Additional Electroconvulsive Therapy Research Articles

Acute catatonia

Catatonia is an underdiagnosed psychomotor syndrome that can occur in the context of various mental and somatic diseases. Malignant catatonia is particularly relevant in the context of intensive medical care. Clear recommendations in guidelines are missing. To present the current state of the diagnosis and treatment of catatonia, especially malignant catatonia. The literature was evaluated with respect to acute catatonic conditions, with aspecial focus on the differential diagnosis, relevance to intensive medical care and treatment of catatonia. In psychiatric inpatients, catatonic syndromes are relatively frequent with aprevalence between 9% and 17%, and in neurological patients somewhat less frequent with aprevalence of 3.3%. There is aclear recommendation for pharmacological treatment with lorazepam. Additional electroconvulsive therapy (ECT) should be considered as early as possible, especially in cases not responding to benzodiazepines. Response rates to ECT have been shown to be 80-100%. In malignant catatonia, ECT should be performed immediately as an emergency indication. Several factors lead to the underdiagnosis of catatonia. It is problematic that even life-threatening malignant catatonia is often not recognized as such, although there is a mortality of about 50% if untreated. The best treatment outcome is achieved with acombination of benzodiazepines and ECT. The treatment of severe malignant catatonia represents an emergency indication for ECT.

Abstract 13369: Takotsubo Cardiomyopathy Following Electroconvulsive Therapy

Case Presentation: A 71-year-old woman presented to our institution for treatment-refractory depression requiring electroconvulsive therapy (ECT). She underwent a transthoracic echocardiogram (TTE) during a pre-ECT evaluation, which demonstrated no regional wall motion abnormalities and a left ventricular ejection fraction (LVEF) of 60 - 65%. The patient subsequently underwent ECT. During the procedure, sinus tachycardia with associated ST-segment changes were noted on telemetry. Esmolol was administered with subsequent improvement in her tachycardia, however ST-segment changes persisted. A twelve-lead electrocardiogram was obtained and was notable for new T-wave inversions in leads V1-V4 and Q-waves in leads III and aVF. However, STEMI criteria was not met. A TTE obtained shortly after her ECT demonstrated ballooning of the LV apex and an LVEF of 35%, consistent with takotsubo cardiomyopathy. Laboratory evaluation was notable for a high sensitivity troponin peak of 130 ng/L and a brain natriuretic peptide level of 746 pg/mL. Cardiac catheterization was not performed as the patient had a negative stress test prior to admission. The patient’s symptoms improved over the next two days, and she was discharged with close outpatient follow-up. Discussion: Takotsubo cardiomyopathy occurs following physical or psychological stress. Greater than half of patients with takotsubo cardiomyopathy have neurologic or psychiatric disorders. Takotsubo cardiomyopathy is an increasingly recognized serious complication of ECT and can be seen in post-menopausal women with depression. The introduction of beta blocker therapy has been used to prevent recurrent episodes of post-ECT takotsubo cardiomyopathy. Despite this, there are reports of post-ECT takotsubo cardiomyopathy in patients on chronic beta blocker therapy. Thus, the risks and benefits of proceeding with additional ECT treatments must be weighed after an initial episode of takotsubo cardiomyopathy.

P.0820 Association of resilience with limbic activity during negative emotional face processing in individuals who experienced childhood maltreatment

In patients suffering from major depressive disorders (MDD), improvements in MDD are related to increased activation of brain-derived neurotrophic factor (BDNF), an endogenous protein that facilitates neural functioning. To treat patients suffering from severe MDD, electroconvulsive therapy (ECT) is considered an efficacious and safe intervention, though the impact of ECT on plasma BDNF levels has thus far barely been investigated. The aim of the present study was therefore to assess plasma BDNF levels and depression of patients suffering from severe MDD treated with additional ECT compared to patients treated with citalopram only.A total of 40 patients (mean age: M = 31.45 years; females 30%) suffering from MDD and all receiving 40 mg/d citalopram were assigned either to a control group (N = 20), or to a target group (N = 20) undergoing additional 12 sessions of ECT. Plasma BDNF and symptom severity were assessed at baseline and four weeks later.Plasma BDNF increased in both groups over time, though the significant Time by Group-interaction revealed an increase of 101% in the target group as compared to the control group. Symptom severity significantly decreased in both groups over time, though without being related to plasma BDNF levels.Data from the present study suggest that, in patients suffering from severe MDD, treatment with citalopram was associated both with an increase of plasma BDNF and amelioration of depression, while additional ECT was associated with even higher plasma BDNF levels. Further studies should focus on possible cognitive and behavioral consequences.

