Electroconvulsive therapy disrupts functional connectivity between hippocampus and posterior default mode network

BACKGROUND

The mechanisms underlying memory deficits after electroconvulsive therapy (ECT) remain unclear but altered functional interactions between hippocampus and neocortex may play a role.

OBJECTIVES

To test whether ECT reduces functional connectivity between hippocampus and posterior regions of the default mode network (DMN) and to examine whether altered hippocampal-neocortical functional connectivity correlates with memory impairment. A secondary aim was to explore if these connectivity changes are present 6 months after ECT.

METHODS

In-patients with severe depression (n = 35) received bitemporal ECT. Functional connectivity of the hippocampus was probed with resting-state fMRI before the first ECT-session, after the end of ECT, and at a six-month follow-up. Memory was assessed with the Verbal Learning Test - Delayed Recall. Seed-based connectivity analyses established connectivity of four hippocampal seeds, covering the anterior and posterior parts of the right and left hippocampus.

RESULTS

Compared to baseline, three of four hippocampal seeds became less connected to the core nodes of the posterior DMN in the week after ECT with Cohen's d ranging from -0.9 to -1.1. At the group level, patients showed post-ECT memory impairment, but individual changes in delayed recall were not correlated with the reduction in hippocampus-DMN connectivity. At six-month follow-up, no significant hippocampus-DMN reductions in connectivity were evident relative to pre-ECT, and memory scores had returned to baseline.

CONCLUSION

ECT leads to a temporary disruption of functional hippocampus-DMN connectivity in patients with severe depression, but the change in connectivity strength is not related to the individual memory impairment.

The efficacy of electroconvulsive therapy in adolescent major depressive disorder with suicidal ideation: A propensity score-matched, retrospective cohort study

BACKGROUND

More evidence is needed to validate the use of ECT in adolescent depression. This study aims to compare the effectiveness of electroconvulsive therapy (ECT) to conventional medication therapy for adolescents with major depression with suicidal ideation.

METHODS

In this retrospective cohort study, we reviewed inpatient records from the First Affiliated Hospital of Chongqing Medical University spanning December 2016 to June 2021. We focused on adolescents diagnosed with severe depression presenting with suicidal tendencies. To equalize baseline differences between patients, we used the one-to-one propensity score matching to match patients who received ECT treatment with those who did not. Multivariate regression analysis was utilized to adjust for potential confounders, and subgroup analyses and sensitivity analyses were conducted to verify the robustness of our findings.

RESULTS

Of the 626 patients in this study, 474 underwent ECT treatment while 152 received medication treatment, all aged between 10 and 18 years. Once matched, each group contained 143 patients. The ECT group demonstrated a significantly higher response rate and greater reductions in both Hamilton Depression Rating Scale and Hamilton Anxiety Scale scores (all P < 0.001). Additionally, the ECT group was more effective in reducing suicidal ideation, with fewer individuals retaining such ideation at discharge. In the multivariable regression analysis, both ECT treatment and shorter disease duration were independently linked to enhanced antidepressant efficacy. Subgroup analyses and sensitivity analyses verified the robustness of the main study effect.

CONCLUSIONS

For adolescents with major depressive disorder and suicidal ideation, combining ECT with pharmacotherapy is more effective than pharmacotherapy alone before medications reach full effect.

Comparing Methods of Seizure Response Monitoring During Electroconvulsive Therapy: Comparer les méthodes de surveillance des interventions en cas de crise durant la thérapie par électrochocs

OBJECTIVE

Electroconvulsive therapy (ECT) is used to treat several mental illnesses. Seizure duration is used to determine if the administered stimulus was adequate. Duration is estimated by electroencephalogram (EEG) interpretation and/or observed motor response (OMR). Neither method is considered the gold standard. This study investigated the relationship between the 2 methods. The hypothesis was that both EEG and OMR would be significantly positively correlated. Previous researchers have suggested that the 2 methods resulted in different estimates.

METHODS

A case series was conducted using recorded estimates obtained prospectively from 102 ECTs on adult psychiatric inpatients.

RESULTS

A strong positive association was not observed in this study, correlation coefficient 0.510 (p < 0.001).

CONCLUSIONS

This study suggests that the 2 methods differ, and further research is needed to determine the best indicator of adequate treatment.

Successful Recovery of a Catatonic Patient with Severe Pneumonia and Respiratory Failure: Modified Electroconvulsive Therapy Following Tracheotomy

BACKGROUD

Catatonia encompasses a group of severe psychomotor syndromes affecting patients' motor, speech, and complex behaviors. Common features include rigidity, reduced mobility, speech, sputum production, defecation, and eating. Risks associated with catatonia, such as increased muscle tension and reduced swallowing and coughing reflexes, along with risks from therapeutic approaches like prolonged bed rest and sedative drugs, can elevate the risk of aspiration pneumonia, severe pneumonia, and acute respiratory failure. These complications significantly impede catatonia treatment, leading to poor prognosis and jeopardizing patient safety.

CASE DESCRIPTION

In this report, we present a case of catatonia complicated by severe pneumonia and respiratory failure, successfully managed with modified electroconvulsive therapy alongside tracheotomy. We hope this case provides valuable insights for psychiatrists encountering similar scenarios, facilitating the development of rational therapeutic strategies for prompt improvement of patient condition.

