Restoration of postictal cortical activity after electroconvulsive therapy relates to recovery of orientation in person, place, and time

BACKGROUND

Most patients show temporary impairments in clinical orientation after electroconvulsive therapy (ECT)-induced seizures. It is unclear how postictal reorientation relates to electroencephalography (EEG) restoration. This relationship may provide additional measures to quantify postictal recovery and shed light on neurophysiological aspects of reorientation after ECT.

METHODS

We analyzed prospectively collected clinical and continuous ictal and postictal EEG data from ECT patients. Postictal EEG restoration up to 1 h was estimated by the evolution of the normalized alpha-delta ratio (ADR). Times to reorientation in the cognitive domains of person, place, and time were assessed postictally. In each cognitive domain, a linear mixed model was fitted to investigate the relationships between time to reorientation and postictal EEG restoration.

RESULTS

In total, 272 pairs of ictal-postictal EEG and reorientation times of 32 patients were included. In all domains, longer time to reorientation was associated with slower postictal EEG recovery. Longer seizure duration and postictal administration of midazolam were related to longer time to reorientation in all domains. At 1-hour post-seizure, most patients were clinically reoriented, while their EEG had only partly restored.

CONCLUSIONS

We show a relationship between postictal EEG restoration and clinical reorientation after ECT-induced seizures. EEG was more sensitive than reorientation time in all domains to detect postictal recovery beyond 1-hour post-seizure. Our findings indicate that clinical reorientation probably depends on gradual cortical synaptic recovery, with longer seizure duration leading to longer postsynaptic suppression after ECT seizures.

Longitudinal resting-state network connectivity changes in electroconvulsive therapy patients compared to healthy controls

OBJECTIVE

Electroconvulsive therapy (ECT) is effective for major depressive episodes. Understanding of underlying mechanisms has been increased by examining changes of brain connectivity but studies often do not correct for test-retest variability in healthy controls (HC). In this study, we investigated changes in resting-state networks after ECT in a multicenter study.

METHODS

Functional resting-state magnetic resonance imaging data, acquired before start and within one week after ECT, from 90 depressed patients were analyzed, as well as longitudinal data of 24 HC. Group-information guided independent component analysis (GIG-ICA) was used to spatially restrict decomposition to twelve canonical resting-state networks. Selected networks of interest were the default mode network (DMN), salience network (SN), and left and right frontoparietal network (LFPN, and RFPN). Whole-brain voxel-wise analyses were used to assess group differences at baseline, group by time interactions, and correlations with treatment effectiveness. In addition, between-network connectivity and within-network strengths were computed.

RESULTS

Within-network strength of the DMN was lower at baseline in ECT patients which increased after ECT compared to HC, after which no differences were detected. At baseline, ECT patients showed lower whole-brain voxel-wise DMN connectivity in the precuneus. Increase of within-network strength of the LFPN was correlated with treatment effectiveness. We did not find whole-brain voxel-wise or between-network changes.

CONCLUSION

DMN within-network connectivity normalized after ECT. Within-network increase of the LFPN in ECT patients was correlated with higher treatment effectiveness. In contrast to earlier studies, we found no whole-brain voxel-wise changes, which highlights the necessity to account for test-retest effects.

Changes in postictal cerebral perfusion are related to the duration of electroconvulsive therapy-induced seizures

OBJECTIVE

Postictal symptoms may result from cerebral hypoperfusion, which is possibly a consequence of seizure-induced vasoconstriction. Longer seizures have previously been shown to cause more severe postictal hypoperfusion in rats and epilepsy patients. We studied cerebral perfusion after generalized seizures elicited by electroconvulsive therapy (ECT) and its relation to seizure duration.

METHODS

Patients with a major depressive episode who underwent ECT were included. During treatment, 21-channel continuous electroencephalogram (EEG) was recorded. Arterial spin labeling magnetic resonance imaging scans were acquired before the ECT course (baseline) and approximately 1 h after an ECT-induced seizure (postictal) to quantify global and regional gray matter cerebral blood flow (CBF). Seizure duration was assessed from the period of epileptiform discharges on the EEG. Healthy controls were scanned twice to assess test-retest variability. We performed hypothesis-driven Bayesian analyses to study the relation between global and regional perfusion changes and seizure duration.

RESULTS

Twenty-four patients and 27 healthy controls were included. Changes in postictal global and regional CBF were correlated with seizure duration. In patients with longer seizure durations, global decrease in CBF reached values up to 28 mL/100 g/min. Regional reductions in CBF were most prominent in the inferior frontal gyrus, cingulate gyrus, and insula (up to 35 mL/100 g/min). In patients with shorter seizures, global and regional perfusion increased (up to 20 mL/100 g/min). These perfusion changes were larger than changes observed in healthy controls, with a maximum median global CBF increase of 12 mL/100 g/min and a maximum median global CBF decrease of 20 mL/100 g/min.

SIGNIFICANCE

Seizure duration is a key factor determining postictal perfusion changes. In future studies, seizure duration needs to be considered as a confounding factor due to its opposite effect on postictal perfusion.