P.230 Treatment-resistant psychotic symptoms in non-syndromic intellectual disability involving an interstitial deletion of 20q13.13

Adult onset Niemann- Pick disease type C (NPC) is a rare autosomal recessive lysosomal storage disorder that presents with heterogenous neuropsychiatric symptoms. Because of the variation of presentations, the diagnosis is often delayed or overlooked. Another treatment challenge is that currently there is only one FDA approved treatment, Miglustat, a reversible glycosphingolipid synthesis inhibitor, and it takes up to six months for therapeutic effect.We present a case report of a 27 year-old woman who was admitted to a medical hospital for inpatient work-up of altered mental status. Her initial symptoms were mild impairments in attention, bradykinesia, and ataxia that eventually progressed to an episode of acute encephalopathy with psychosis and catatonia. She underwent a comprehensive neurologic and medical work-up which was non-revealing, and then had genetic testing which revealed NPC. She was trialed on multiple medications in an attempt to manage her neuropsychiatric symptoms with minimal benefit. The decision was made to proceed with electroconvulsive therapy (ECT) with marked improvement in her symptoms after just one treatment, and continued response throughout all 18 treatments she has received thus far. While the patient has had relapses in her encephalopathic symptoms during the course of ECT treatments, additional ECT treatments following have been the most effective in returning her to her new baseline and allowing her to remain functional during this time.

Effectiveness of Electroacupuncture and Electroconvulsive Therapy as Additional Treatment in Hospitalized Patients With Schizophrenia: A Retrospective Controlled Study.

Electroacupuncture (EA) and electroconvulsive therapy (ECT) are often used in the management of schizophrenia. This study sought to determine whether additional EA and ECT could augment antipsychotic response and reduce related side effects. In this retrospective controlled study, 287 hospitalized schizophrenic patients who received antipsychotics (controls, n = 50) alone or combined with EA (n = 101), ECT (n = 55) or both (EA + ECT, n = 81) were identified. EA and ECT were conducted for 5 and 3 sessions per week, respectively, with a maximum of 12 sessions for ECT during hospitalization. The Scale for the Assessment of Positive Symptoms (SAPS) and Scale for the Assessment of Negative Symptoms (SANS) were used to assess the severity of psychotic symptoms. Clinical response on SAPS and SANS, weight gain, and adverse events were compared. Survival analysis revealed that the ECT and EA + ECT groups had markedly greater clinical response rate than controls on SAPS [72.7 and 90.1% vs. 64.0%; relative risk (RR), 1.974 and 2.628, respectively, P ≤ 0.004] and on SANS (67.3 and 70.4% vs. 42.0%; RR, 1.951 and 2.009, respectively, P ≤ 0.015). A significantly greater response rate on SANS than controls was also observed in the EA group (64.4% vs. 42.0%; RR = 1.938, P = 0.008). EA-containing regimens remarkably reduced weight gain and incidences of headache, insomnia, dry mouth, and electrocardiographic abnormalities. These results suggest that EA and ECT can serve as additional treatment for enhancing antipsychotic response and reduce the side effects in hospitalized patients with schizophrenia.Clinical Trial Registration: http://www.chictr.org.cn/showprojen.aspx?proj=38901, identifier ChiCTR1900023563.

Catatonia in Down syndrome: systematic approach to diagnosis, treatment and outcome assessment based on a case series of seven patients.