Behavioral and transcriptional effects of repeated electroconvulsive seizures in the neonatal MK-801-treated rat model of schizophrenia

RATIONALE

Electroconvulsive therapy (ECT) is an effective treatment modality for schizophrenia. However, its antipsychotic-like mechanism remains unclear.

OBJECTIVES

To gain insight into the antipsychotic-like actions of ECT, this study investigated how repeated treatments of electroconvulsive seizure (ECS), an animal model for ECT, affect the behavioral and transcriptomic profile of a neurodevelopmental animal model of schizophrenia.

METHODS

Two injections of MK-801 or saline were administered to rats on postnatal day 7 (PN7), and either repeated ECS treatments (E10X) or sham shock was conducted daily from PN50 to PN59. Ultimately, the rats were divided into vehicle/sham (V/S), MK-801/sham (M/S), vehicle/ECS (V/E), and MK-801/ECS (M/E) groups. On PN59, prepulse inhibition and locomotor activity were tested. Prefrontal cortex transcriptomes were analyzed with mRNA sequencing and network and pathway analyses, and quantitative real-time polymerase chain reaction (qPCR) analyses were subsequently conducted.

RESULTS

Prepulse inhibition deficit was induced by MK-801 and normalized by E10X. In M/S vs. M/E model, Egr1, Mmp9, and S100a6 were identified as center genes, and interleukin-17 (IL-17), nuclear factor kappa B (NF-κB), and tumor necrosis factor (TNF) signaling pathways were identified as the three most relevant pathways. In the V/E vs. V/S model, mitophagy, NF-κB, and receptor for advanced glycation end products (RAGE) pathways were identified. qPCR analyses demonstrated that Igfbp6, Btf3, Cox6a2, and H2az1 were downregulated in M/S and upregulated in M/E.

CONCLUSIONS

E10X reverses the behavioral changes induced by MK-801 and produces transcriptional changes in inflammatory, insulin, and mitophagy pathways, which provide mechanistic insight into the antipsychotic-like mechanism of ECT.

Changed brain entropy and functional connectivity patterns induced by electroconvulsive therapy in majoy depression disorder

OBJECTIVE

Our objective is to innovatively integrate both linear and nonlinear characteristics of brain signals in Electroconvulsive Therapy (ECT) research, with the goal of uncovering deeper insights into the pathogenesis of Major Depressive Disorder (MDD) and identifying novel targets for other physical intervention therapies.

METHODS

We measured brain entropy (BEN) in 42 MDD patients and 42 matched healthy controls (HC) using rs-fMRI data. Brain regions that differed significantly in patients with MDD before and after ECT were extracted. Then, we use these brain regions as seed points to investigate the differences in whole-brain resting-state functional connectivity (RSFC) patterns before and after ECT.

RESULTS

Compared to HCs, patients had higher BEN levels in the right precuneus (PCUN.R) and right angular gyrus (ANG.R). After ECT, patients had lower BEN levels in the PCUN.R and ANG.R. Compared with before ECT, patients showed significantly increased RSFC after ECT between the PCUN.R and right middle temporal gyrus and ANG.R. Significantly increased RSFC was observed between the ANG.R and right middle frontal gyrus and right supramarginal gyrus after ECT.

CONCLUSION

Combining the linear and nonlinear characteristics of brain signals can effectively explore the pathogenesis of depression and provide new targets for ECT.

Mechanism of electroconvulsive therapy in schizophrenia: a bioinformatics analysis study of RNA-seq data

OBJECTIVE

The molecular mechanism of electroconvulsive therapy (ECT) for schizophrenia remains unclear. The aim of this study was to uncover the underlying biological mechanisms of ECT in the treatment of schizophrenia using a transcriptional dataset.

METHODS

The peripheral blood mRNA sequencing data of eight patients (before and after ECT) and eight healthy controls were analyzed by integrated co-expression network analysis and the differentially expressed genes were analyzed by cluster analysis. Gene set overlap analysis was performed using the hypergeometric distribution of phypfunction in R. Associations of these gene sets with psychiatric disorders were explored. Tissue-specific enrichment analysis, gene ontology enrichment analysis, and protein-protein interaction enrichment analysis were used for gene set organization localization and pathway analysis.

RESULTS

We found the genes of the green-yellow module were significantly associated with the effect of ECT treatment and the common gene variants of schizophrenia ( P  = 0.0061; family-wise error correction). The genes of the green-yellow module are mainly enriched in brain tissue and mainly involved in the pathways of neurotrophin, mitogen-activated protein kinase and long-term potentiation.

CONCLUSION

Genes associated with the efficacy of ECT were predominantly enriched in neurotrophin, mitogen-activated protein kinase and long-term potentiation signaling pathways.

[Diagnosis and treatment of late-life depression]

Late-life depression is a common pathology. The diagnosis can be difficult to make, due to intricacy of comorbidities, aging and treatments. The presentation is frequently atypical, with a high prevalence of somatic complaints. Depression is, in fact, underdiagnosed in this population and, when it is, poorly managed. This pathology constitutes a real public health problem due to impairment of functioning and quality of life, increase of comorbidities, use of health care and overall mortality, particularly by suicide. Treatment consists of psychotherapy, pharmacotherapy and/or electroconvulsive therapy.