Electroconvulsive therapy-induced volumetric brain changes converge on a common causal circuit in depression

Neurostimulation is a mainstream treatment option for major depression. Neuromodulation techniques apply repetitive magnetic or electrical stimulation to some neural target but significantly differ in their invasiveness, spatial selectivity, mechanism of action, and efficacy. Despite these differences, recent analyses of transcranial magnetic stimulation (TMS) and deep brain stimulation (DBS)-treated individuals converged on a common neural network that might have a causal role in treatment response. We set out to investigate if the neuronal underpinnings of electroconvulsive therapy (ECT) are similarly associated with this causal depression network (CDN). Our aim here is to provide a comprehensive analysis in three cohorts of patients segregated by electrode placement (N = 246 with right unilateral, 79 with bitemporal, and 61 with mixed) who underwent ECT. We conducted a data-driven, unsupervised multivariate neuroimaging analysis Principal Component Analysis (PCA) of the cortical and subcortical volume changes and electric field (EF) distribution to explore changes within the CDN associated with antidepressant outcomes. Despite the different treatment modalities (ECT vs TMS and DBS) and methodological approaches (structural vs functional networks), we found a highly similar pattern of change within the CDN in the three cohorts of patients (spatial similarity across 85 regions: r = 0.65, 0.58, 0.40, df = 83). Most importantly, the expression of this pattern correlated with clinical outcomes (t = -2.35, p = 0.019). This evidence further supports that treatment interventions converge on a CDN in depression. Optimizing modulation of this network could serve to improve the outcome of neurostimulation in depression.

A Multicenter Retrospective Chart Review on the Effectiveness and Tolerability of Electroconvulsive Therapy in Adolescents and Young Adults With Major Depressive Disorder or Bipolar Depression

BACKGROUND

Major depressive disorder and bipolar depression in adolescents and young adults are prevalent and major contributors to the global burden of disease, whereas effective interventions are limited. Available evidence is insufficient to assess effectiveness and tolerability of electroconvulsive therapy in depressed adolescents and young adults.

METHODS

A retrospective chart review was conducted in patients with major depressive disorder or bipolar depression who underwent electroconvulsive therapy from 2001 to 2021 in 12 centers in the Netherlands. Patients were classified as young (15-25 years) and older adults (26-80 years). Primary outcome was effectiveness, expressed as response (≥50% reduction in rating scale score compared with baseline) and remission. Rating scale scores were cross-sectionally assessed at baseline and at the end of the index course. Outcomes of remitters were included in responders. Secondary outcome was occurrence of subjective cognitive impairment and adverse events. Long-term outcomes were not available.

RESULTS

In the young (n = 57) and older adult (n = 41) group, 40.4% and 56.1% (P = 0.153) of patients achieved response and 28.1% and 39.0% (P = 0.281) remission, respectively. Subjective cognitive impairment (80.5% vs 56.3%; P = 0.001) and transient cardiac arrhythmia (14.6% vs 2.8%; P = 0.020) were reported significantly more frequently in the older adult group.

CONCLUSIONS

Despite significantly more comorbidity of personality disorders, autism spectrum disorders, and anxiety disorders, effectiveness in the young was similar to the older adults. Tolerability was even superior in the young, despite significantly more bilateral treatment. Electroconvulsive therapy could be considered a viable treatment option in depressed adolescents and young adults.

Cortical excitation/inhibition ratios in patients with major depression treated with electroconvulsive therapy: an EEG analysis

Electroconvulsive therapy (ECT) is an effective treatment for major depression, but its working mechanisms are poorly understood. Modulation of excitation/inhibition (E/I) ratios may be a driving factor. Here, we estimate cortical E/I ratios in depressed patients and study whether these ratios change over the course of ECT in relation to clinical effectiveness. Five-minute resting-state electroencephalography (EEG) recordings of 28 depressed patients were recorded before and after their ECT course. Using a novel method based on critical dynamics, functional E/I (fE/I) ratios in the frequency range of 0.5-30 Hz were estimated in frequency bins of 1 Hz for the whole brain and for pre-defined brain regions. Change in Hamilton Depression Rating Scale (HDRS) score was used to estimate clinical effectiveness. To account for test-retest variability, repeated EEG recordings from an independent sample of 31 healthy controls (HC) were included. At baseline, no differences in whole brain and regional fE/I ratios were found between patients and HC. At group level, whole brain and regional fE/I ratios did not change over the ECT course. However, in responders, frontal fE/I ratios in the frequencies 12-28 Hz increased significantly (pFDR < 0.05 [FDR = false discovery rate]) over the ECT course. In non-responders and HC, no changes occurred over time. In this sample, frontal fE/I ratios increased over the ECT course in relation to treatment response. Modulation of frontal fE/I ratios may be an important mechanism of action of ECT.

Effective resting-state connectivity in severe unipolar depression before and after electroconvulsive therapy

BACKGROUND

Electroconvulsive therapy (ECT) is one of the most effective treatments for severe depressive disorders. A recent multi-center study found no consistent changes in correlation-based (undirected) resting-state connectivity after ECT. Effective (directed) connectivity may provide more insight into the working mechanism of ECT.

OBJECTIVE

We investigated whether there are consistent changes in effective resting-state connectivity.

METHODS

This multi-center study included data from 189 patients suffering from severe unipolar depression and 59 healthy control participants. Longitudinal data were available for 81 patients and 24 healthy controls. We used dynamic causal modeling for resting-state functional magnetic resonance imaging to determine effective connectivity in the default mode, salience and central executive networks before and after a course of ECT. Bayesian general linear models were used to examine differences in baseline and longitudinal effective connectivity effects associated with ECT and its effectiveness.

RESULTS

Compared to controls, depressed patients showed many differences in effective connectivity at baseline, which varied according to the presence of psychotic features and later treatment outcome. Additionally, effective connectivity changed after ECT, which was related to ECT effectiveness. Notably, treatment effectiveness was associated with decreasing and increasing effective connectivity from the posterior default mode network to the left and right insula, respectively. No effects were found using correlation-based (undirected) connectivity.

