Influence of age on effectiveness and tolerability of electroconvulsive therapy

History of tobacco smoking and alcohol use can predict the effectiveness of electroconvulsive therapy in individuals with schizophrenia: A multicenter clinical trial

BACKGROUND

Current research has found that factors such as gender, age, and family history can predict the efficacy of electroconvulsive therapy (ECT) in individuals with schizophrenia. In our clinical practice, we anecdotally observed that tobacco smokers and alcohol drinkers with schizophrenia seemed to respond more effectively to ECT than non-smokers and non-drinkers. The current study aimed to examine whether history of tobacco smoking or alcohol consumption serve as indicators for predicting therapeutic efficacy of ECT in individuals with schizophrenia.

METHODS

A total of 481 individuals receiving ECT combined with antipsychotic medication (ECT + AP medication) completed a two-week (six sessions of ECT) follow-up; 106 individuals receiving only antipsychotic medication (AP medication) also completed a two-week follow-up. Smoking, alcohol consumption, and AP medication usage was recorded for these individuals. Severity of psychotic symptoms was assessed using the Positive and Negative Syndrome Scale (PANSS).

RESULTS

ECT + AP medication: Compared to schizophrenic individuals without a history of smoking (non-smokers), those with a history of smoking (smokers) showed a high decrease in negative symptoms (36.96% vs 24.76%; F = 5.974, p = 0.015). While, compared to individuals without a history of alcohol consumption (non-drinkers), those with a history of alcohol consumption (drinkers) showed a high decrease in positive symptoms (48.90% vs 41.47%; F = 5.074, p = 0.025). AP medication: No differences were found in symptom reduction between smokers and non-smokers or between drinkers and non-drinkers (p > 0.05).

CONCLUSIONS

Smoking history in schizophrenic individuals independently predicts better improvement in negative symptoms after ECT, while alcohol consumption history independently predicts better improvement in positive symptoms after ECT. This is a clinically significant finding.

Clinical Outcomes of Electroconvulsive Therapy (ECT) for Depression in Older Old People Relative to Other Age Groups Across the Adult Life Span: A CARE Network Study

INTERVENTION

Electroconvulsive therapy (ECT) is a commonly used treatment for severe psychiatric illness in older adults, including in the 'older old' population aged 80 years and above. However, there can sometimes be a reluctance to treat the 80+ year old age group with ECT due to medical comorbidities, frailty, and concerns about cognition.

OBJECTIVE, DESIGN, SETTING, AND PARTICIPANTS

This multi-site, longitudinal Australian study aimed to investigate the effectiveness and safety of ECT in older old people compared with younger age groups. Data from 310 people receiving ECT for depression at three participating hospitals was collected in a naturalistic setting, between 2015 and 2022.

MEASUREMENTS

Clinical ratings were conducted pre-ECT and end-acute ECT using the Montgomery-Åsberg Depression Rating Scale (MADRS). Cognitive outcomes were assessed using the Montreal Cognitive Assessment (MoCA).

RESULTS

Older old adults demonstrated a significant reduction MADRS scores at post-treatment. They were more likely to meet remission criteria compared with the younger age groups. Older old adults were also less likely to show clinically significant cognitive decline post-ECT, and were more likely to show clinically significant cognitive improvement post-ECT compared with younger age groups.

CONCLUSIONS

ECT is highly effective in treating severe psychiatric illness in older old adults. Relative to the younger age groups, the older old group were more likely to remit with ECT and a greater proportion showed cognitive improvement post-ECT. These findings suggest that ECT should be considered as a valuable and safe treatment option for older old individuals with depression.

Electroconvulsive Therapy for Unipolar Depression in Older Adults: Overall Outcomes and Clinical Trajectories of Nonresponders

OBJECTIVES

Electroconvulsive therapy (ECT) is a safe and effective procedure in unipolar depression in older adults; however, less is known about clinical features and trajectories among patients who do not respond. In this retrospective, naturalistic study, we examine characteristics associated with ECT response among older adults with unipolar depression who received ECT over an 8-year period and describe long-term outcomes for nonresponders.

