Electroconvulsive Therapy for the Treatment of Somatic Delusions

Somatic delusions occur in various psychiatric disorders and are associated with higher mortality and lower quality of life. In this case report, we present a 68-year-old man with the diagnosis of schizoaffective disorder, bipolar type with associated somatic delusions, and auditory hallucinations. His somatic delusions were alleviated by the 20th ECT treatment with additional clinical improvements in his speech, thought processes, and judgment. This case report supports the utilization of ECT for patients with schizoaffective disorder and somatic delusions.

A Case of Cannabis-Induced Catatonia and Management With Electroconvulsive Therapy

This is a case of cannabis-induced catatonia in an 18-year-old Hispanic male with no prior psychiatric history. Shortly after consuming marijuana, the patient experienced catatonic symptoms and demonstrated resistance to several medicinal therapies. Electroconvulsive therapy (ECT) proved to be a useful treatment choice, resulting in significant improvement in symptoms. This example emphasizes the potential dangers of cannabis usage, particularly in susceptible individuals, and underscores the importance of recognizing and treating catatonia as a possible side effect of cannabis use.

The Relative Effectiveness of Bilateral and Unilateral Electrode Placement in Electroconvulsive Therapy (ECT) in Patients With Major Depressive Disorder: A Retrospective Cohort Study

Background This study is focused on the comparative efficacy of bilateral and unilateral electroconvulsive therapy (ECT) on depressive symptoms in patients at the Perth Clinic for the period from 2016 to 2021. Methods This was a retrospective cohort study of 485 patients who received ECT treatment. The expected improvements in depressive symptoms were evaluated by the Depression Anxiety Stress Scale (DASS) assessment tool filled out by the patients on admission and discharge from the hospital. Only the depression score of the DASS scale was utilised for this research. Results The results suggested that both electrode placements resulted in a significant improvement in depressive symptoms. The positive response rates for the bilateral and unilateral electrode placements were 78.3% and 71.6%, respectively. There was no difference between males and females in the average DASS score at discharge for bilateral and unilateral electrode placements. Conclusions This study confirmed that the results obtained at the Perth Clinic are similar to the existing international research results on the same topic. Bifrontal and unilateral ECT electrode placements are equally efficacious in improving depressive symptoms in patients suffering from major depressive disorder (MDD).

Recurrent Catatonia and Demyelinating Disorders

Catatonia, a neuropsychiatric syndrome characterized by psychomotor and behavioral symptoms, can be associated with various underlying conditions, including demyelinating diseases such as multiple sclerosis. This paper presents a case study of a 47-year-old female with recurrent catatonic relapses and an underlying demyelinating disease. The patient exhibited symptoms of confusion, decreased oral intake, and difficulty with movement and speech. Neurological examinations, brain imaging, and laboratory tests were conducted to evaluate the etiology and guide treatment. The patient showed improvement with lorazepam and electroconvulsive therapy (ECT). However, relapses occurred after the abrupt withdrawal of medication. The case study highlights the potential connection between demyelinating diseases and catatonia and emphasizes the importance of considering demyelinating diseases in the workup, treatment, and relapse prevention of catatonia. Further research is needed to explore the mechanisms underlying the relationship between demyelination and catatonia and to investigate how different etiologies may impact the recurrence rates of catatonic episodes.

Ketamine Augmentation of Electroconvulsive Therapy: A Scoping Review of Dose-Dependent Effects in Major Depressive Disorder

Intravenous ketamine infusions in subanesthetic doses have been shown to rapidly alleviate depressive symptoms. However, the efficacy of ketamine as an anesthetic during electroconvulsive therapy (ECT) for major depression has not yet been answered by a large randomized control trial (RCT). This scoping review aims to examine the available literature to determine whether the dose of ketamine used during ECT influences the response to treatment. A literature search was conducted on PubMed to identify all published RCTs within the last 10 years which compared ketamine anesthesia during ECT for major depression with another anesthetic. Studies using low (<0.8 mg/kg) versus high (≥0.8 mg/kg) doses of ketamine during ECT were evaluated for the differences in outcomes using depression rating scales. Studies that examined ketamine as a standalone treatment for depression or focused primarily on the anesthetic benefits of ketamine were excluded from our review. Fifteen studies were utilized for this literature review. Overall, the studies showed inconsistent results in terms of the speed and magnitude of response to ketamine-assisted ECT in patients with major depression. Limitations of the available literature are discussed, including the lack of head-to-head comparisons, differences in methodology, inclusion/exclusion criteria, and primary and secondary endpoints.