CONCLUSIONS

A beneficial response to ECT may depend on how brain regions influence each other in networks important for emotion and cognition. These findings further elucidate the working mechanisms of ECT and may provide directions for future non-invasive brain stimulation research.

[Consider (es)ketamine for treatment-resistant depression]

Major depressive disorder has a high prevalence globally. Although pharmacotherapy and psychotherapy are effective for most patients, about one third is treatment resistant. Ketamine, known as an anesthetic, is a new treatment option that can be effective in patients with treatment-resistant depression. (es)ketamine works relatively fast. However, the long-term effects are still relatively unknown. In the Netherlands, S-Ketamine is currently administered in various forms, of which only the nasal spray is registered for treatment-resistant depression. Currently, many studies have been conducted on the use of (es)ketamine. In this article we describe the latest state of affairs regarding its effectiveness and safety.

Severe Postictal Confusion After Electroconvulsive Therapy: A Retrospective Study

OBJECTIVES

Severe postictal confusion (sPIC) is an important but poorly investigated adverse effect of electroconvulsive therapy (ECT). In this retrospective study, prevalence of sPIC and potential risk factors were explored.

METHODS

Medical charts of 295 ECT patients (mean ± SD age, 57 ± 15 years; male, 36%) were scrutinized for occurrence of sPIC, as well as demographic, clinical, and treatment characteristics. Patients showing sPIC were compared with patients who did not, using univariate statistics. Multivariate analyses with a split-sample validation procedure were used to assess whether predictive models could be developed using independent data sets.

RESULTS

O 295 patients, 74 (25.1%) showed sPIC. All patients showing sPIC needed extra medication, 9% (n = 7) required physically restraints, and 5% (n = 4) had to be secluded. Univariate analyses showed several trends: patients with sPIC were more often males (P = 0.05), had more often history of cerebrovascular incident (P = 0.02), did not use concomitant selective serotonin reuptake inhibitors (P = 0.01), received higher median dosage of succinylcholine (P = 0.02), and received pretreatment with flumazenil more often (P = 0.07), but these associations did not remain significant after correction for multiple comparisons. Multiple logistic regression analysis did not result in a model that could predict sPIC in the holdout data set.

CONCLUSIONS

In this retrospective naturalistic study in 295 ECT patients, the prevalence of sPIC appeared to be 25%. Patients showing sPIC were characterized by male sex, history of cerebrovascular incident, use of higher-dose succinylcholine, and pretreatment with flumazenil. However, multivariate analysis revealed no significant model to predict sPIC in independent data.

Medication preventing postictal hypoperfusion and cognitive side-effects in electroconvulsive therapy: A retrospective cohort study

BACKGROUND

Electroconvulsive therapy (ECT) is associated with postictal confusion and cognitive side-effects. In rats, acetaminophen, non-steroidal anti-inflammatory drugs (NSAIDs) and calcium antagonists decreased postictal cerebral hypoperfusion along with reduction in postictal symptoms. In this study, in ECT-patients, we explore associations between use of these potentially protective medications and occurrence of postictal confusion and cognitive outcome.

MATERIALS AND METHODS

In this retrospective, naturalistic cohort study, patient-, treatment-, and ECT-characteristics, were collected from medical files of patients treated with ECT for major depressive disorder (MDD) or bipolar depressive episode. To test for associations of use of these medications with occurrence of postictal confusion, 295 patients could be included. Cognitive outcome data were available in a subset of 109 patients. Univariate analyses and multivariate censored regression models were used to test for associations.

RESULTS

Occurrence of severe postictal confusion was not associated with use of acetaminophen, NSAIDs or calcium antagonists (n = 295). Regarding the cognitive outcome measure (n = 109), use of calcium antagonists was associated with higher post-ECT cognitive scores (i.e., better cognitive outcome; β = 2.23; p = 0.047), adjusted for age (β = -0.02; p = 0.23), sex (β = -0.21; p = 0.73), pre-ECT cognitive score (β = 0.47; p < 0.0001), and post-ECT depression score (β = -0.02; p = 0.62), but use of acetaminophen (β = -1.55; p = 0.07) as well as NSAIDs (β = -1.02; p = 0.23) showed no associations.

CONCLUSION

This retrospective study does not find arguments for protective effects of acetaminophen, NSAIDs or calcium antagonists against severe postictal confusion in ECT. As a preliminary finding, the use of calcium antagonists was associated with improved cognitive outcome after ECT in this cohort. Prospective controlled studies are necessary.

Study of effect of nimodipine and acetaminophen on postictal symptoms in depressed patients after electroconvulsive therapy (SYNAPSE)

Background

Postictal phenomena as delirium, headache, nausea, myalgia, and anterograde and retrograde amnesia are common manifestations after seizures induced by electroconvulsive therapy (ECT). Comparable postictal phenomena also contribute to the burden of patients with epilepsy. The pathophysiology of postictal phenomena is poorly understood and effective treatments are not available. Recently, seizure-induced cyclooxygenase (COX)-mediated postictal vasoconstriction, accompanied by cerebral hypoperfusion and hypoxia, has been identified as a candidate mechanism in experimentally induced seizures in rats. Vasodilatory treatment with acetaminophen or calcium antagonists reduced postictal hypoxia and postictal symptoms. The aim of this clinical trial is to study the effects of acetaminophen and nimodipine on postictal phenomena after ECT-induced seizures in patients suffering major depressive disorder. We hypothesize that (1) acetaminophen and nimodipine will reduce postictal electroencephalographic (EEG) phenomena, (2) acetaminophen and nimodipine will reduce magnetic resonance imaging (MRI) measures of postictal cerebral hypoperfusion, (3) acetaminophen and nimodipine will reduce clinical postictal phenomena, and (4) postictal phenomena will correlate with measures of postictal hypoperfusion.

