Medication management during electroconvulsant therapy

Pharmacologic management of adolescent catatonia: A dual-case series

Introduction

Catatonia is a syndrome characterized by psychomotor and behavioral disturbances and is associated with a substantially increased mortality risk in adolescent patients. There is a dearth of published literature describing treatment strategies for pediatric patients with catatonia. This dual-case series will describe the treatment course of 2 adolescent patients with catatonia at our pediatric inpatient psychiatric facility.

Case Series

This case series presents 2 adolescent patients (a 17-year-old male and a 16-year-old female) who initially presented with worsening agitation and paranoia, later developing catatonia. Both patients required long durations of hospitalization and were treated with high-dose lorazepam before requiring the addition of electroconvulsive therapy (ECT).

Discussion

Treatment of pediatric patients with catatonia creates a significant burden on patients, families, and the healthcare system. Treatment with high-dose benzodiazepines is high risk, while ECT is both difficult to access and comes with its own risks. Both patients discussed are transitional age, meaning they will soon be young adults who will continue to require high-level psychiatric care. Psychiatric pharmacists have a large role to play in ensuring safe medication management for these complex patients.

Conclusions

This case series of 2 adolescent patients with catatonia demonstrates marginal reduction in symptoms with high-dose lorazepam in conjunction with ECT, with minimal side effects. This case series adds to the limited available literature regarding treatment of catatonia in pediatric patients and highlights the need for further study into effective treatment alternatives.

Use of ECT in Autism Spectrum Disorder and/or Intellectual Disability: A Single Site Retrospective Analysis

Autism spectrum disorder (ASD) and intellectual disability (ID) are heterogenous and prevalent conditions which may occur in isolation or as a co-morbidity. Psychiatric co-morbidity is common with limited treatment options. Preliminary research into electroconvulsive therapy (ECT) for these conditions has been encouraging. Thus, further research in this patient population is warranted. We conducted a 10-year retrospective review of the electronic medical record and identified intellectually capable individuals with ASD (IC-ASD), and those with ASD+ID or ID who received at least three ECT treatments. 32 patients were identified of which 30 (94%) experienced positive clinical response, defined as a clinical global impression-improvement (CGI-I) score of 3 or less. The average retrospective CGI-I score across all groups was 1.97, and results of a t-test performed on CGI-I scores indicated improvement across all groups [t = - 16.54, df = 31, p < 0.001, 95% CI = (1.72, 2.22)]. No significant adverse events were identified based on clinical documentation. Our findings further support previous ECT research in this patient population.

Ketamine or ECT? What Have We Learned From the KetECT and ELEKT-D Trials?

1. Two recent clinical trials, KetECT and ELEKT-D, compared the effectiveness of ketamine and electroconvulsive therapy (ECT) for major depressive disorder. Notably, these trials reported marked differences in ECT's clinical outcomes of, with remission rates of 63% for KetECT and a strikingly lower rate of 22% for ELEKT-D, while the remission rates for ketamine were 46% and 38%, respectively. Considering that the primary objective of both trials was to compare the standard treatment (ECT) with an experimental intervention (ketamine), it is crucial to highlight the pronounced disparities in ECT's clinical outcomes. This article offers a comprehensive comparison of these trials while also exploring how patient characteristics, treatment protocols, and study designs may contribute to such pronounced outcome discrepancies. These differences highlight the heterogeneous nature of depression and underscore the need for personalized treatments. These studies also provide valuable insights into identifying the most suitable candidates for ketamine and ECT.

[Contemporary methods of non-drug therapy for depression]

The review presents information on the most effective current non-drug methods of treatment of depression used in practice. A review of publications in PubMed and PsycINFO and Cochrane Library over the past 10 years was conducted. Non-drug biological therapies demonstrate high efficacy in the reduction of depressive symptoms in patients with recurrent depressive disorder. The use of non-drug therapy does not preclude the continuation of pharmacological therapy. In order to choose an optimal method of treatment, the psychophysical state of a patient, severity of depressive symptoms, response to drug therapy, and possibility of prescribing pharmacological therapy should be taken into account, and the principles of evidence-based medicine should be taken into consideration when making a decision.