Late-Onset Bipolar Disorder: Considerations for Diagnosis and Treatment

Bipolar I disorder is characterized by the presence of at least one manic episode (DSM-5). Despite a decent percentage of individuals being diagnosed later in life, there currently exist no formal treatment guidelines for late-onset bipolar disorder (LOBD), which remains poorly understood. Typically, manic or manic-like episodes in elderly individuals can be thought of as arising from a secondary, physical cause. However, in the absence of a pre-existing neurological disorder - and when laboratory, imaging, and exam findings do not fully support a neurological picture - the determination of a structural versus primary etiology for LOBD becomes challenging. We present the case of Ms. S, a 79-year-old woman with a past psychiatry history of bipolar disorder diagnosed after 2012 and non-contributory past medical history who was admitted to a state mental hospital on a probate court order from local jail secondary to labile mood and physical aggression toward an officer. Initial labs were remarkable for slightly elevated low-density lipoprotein and a B12 at the lower limit of normal. She was started on a regiment oral B12 supplement, valproic acid 500 mg twice daily, haloperidol 5 mg nightly, and diphenhydramine 25 mg nightly. Despite her medication regimen, she continued to display marked mood lability, tangential thought processes, grandiose delusions, and paranoia. A CT head one week into admission revealed bilateral periventricular white-matter hyperintensities with decreased attenuation and chronic white-matter infarcts. She underwent five sessions of electroconvulsive therapy (ECT), with significantly improving Montreal Cognitive Assessment and Young Mania Rating Scale scores. At the time of discharge on day 32, the patient was fully oriented to self and surroundings with good hygiene, a normal rate of speech, euthymic mood, and congruent affect. The case of Ms. S underscores the importance of a thorough workup to rule out secondary causes of mania. In addition, it is a clarion call for revisiting and researching a comprehensive management approach to LOBD, for which serial cognitive assessments and ECTs may play an important role.

Efficacy of Electroconvulsive Therapy for the Treatment of Movement Disorders: A Literature Review

Electroconvulsive therapy (ECT) is a safe and effective treatment modality for various psychiatric disorders. However, evidence suggests a putative role of ECT in treating movement disorders that are refractory to less invasive modalities. ECT is primarily used in treatment-resistant psychiatric disorders. However, growing evidence exists for its use in movement disorders with and without psychiatric comorbidity.

The primary objective of this systematic review was to examine the efficacy of ECT as a primary treatment modality for movement disorders. Relevant, peer-reviewed publications were retrieved from PubMed, SCOPUS, CINAHL, and PsycINFO. Keywords related to ECT and movement disorders were used as search phrases to identify relevant articles. A total of 90 articles that met the inclusion criteria were included in this review. Core findings were subsequently appraised on the role of ECT in treating movement disorders.

Inclusion and exclusion criteria were developed to guide the search and selection process. Sources that met the inclusion criteria were those published between 2001 and January 2023. Additionally, peer-reviewed journals published in the English language covering the role of ECT in movement disorders were deemed appropriate for inclusion. Sources published before 2001, written in a non-English language, and not from peer-reviewed journals were excluded from this systematic review. The exclusion criteria also entailed eliminating duplicates from the review list.

Most reviewed sources revealed that ECT improved outcomes in symptoms associated with various movement symptoms. However, ECT does not have a long-lasting impact on neuroacanthocytosis symptoms. Additionally, ECT is negatively associated with aggression and agitation, two of the most critical movement symptoms of Alzheimer’s disease.

Evidence affirms the efficacy of ECT in providing symptomatic relief for movement disorders aside from psychiatric comorbidities. This positive association highlights the need for randomized controlled studies to identify movement disorder sub-populations that may respond to ECT.

Maintenance Electroconvulsive Therapy, Developmental Regression, Depression and Catatonia in an Adolescent With Down Syndrome: A Case Report