Methods

We propose a prospective, three-condition cross-over design trial with randomized condition allocation, open-label treatment, and blinded end-point evaluation (PROBE design). Thirty-three patients (age > 17 years) suffering from a depressive episode treated with ECT will be included. Randomly and alternately, single doses of nimodipine (60 mg), acetaminophen (1000 mg), or water will be given two hours prior to each ECT session with a maximum of twelve sessions per patient. The primary outcome measure is ‘postictal EEG recovery time’, expressed and quantified as an adapted version of the temporal brain symmetry index, yielding a time constant for the duration of the postictal state on EEG. Secondary outcome measures include postictal cerebral perfusion, measured by arterial spin labelling MRI, and the postictal clinical ‘time to orientation’.

Discussion

With this clinical trial, we will systematically study postictal EEG, MRI and clinical phenomena after ECT-induced seizures and will test the effects of vasodilatory treatment intending to reduce postictal symptoms. If an effect is established, this will provide a novel treatment of postictal symptoms in ECT patients. Ultimately, these findings may be generalized to patients with epilepsy.

Trial registration

Inclusion in SYNAPSE started in December 2019. Prospective trial registration number is NCT04028596 on the international clinical trial register on July 22, 2019.

Pharmacological interventions to diminish cognitive side effects of electroconvulsive therapy: A systematic review and meta-analysis

OBJECTIVE

The authors conducted a systematic review and meta-analysis of pharmacological interventions to diminish cognitive side effects of ECT.

METHODS

Electronic databases of Pubmed, PsycInfo, Embase and Scopus were searched from inception through 1 April, 2021, using terms for ECT (e.g. electroconvulsive therapy), cognitive outcome (e.g. cogni*) and pharmacological intervention (e.g. calcium channel blocker and general terms, like protein). Original studies with humans receiving ECT were included, which applied pharmacological interventions in comparison with placebo or no additive intervention to diminish cognitive side effects. Data quality was assessed using Risk of Bias and GRADE. Random-effects models were used. PROSPERO registration number was CRD42021212773.

RESULTS

Qualitative synthesis (systematic review) showed 52 studies reporting sixteen pharmacological intervention-types. Quantitative synthesis (meta-analysis) included 26 studies (1387 patients) describing twelve pharmacological intervention-types. Low-quality evidence of efficacy was established for memantine (large effect size) and liothyronine (medium effect size). Very low-quality evidence shows effect of acetylcholine inhibitors, piracetam and melatonin in some cognitive domains. Evidence of no efficacy was revealed for ketamine (very low-quality), herbal preparations with anti-inflammatory properties (very low to low-quality) and opioid receptor agonists (low-quality).

CONCLUSION

Memantine and liothyronine are promising for further research and future application. Quality of evidence was low because of differences in ECT techniques, study populations and cognitive measurements. These findings provide a guide for rational choices of potential pharmacological intervention research targets to decrease the burden of cognitive side effects of ECT. Future research should be more uniform in design and attempt to clarify pathophysiological mechanisms of cognitive side effects of ECT.

Seizures induced in electroconvulsive therapy as a human epilepsy model: A comparative case study

OBJECTIVE

Standardized investigation of epileptic seizures and the postictal state may contribute to a better understanding of ictal and postictal phenomena. This comparative case study aims to assess whether electrically induced seizures in electroconvulsive therapy (ECT) show sufficient similarities with spontaneous seizures to serve as a human epilepsy model.

METHODS

We compared six EEG recordings, three ECT-induced seizures and three generalized tonic-clonic seizures, using quantitative electroencephalography (EEG) analyses. EEG recordings during and after ECT sessions (under general anesthesia and muscle paralysis) were collected prospectively, whereas epilepsy data were selected retrospectively. Time-frequency representations, dominant ictal frequencies, and postictal alpha-delta ratios were calculated.

RESULTS

In all EEG recordings, a decrease in dominant ictal frequency was observed, as well as postictal suppression. Postictal alpha-delta ratio indicated the same trend for all: a gradual increase from predominantly delta to alpha frequencies on timescales of hours after the seizure. Postictal spectral representation was similar. Muscle artifacts were absent in ECT-induced seizures and present in spontaneous seizures. Ictal amplitude was higher in epileptic than in ECT-induced seizures. Temporospectral ictal dynamics varied slightly between groups.

SIGNIFICANCE

We show that ictal and postictal characteristics in ECT and patients with generalized tonic-clonic seizures are essentially similar. ECT-induced seizures may be used to investigate aspects of ictal and postictal states in a highly predictable manner and well-controlled environment. This suggests that clinical and electrophysiological observations during ECT may be extrapolated to epilepsy with generalized tonic-clonic seizures.