Comparative Efficacy of Augmenting Escitalopram with Modified Electroconvulsive Therapy or High-Frequency Repetitive Transcranial Magnetic Stimulation on Depressive Symptoms, Quality of Life, and Cognitive Function in Treatment-Resistant Depression

Treatment-resistant depression (TRD) poses significant therapeutic challenges despite available interventions. Escitalopram (ESC) is a highly selective antidepressant. This study aimed to compare ESC alone and ESC combined with modified electroconvulsive therapy (MECT) or high-frequency repetitive transcranial magnetic stimulation (HF-rTMS) in TRD patients. Ninety participants were randomized into ESC alone, ESC + MECT, and ESC + HF-rTMS groups. Notable differences were observed in Hamilton Depression Rating Scale (HDRS-17) scores at 12 weeks among ESC (14.37), ESC + MECT (10.27), and ESC + HF-rTMS (10.77) groups (P = 0.006). In terms of overall quality of life (QoL) evaluated using the World Health Organization Quality of Life Questionnaire (WHOQOL-BREF) at 12 weeks, the ESC, ESC + MECT, and ESC + HF-rTMS groups scored 2, 3, and 3.5, respectively. ESC + MECT/HF-rTMS groups showed reduced depressive symptoms compared to the ESC group, accompanied by higher overall QoL scores and increased satisfaction with health. Patients receiving ESC + MECT demonstrated no significant alterations in short-term memory and orientation, as measured by the Montreal Cognitive Assessment (MoCA), before and after treatment. Moreover, a decline in language was observed compared to baseline (12 weeks: median 2, IQR 2-3; baseline: median 1, IQR 1-3; P = 0.022). The positive impact of ESC with HF-rTMS on cognitive function was evidenced by improvements in all domines MoCA.Combining ESC with MECT or HF-rTMS exhibited enhanced effectiveness in alleviating depressive symptoms and enhancing QoL compared to ESC monotherapy. Specifically, the ESC + HF-rTMS combination displayed potential as a comprehensive treatment strategy for TRD, addressing both emotional and cognitive aspects.

Augmenting Virtual Reality Exposure Therapy for Social and Intergroup Anxiety With Transcranial Direct Current Stimulation

OBJECTIVES

Exposure therapy is a cornerstone of social anxiety treatment, yet not all patients respond. Symptoms in certain social situations, including intergroup (ie, out-group) contexts, may be particularly resistant to treatment. Exposure therapy outcomes may be improved by stimulating neural areas associated with safety learning, such as the medial prefrontal cortex (mPFC). The mPFC also plays an important role in identifying others as similar to oneself. We hypothesized that targeting the mPFC during exposure therapy would reduce intergroup anxiety and social anxiety.

METHODS

Participants (N = 31) with the public speaking subtype of social anxiety received active (anodal) or sham transcranial direct current stimulation (tDCS) targeting the mPFC during exposure therapy. Exposure therapy consisted of giving speeches to audiences in virtual reality. To target intergroup anxiety, half of the public speaking exposure trials were conducted with out-group audiences, defined in this study as audiences of a different ethnicity.

RESULTS

Contrary to hypotheses, tDCS did not facilitate symptom reduction. Some evidence even suggested that tDCS temporarily increased in-group favoritism, although these effects dissipated at 1-month follow-up. In addition, collapsing across all participants, we found reductions across time for public speaking anxiety and intergroup anxiety.

CONCLUSIONS

The data provide evidence that standard exposure therapy techniques for social anxiety can be adapted to target intergroup anxiety. Transcranial direct current stimulation targeting the mPFC may boost safety signaling, but only in contexts previously conditioned to signal safety, such as an in-group context.

Catatonic postpartum paternal depression as a first debut of a bipolar disorder: a case report

Paternal postpartum depression (PD) is considered an affective disorder that affects fathers during the months following childbirth. Interestingly, it has been observed that during these months the chances of a male parent suffering from depression are double that for a non-parent male counterpart. We present the case of a 34-year-old man with no relevant medical history in who, overlapping her daughter's birth, several depressive symptoms emerged, such as fatigue, lack of concentration, sleeping disturbances and abandonment of care of the newborn. Prior to consultation, patient refused to eat and open his eyes, and his speech became progressively more parsimonious until reaching mutism. The patient was diagnosed with a severe depressive disorder with catatonia. Given the lack of improvement with pharmacological treatment and due to the evidence of electroconvulsive therapy (ECT)'s effectiveness on patients with catatonia, acute ECT treatment was indicated and started. It should be noted that PD is an important entity to consider in our differential diagnosis of young parents who present a depressive episode. Few cases of relatively young patients presenting with such clinical presentation have been described and, although this case presents some of the characteristics described in the epidemiology of PD, other clinical aspects are not typical of this entity. Informed consent was obtained from the patient for the purpose of publication.

Receipt of Electroconvulsive Therapy in Outpatient Settings in a National Sample of Privately Insured Patients With Mood Disorders

PURPOSE

Electroconvulsive therapy (ECT), an effective treatment for bipolar and major depressive disorder, is underused. Little information is available on use of ECT in potentially less costly outpatient settings, possibly reducing cost barriers.