METHODS

We retrospectively identified patients 65 years or older with major depressive disorder who were treated with ECT during an 8-year period. We reviewed demographic and clinical factors among patients who responded to ECT and those who did not. Clinic notes were reviewed for ECT nonresponders to determine Clinical Global Impressions scores in the 24 months after ECT treatment.

RESULTS

We identified 140 patients meeting the inclusion criteria. Most patients (65%) responded to ECT. Fewer previous antidepressant trials, lower baseline Montreal Cognitive Assessment scores, and lower baseline Montgomery-Asberg Depression Rating Scale scores were associated with an increased likelihood of ECT response. Among the 49 (35%) nonresponders, another 12 (24.5%) responded to a variety of treatments within 2 years after ECT. There were no serious adverse effects of treatment.

CONCLUSIONS

Most patients responded to ECT, many of whom had severe illness that had been refractory to numerous medication trials. Among nonresponders, a subset improved over time through a variety of treatments. However, most patients who did not respond to ECT had persistent depression after 2 years.

Real-world evidence of age-independent electroconvulsive therapy efficacy: A retrospective cohort study

OBJECTIVES

Electroconvulsive therapy (ECT) is an effective treatment for depressive disorders and approved for use in adolescents and adults, but it is unclear whether efficacy or cognitive side effect burden differs with age or if effectiveness in usual clinical practice matches that in prospective studies. We examined the effects of ECT on depression and cognition in a large clinical cohort.

METHODS

A retrospective cohort study of patients ages 16 and older receiving ECT between 2011 and 2020 and who were evaluated with the Quick Inventory of Depressive Symptomatology (QIDS), the Behavior and Symptom Identification Scale-24 (BASIS-24), and the Montreal Cognitive Assessment (MoCA) at baseline and after treatment #10.

RESULTS

Among 1698 patients, ECT was associated with a decrease in depression symptoms (QIDS reduction from 17.1 ± 4.9 to 10.1 ± 5.2) and improvement in self-reported mental health (BASIS-24 scores improved from 1.92 ± 0.55 to 1.17 ± 0.60). There was a reduction in MoCA scores from 25.8 ± 3.1 to 25.4 ± 3.1. In multivariate models, age was not associated with a differential QIDS or BASIS-24 response, but older age was associated with a lesser reduction in MoCA.

CONCLUSION

Among 1698 patients aged 16 and older, ECT was associated with improvement in depression and overall self-reported mental health, with a slight decrease in cognition. Age was not associated with changes in efficacy, but older age was associated with a lesser cognitive change as measured by the MoCA. These results provide normative data of real-world effectiveness of ECT, and add further support to its utility in patients with severe psychiatric illness.

Electroconvulsive Therapy and Age: Effectiveness, Safety and Tolerability in the Treatment of Major Depression among Patients under and over 65 Years of Age

Electroconvulsive therapy (ECT) remains the most effective therapy in treatment-resistant depression. However, the safety of ECT has been consistently questioned, particularly among elderly patients. We assessed the efficacy and safety of ECT in patients before and after 65 years old. The study was conducted between 2015 and 2018 and included 91 patients (61 under and 29 over 65 years old) with major depression undergoing ECT. The Hamilton Depression Rating Scale was used to evaluate efficacy. Cognitive functions were assessed using: MMSE, RAVLT, Trail Making Test, Stroop Test and Autobiographical Memory Interview-Short Form. ECT was more effective in older patients as compared to younger (p < 0.001). No serious adverse events were observed in either group. Increased blood pressure and arrhythmias were more common in the older compared to the younger group (p = 0.044 and p = 0.047, respectively), while disturbances of consciousness did not differ between groups (p = 0.820). Most of the cognitive functions remained unchanged compared to baseline, whereas the outcomes of MMSE, RAVLT and Stroop tests showed greater improvements in the older compared to the younger group (all p < 0.05). The decline in the retrieval consistency of autobiographical memory was more pronounced in the younger group (p = 0.024). ECT is a highly effective, safe and well-tolerated method of treating depression regardless of age.

Right unilateral versus bilateral formula-based electroconvulsive therapy in the treatment of major depression in elderly patients: a randomised, open label, pilot controlled trial

BACKGROUND

Electroconvulsive therapy (ECT) remains the most effective treatment of depression in the elderly population; however, it is still unclear which type of ECT is most beneficial in this population. The aims of this study were: (i) to assess the feasibility of a randomised controlled trial in elderly depressed patients treated with right unilateral (RUL) or fronto-temporal bilateral (BT) formula-based ECT; (ii) to compare formula-based RUL and BT ECT in terms of efficacy, safety and tolerability in this population.