Factors Predicting Ictal Quality in Bilateral Electroconvulsive Therapy Sessions

In electroconvulsive therapy (ECT), ictal characteristics predict treatment response and can be modified by changes in seizure threshold and in the ECT technique. We aimed to study the impact of ECT procedure-related variables that interact during each session and might influence the seizure results. Two hundred and fifty sessions of bilateral ECT in forty-seven subjects were included. Seizure results were evaluated by two different scales of combined ictal EEG parameters (seizure quality index (SQI) and seizure adequacy markers sum (SAMS) scores) and postictal suppression rating. Repeated measurement regression analyses were performed to identify predictors of each session’s three outcome variables. Univariate models identified age, physical status, hyperventilation, basal oxygen saturation, days between sessions, benzodiazepines, lithium, and tricyclic antidepressants as predictors of seizure quality. Days elapsed between sessions, higher oxygen saturation and protocolized hyperventilation application were significant predictors of better seizure quality in both scales used in multivariate models. Additionally, lower ASA classification influenced SQI scores as well as benzodiazepine use and lithium daily doses were predictors of SAMS scores. Higher muscle relaxant doses and lower applied stimulus intensities significantly influenced the postictal suppression rating. The study found several modifiable procedural factors that impacted the obtained seizure characteristics; they could be adjusted to optimize ECT session results.

Successful bilateral electroconvulsive therapy in a patient with a seizure disorder taking levetiracetam, lorazepam, and zonisamide: A case report

Electroconvulsive therapy (ECT) may be considered for treatment of severe, treatment-resistant, and emergent depression associated with MDD or bipolar disorder. Patients with epilepsy usually take medications that raise the seizure threshold, which poses challenges during ECT. We report a 66-year-old male with epilepsy taking levetiracetam extended-release (XR), lorazepam, and zonisamide requiring ECT for severe MDD. After literature review, the XR form of levetiracetam was changed to higher doses of the immediate-release (IR) formulation, and zonisamide was discontinued 2 days prior to ECT in the hospital and was resumed when the patient underwent outpatient continuation ECT. The patient was treated to remission after receiving 8 acute bilateral ECT treatments before being transitioned to continuation ECT. We provide a brief review of medication management of antiepileptic drugs and other medications that increase the seizure threshold during ECT. To our knowledge, this is the first reported case describing the management of levetiracetam, lorazepam, and zonisamide concomitantly during ECT. Our case suggests that utilizing the IR formulation of levetiracetam, administering the evening dose early the day prior to the procedure, and temporarily discontinuing zonisamide prior to bilateral ECT is effective for the treatment of severe MDD while maintaining seizure prophylaxis.

Case report: delayed response after electroconvulsive therapy in a patient with major depressive disorder

BACKGROUND

Major depressive disorder and associated mood syndromes are amongst the most common psychiatric disorders. To date, electroconvulsive therapy (ECT) is considered the most effective short-term treatment for patients with severe or treatment-resistant depression. In clinical practice, there is considerable variation in the ECT dosing schedule, with the number of sessions typically ranging from 6 to 12, with early antidepressant effects being predictive of increased positive outcomes. We describe here an unusual case of a female patient with severe depression who did not respond to ECT until the 11th session, after which she had shown a drastic improvement in her mental state.

CASE PRESENTATION

A 75-year-old female presented to the old age psychiatry inpatient unit with new onset dysphoric mood, anhedonia, and severe negativity. She scored 23 on the 17-item Hamilton Rating Scale for Depression (HAM-D), and was rated 6 on Clinical Global Impression severity (CGIS) by the responsible clinician. She suffered from post-natal depression fifty years ago and was successfully treated with ECT. She was therefore initiated on a course of ECT treatment. Her condition initially deteriorated, displaying features of catatonia and psychosis, unresponsive to ECT treatment or concurrent psychotropic medications. After 11th ECT session, she started to show signs of clinical improvement and returned close to her baseline mental state after a total of 17 ECT sessions. She remained well 3 months post-treatment, scoring 4 on HAM-D, Clinical Global Improvement or change (CGI-C) rated as 1 (very much improved). The diagnosis was ICD-10 F32.3 severe depressive episode with psychotic symptoms.

CONCLUSIONS

we describe here an unusual case of delayed response to electroconvulsive therapy in the treatment of severe depressive disorder. Studies have shown the number of acute ECT treatments to be highly variable, affected by a number of factors including treatment frequency, condition treated and its severity, the ECT technical parameters, as well as concurrent use of pharmacological treatment. This may call for re-consideration of the current ECT treatment guidelines, requiring more research to help stratify and standardize the treatment regime.