METHODS

Insurance claims from the 2008 to 2017 MarketScan Commercial Database for patients diagnosed with mood disorders were used to compare 4 groups of ECT users in each year: those receiving (1) exclusively outpatient ECT, (2) first inpatient and subsequently outpatient, (3) outpatient and subsequently inpatient, and (4) exclusively inpatient ECT. Groups were compared on the proportion receiving ECT in each group over time as well as on the total numbers of treatments received along with group differences in sociodemographic and diagnostic characteristics and health care costs.

RESULTS

Among 2.9 million patients diagnosed with mood disorders, the proportion who received ECT (n = 8859) was small (0.30%) and declined over the decade to 0.17%. Among those who received ECT, most did so exclusively as outpatients (52.3%), the group with fewest comorbidities and lowest costs. This proportion increased by 19.7% over the decade, whereas the proportion receiving ECT exclusively in an inpatient setting (12.1%) fell by 30.6%. The total number of treatments per patient averaged 11.7 per year and increased by 28.0% over the decade, with outpatients decreasing to slightly less than average. Health care costs were greatest for those who started ECT as inpatients.

CONCLUSIONS

Although the proportion of privately insured patients receiving ECT in outpatient settings has increased, reducing cost barriers, the use of ECT continued to be extremely limited and declining.

Standards for medical devices: Electroconvulsive therapy machine

The manuscript calls for establishing a standard for electroconvulsive devices by manufacturers for better regulation in India. This is most relevant in the context of two recent developments, (a) Notification of medical devices rules, 2017 with classification of ECT as Class C and (b) Recent change in classification of ECT devices by US-FDA in 2018. The establishment of standards would help in upregulating the standard of ECT devices as well as ECT practices.

High-Definition Transcranial Direct Current Stimulation-Primed Intermittent Theta Burst Stimulation in Treatment-Resistant Depression: A Controlled Study

OBJECTIVES

The aim of this study was to evaluate whether high-definition transcranial direct current stimulation (HDtDCS) priming improves the efficacy of intermittent theta burst stimulation (iTBS) in improving TRD.

METHODOLOGY

A prospective hospital-based, randomized control study where the participants were divided into active or sham HDtDCS-primed iTBS stimulation groups for a total of 10 sessions and were assessed on clinical parameters at baseline, end of week 1, and end of week 2 was done. Primary outcome of the study was the difference in Hamilton Depression Rating Scale (HDRS) scores over 2 weeks of HDtDCS-primed iTBS.

RESULT

A significant effect of time was seen over HDRS scores in both active and sham groups with a large effect size. Significant effect of time was also found over the Clinical Global Impressions-Severity Scale scores of patients with a large effect size. The difference in the improvement in depressive severity as measured using HDRS and Clinical Global Impressions-Severity Scale scores between active and sham groups was also found to be significant with large effect sizes.

CONCLUSION

High-definition tDCS-primed iTBS is superior to normal iTBS in patients with depression who have failed a trial of 2 antidepressants, whereas both mechanisms are of benefit to the patients.

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.

Effectiveness of High-Frequency Repetitive Transcranial Magnetic Stimulation in Patients With Spinocerebellar Ataxia Type 3

OBJECTIVE

To investigate the effectiveness of high-frequency repetitive transcranial magnetic stimulation (HF-rTMS) on improvement of clinical symptoms in patients with spinocerebellar ataxia type 3 (SCA3).

METHODS

Sixteen SCA3 participants diagnosed by genetic testing were enrolled in this sham-controlled and double-blind trial. They received either a 2-week 10-Hz rTMS intervention or sham stimulation targeting the vermis and cerebellum. The Scale for Assessment and Rating of Ataxia and the International Cooperative Ataxia Rating Scale were completed at baseline and poststimulation.

RESULTS

Compared with baseline, the HF-rTMS group demonstrated a significant improvement in the total Scale for Assessment and Rating of Ataxia ( P < 0.0001) and the International Cooperative Ataxia Rating Scale scores ( P = 0.002). After 2-week treatment, the real group exhibited decreasing pattern in 3 subgroups, especially for limb kinetic function ( P < 0.0001).

CONCLUSIONS

Short-term HF-rTMS treatment is a potentially promising and feasible tool for rehabilitation in patients with SCA3. Studies with long-term follow-up need to be carried out in the future and further need to assess gait, limb kinetic function, speech and oculomotor disorders.

Molecular basis underlying changes of brain entropy and functional connectivity in major depressive disorders after electroconvulsive therapy

INTRODUCTION

Electroconvulsive therapy (ECT) is widely used for treatment-resistant depression. However, it is unclear whether/how ECT can be targeted to affect brain regions and circuits in the brain to dynamically regulate mood and cognition.

METHODS

This study used brain entropy (BEN) to measure the irregular levels of brain systems in 46 major depressive disorder (MDD) patients before and after ECT treatment. Functional connectivity (FC) was further adopted to reveal changes of functional couplings. Moreover, transcriptomic and neurotransmitter receptor data were used to reveal genetic and molecular basis of the changes of BEN and functional connectivities.