METHODS

The study lasted 3 years and managed to randomise 29 patients over 65 years old to receive either BT (n = 14) or RUL (n = 15) ECT. Brief pulse width (0.5 ms) and age-based dosing method were applied. The clinical efficacy was assessed using Hamilton Depression Rating Scale, somatic state was monitored throughout the ECT course. In neuropsychological examination general cognitive performance, executive functions, verbal fluency, memory, autobiographical memory were evaluated.

RESULTS

The recruitment was poor due to small number of patients able to give informed consent. ECT proved to be a highly effective and safe method of treatment among elders. Formula-based RUL ECT did not differ from BT in antidepressant efficacy and had cognitive advantages - the indices of general cognitive performance, verbal fluency and memory were significantly better than before the treatment in the RUL group. Decline in retrieval consistency of autobiographical memory was more pronounced in the BT group, although it was observed across both groups.

CONCLUSIONS

Formula-based RUL ECT might not differ from BT in antidepressant efficacy and has an advantage in terms of tolerability.

Influence of age on ECT efficacy in depression and the mediating role of psychomotor retardation and psychotic features

OBJECTIVE

To investigate whether older age predicts a higher efficacy of electroconvulsive therapy (ECT) in severely depressed patients. Also, to analyze whether psychomotor disturbance and/or psychotic features might explain the potential higher efficacy of ECT in older age.

METHOD

A total of 96 patients with major depressive disorder treated with bilateral ECT were evaluated. The 17-item HAM-D and the MADRS were used to evaluate the efficacy of ECT and time to remission, respectively. Psychomotor disturbance was defined according the HAM-D.

RESULTS

Middle-aged (MA; 50-70 years) and older-aged (OA; ≥70 years) patients had a non-significant larger symptom reduction compared with young-aged (YA; <50 years) patients. Medium effect size was found in favor of MA (d = 0.44) and small effect size in favor of OA (d = 0.30), when compared to YA. Patients with psychotic features and patients with psychomotor retardation had a significantly larger symptom reduction (p < 0.001 and p = 0.005, respectively; d = 0.88 and d = 0.66, respectively). The association between age and ECT efficacy is mediated by psychomotor retardation (p = 0.049) and in lesser extent by psychotic features (p = 0.071).

CONCLUSION

The results show that psychomotor retardation and psychotic features are strong predictors of ECT efficacy and explain the association between age and ECT efficacy. Instead of focusing on the age of a patient, clinicians should focus on the presence of psychomotor disturbances and psychotic features of depression, when considering ECT treatment.

Pratique de l'électroconvulsivothérapie dans un hôpital universitaire Tunisien

This study aimed to describe the practice of electroconvulsivotherapy (ECT) at the University Hospital of Monastir (Tunisia). We conducted a retrospective study of all patients treated by ECT at the University Hospital of Monastir between 2002 and 2013. 80 patients were enrolled in the study (60 men and 20 women, with an average age of 42.1±15.7 years), accounting for 1.4% of all patients hospitalized in Psychiatry Department during the study period. The total number of ECT sessions was 784. In 50% of patients, the primary diagnosis was a major isolated or recurring depressive disorder. The majority of patients (78.8%) had undergone only one ECT session, with an average number of sessions of 8.1 ± 4.9. The most used anesthetic product was the propofol (97.4%). In 71% of cases the energy delivered was between 40 and 80 joules and it was positively correlated with patients' age. The average duration of the motor seizure was 22.3 ± 7.2 seconds and it was negatively correlated with patients' age. The highest response rate was found in depression scores (64.3%). Immediate adverse effects occurred in 51.2% of patients. Finally, 20% of patients continued to undergo maintenance ECT sessions on a weekly or a biweekly basis. The practice of ECT at the University Hospital of Monastir has been little developed in terms of number of patients and ECT sessions. Efforts should be made to promote the use of this method.