Impact of vascular risk factors on clinical outcome in elderly patients with depression receiving electroconvulsive therapy

BACKGROUND

Although electroconvulsive therapy (ECT) is a highly effective, safe, and well-tolerated antidepressant treatment for late-life depression (LLD), there is large variability in response rates across individuals. We hypothesized that these variations would be in part explained by the level of vascular risk in this population. We therefore compared response rates to ECT in patients with LLD presenting with or without vascular risk factors (VRF).

METHODS

52 patients with LLD (age > 55) who received a course of ECT were separated into 2 groups according to the presence of VRF (n = 20) or not (n = 32). Framingham score (10-year risk for developing a coronary heart disease) was calculated for each patient. Our primary outcome was the number of responders to ECT in each group (defined as at least 50% decrease of the Montgomery-Åsberg Depression Rating Scale score following ECT course). Scores at the self-rated Beck Depression Inventory are also reported.

RESULTS

Patients with VRF presented significant lower response rates to ECT (12 out of 20; 60%) than patients without VRF (30 out of 32; 94%; p = 0.004). A negative correlation was found between Framingham score and changes in depression scores pre/post ECT (r = -0.42; p = 0.0039).

LIMITATIONS

Our study was limited by sample size and retrospective design.

CONCLUSION

Patients with LLD and VRF showed lower response rates to ECT than those without VRF. The more the VRF increased, the less the antidepressant effect of ECT was observed. Results are discussed in light of the role of apathy in clinical response to ECT.

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

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

Neuroleptic malignant syndrome: A case report

Electroconvulsive therapy (ECT) is an increasingly popular treatment for drug-resistant depression that may have utility for some patients with neuroleptic malignant syndrome (NMS) who are unresponsive to pharmacotherapy. Using a case study as an example, this article discusses the diagnosis of a patient with NMS, the use of ECT as a treatment for NMS, and the importance of nursing care for these patients.

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

CONTEXT

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

METHOD

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

RESULTS

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

DISCUSSION

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

Effects of video psychoeducation on perceptions and knowledge about electroconvulsive therapy

This study examined the effects of video psychoeducation about electroconvulsive therapy (ECT) on perceptions and knowledge about ECT. A pre-post design was used with a national sample of 1,068 adults who screened positive for depression. Participants' perceptions and knowledge about ECT were assessed before and after watching a psychoeducational video about ECT. Participants showed significant increases in positive perceptions and accurate knowledge about ECT after watching the psychoeducational video. In the perception domain, the items "ECT can be lifesaving" and "fears that ECT can be painful" showed the largest positive increases. In the knowledge domain, items related to "ECT is one of the safest procedures performed" and "ECT can be given safely to older persons" showed the largest increases. Over 20% of participants changed their mind and reported they were willing to try ECT after watching the video. Together, these findings suggest video psychoeducation about ECT holds great potential to improve perceptions and knowledge about ECT, particularly as new technologies are developed to create, distribute, and host videos to reach large audiences.

Electroconvulsive Therapy in Geriatric Psychiatry: A Selective Review

Electroconvulsive therapy (ECT) remains an important treatment of geriatric patients. ECT treats severe depression, mania, psychosis, catatonia, and comorbid depression and agitation in dementia. ECT also serves a crucial role in treating urgent illness requiring expedient recovery, such as catatonia, or in patients with severe suicidal ideation or intent. ECT is even more effective in the elderly than in mixed-age adult populations. ECT is a safe treatment option with few medical contraindications. Cognitive effects are largely transient, even in patients with preexisting cognitive impairment.

The impact of electroconvulsive therapy on the spatial QRS-T angle and cardiac troponin T concentration in psychiatric patients

Background

Electroconvulsive therapy (ECT) is an effective treatment method used in psychiatry; however, its cardiac safety has not been clearly demonstrated. The aim of the study was evaluation of the ECT effects on the myocardium based on troponin T concentrations and the following ECG parameters: the spatial QRS-T angle (QRS-TA), QRS duration (QRSd) and the corrected QT interval (QTc).