ObjectiveThe goal is to expand our knowledge of catatonia occurring in adolescents and young adults with Down syndrome (DS) by describing the first prospective, consecutive, well-characterized cohort of seven young people with DS diagnosed with catatonia and treated between 2013 and 2018, and to assess each patient’s treatment responses. Longitudinal assessment of each patient’s response to treatment is intended to provide clinicians and psychiatrists a firm foundation from which assess treatment efficacy.Study designYoung adults with Down syndrome were consecutively enrolled in the study as they were diagnosed with catatonia. A comprehensive data set included medical, laboratory, developmental, demographic, family, social and genetic data, including query into disorders for which individuals with DS are at risk. Catatonia was diagnosed based on an unequivocal history of regression, positive Bush-Francis Catatonia Rating Scale and positive response to intravenous lorazepam. Patients’ longitudinal progress was monitored using the Catatonia Impact Scale (CIS) developed for this purpose.ResultsSeven consecutive DS patients, who presented with unequivocal regression were diagnosed with catatonia and treated for 2.7–6 years using standard-of-care therapies; primarily GABA agonist, lorazepam, electroconvulsive therapy (ECT) and glutamate antagonists (dextromethorphan/quinidine, memantine, minocycline). Responses to each treatment modality were assessed at clinic visits and through weekly electronic CIS reports.ConclusionSeven young adults with DS were diagnosed with catatonia; all responded to Lorazepam and/or ECT therapy with good to very good results. Though ECT most dramatically returned patients to baseline, symptoms often returned requiring additional ECT. Dextromethorphan/quinidine, not used until mid-2017, appeared to reduce the reoccurrence of symptoms following ECT. Though all seven patients improved significantly, each continues to require some form of treatment to maintain a good level of functioning. Findings of a significant number of autoimmune disorders and laboratory markers of immune activation in this population may guide new diagnostic and treatment opportunities.

Effects of continuation electroconvulsive therapy on quality of life in elderly depressed patients: A randomized clinical trial

We examined whether electroconvulsive therapy (ECT) plus medications (“STABLE + PHARM” group) had superior HRQOL compared with medications alone (“PHARM” group) as continuation strategy after successful acute right unilateral ECT for major depressive disorder (MDD). We hypothesized that scores from the Medical Outcomes Study Short Form-36 (SF-36) would be higher during continuation treatment in the “STABLE + PHARM” group versus the “PHARM” group. The overall study design was called “Prolonging Remission in Depressed Elderly” (PRIDE). Remitters to the acute course of ECT were re-consented to enter a 6 month RCT of “STABLE + PHARM” versus “PHARM”. Measures of depressive symptoms and cognitive function were completed by blind raters; SF-36 measurements were patient self-report every 4 weeks.Participants were 120 patients >60 years old. Patients with dementia, schizophrenia, bipolar disorder, or substance abuse were excluded. The “PHARM” group received venlafaxine and lithium. The “STABLE + PHARM” received the same medications, plus 4 weekly outpatient ECT sessions, with additional ECT session as needed. Participants were mostly female (61.7%) with a mean age of 70.5 ± 7.2 years. “STABLE + PHARM” patients received 4.5 ± 2.5 ECT sessions during Phase 2. “STABLE + PHARM” group had 7 point advantage (3.5–10.4, 95% CI) for Physical Component Score of SF-36 (P < 0.0001), and 8.2 point advantage (4.2–12.2, 95% CI) for Mental Component Score (P < 0.0001). Additional ECT resulted in overall net health benefit. Consideration should be given to administration of additional ECT to prevent relapse during the continuation phase of treatment of MDD. Clinical Trials.govNCT01028508

Transient Febrile Reaction After Electroconvulsive Therapy (ECT) in a Young Adult With Intellectual Disability and Bipolar Disorder

We report the case of a 27-year-old man with mild-moderate intellectual disability (ID) and bipolar disorder treated with electroconvulsive therapy (ECT). He was psychiatrically hospitalized for agitation, aggression, and manic symptoms including insomnia, rapid and pressured speech, and hyperactivity. After multiple medication trials, ECT was recommended. The treatment was delayed owing to the need to obtain evaluation for incapacity and then substituted consent from the patient's mother. He received 2 ECT treatments with marked improvement but complicated by transient fevers, which resolved without treatment. Fever workup was unremarkable. The patient became calm and cooperative and was discharged home. He was readmitted 3 weeks later, again in an agitated manic state. He received 5 additional ECT treatments, but this time with no post-ECT fevers. Once again, his manic symptoms resolved, and he was safely discharged. Whereas patients with ID pose special challenges, our case is in keeping with the previous literature, which supports the use of ECT in patients with ID and comorbid psychiatric disorders.