Electroconvulsive therapy and age: Age-related clinical features and effectiveness in treatment resistant major depressive episode

OBJECTIVE

This study was aimed to compare clinical features, treatments outcomes and tolerability between young (18-45 years), middle age (46-64 years) and old (≥ 65 years) patients treated with bilateral ECT for treatment resistant major depressive episode.

METHOD

402 patients were evaluated 1 day prior to ECT and a week after the treatment termination using the Clinical Global Impression Scale (CGI), the Hamilton Rating Scale for Depression-17 items (HAM-D-17), the Brief Psychiatric Rating Scale (BPRS), the Young Mania Rating Scale (YMRS) and the Mini Mental State Examination (MMSE). Response was defined as a reduction of at least 50% from baseline on the HAM-D-17 score. Remission was defined as a score ≤ 7 on the HAM-D-17 at the final evaluation.

RESULTS

Rates of response were not statistically different in the three groups (69.6% in old versus 63.5% in young and 55.5% in middle age groups). No significant differences were also observed in the proportions of remitters between the age groups (31.4% in young group, 27.7% in middle age group and 29.3% in old group). One week after the end of the ECT course the middle and old age groups showed a statistically significant increase in the MMSE score compared to baseline. We did not find significant differences between the three age groups in rates of premature drops-out due to ECT-related side effects.

CONCLUSION

Our data support the use of ECT in elderly patients with treatment-resistant major depressive episode, with rates of response around 70% and effectiveness being independent from age. In the old age group the baseline cognitive impairment improved after ECT and no life-threatening adverse event was detected.

Short- and long-term evaluation of cognitive functions after electroconvulsive therapy in a Japanese population

AIM

While electroconvulsive therapy (ECT) is a well-established, safe, and effective treatment for mental illnesses, the potential for adverse effects on cognitive functions remains controversial. We aimed to evaluate multiple cognitive functions in different time periods before and after ECT in a Japanese population.

METHODS

A battery of five neurocognitive tests was administered to patients who underwent a course of ECT treatment at three time points: before, immediately after, and 4 weeks after ECT.

RESULTS

A transient but significant decline in letter fluency function was observed immediately after ECT, but had recovered well by 4 weeks. We also observed a significant improvement in the trail-making task at 4 weeks after ECT.

CONCLUSION

In a Japanese population, adverse effects of ECT on verbal fluency function-related and other cognitive impairments were transient. Over the longer term, we detected significant improvements in the performance of tasks that presumably reflected information processing speed and executive functions.

Depression Among Older Adults: A 20-Year Update on Five Common Myths and Misconceptions

Is depression among older adults symptomatically different than younger adults? Is it more common or chronic or difficult to treat? Is depression in late life more likely to be attributed to psychological problems? Twenty-years ago, Dan Blazer, a pioneer known for his groundbreaking work on depression in older adulthood, conducted an important review of the existing literature to refute five commonly held beliefs about depression in late life. Now, two decades later, we call upon selected articles that are representative of our current knowledge to provide an update and identify research priorities. The research consensus spanning the past 20 years suggests that when compared with their younger counterparts, depression in older adults is not more common and is not more often caused by psychological factors. Although some studies have suggested that depression in late life may be symptomatically different and characterized by a more somatic presentation, there is insufficient empirical evidence to conclude that depression presents differently across adulthood. Overall, older adults respond to psychological interventions as well as younger adults, although evidence suggests that antidepressants are less efficacious in late life. Finally, compared with middle-aged adults, depression in older adults is associated with a more chronic course (i.e., higher rate of relapse), which is likely moderated by medical comorbidity. This special article summarizes our current understanding of the nature and treatment of late-life depression and highlights areas of inquiry in need of further study.

The mortality rate of electroconvulsive therapy: a systematic review and pooled analysis

OBJECTIVE

Electroconvulsive therapy (ECT) remains underutilized because of fears of cognitive and medical risks, including the risk of death. In this study, we aimed to assess the mortality rate of ECT by means of a systematic review and pooled analysis.

METHOD

The study was conducted in adherence with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline. The ECT-related mortality rate was calculated as the total number of ECT-related deaths reported in the included studies divided by the total number of ECT treatments.