Electric field strength induced by electroconvulsive therapy is associated with clinical outcome

The clinical effect of electroconvulsive therapy (ECT) is mediated by eliciting a generalized seizure, which is achieved by applying electrical current to the head via scalp electrodes. The anatomy of the head influences the distribution of current flow in each brain region. Here, we investigated whether individual differences in simulated local electrical field strength are associated with ECT efficacy. We modeled the electric field of 67 depressed patients receiving ECT. Patient's T1 magnetic resonance images were segmented, conductivities were assigned to each tissue and the finite element method was used to solve for the electric field induced by the electrodes. We investigated the correlation between modelled electric field and ECT outcome using voxel-wise general linear models. The difference between bilateral (BL) and right unilateral (RUL) electrode placement was striking. Even within electrode configuration, there was substantial variability between patients. For the modeled BL placement, stronger electric field strengths appeared in the left hemisphere and part of the right temporal lobe. Importantly, a stronger electric field in the temporal lobes was associated with less optimal ECT response in patients treated with BL-ECT. No significant differences in electric field distributions were found between responders and non-responders to RUL-ECT. These results suggest that overstimulation of the temporal lobes during BL stimulation has negative consequences on treatment outcome. If replicated, individualized pre-ECT computer-modelled electric field distributions may inform the development of patient-specific ECT protocols.

Intoxicated persons showing challenging behavior demand complexity interventions: a pilot study at the interface of the ER and the complexity intervention unit

Intoxicated persons showing challenging behavior (IPCBs) under influence of alcohol and/or drugs frequently have trouble finding appropriate acute care. Often IPCBs are stigmatized being unwilling or unable to accept help. Separated physical and mental healthcare systems hamper integrated acute care for IPCBs. This pilot aimed to substantiate the physical, psychiatric, and social health needs of IPCBs visiting the emergency room (ER) during a 3-month period. All ER visits were screened. After triage by the ER physician, indicated IPCBs were additionally assessed by the consultation-liaison-psychiatry physician. If needed, IPCBs were admitted to a complexity intervention unit for further examinations to provide integrated treatments and appropriate follow-up care. The INTERMED and Health of the Nation Outcome Scale (HoNOS) questionnaires were used to substantiate the complexity and needs. Field-relevant stakeholders were interviewed about this approach for acute integrated care. Alongside substance abuse, almost half of identified IPCBs suffered from comorbid psychiatric disturbances and one third showed substantial physical conditions requiring immediate medical intervention. Almost all IPCBs (96%) accepted the acute medical care voluntarily. IPCBs showed high mean initial scores of INTERMED (27.8 ± 10.0) and HoNOS (20.8 ± 6.9). At discharge from the complexity intervention unit, the mean HoNOS score decreased significantly (13.4 ± 8.6; P < 0.001). Field-relevant stakeholders strongly supported the interdisciplinary approach and ER-facility for IPCBs and acknowledged their unmet health needs. A biopsychosocial assessment at the ER, followed by a short admission if necessary, is effective in IPCBs. This approach helps to merge separated healthcare systems and may reduce stigmatization of IPCBs needing help.

Effectiveness of Emotional Memory Reactivation vs Control Memory Reactivation Before Electroconvulsive Therapy in Adult Patients With Depressive Disorder: A Randomized Clinical Trial

IMPORTANCE

Although electroconvulsive therapy (ECT) is often effective, approximately half of patients with depression undergoing ECT do not benefit sufficiently, and relapse rates are high. ECT sessions have been shown to weaken reactivated memories. The effect of emotional memory retrieval on cognitive schemas remains unknown.

OBJECTIVE

To assess whether emotional memory retrieval just before patients receive ECT sessions weakens underlying cognitive schemas, improves ECT effectiveness, increases ECT response, and reduces relapse rates.

DESIGN, SETTING, AND PARTICIPANTS

In this multicenter randomized clinical trial conducted from 2014 to 2018 in the departments of psychiatry in 3 hospitals in the Netherlands, 72 participants were randomized 1:1 to 2 parallel groups to receive either emotional memory reactivation (EMR-ECT) or control memory reactivation (CMR-ECT) interventions before ECT sessions. The Hamilton Depression Rating Scale (HDRS [total score range: 0-52, with 0-7 indicating no depression and ≥24 indicating severe depression]) was used to measure symptoms of depression during and after ECT, with a 6-month follow-up period. Participants were between ages 18 and 70 years with a primary diagnosis of unipolar major depressive disorder (MDD) according to the Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition, Text Revision) and in whom ECT was indicated. Data analysis was performed from July to November 2019.

INTERVENTIONS

EMR-ECT or CMR-ECT interventions prior to ECT sessions.

MAIN OUTCOMES AND MEASURES

Depression scores and relapse rates within 6 months were assessed with the HDRS and analyzed using logistic and linear multiple regression analyses.

RESULTS

A total of 66 patients (mean [SD] age, 49.3 [12.3] years; 39 [59.1%] women) were randomized to the EMR-ECT group (n = 32) or the CMR-ECT group (n = 34). Regardless of the memory intervention, 42.4% (28 of 66) of patients responded (≥50% decrease of symptom severity on the HDRS). Of patients who responded, 39.3% (11 of 28) relapsed within 6 months. Remission rates (CMR-ECT group, 29.4% [10 of 34] vs EMR-ECT group, 25.0% [8 of 32]; P = .58), mean (SD) HDRS scores after the ECT course (CMR-ECT group, 14.6 [8.6] vs EMR-ECT group, 14.9 [8.8]; P = .88), total mean (SD) number of required ECT sessions for response (CMR-ECT group, 14.9 [7.9] vs EMR-ECT group, 15.6 [7.3]; P = .39), and relapse rates (CMR-ECT group, 46.7% [7 of 15] vs EMR-ECT group, 30.8% [4 of 13]; P = .33) were not significantly altered by the intervention.