Methods

In the study 44 patients (12 female and 32 male) were enrolled diagnosed with schizophrenia (n = 21) and major depressive disorders (n = 23), according to the DSM-IVR criteria. All cases were undergoing ECT procedures. The mean age of the patients was 36.9±16 years (range: 18–74). Resting ECG was recorded before performing ECG and 1 hour after. The spatial QRS-TA was reconstructed from 12-lead ECG using the inverse Dower method. Troponin T concentration was assessed before the procedure and 6 hours after ECT.

Results

No significant changes to troponin T concentrations were observed during the ECT series. The pre-ECT value of the spatial QRS-TA was 41.1±18.9°. The follow-up examinations did not reveal any significant increase of this parameter (p = 0.09) in any of the consecutive measurements. There were no significant changes in the QTc interval duration or the QRS complex duration demonstrated before the third, fifth and last procedure in the cycle (p>0.05). No significant changes to troponin T concentrations were observed during the ECT series.

Conclusions

Our findings indicate a lack of negative ECT effects on the risk of adverse cardiovascular events measured by the spatial QRS-T angle and cardiac troponin T concentration.

Effect of Electroconvulsive Therapy on Anxiety in Linear and Non-Linear Rats with Depressive-Like Disorders Induced by Ultrasound Stimulation

We performed a comparative study of the effect of electroconvulsive therapy on anxiety in outbred rats and Sprague-Dawley rats with depressive-like disorder induced by exposure to ultrasound of variable frequency (20-45 Hz). The anxiogenic effect of therapy was revealed in elevated plus maze and open-field tests in both linear and non-lineal rats, but was more pronounced in linear animals. Differences between outbred rats and Sprague-Dawley rats by the anxiety level were demonstrated. These results suggest that electroconvulsive therapy should be used with cautious in patients with depression and comorbid anxiety disorders. Pronounced behavioral differences between linear and non-linear rats should be considered when choosing optimal experimental object in this research field.

Electroconvulsive Therapy in Geriatric Psychiatry: A Selective Review

Electroconvulsive therapy (ECT) remains an important treatment of geriatric patients. ECT treats severe depression, mania, psychosis, catatonia, and comorbid depression and agitation in dementia. ECT also serves a crucial role in treating urgent illness requiring expedient recovery, such as catatonia, or in patients with severe suicidal ideation or intent. ECT is even more effective in the elderly than in mixed-age adult populations. ECT is a safe treatment option with few medical contraindications. Cognitive effects are largely transient, even in patients with preexisting cognitive impairment.

Effect of Electroconvulsive Therapy on Cognitive Functions of Rats with Depression-Like Disorders Induced by Ultrasound Exposure

We studied the effect of electroconvulsive therapy on cognitive functions in rats with depression-like disorder caused by exposure to ultrasound of varying frequency (20-45 kHz). Object recognition and Morris water-maze tests revealed no negative effects of the therapy on memory. Moreover, positive effect of therapy was demonstrated that manifested in amelioration of memory disturbances in depression-like disorders in these behavioral tests. The results of this study do not support the idea about side effects of electroconvulsive therapy, in particular, development of transient amnesia, and are a prerequisite for a more thorough study of internal mechanisms of the effect of the therapy on cognitive sphere.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION

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

Effect of Manual Acupuncture Stimulation at "Bai-Hui" (GV 20) or "Yintáng" (Ex-HN3) on Depressed Rats

A previous study on rats showed that simultaneous acupuncture stimulation at the "Bai-Hui" (GV 20) and the "Yintáng" (Ex-HN3) acupoints alleviated the state of depression to an extent similar to that achieved by pharmacotherapy. This study investigated whether the alleviation of the depressed state required simultaneous acupuncture at these two acupuncture points. For the purposes of testing the effect of acupuncture on depressive symptoms, we treated a depression model rat, where depression had been induced by using a mild water-immersion stress technique, with either acupuncture stimulation at only one acupuncture point (GV 20 or Ex-HN3) or an antidepressant, and we measured the immobile time for evaluating the state of depression. Anxiety, as a symptom commonly associated with depression, was also evaluated by measuring the number of head dips. Neither the immobile time nor the number of head dips decreased upon acupuncture stimulation. From this study, single acupuncture stimulation at either "GV 20" or "Ex-HN3" alleviated neither the state of depression nor the anxiety. The water-immersion stress used to make the depression model rats was shown not to induce anxiety; however, the stress induced by immobilizing the rats for acupuncture stimulation did lead to anxiety.