RESULTS

Fifteen studies with data from 32 countries reporting on a total of 766 180 ECT treatments met the inclusion criteria. Sixteen cases of ECT-related death were reported in the included studies yielding an ECT-related mortality rate of 2.1 per 100 000 treatments (95% CI: 1.2-3.4). In the nine studies that were published after 2001 (covering 414 747 treatments), there was only one reported ECT-related death.

CONCLUSION

The ECT-related mortality rate was estimated at 2.1 per 100 000 treatments. In comparison, a recent analysis of the mortality of general anesthesia in relation to surgical procedures reported a mortality rate of 3.4 per 100 000. Our findings document that death caused by ECT is an extremely rare event.

Systematic Review of Cognitive Effects of Electroconvulsive Therapy in Late-Life Depression

OBJECTIVE

Late-life depression (LLD) is known to negatively impact cognition even after remission of mood symptoms. Electroconvulsive therapy (ECT) and newer nonconvulsive electrical and magnetic brain stimulation interventions have been shown to have cognitive effects in patients with neuropsychiatric disorders.

METHODS

This review systematically assessed the effects of ECT on cognition in LLD. EMBASE, Ovid Medline, and PsycINFO were systematically searched through June 2015. The search was limited to publications from peer-reviewed journals in the English language.

RESULTS

A total of 5,154 publications was identified; 318 were reviewed in full text, of which 39 publications related to ECT were included. We focused this review only on ECT because evidence on newer interventions was deemed insufficient for a systematic review. This literature suggests increased rates of interictal and postictal cognitive decline with ECT but no long-term (i.e., 6 months or longer) deleterious effects on cognition. Instead, long-term cognitive outcomes with ECT have been reported as either not changed or improved. This literature favors nondominant unilateral ECT over bilateral ECT for cognition.

CONCLUSION

Published literature on brain stimulation interventions in LLD is mainly limited to ECT. This literature suggests that deleterious effects of ECT in LLD are limited and transient, with better cognitive outcomes with unilateral ECT. There is not enough evidence to fully characterize long-term deleterious effects of ECT or effects of newer brain stimulation techniques on cognition in LLD.

Use of ECT in Nepal: A One Year Study From the Country's Largest Psychiatric Facility

INTRODUCTION

Electro-Convulsive Therapy (ECT) refers to the electrical stimulation of the brain to produce seizures for therapeutic purpose. Since the development of ECT, it's use has been consistent. Inspite of the common use, data pertaining to the use of ECT in Nepal is lacking.

AIM

This study was undertaken with the aim of exploring the clinico-demographic profile of patients treated with ECT in the largest psychiatry facility in the country.

MATERIALS AND METHODS

It is a retrospective descriptive study of patients who were treated with ECT after admission in the inpatient psychiatry unit of Universal College of Medical Sciences Teaching Hospital, Bhairahawa, Nepal during a period of one year (August 2012 to July 2013).

RESULTS

Out of 1095 patients admitted during the specified period, 81 (7.39%) patients received ECT. About 44.44% of the patients belonged to 20-29 years age group. Female patients constituted more than half of the subjects (55.56%). Review of diagnostic profile showed that majority of patients receiving ECT were suffering from Schizophrenia (44.4%), followed by Bipolar Affective Disorder/Mania (29.6%), Depressive disorder (11.1%), Acute and Transient Psychotic Disorder (6.2%), Post-partum Psychosis (3.7%) and substance induced mood/psychotic disorders (3.7%). A significant majority of subjects (75.3%) received about 5-7 ECT treatments. The mean seizure duration after ECT treatment was 31.13±5.79 seconds. No any major complications were noted during ECT treatment.

CONCLUSION

This study suggests that ECT, use, as a treatment modality is common in young adults and females with Schizophrenia being the most common indication. Direct ECT is safe when used judiciously.