RESULTS

Compared to pretreatment, the BEN in the posterior cerebellar lobe (PCL) significantly decreased and FC between the PCL and the right temporal pole (TP) significantly increased in MDD patients after treatment. Moreover, we found that these changes of BEN and FC were closely associated with genes' expression profiles involved in MAPK signaling pathway, GABAergic synapse, and dopaminergic synapse and were significantly correlated with the receptor/transporter density of 5-HT, norepinephrine, glutamate, etc. CONCLUSION: These findings suggest that loops in the cerebellum and TP are crucial for ECT regulation of mood and cognition, which provides new evidence for the antidepressant effects of ECT and the potential molecular mechanism leading to cognitive impairment.

Regulatory and Service System Challenges in Accessing Electroconvulsive Therapy for Catatonia in the Presence of Autism Spectrum Disorder

In a recent letter to the editor, Dr. Miller and colleagues1 highlighted the disparity of electroconvulsive therapy (ECT) across different states, and the challenges faced by a patient in Colorado for whom ECT was deemed the most appropriate treatment but was not available in this location, forcing the patient to seek care in New Mexico. A subsequent letter by Dr. Ong and colleagues2 presented an additional case, in a different location, where a delay in ECT treatment because of state regulations contributed to substantial patient morbidity. In this letter, we present a patient seen at our facility in California, a state with some of the most stringent regulations regarding ECT treatment in adolescents.3 This case illustrates how ECT was eventually approved by the court system only after the patient's continual deterioration, despite receiving intensive medical treatment on an inpatient pediatric medical unit for a duration of 80 days. Care providers and the patient's family were forced to witness this decline until the patient reached "an emergency situation" and ECT was "deemed a lifesaving treatment," as the California Welfare and Institutions Code (WIC) § 5,326.8(a) forbids the procedure under any other circumstances.

No Effect of Serum Electrolyte Levels on Electroconvulsive Therapy Seizure Quality Parameters

INTRODUCTION

Seizure quality is considered to be associated with treatment outcomes of electroconvulsive therapy (ECT). A wide range of treatment parameters and patient characteristics are known to influence seizure quality. However, conflicting results exist for the role of serum electrolyte levels and seizure quality.

METHODS

We retrospectively analyzed a total of 454 patients and a total of 2119 individual acute ECT sessions irrespective of diagnosis where a clinical evaluation of serum levels of sodium, potassium, and calcium took place routinely up to 2 days before the ECT session. To assess the impact of serum electrolyte levels on seizure quality parameters, we used mixed-effects linear regression analysis with Bonferroni correction for multiple testing.

RESULTS

Serum sodium, potassium, and calcium levels were not associated with seizure quality markers after correcting the significance level for multiple testing. Younger age was consistently associated with higher postictal suppression, interhemispheric coherence, midictal amplitude, and peak heart rate. Lower dose was consistently associated with longer electroencephalogram and motor seizure duration.

CONCLUSIONS

Our results suggest that there is no clinically relevant effect of serum electrolyte levels on seizure quality, at least within clinically commonly observed ranges of serum electrolyte concentrations.

Clinical characteristics and treatment exposure of patients with marked treatment-resistant unipolar major depressive disorder: A RECOVER trial report

BACKGROUND

RECOVER is a randomized sham-controlled trial of vagus nerve stimulation and the largest such trial conducted with a psychiatric neuromodulation intervention.

OBJECTIVE

To describe pre-implantation baseline clinical characteristics and treatment history of patients with unipolar, major depressive disorder (MDD), overall and as a function of exposure to interventional psychiatric treatments (INTs), including electroconvulsive therapy, transcranial magnetic stimulation, and esketamine.

METHODS

Medical, psychiatric, and treatment records were reviewed by study investigators and an independent Study Eligibility Committee prior to study qualification. Clinical characteristics and treatment history (using Antidepressant Treatment History [Short] Form) were compared in those qualified (N = 493) versus not qualified (N = 228) for RECOVER, and among the qualified group as a function of exposure to INTs during the current major depressive episode (MDE).

RESULTS

Unipolar MDD patients who qualified for RECOVER had marked TRD (median of 11.0 lifetime failed antidepressant treatments), severe disability (median WHODAS score of 50.0), and high rate of baseline suicidality (77% suicidal ideation, 40% previous suicide attempts). Overall, 71% had received at least one INT. Compared to the no INT group, INT recipients were younger and more severely depressed (QIDS-C, QIDS-SR), had greater suicidal ideation, earlier diagnosis of MDD, and failed more antidepressant medication trials.

CONCLUSIONS

RECOVER-qualified unipolar patients had marked TRD and marked treatment resistance with most failing one or more prior INTs. Treatment with ≥1 INTs in the current MDE was associated with earlier age of MDD onset, more severe clinical presentation, and greater treatment resistance relative to patients without a history of INT.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier NCT03887715.

Antidepressant effects of dexmedetomidine compared with ECT in patients with treatment-resistant depression

OBJECTIVE

This pilot study was designed to investigate the antidepressant effects of dexmedetomidine (DEX), a selective α2-adrenergic receptor agonist, in patients with treatment-resistant depression (TRD). The antidepressant effects of dexmedetomidine was compared with ECT, which is widely used in clinical practice for treatment of patients with TRD.