Additional ECT increases BDNF-levels in patients suffering from major depressive disorders compared to patients treated with citalopram only

BackgroundIn patients suffering from major depressive disorders (MDD), improvements in MDD are related to increased activation of brain-derived neurotrophic factor (BDNF), an endogenous protein that facilitates neural functioning. To treat patients suffering from severe MDD, electroconvulsive therapy (ECT) is considered an efficacious and safe intervention, though the impact of ECT on plasma BDNF levels has thus far barely been investigated. The aim of the present study was therefore to assess plasma BDNF levels and depression of patients suffering from severe MDD treated with additional ECT compared to patients treated with citalopram only. MethodsA total of 40 patients (mean age: M = 31.45 years; females 30%) suffering from MDD and all receiving 40 mg/d citalopram were assigned either to a control group (N = 20), or to a target group (N = 20) undergoing additional 12 sessions of ECT. Plasma BDNF and symptom severity were assessed at baseline and four weeks later. ResultsPlasma BDNF increased in both groups over time, though the significant Time by Group-interaction revealed an increase of 101% in the target group as compared to the control group. Symptom severity significantly decreased in both groups over time, though without being related to plasma BDNF levels. ConclusionsData from the present study suggest that, in patients suffering from severe MDD, treatment with citalopram was associated both with an increase of plasma BDNF and amelioration of depression, while additional ECT was associated with even higher plasma BDNF levels. Further studies should focus on possible cognitive and behavioral consequences.

Electroconvulsive therapy improves antipsychotic and somnographic responses in adolescents with first-episode psychosis — A case–control study

ObjectivePrevious studies have demonstrated the effectiveness of electroconvulsive therapy (ECT) in pharmacotherapy-resistant neuropsychiatric conditions. This study aimed to evaluate the efficacy and safety of ECT in adolescents with first-episode psychosis. MethodThis case–control study was conducted in inpatients aged 13–20years with first-episode psychosis. Every three similar age and same gender patients consecutively recruited were randomly allocated to control and ECT group at a ratio of 1:2, while they had antipsychotic treatment. ECT treatment was performed for 3 sessions per week with a maximum of 14 sessions. The endpoint was discharge from hospital. Clinical outcomes were measured using hospital stay days, the Positive and Negative Syndrome Scale (PANSS) and response rate. Polysomnography (PSG) was conducted at baseline and at week 2. Safety and tolerability were also evaluated. ResultsBetween March 2004 and November 2009, 112 eligible patients were allocated to control (n=38) and ECT (n=74) group. Additional ECT treatment significantly reduced hospital stay compared to controls (23.2±8.2days versus 27.3±9.3days, mean±SD, P=0.018). Survival analysis revealed that the ECT-treated group had a significantly higher cumulative response rate than controls (74.3% versus 50%, relative risk (RR)=1.961, P=0.001). Additional ECT also produced significantly greater improvement in sleep efficiency, rapid eye movement (REM) latency and density than control condition. The PSG improvement significantly correlated with reduction in scores on overall PANSS, positive symptoms, and general psychopathology. No patients discontinued ECT treatment regimen during hospital stay. The incidence of most adverse events was not different in the two groups, but ECT-treated group had more complaints of transient headache and dizziness than controls. ConclusionsECT is an effective and safe intervention used in adolescents with first-episode psychosis. Its antipsychotic effects are associated with improved PSG variables. ECT can be considered as an early psychosis intervention.