Repeated dose titration versus age-based method in electroconvulsive therapy: a pilot study

In electroconvulsive therapy (ECT), a dose titration method (DTM) was suggested to be more individualized and therefore more accurate than formula-based dosing methods. A repeated DTM (every sixth session and dose adjustment accordingly) was compared to an age-based method (ABM) regarding treatment characteristics, clinical outcome, and cognitive functioning after ECT. Thirty-nine unipolar depressed patients dosed using repeated DTM and 40 matched patients treated with ABM were compared. Montgomery-Åsberg Depression Rating Scale (MADRS) and Mini-Mental State Examination (MMSE) were assessed at baseline and at the end of the index course, as well as the total number of ECT sessions. Both groups were similar regarding age, sex, psychotic features, mean baseline MADRS, and median baseline MMSE. At the end of the index course, the two methods showed equal outcome (mean end MADRS, 11.6 ± 8.3 in DTM and 9.5 ± 7.6 in ABM (P = 0.26); median end MMSE, 28 (25-29) and 28 (25-29.8), respectively (P = 0.81). However, the median number of all ECT sessions differed 16 (11-22) in DTM versus 12 (10-14.8) in ABM; P = 0.02]. Using regression analysis, dosing method and age were independently associated with the total number of ECT sessions, with less sessions needed in ABM (P = 0.02) and in older patients (P = 0.001). In this comparative cohort study, ABM and DTM showed equal outcome for depression and cognition. However, the median ECT course duration in repeated DTM appeared longer. Additionally, higher age was associated with shorter ECT courses regardless of the dosing method. Further prospective studies are needed to confirm these findings.

Clinical efficacy of formula-based bifrontal versus right unilateral electroconvulsive therapy (ECT) in the treatment of major depression among elderly patients: a pragmatic, randomized, assessor-blinded, controlled trial

BACKGROUND

No prior study has compared the efficacy of bifrontal (BF) vs right unilateral (RUL) electroconvulsive therapy (ECT) by including the subgroup that is most likely to receive it: only elderly patients with major depression (MD).

METHODS

This single-site, randomized, assessor-blinded, controlled trial was conducted from 2009 to 2013. Seventy-three elderly patients with MD, unipolar and bipolar, were treated with a course of formula-based BF ECT or RUL ECT. The 17-item Hamilton Rating Scale for Depression (HRSD17) was used to measure efficacy. Safety was assessed with the Mini Mental State Examination (MMSE).

RESULTS

Both electrode placements resulted in highly significant downward trends in symptom severity (all p<0.001), with a non-significant difference between methods (p=0.703). At the end of the ECT course, response rates for the BF and RUL group were 63.9% and 67.6%, respectively. Short-term remission, defined as an HRSD17 score≤7, was achieved in 14 (38.9%) patients in the BF group and 19 (51.4%) patients in the RUL group. Global cognitive function, as measured by the MMSE, did not deteriorate in the two treatment groups.

LIMITATIONS

The small number of subjects may have led to reduced power to detect real differences. The MMSE is not sufficient to ascertain the negative effect of ECT on cognition.

CONCLUSIONS

This study indicates that formula-based BF and RUL ECT are equally efficacious, and that remission rates of formula-based dosing are lower than those previously reported for titrated dosing, in a clinical sample of elderly patients with MD.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01559324.

Use of electroconvulsive therapy in the treatment of catatonia

ABSTRACT: 

While the mechanisms of catatonia remain poorly understood, there are known and effective treatments for it, namely high-dose benzodiazepines and electroconvulsive therapy (ECT). For more than 75 years, ECT has been successfully used for the treatment of severe psychiatric disorders, including catatonia. This special report describes ECT in patients with catatonia, its indications, treatment logistics, decision-making about when to use ECT instead of conservative treatment, special circumstances and adverse effects.

Electroconvulsive therapy use in Otago, New Zealand: a 10-year retrospective audit of patient-level treatment data

OBJECTIVES

There are wide global variations in electroconvulsive therapy (ECT) use patterns. This audit reviewed patient-level ECT use patterns over 10 years at a single New Zealand clinic, including factors associated with clinical response and patterns of repeated administration.

METHODS

Retrospective audit of all 2003-2012 ECT and clinical file data.

RESULTS

A total of 199 patients received ECT, which was used to treat mostly affective disorders in a predominantly female, older population, generally with a single course of treatment. There were different demographics and patterns of ECT use between patients being treated for affective and psychotic disorders. Overall treatment response was high, with over 90% of patients having a full or partial response. Treatment response was not associated with diagnosis, gender, or medication use, but showed a trend in significance for greater response in elderly patients.

CONCLUSIONS

ECT use patterns in Otago New Zealand are similar to those reported in Australia, USA, and UK, although yearly use rate in Otago is lower. Because of their different demographic and ECT treatment patterns, future studies should report data for patients with affective and psychotic disorders separately.