This is a case report involving a 22-year-old male with a past medical history of Down syndrome and major depressive disorder who, at age 16, became preoccupied with returning to an infant-like state. He experienced a gradual deterioration in his mood over a year and began to show symptoms consistent with catatonia. These symptoms included waxy flexibility, hypokinesis, decreased appetite, mutism, and altered sleep habits. Pharmacologic therapy was initiated, and the patient experienced a waxing and waning pattern of improvement and regression. Over several years, various combinations of antidepressants, benzodiazepines, and second-generation antipsychotics were attempted. The patient and his family discontinued all medications except his benzodiazepine in early 2019 and decided to try electroconvulsive therapy (ECT). After more than 100 sessions of ECT between 2019 and 2022, the patient showed notable improvement in overall mood, and his appetite and sleep completely returned to baseline. His speech, affect, and movement also improved. With ECT, the patient showed the most sustained and substantial improvement in his catatonic symptoms. ECT has been historically shown to improve these types of symptoms in catatonic patients, including those who have Down syndrome. Often, clinicians do not consider the possibility of catatonia in patients with this type of presentation, which is unfortunate as misdiagnosis leads to increased morbidity. Additionally, there has not been much discussion of the optimal length of treatment and the necessity of slowly tapered maintenance therapy in the literature. This case report illustrates how catatonia can be a major cause of developmental regression in patients with Down syndrome and offers an example of a promising management strategy for the treatment of this condition.

Treatment of Ekbom Syndrome With Clozapine and Electroconvulsive Therapy

Delusion of parasitosis (DP), which is also known as Ekbom syndrome, is a delusional disorder characterised by a false, fixed belief of being infested by insects or mites, despite the lack of supporting medical evidence. This disorder presents most commonly with the "Matchbox sign." DP can present as a primary or secondary delusional disorder. It can be associated with various psychiatric conditions such as schizophrenia spectrum disorders, mood disorders, anxiety or substance abuse. Several organic conditions such as dementia, malignancies, vitamin deficiencies and cerebrovascular accidents can mimic symptoms of DP. Hereby, we present a case of schizophrenia in a young woman associated with DP in our inpatient care and the treatment outcome with the use of clozapine and electroconvulsive therapy (ECT) regimen.

Neuromodulation for obsessive-compulsive disorder

Neuromodulation shows increasing promise in the treatment of psychiatric disorders, particularly obsessive-compulsive disorder (OCD). Development of tools and techniques including deep brain stimulation, transcranial magnetic stimulation, and electroconvulsive therapy may yield additional options for patients who fail to respond to standard treatments. This article reviews the motivation for and use of these treatments in OCD. We begin with a brief description of the illness followed by discussion of the circuit models thought to underlie the disorder. These circuits provide targets for intervention. Basal ganglia and talamocortical pathophysiology, including cortico-striato-thalamo-cortical loops is a focus of this discussion. Neuroimaging findings and historical treatments that led to the use of neuromodulation for OCD are presented. We then present evidence from neuromodulation studies using deep brain stimulation, electroconvulsive therapy, and transcranial magnetic stimulation, with targets including nucleus accumbens, subthalamic nucleus inferior thalamic peduncle, dorsolateral prefrontal cortex, supplementary motor area, and orbitofrontal cortex. Finally, we explore potential future neuromodulation approaches that may further refine and improve treatment.

Monitoring daily affective symptoms and memory function using interactive voice response in outpatients receiving electroconvulsive therapy

OBJECTIVE

Recently, there has been a gradual shift from inpatient-only electroconvulsive therapy (ECT) toward outpatient administration. Potential advantages include convenience and reduced cost. But providers do not have the same opportunity to monitor treatment response and adverse effects as they do with inpatients. This can obviate some of the potential advantages of outpatient ECT, such as tailoring treatment intervals to clinical response. Scheduling is typically algorithmic rather than empirically based. Daily monitoring through an automated telephone, interactive voice response (IVR), is a potential solution to this quandary.

METHODS

To test feasibility of clinical monitoring via IVR, we recruited 26 patients (69% female; mean age, 51 years) receiving outpatient ECT to make daily IVR reports of affective symptoms and subjective memory for 60 days. The IVR also administered a word recognition task daily to test objective memory. Every seventh day, a longer IVR weekly interview included questions about suicidal ideation.

RESULTS

Overall daily call compliance was high (mean, 80%). Most participants (96%) did not consider the calls to be time-consuming. Longitudinal regression analysis using generalized estimating equations revealed that participant objective memory functioning significantly improved during the study (P < 0.05). Of 123 weekly IVR interviews, 41 reports (33%) in 14 patients endorsed suicidal ideation during the previous week.

CONCLUSIONS

Interactive voice response monitoring of outpatient ECT can provide more detailed clinical information than standard outpatient ECT assessment. Interactive voice response data offer providers a comprehensive, longitudinal picture of patient treatment response and adverse effects as a basis for treatment scheduling and ongoing clinical management.

Declining use of electroconvulsive therapy in United States general hospitals

BACKGROUND

Falling duration of psychiatric inpatient stays over the past 2 decades and recent recommendations to tighten federal regulation of electroconvulsive therapy (ECT) devices have focused attention on trends in ECT use, but current national data have been unavailable.