METHODS

Seventy six patients with TRD were randomly assigned to receive 10 sessions of DEX infusions or electroconvulsive therapy (ECT) treatment. The primary outcome was the changes of depression severity determined by the improvement of 24-item Hamilton Depression Rating Scale (HDRS-24). The second outcomes were the rates of therapeutic response (reduction in HDRS-24 ≥ 50 %) and remission (HDRS-24 ≤ 10 and reduction in HDRS-24 ≥ 60 %) at posttreatment and after 3 months of follow-up visits.

RESULTS

We found that 10 sessions of DEX infusions or ECT treatments significantly improved HDRS-24 scores at posttreatment and after 3 months of follow-up visits compared with the baseline. In addition, there was no significant difference between DEX infusions and ECT treatments regarding HDRS-24 at these evaluating points. Furthermore, the depression severity dropped to mild after 2 sessions of DEX infusion. In contrast, at least 6 sessions of ECT treatment were needed to achieve a same level. Finally, the rates of therapeutic response and remission were comparable between the two groups. No serious adverse events were observed.

CONCLUSIONS

Based on current published evidence, we conclude that DEX exhibits rapid and durable antidepressant properties similar to ECT but with fewer side effects.

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.

Significant efficacy of electroconvulsive therapy on the behavioural symptoms of anti-N-methyl-d-aspartate receptor encephalitis

SummaryThe common features of anti-N-methyl-d-aspartate (NMDA) receptor encephalitis are neuropsychiatric symptoms that are often challenging, treatment refractory and take years to recover. Electroconvulsive therapy (ECT) is effective in treating these symptoms in the acute phase, including catatonia and psychiatric issues.We describe the case of a man in his 30s with anti-NMDA receptor encephalitis characterised by neuropsychiatric features and treatment-refractory impulsivity, who was successfully treated with ECT. This case suggests that ECT use for behavioural symptoms can be associated with a significant response and may contribute to faster recovery from the disease.

Examining the clinical effectiveness of continuation and maintenance electroconvulsive therapy in schizophrenia

OBJECTIVE

There are few studies that examine the effectiveness of Continuation/Maintenance Electroconvulsive Therapy (C/M-ECT) in schizophrenia, despite the documented effectiveness of acute ECT treatment. We aimed to investigate the clinical effectiveness of C/M-ECT for in-patients with Schizophrenia in a naturalistic setting. We examined the medical records of 46 in-patients who were diagnosed with Schizophrenia and had received C/M-ECT belonging to non-acute extended care service in a public psychiatry hospital in Sydney, Australia. The focus of analysis was on 138 treatment cycles (71 acute only cycles and 67 acute-continuation/maintenance cycles) across 45 subjects. A linear mixed effects model was used to describe the change in clinical global impression-severity (CGI-S) over time 4 time points viz., pre-post acute and pre-post continuation/maintenance ECT.

RESULTS

Acute-only cycles and acute-continuation/maintenance cycles had identical pre- (M = 5, C.I. = 4-6), post-cycle CGI-S scores, and identical CGI-S difference scores (M = 0, C.I. = -1 - 1). Broadly in each continuation/maintenance cycle, we observed an initial sharp decrease in CGI-S scores followed by a logarithmic increase in scores over time, with satisfactory CGI-S score maintenance observed for approximately 6 months. Bitemporal ECT influenced CGI-S across maintenance ECT (p < 0.05) indicating smaller declines in CGI-S scores over time.

CONCLUSION

In schizophrenia, C/M ECT preserves effects on illness severity for at least upto 6 months following an acute course of ECT. Bitemporal ECT vis a vis other electrode positions differentiated clinical severity over time.

Electroconvulsive therapy improves hematological inflammatory markers in bipolar disorder

BACKGROUND

Immune dysfunction and inflammation participate in the pathophysiology of bipolar disorder (BD). Abnormal levels of inflammatory markers, namely, red cell distribution width (RDW) and platelet distribution width (PDW), were detected in BD. Electroconvulsive therapy (ECT) for various mental disorders including BD was linked to changes in these inflammatory mediators. Hence, we aimed to assess the impact of ECT on PDW and RDW in patients with BD.

METHODS

Seventy-two patients aged ≥ 16 were enrolled in the current prospective cohort study over 6 months, diagnosed as BD based on DSM-IV and indicated for ECT and complete blood count (CBC) drawn pre-ECT and after four ECT sessions.

RESULTS

By the end of the ECT sessions, we noticed a significant elevation in PDW with lowering in RDW levels. However, no significant differences were detected before and after ECT regarding platelet (PLTs) count, mean platelet volume (MPV), and Plateletcrit (PCT).

CONCLUSION

ECT seems to improve the CBC-derived inflammatory markers (RDW and PDW) subsequently, improving the underlying inflammatory process in BD without disturbing PLT homeostasis which support its anti-inflammatory role in BD.