Electroconvulsive therapy: is there a role for treating older patients?

Electroconvulsive therapy (ECT) is a powerful acute treatment for severe and resistant depression. We review literature related to the efficacy, safety and tolerability of ECT in older people, with an emphasis on research studies and reviews published in the last 25 years. In general ECT has been considered a very effective and safe treatment for depression and other psychiatric and non-psychiatric disorders in older people. Amnesia is commonly attributed to ECT treatment, but studies suggest that the negative effects of ECT on cognition are probably small in older patients. Currently the balance of risks and benefits of ECT justify its use for severe depression in older patients, both with and without dementia.

Dopamine D₃ receptor gene variation: impact on electroconvulsive therapy response and ventral striatum responsiveness in depression

Dysfunction of dopamine D₃ receptors, particularly in the mesocorticolimbic system, has been linked to the pathogenesis of major depression. Preclinical data show enhanced D₃ receptor binding in the striatum upon antidepressant medication and electroconvulsive therapy (ECT). Thus, the potential impact of dopamine D₃ receptor gene (DRD3) variation on ECT outcome in treatment-resistant major depression was evaluated by applying a combined molecular and imaging genetic approach. Altogether, 10 representative variants covering 95.4% of DRD3 gene variation were investigated for association with response to ECT in a sample of 104 (71 female, 33 male) Caucasian patients with pharmacorefractory major depression. Additionally, ventral striatum responsiveness to happy faces was assessed in two independent samples of depressed patients (total N=54) by means of functional magnetic resonance imaging at 3 T. Significant association of DRD3 rs3732790, rs3773679 and rs9817063 variants with response (uncorrected p=0.02-0.03) and remission (uncorrected p=0.01) after ECT was discerned. Logistic regression analyses revealed association of rs3732790 (uncorrected p=0.009; corrected p=0.045) and rs3773679 (uncorrected p=0.009; corrected p=0.045) with remission when applying a recessive model of inheritance. The rs3732790T allele conferring a more favourable treatment response was furthermore found to be associated with stronger striatal responsiveness to happy facial expressions (sample 1: cluster-corrected p=0.002; sample 2: p=0.023). In summary, the present study suggests some impact of DRD3 gene variation on ECT response, potentially mediated by alteration of striatal engagement during the processing of emotionally rewarding stimuli.

Speed of response in ultrabrief and brief pulse width right unilateral ECT

Ultrabrief pulse width stimulation electroconvulsive therapy (ECT) results in less cognitive side-effects than brief pulse ECT, but recent work suggests that more treatment sessions may be required to achieve similar efficacy. In this retrospective analysis of subjects pooled from three research studies, time to improvement was analysed in 150 depressed subjects who received right unilateral ECT with a brief pulse width (at five times seizure threshold) or ultrabrief pulse width (at six times seizure threshold). Multivariate Cox regression analyses compared the number of treatments required for 50% reduction in depression scores (i.e. speed of response) in these two samples. The analyses controlled for clinical, demographic and treatment variables that differed between the samples or that were found to be significant predictors of speed of response in univariate analyses. In the multivariate analysis, older age predicted faster speed of response. There was a non-significant trend for faster time to 50% improvement with brief pulse ECT (p = 0.067). Remission rates were higher after brief pulse ECT than ultrabrief pulse ECT (p = 0.007) but response rates were similar. This study, the largest of its kind reported to date, suggests that fewer treatments may be needed to attain response with brief than ultrabrief pulse ECT and that remission rates are higher with brief pulse ECT. Further research with a larger randomized and blinded study is recommended.

Clinical effects of electroconvulsive therapy in severe depression and concomitant changes in cerebral glucose metabolism--an exploratory study

OBJECTIVE

Electroconvulsive therapy (ECT) is an effective mode of treatment--especially for severe depression and for depression refractory to pharmacotherapy, nevertheless the mode of action of ECT is far from being fully understood. This study assessed the effects of a series of ECT in depressive subjects on cerebral glucose metabolism measured by FDG-PET scans pre- and post-therapy in thus far the largest group of 12 patients.