CONCLUSIONS AND RELEVANCE

Study findings suggest that the EMR-ECT intervention just before patient receipt of ECT for depression did not improve effectiveness, increase speed of response, or reduce relapse rates after the ECT course compared with patients receiving CMR-ECT.

TRIAL REGISTRATION

Trialregister.nl Identifier: NL4289.

The postictal state - What do we know?

This narrative review provides a broad and comprehensive overview of the most important discoveries on the postictal state over the past decades as well as recent developments. After a description and definition of the postictal state, we discuss postictal sypmtoms, their clinical manifestations, and related findings. Moreover, pathophysiological advances are reviewed, followed by current treatment options.

The Link Between Structural and Functional Brain Abnormalities in Depression: A Systematic Review of Multimodal Neuroimaging Studies

BACKGROUND

Adequate and timely identification of depression is essential to improve patient care. A potential method to achieve this is by using neuroimaging. Many neuroimaging studies have revealed widespread abnormalities in brain structure and function in patients with depression, but in most studies only single neuroimaging modalities were used. Links between abnormalities in brain structure and function need to be therefore further explored in order to define diagnostic and therapeutic applications.

METHODS

A systematic literature review according to preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines was conducted.

RESULTS

Out of 2,516 articles, only 14 studies were eligible to be included. These studies combined structural and functional neuroimaging methods in depressed patients compared to controls. Four studies reported a negative relationship between brain structure and function within the default mode network: reduced gray or white matter integrity in depressed patients compared to healthy controls was associated with enhanced neural activity or connectivity. The other studies reported positive relationships (two studies), mixed relationships (two studies), or no link (six studies) between structural and functional brain abnormalities.

CONCLUSION

This systematic literature review revealed no robust relationship between abnormalities in brain structure and function in patients with depression. Remarkably, only 14 studies could be included and four of these suggested enhanced default mode network connectivity associated with reduced structural brain integrity. In the ongoing development of the diagnostic and treatment applications of neuroimaging, large-scale studies that combine structural with functional neuroimaging are required to determine the relationship between structural and functional abnormalities in depression.

[A psychotic patient who refuses somatic care]

Physical and emotional pain are signalling and protective functions. In this clinical lesson, we describe the case of a patient with a psychotic disorder who had an episode of seriously disturbed pain awareness and experience, which caused severe delays in care and resulted in severe permanent damage. Due to his psychosis and lack of pain, the patient refused medical treatment and his leg henceforth developed mummification necrosis. Once admitted to a medical psychiatric unit, he was declared incompetent by his doctor and curator and his leg could be amputated. His psychosis adapted to the new situation, which he could then accept. This clinical lesson underlines the importance of awareness on disturbed pain and pain experience when it concerns a patient with a psychotic disorder, and that adequate medical treatment should not be ignored due to incompetence of the patient.

The Longitudinal Effects of Electroconvulsive Therapy on Ictal Interhemispheric Coherence and Its Associations With Treatment Outcome: A Naturalistic Cohort Study

OBJECTIVES

Electroconvulsive therapy (ECT) is an effective treatment for severe depression. Electroencephalogram (EEG) measures between ECT sessions seem to be related to the antidepressant efficacy of ECT. In this naturalistic cohort study, we examine longitudinal effects of ECT on interhemispheric EEG coherence measures during seizure activity and its relation to the antidepressant efficacy.

METHODS

This study included 65 patients diagnosed with severe depressive disorder. Depressive symptoms were rated according to the Montgomery-Åsberg Depression Rating Scale before and after the course of ECT. Frequency-specific ictal interhemispheric (fp1-fp2) EEG coherence measures were established during the first and each consecutive sixth treatment session. Linear mixed-effect models were used to determine longitudinal changes in ictal coherence measures during the course of ECT and its relation to treatment efficacy.

RESULTS

Ictal interhemispheric coherence in the theta and alpha frequency bands increased over the course of treatment, whereas no significant change was found for the delta and beta frequency bands. A main effect of treatment efficacy on the interhemispheric coherence in the delta and theta band was revealed. However, the longitudinal effects of ECT were not associated with treatment efficacy.

CONCLUSION

The current study suggests that interhemispheric coherence during ECT-induced seizures increases over the course of treatment. Furthermore, these longitudinal effects seem to be unrelated to the antidepressant efficacy of ECT. These findings contribute to the understanding of the mechanism of action of ECT.

Identifying value-based quality indicators for general hospital psychiatry

OBJECTIVE

To define generic quality indicators for general hospital psychiatry from the perspectives of patients, professionals (physicians, nurses, and managers), and payers (health insurance companies).

METHODS

Quality variables were identified by reviewing the relevant literature. A working. group consisting of patients', professionals' and payers' representatives was mandated by their respective umbrella organizations. The working group prioritized the quality variables that were identified. Core values were defined and subsequently linked to preliminary quality indicators. These were tested for feasibility in ten hospitals in a four-week period. Stakeholder consultation took place by means of two invitational conferences and two written commentary rounds.

RESULTS

Forty-one quality variables were identified from the literature. After prioritization, seven core values were defined and translated to 22 preliminary indicators. Overall, the feasibility study showed high relevance scores and good implementability of the preliminary quality indicators. A final set of twenty-two quality indicators (17 structure, 3 process and 2 outcome indicators) was then established using a consensus-based approach.

