal electroconvulsive therapy. Aust N Z J Psychiatry 2020; 54:433-434. [PMID: 31773981 DOI: 10.1177/0004867419889408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Gordon Parker
- School of Psychiatry, University of New South Wales, Sydney, NSW, Australia
| | - Colleen Loo
- School of Psychiatry, University of New South Wales, Sydney, NSW, Australia
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Clinical outcome after discontinuation of maintenance Electroconvulsive Therapy. A retrospective follow-up study. REVISTA DE PSIQUIATRIA Y SALUD MENTAL 2019; 13:5-10. [PMID: 31473181 DOI: 10.1016/j.rpsm.2019.07.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Revised: 06/21/2019] [Accepted: 07/01/2019] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Continuation and maintenance electroconvulsive therapy (c/m-ECT) is a therapeutic option after an acute ECT course. Although it is widely used, both duration and the outcome of patients when ECT-c/m is discontinued is not yet well established. The aim of the study was to evaluate the recurrence rate and associated clinical factors when c/m-ECT is discontinued. MATERIALS AND METHODS Retrospective evaluation of 73 patients who were discontinued from c/m-ECT. The minimum evaluation time was one year. The need of hospital admission or a new acute course of ECT was considered a relapse. The recurrence rate was calculated as a percentage and the estimated time to recurrence was analyzed through a survival analysis. Possible associations between clinical variables and recurrence were analyzed by univariate and multivariate Cox analysis. RESULTS Thirty-six patients (49.3%) relapsed: 61.1% of them relapsed during the first year after the c/m-ECT discontinuation (36.1% during the first 6 months). The estimated time to recurrence was 38.67 months. Fifty percent of patients who relapsed required a new acute course of ECT and 44.4% of them restarted c/m-ECT. Patients with an interval between sessions of less than one month and those with more previous episodes showed a higher risk of recurrence. CONCLUSIONS The risk of recurrence should be considered before the discontinuation of c/m-ECT. After the discontinuation, almost half of the patients relapsed, most of them within the first year. Close monitoring should be conducted in these patients and the discontinuation is not recommended when it is administered at intervals between sessions of less than a month. Further studies are required to identify risk groups for relapse.
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Kellner CH. Electroconvulsive therapy in unipolar depression treatment guidelines. Acta Psychiatr Scand 2018; 138:274. [PMID: 30295322 DOI: 10.1111/acps.12893] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- C H Kellner
- Electroconvulsive Therapy (ECT), New York Community Hospital, Brooklyn, NY, USA.,Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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