METHODS

Our analysis included careful repeated evaluation of clinical changes in mood and behaviour by standardised questionnaires, which allowed testing for a potential correlation between clinical and cerebral metabolic changes. PET scanning was done within a predefined time window and we used predefined ROIs with counts normalized to the pons activity.

RESULTS

We observed few changes in cerebral glucose metabolism over time. There was a marginal increase in the left temporal and a trend for a decrease in left frontobasal areas subsequent to treatment in our sample. FDG uptake patterns remained remarkably stable in all the other predefined ROIs pre- and post-treatment. There were no significant correlations between changes in relative metabolic rates and changes in depression scores and parameters derived from neurocognitive testing.

CONCLUSIONS

Our study thus cannot support the view that FDG-PET can assess the functional brain changes that are likely to occur subsequent to ECT in such a scenario, but this may be related to limited sensitivity given the sample size. Future studies thus might wish to challenge this notion in larger patient samples to clarify this issue.

Older adults with severe, treatment-resistant depression

Depression is a common, disabling, and costly condition encountered in older patients. Effective strategies for detection and treatment of late-life depression are summarized based on a case of a 69-year-old woman who struggled with prolonged depression. Clinicians should screen older patients for depression using a standard rating scale, initiate treatment such as antidepressant medications or evidence-based psychotherapy, and monitor depression symptoms. Patients who are not improving should be considered for psychiatric consultation and treatment changes including electroconvulsive therapy. Several changes in treatment approaches are usually needed before patients achieve complete remission. Maintenance treatment and relapse-prevention planning (summarization of early warning signs for depression, maintenance treatments such as medications, and other strategies to reduce the risk of relapse [eg, regular physical activity or pleasant activities]) can reduce the risk of relapse. Collaborative programs, in which primary care clinicians work closely with mental health specialists following a measurement-based treatment-to-target approach, are significantly more effective than typical primary care treatment.

Electroconvulsive therapy for treating schizophrenia: a chart review of patients from two catchment areas

To examine disease and treatment characteristics of patients with schizophrenia treated with electroconvulsive therapy (ECT). We examined charts from 79 patients diagnosed with schizophrenia (n = 55), persistent delusional disorders (n = 7), and schizoaffective disorders (n = 17) between 2003 and 2008. We recorded age, sex, indication for ECT, number of ECT sessions, ECT series, outcome, maintenance ECT, use of antipsychotics, duration of illness, and duration of the current exacerbation. All patients were taking antipsychotics at the time of enrolment in the study. Acute ECT included 2-26 sessions; maintenance ECT (M-ECT) was given to 18 patients for up to 12 years. Initial indications for ECT included psychosis (n = 28), pronounced affective symptoms (n = 28), delirious states (n = 20), and M-ECT (n = 3). Most patients experienced excellent/good outcomes (n = 66), but others experienced moderate (n = 8) or poor (n = 5) outcomes. No factors were identified that predicted treatment responses in individual patients. ECT proved to be effective in a population of patients that were severely ill with treatment-refractory schizophrenia. This does not imply that the patients were cured from schizophrenia. Rather, it reflects the degree of relief from psychosis and disruptive behaviour, as described in the patient charts. The treatment was often offered to patients after considerable disease durations.

Electroconvulsive therapy for treatment of major depression in a 100-year-old patient with severe aortic stenosis: a 5-year follow-up report

Although there is no specific age cutoff for electroconvulsive therapy (ECT) and no absolute contraindication to its use, very old age and the presence of cardiac conditions such as aortic stenosis are factors that may negatively affect the physician's decision to administer ECT in individual cases. We report our follow-up of a 100-year-old woman with severe aortic stenosis who has received ECT safely for 5 years now. No cardiac complications have emerged during this period. Her prior unipolar depressive episode with catatonic features remains in remission with a single prophylactic ECT session every 3 months. We have observed from our experience with this unique case that periodic multidisciplinary re-evaluation of the evolving risk-benefit profile of ECT is essential along with the inclusion of family members in this dialogue. Our patient's course illustrates that neither advanced age nor severe aortic stenosis is an absolute contraindication to ECT even over an extended period of time. Each case needs to be evaluated on its merits. To our knowledge, this case represents the oldest patient in the literature where ECT has been administered safely for such an extended period in the setting of severe aortic stenosis.