METHODS

We calculated the annual number of inpatient stays involving ECT and proportion of general hospitals conducting the procedure at least once in the calendar year with a national sample of discharges from 1993 to 2009. We estimated adjusted probabilities that inpatients with severe recurrent major depression (n = 465,646) were treated in a hospital that conducts ECT and, if so, received the procedure.

RESULTS

The annual number of stays involving ECT fell from 12.6 to 7.2/100,000 adult US residents, driven by dramatic declines among elderly persons, whereas the percentage of hospitals conducting ECT decreased from 14.8% to 10.6%. The percentage of stays for severe recurrent major depression in hospitals that conducted ECT fell from 70.5% to 44.7%, whereas receipt of ECT where conducted declined from 12.9% to 10.5%. For depressed inpatients, the adjusted probability that the treating hospital conducts ECT fell 34%, whereas probability of receiving ECT was unchanged for patients treated in facilities that conducted the procedure. Adjusted declines were greatest for elderly persons. Throughout the period inpatients from poorer neighborhoods or who were publicly insured or uninsured were less likely to receive care from hospitals conducting ECT.

CONCLUSIONS

Electroconvulsive therapy use for severely depressed inpatients has fallen markedly, driven exclusively by a decline in the probability that their hospital conducts ECT.

Racial differences in the availability and use of electroconvulsive therapy for recurrent major depression

BACKGROUND

Black Americans with depression were less likely to receive electroconvulsive therapy (ECT) than whites during the 1970s and 80s. This pattern was commonly attributed to treatment of blacks in lower quality hospitals where ECT was unavailable. We investigated whether a racial difference in receiving ECT persists, and, if so, whether it arises from lesser ECT availability or from lesser ECT use within hospitals conducting the procedure.

METHODS

Black or white inpatient stays for recurrent major depression from 1993 to 2007 (N=419,686) were drawn from an annual sample of US community hospital discharges. The marginal disparity ratio estimated adjusted racial differences in the probabilities of (1) admission to a hospital capable of conducting ECT (availability), and (2) ECT utilization if treated where ECT is conducted (use).

RESULTS

Across all hospitals, the probability of receiving ECT for depressed white inpatients (7.0%) greatly exceeded that for blacks (2.0%). Probability of ECT availability was slightly greater for whites than blacks (62.0% versus 57.8%), while probability of use was markedly greater (11.8% versus 3.9%). The white versus black marginal disparity ratio for ECT availability was 1.07 (95% confidence interval 1.06-1.07) and stable over the period, while the ratio for use fell from 3.2 (3.1-3.4) to 2.5 (2.4-2.7).

LIMITATIONS

Depressed persons treated in outpatient settings or receive no care are excluded from analyses.

CONCLUSIONS

Depressed black inpatients continue to be far less likely than whites to receive ECT. The difference arises almost entirely from lesser use of ECT within hospitals where it is available.

Differential heart rate response to magnetic seizure therapy (MST) relative to electroconvulsive therapy: a nonhuman primate model

Electroconvulsive therapy (ECT) is an effective treatment for severe depression; however, the induced therapeutic seizure acts on the autonomic nervous system and results in significant cardiac effects. This is an important consideration particularly in the elderly. Magnetic seizure therapy (MST) is in development as a less invasive alternative, but its effects on cardiac function have not been studied. We sought to model those effects in nonhuman primates to inform the development of safer neurostimulation interventions. Twenty four rhesus monkeys were randomly assigned to receive 6 weeks of daily treatment with electroconvulsive stimulation (ECS), magnetic seizure therapy (MST) or anesthesia-alone sham. Digitally acquired ECG and an automated R-wave and inter-R interval (IRI) sampling were used to measure intervention effects on heart rate (HR). Significant differences between experimental conditions were found in the HR as evidenced by changes in the immediate post-stimulus, ictal and postictal epochs. Immediate post-stimulus bradycardia was seen with ECS but not with MST. ECS induced significantly more tachycardia than MST or sham in both the ictal and postictal periods. MST resulted in a small, but statistically significant increase in HR during the postictal period relative to baseline. HR was found to increase by 25% and 8% in the ECS and MST conditions, respectively. MST resulted in significantly less marked sympathetic and parasympathetic response than did ECS. This differential physiological response is consistent with MST having a more superficial cortical site of action with less impact on deeper brain structures implicated in cardiac control relative to ECT. The clinical relevance of the topographical seizure spread of MST and its associated effects on the autonomic nervous system remain to be determined in human clinical trials.