Identification of the antidepressant effect of electroconvulsive stimulation-related genes in hippocampal astrocyte

Major depressive disorder (MDD) remains a significant global health concern, with limited and slow efficacy of existing antidepressants. Electroconvulsive therapy (ECT) has superior and immediate efficacy for MDD, but its action mechanism remains elusive. Therefore, the elucidation of the action mechanism of ECT is expected to lead to the development of novel antidepressants with superior and immediate efficacy. Recent studies suggest a potential role of hippocampal astrocyte in MDD and ECT. Hence, we investigated antidepressant effect of electroconvulsive stimulation (ECS), an animal model of ECT, -related genes in hippocampal astrocyte with a mouse model of MDD, in which corticosterone (CORT)-induced depression-like behaviors were recovered by ECS. In this model, both of CORT-induced depression-like behaviors and the reduction of hippocampal astrocyte were recovered by ECS. Following it, astrocytes were isolated from the hippocampus of this model and RNA-seq was performed with these isolated astrocytes. Interestingly, gene expression patterns altered by CORT were reversed by ECS. Additionally, cell proliferation-related signaling pathways were inhibited by CORT and recovered by ECS. Finally, serum and glucocorticoid kinase-1 (SGK1), a multi-functional protein kinase, was identified as a candidate gene reciprocally regulated by CORT and ECS in hippocampal astrocyte. Our findings suggest a potential role of SGK1 in the antidepressant effect of ECS via the regulation of the proliferation of astrocyte and provide new insights into the involvement of hippocampal astrocyte in MDD and ECT. Targeting SGK1 may offer a novel approach to the development of new antidepressants which can replicate superior and immediate efficacy of ECT.

Evaluation of the Online Component of a Blended Learning Electroconvulsive Therapy Curriculum for Psychiatry Residents to Treat Depression in Older Adults

OBJECTIVE

The objective of this study was to evaluate the online component of a blended curriculum for psychiatry residents on the use of electroconvulsive therapy (ECT) to treat depression in older adults.

METHODS

Second- and third-year general psychiatry residents completed a blended learning curriculum during their core geriatric psychiatry rotation. The curriculum consisted of didactic seminars, hands-on clinical management, and two online clinical cases focused on the management of late-life depression with ECT. Knowledge acquisition following module completion was measured using a nine-question multiple-choice test. The authors adapted the Medical E-Learning Evaluation Survey (MEES) to measure resident satisfaction, clinical relevance, and instructional design.

RESULTS

A total of 37 residents completed both online modules. Of these, 35 residents completed the knowledge test and 23 completed the adapted MEES. Almost all participants (96%) agreed or strongly agreed that the modules were relevant to their clinical work, evidence-based, able to be completed in a reasonable amount of time, and a valuable learning experience. The average score on the knowledge test, after removing one outlier, was 83%.

CONCLUSION

Psychiatry residents are very satisfied with the content and delivery of the online component of a blended curriculum for understanding the use of ECT for late-life depression. Future work should examine satisfaction with the remainder of the curricula as well as the impact on longer-term knowledge acquisition and patient care.

The role of immune inflammation in electroconvulsive therapy for schizophrenia: Treatment mechanism, and relationship with clinical efficacy: Immune-inflammation in ECT for schizophrenia

Schizophrenia is a devastating psychiatric disorder that has detrimental effects on a significant portion of the global population. Electroconvulsive therapy (ECT), as a safe and effective physical therapy for schizophrenia, has demonstrated the ability to rapidly improve both positive and negative symptoms. Despite being used to treat schizophrenia for over 80 years, the therapeutic mechanisms of ECT are still in the early stages of exploration. Evidence has suggested that immune inflammation contributes to the pathogenesis of schizophrenia by interacting with neurotransmitters, neurodevelopment, and neurodegeneration. Given the importance of ECT as a fast-acting physical therapy for schizophrenia, gaining a deeper understanding of the role of immune inflammation may lead to developing innovative therapeutic approaches. This review summarized existing research that examined changes in peripheral inflammation following ECT in schizophrenia patients, and the effects of electroconvulsive stimulation (ECS) on neuroinflammation in animal studies.

Effects of electroconvulsive therapy on functional brain networks in patients with schizophrenia

BACKGROUND

Schizophrenia is a kind of intractable brain disorder. Electroconvulsive therapy (ECT) has been used to rapidly improve the clinical symptoms of patients with schizophrenia, but the effect of ECT on topological attributes of brain functional network in patients with schizophrenia has not been clear. The purpose of this study was to investigate the brain functional network mechanism of ECT against schizophrenia.

METHODS

Thirty-one patients with schizophrenia and fifty healthy controls matching age, gender, and years of education were included. All participants underwent general data collection and magnetic resonance imaging scanning before ECT, and clinical symptoms were assessed using the Positive And Negative Syndrome Scale (PANSS). MRI and clinical symptoms were collected again after the first and eighth ECT application. The functional brain network was constructed on the basis of magnetic resonance imaging, and the global and node topological properties were analyzed. Repeated measure variance analysis was used to explore the changes of the topological attribute values and clinical symptom scores before and after ECT, and Bonferroni post hoc analysis was performed. The independent sample t-test was used to compare the differences in the topological attribute values between patients and healthy controls at three time points before and after ECT. Partial correlation analysis was performed for topological attribute values and clinical symptom scores of abnormal brain regions in the patient groups and their changes during ECT. A general linear regression model was used to predict the outcome after the final eighth ECT using the patient's response to the first ECT.