CONCLUSION

Consensus on a quality framework for general hospital psychiatry was built by incorporating the perspectives of relevant stakeholders. Results of the feasibility study suggest broad support and good implementability of the final quality indicators. Structural indicators were broadly defined, and process and outcome indicators are generic to facilitate quality measurement across settings. The quality indicator set can now be used to facilitate quality and outcome assessment, stimulate standardization of services, and help demonstrate (cost-) effectiveness.

[Dichotomy of psychiatric and somatic emergency care; fundamental flaw should be addressed]

In the Netherlands, acute psychiatric care is characterised by mind-body dualism. For acute psychiatric patients, the first port of call is the general practitioner (GP); after-hour care is provided by the out-of-hours GP service. In contrast to patients with other medical illnesses, the out-of-hours GP service does not usually refer patients with acute psychiatric issues to the accident and emergency (A&E) department of the general hospital, but to the local ambulant psychiatric 'crisis' service. However, some of these patients still end up at the A&E department, as our three cases demonstrate. Integration of the out-of-hours GP service, A&E and acute psychiatric care, therefore, would enable elimination of the current partitioning of somatic and psychiatric medicine in acute emergency care. This solution would not only improve acute emergency care, but would also ensure a targeted and efficient implementation of services and might even lead to a decreased stigmatisation of psychiatric patients in general.

Pre-treatment amygdala volume predicts electroconvulsive therapy response

BACKGROUND

Electroconvulsive therapy (ECT) is an effective treatment for patients with severe depression. Knowledge on factors predicting therapeutic response may help to identify patients who will benefit most from the intervention. Based on the neuroplasticity hypothesis, volumes of the amygdala and hippocampus are possible candidates for predicting treatment outcome. Therefore, this prospective cohort study examines the predictive value of amygdala and hippocampal volumes for the effectiveness of ECT.

METHODS

Prior to ECT, 53 severely unipolar depressed patients [mean age 57 ± 14 years; 40% (n = 21) male] received structural magnetic resonance imaging (MRI) at 1.5 T. Normalized amygdala and hippocampal volumes were calculated based on automatic segmentation by FreeSurfer (FS). Regression analyses were used to test if the normalized volumes could predict the response to a course of ECT based on the Montgomery-Åsberg Depression Rating Scale (MADRS) scores.

RESULTS

A larger amygdala volume independently and significantly predicted a lower post-ECT MADRS score (β = -0.347, P = 0.013). The left amygdala volume had greater predictive value for treatment outcome relative to the right amygdala volume. Hippocampal volume had no independent predictive value.

CONCLUSION

A larger pre-treatment amygdala volume predicted more effective ECT, independent of other known predictors. Almost all patients continued their medication during the study, which might have influenced the course of treatment in ways that were not taken into account.

Clinical predictors of seizure threshold in electroconvulsive therapy: a prospective study

At the start and during the course of electroconvulsive therapy (ECT), estimation of the seizure threshold (ST) is useful in weighing the expected effectiveness against the risks of side effects. Therefore, this study explores clinical factors predicting initial ST (IST) and levels of ST during the ECT course. This prospective observational study included patients aged ≥18 years receiving ECT without contraindications for dose titration. At the first and every sixth consecutive ECT session, ST level was measured. Using multivariate linear regression and multilevel models, predictors for IST and change in ST levels were examined. A total of 91 patients (mean age, 59.1 ± 15.0 years; 37 % male; 97 % diagnosis of depression) were included. In multivariable analysis, higher age (β = 0.24; P = 0.03) and bifrontotemporal (BL) electrode placement (β = 0.42; P < 0.001) were independent predictors for higher IST, explaining 49 % of its variation. Also, these two variables independently predicted higher ST levels at different time points during the course. Using multilevel models, absence of a previous ECT course(s) predicted a steeper rise in ST during the course (P = 0.03 for the interaction term time*previous ECT). The age-adjusted dose-titration method is somewhat crude, resulting in some measurement error. Concomitant medication use could have influenced ST levels. Increasing age and BL electrode placement predicted higher (I)ST, which should be taken into account when selecting ECT dosage. Previous ECT course(s) may avoid an increase in ST during the course of ECT.

Electroconvulsive therapy in a terminally ill patient: when every day of improvement counts

Electroconvulsive therapy (ECT) is seldom used in a palliative setting. Although literature on the application of ECT in terminally ill patients is sparse, ECT may be useful to rapidly improve the quality of life in these patients. We present the case of a 71-year-old man with metastasized pancreas carcinoma complicated by severe depression. After 3 ECT sessions, the communication between the patient and his family in the last moments of his life improved. We conclude that ECT should be considered to treat mood disorders in terminally ill patients when every day of improvement counts.

Reassessment of suicide attempters at home, shortly after discharge from hospital

BACKGROUND

Assessment of suicide attempters in a general hospital may be influenced by the condition of the patient and the unfavorable circumstances of the hospital environment.

AIMS

To determine whether the results of a reassessment at home shortly after discharge from hospital differ from the initial assessment in the hospital.

METHODS

In this prospective study, systematic assessment of 52 suicide attempters in a general hospital was compared with reassessment at home, shortly after discharge.

RESULTS

Reassessments at home concerning suicide intent, motives for suicide attempt, and dimensions of psychopathology did not differ significantly from the initial hospital assessment. However, patients' motives for the suicide attempt had changed to being less impulsive and more suicidal, worrying was significantly higher, and self-esteem was significantly lower. A third of the patients had forgotten their aftercare arrangements and most patients who initially felt no need for additional help had changed their mind at reassessment.