RESULTS

(1) One ECT can restore the gamma(γ), lamuda(λ), sigma(σ), nodal global efficiency (Ne) of right insular gyrus ventral agranular insula (INS_R_vIa) and nodal local efficiency (NLe) of bilateral fusiform gyrus medioventral area37 (FuG_A37mv). Eight ECT can also restore the NLe of cortex rostral lingual gyrus (MVOcC _R_rLinG). Eight ECT did not improve the Ne of right superior parietal lobule rostral area 7 (SPL_R_A7r) and NLe of left superior frontal gyrus medial area 6 (SFG_L_A6m). (2) Even after only the first use of ECT, total PANSS scores began to decrease (mean ΔPANSSECT1 was 11.7%; Range, 2%-32.8%), decreased significantly after the eighth application (mean ΔPANSSECT8 was 86.0%; Range,72.5% to 97.9%). Five patients met the response criteria after ECT1 (20% reduction in PANSS total score), and all patients met the response criteria after ECT8. (3) Linear regression analysis showed that ΔPANSSECT1 was a significant predictor of ΔPANSSECT8 (F=5.387, P=0.028), and ΔPANSSECT1 explained 15.7% of the variance of ΔPANSSECT8 (R2=0.157).

CONCLUSIONS

ECT was able to normalize γ, λ, σ, Ne of INS_R_vIa, NLe of bilateral FuG_A37mv in SZ patients after the first treatment, and NLe of MVOcC_R_rLinG after the eighth ECT. ECT significantly alleviates psychotic symptoms in patients with SZ, and its efficacy after eight sessions can be predicted by the patient's response to the first session of ECT.

Neurobiological mechanisms and therapeutic impact of electroconvulsive therapy (ECT)

Electroconvulsive therapy (ECT) is an efficient therapeutic resource for psycho-pharmacotherapeutic resistant forms of depression. ECT is a form of electrical brain stimulation involving the induction of a controlled seizure, clinically similar to an epileptic seizure, that is initiated in the prefrontal region of the brain and spreads to the cortex and subcortex, including the diencephalic structures. This is achieved by creating a transcranial electric field and synchronously depolarizing neuronal membranes. The mechanisms of action of ECT are not yet fully understood, but several hypotheses have been proposed to explain how it affects the brain: neurotransmitter changes, neuroplasticity, network connectivity, endocrine system regulation and changes in regional cerebral blood flow and regional metabolism.

Altered in vivo early neurogenesis traits in patients with depression: Evidence from neuron-derived extracellular vesicles and electroconvulsive therapy

BACKGROUND

The neurogenesis hypothesis is a promising candidate etiologic hypothesis for depression, and it is associated with electroconvulsive therapy (ECT). However, human in vivo molecular-level evidence is lacking.

OBJECTIVE

We used neuron-derived extracellular vesicles (NDEVs) as a "window to the neurons" to explore the in vivo neurogenesis status associated with ECT in patients with treatment-resistant depression (TRD).

METHODS

In this study, we enrolled 40 patients with TRD and 35 healthy controls (HCs). We isolated NDEVs from the plasma of each participant to test the levels of doublecortin (DCX), a marker of neurogenesis, and cluster of differentiation (CD) 81, a marker of EVs. We also assessed the plasma levels of brain-derived neurotrophic factor (BDNF), a protein that is known to be associated with ECT and neuroplastic processes.

RESULTS

Our findings indicated that both the levels of DCX in NDEVs and BDNF in plasma were significantly lower in TRD patients compared to HCs at baseline, but increased following ECTs. Conversely, levels of CD81 in NDEVs were found higher in TRD patients at baseline, but did not change after the ECT treatments. Exploratory analyses revealed that lower levels of BDNF in plasma and DCX in NDEVs, along with higher CD81 levels in NDEVs, were associated with more severe depressive symptoms and reduced cognitive function at baseline. Furthermore, higher baseline CD81 concentrations in NDEVs were correlated with greater decreases in depression symptoms.

CONCLUSIONS

We first present human in vivo evidence of early neurogenesis using DCX through NDEVs: decreased in TRD patients, increased after ECTs.

Catatonia and ECT across the lifespan

Electroconvulsive therapy (ECT) is a safe and effective treatment for catatonia with high response rates. Although empirical data suggest that tolerability and efficacy are at least as good as in adults, ECT treatment of children, adolescents, and geriatric patients seems to pose a specific challenge for many practitioners. This article intends to explore and discuss reasons hindering the use of ECT in these patient groups, give an overview on the use of ECT to treat catatonia and provide practical advice on ECT in children, adolescents, and geriatric patients for the treatment of catatonia. Classification of catatonia as a subform of schizophrenia and a diagnostic overlap with other common conditions in children, adolescents, and geriatric patients might lead to underdiagnosis of catatonia. Concerns about the mechanism of action and about a lack of controlled studies as well as general concerns about the use of ECT in children and adolescents might lead to underutilization of ECT. However, studies of ECT to treat catatonia in children, adolescents, and geriatric patients consistently show its safety and effectiveness. Administration of ECT needs to consider some specific characteristics of children, adolescents, and geriatric patients. In conclusion, ECT is a safe and highly effective treatment for catatonia across the lifespan. Existing evidence does not warrant restrictions of its use in certain age groups.