CONCLUSIONS

Results from this group of suicide attempters suggest that a brief reassessment at home shortly after discharge from hospital should be considered.

A retrospective study of 34 catatonic patients: analysis of clinical care and treatment

OBJECTIVE

To analyze clinical characteristics, time lag between diagnosis and treatment, and outcome of patients treated for catatonia, with the intention to improve daily clinical care.

METHOD

A retrospective case study.

RESULTS

Between 1991 and 2009, a total of 34 patients were clinically diagnosed to have benign catatonia (n=13), malignant catatonia (n=11) and neuroleptic malignant syndrome (n=10). A total of 63 additional psychiatric diagnoses were present, and half of the patients had comorbid medical and neurological disorders. The mean time lags between first catatonic symptoms and first treatment and between first catatonic symptoms and second treatment were 15±36 and 58±92 days, respectively. Of the 34 patients, 26 (76%) improved, with complete remission in 20 (58%); mortality rate was 9% (n=3).

CONCLUSIONS

Retrospective evaluation of 34 catatonic patients revealed a great variety of psychiatric diagnoses and somatic comorbidity. Although treatment was effective in 76%, time lag between the first symptoms and effective treatment was remarkably long. Based on our retrospective critical evaluation, a clinical protocol has been developed to improve daily care for these complex and very ill patients.

Meta-analysis of initial seizure thresholds in electroconvulsive therapy

In electroconvulsive therapy (ECT), electrical dosage is determined using 'fixed-dose', 'age-based' dose, or empirical titration methods. Estimation of initial seizure threshold (IST) has been claimed to be imperative for suprathreshold dosing. This systematic review aimed to determine common levels of IST, to define cut-off values for high IST, and to summarize reported IST associated factors. Medline and PsycINFO were searched from 1966 to January 2008 and relevant references were cross-checked. Subject headings including ECT, seizure threshold, dosage, and dosing were used. All articles reporting on levels of IST and/or associated factors were included. Of 395 potentially relevant reports, 46 studies on 70 samples concerning 3,023 patients were selected. Nine samples (n = 306 patients) without available standard deviation and four samples (n = 275 patients) treated with mixed electrode placement were excluded. Meta-analysis was done on 30 unilaterally treated samples (n = 1,326 patients) and 27 bilaterally treated samples (n = 1,116 patients). In unilateral ECT, weighted mean of IST was 68.2 milliCoulombs (mC; 95% CI 63.2-73.3 mC), and in bilateral ECT 111.6 mC (95% CI 103.7-119.4 mC). Calculated cut-off values for high IST were 121 mC for unilateral ECT and 221 mC for bilateral ECT. According to the literature, male gender and use of bilateral electrode placement appeared to increase IST most prominently. In conclusion, calculated electrical doses for 'suprathreshold' right unilateral ECT and for 'moderate above threshold' bilateral ECT, using commonly reported IST levels, were in the same though narrower ranges as provided in 'fixed-dose' and 'half-age' based strategies, respectively.

A within-subjects comparison of learning and memory performance before and after cardiac catheterization

OBJECTIVE

To investigate the influence of stress on the recall of neutral information in a clinical setting, a prospective study was performed on patients who were admitted to the hospital for cardiac catheterization.

METHODS

During their hospital stay, 39 cardiac patients were tested for verbal recall and face recognition before cardiac catheterization (day 1) and 24 h after (day 2). Plasma cortisol levels were also determined. After catheterization, recognition of faces presented to each patient before catheterization was assessed.

RESULTS

Patients' verbal recall scores on both day 1 and day 2 were within normal limits for the age group but were significantly higher on day 1. Face recognition on day 2 was excellent. Blood cortisol levels did not differ significantly on days 1 and 2, and no significant relationship was found between change in cortisol levels and change in verbal recall scores.

CONCLUSIONS

In this small group of selected patients, the stress of hospital admission and cardiac catheterization may not have impaired the recall of neutral information. These preliminary results may indicate that whenever it is necessary to provide information to the patient it is advisable to do so before cardiac catheterization.

Availability, content and quality of local guidelines for the assessment of suicide attempters in university and general hospitals in the Netherlands

OBJECTIVE

This study was performed to investigate the availability, content and quality of local guidelines for the assessment of suicide attempters in the Netherlands.

METHOD

All university and general hospitals in the Netherlands were asked to provide their local guidelines. Published national guidelines and the Appraisal of Guidelines for Research and Education (AGREE) instrument were used to evaluate the content and quality of the local guidelines.

RESULTS

Eighty-eight hospitals (90.7%) responded; 34 (38.6%) reported that they used local guidelines. Twenty-seven guidelines were submitted for evaluation. Most of the guidelines were more than 5 years old and had not been updated recently. The contents of the guidelines differed. Criteria addressing patient safety, staff attitude toward patients, reassessment of nonalert patients, relevant stressors, involvement of significant others and aftercare were found in less than 50% of the guidelines. Although psychiatric consultation was incorporated in almost 80%, the psychiatrist's tasks were specified infrequently. The guidelines seldom required monitoring of staff compliance. Only in the AGREE domain "clarity and presentation" was the mean score above 60% of the maximum. According to the instructions for the AGREE instrument, 10 (37.0%) of the 27 guidelines were recommended (with provisos or alterations) and 1 was strongly recommended for use in practice.

CONCLUSIONS

In the Netherlands, a minority of hospitals reported use of local guidelines for the assessment of suicide attempters. When available, the guidelines were mostly not based on international standards, their contents varied greatly and their quality was unsatisfactory.