Acute and Maintenance Electroconvulsive Therapy for Treatment of Severe Major Depression During the Second and Third Trimesters of Pregnancy With Infant Follow-Up to 18 Months

Electroconvulsive therapy (ECT) is considered to be a safe and effective treatment in the management of severe mood disorders during pregnancy. Nevertheless, for the clinician in practice, decision making regarding ECT administration in this special population is challenging. This is due both to the risks of untreated or inadequately treated mental illness for the mother and the fetus as well as the risks of complications from ECT itself during pregnancy. Special measures and modifications of ECT procedures are required to minimize the risk of complications in pregnant patients undergoing ECT. Here we report the successful and safe administration of acute and continuation ECT in a 39-year-old pregnant patient with severe major depression. A total of 18 bilateral-bifrontal treatments were administered in the second and third trimesters of pregnancy with presession and postsession fetal monitoring. Following an elective cesarean delivery at 37 weeks of a healthy female infant, a total of 13 additional ECT treatments were administered as maintenance treatment in the first 6 months postpartum during which time the patient was successfully transitioned to antidepressant medication. Development of the child has been assessed as fully normal in all follow-up visits with the pediatrician out to 18 months.

A Review of Continuation Electroconvulsive Therapy

Electroconvulsive therapy (ECT) is a neurostimulation therapeutic intervention that is highly effective and frequently used to treat certain psychiatric conditions, particularly major depressive disorder. Despite its high efficacy, a major limitation of ECT is the significant rate at which patients relapse after treatment. Providing additional ECT treatments after completion of a short-term course of ECT, referred to as continuation ECT (C-ECT), is a strategy used to reduce the risk of relapse. Specifically, C-ECT involves the administration of additional ECT treatments during the 6-month period after remission. This article summarizes the available literature regarding C-ECT including indication for use, patient selection, treatment guidelines/parameters, and safety. The efficacy of C-ECT is also discussed, with a focus on major depressive disorder and schizophrenia. On the basis of the current literature, indications for use and patient selection for C-ECT are predominately similar to those for a short-term ECT course. The treatment guidelines/parameters for C-ECT are recommended to be consistent with the parameters used to achieve remission, with the exception of greater intertreatment intervals during C-ECT. Although adverse cognitive effects can occur during C-ECT, the risk and severity of cognitive impairment are generally low, possibly because of the greater intertreatment intervals. Most research supports the use of C-ECT to prolong remission; however, methodologic limitations mitigate firm conclusions and generalizability of these findings. Nonetheless, the available evidence supports the use of C-ECT as a safe and effective method in relapse prevention.

Electroconvulsive therapy‐associated Pisa syndrome in clozapine treatment

PISA SYNDROME is a rare type of truncal dystonia. It is characterized by sustained tonic flexion of the trunk with the head to one side. There have been several reports indicating that this movement side-effect is related to the use of classical or atypical antipsychotics.1 There have been no reports, however, of this movement disorder occurring in the patients who receive electroconvulsive therapy (ECT). We here report a schizophrenic patient whose refractory psychosis did not respond to 400 mg/day of clozapine and who developed Pisa syndrome when she received additional ECT. A 57-year-old female patient had chronic and treatment-refractory schizophrenia for 30 years. She had no past medical or surgical history, and there was no family history of psychiatric disorders. The patient has been hospitalized in the chronic ward at Armed Forces Beitou Hospital, Taipei, since 2003. On 4 April 2006 the patient's symptoms of paranoid thoughts, auditory hallucinations, and violent behavior became exacerbated and she was transferred to the acute ward. The patient was initially treated with clozapine and the dose was gradually titrated up to 400 mg/day, but her psychosis and violence did not respond to the clozapine therapy. As a result, the patient had her first bilateral ECT on 21 April 2006. After the patient had received the 10th ECT she was noted to have symptoms of sustained tonic flexion of her head and trunk, tilting to the right side. Due to the likelihood of ECT-associated Pisa syndrome, her ECT was discontinued. The clozapine dose was reduced from 400 mg/day down to 25 mg/day. Biperiden 2 mg three times a day was prescribed. On this regimen the patient's dystonic symptoms gradually remitted, and clozapine 300 mg/day was then resumed. Subsequent brain computed tomography and electroencephalography showed no abnormalities, and the patient remained in a relatively stable condition on clozapine. The present case suggests that not only classical or atypical antipsychotics can cause Pisa syndrome,1 but also ECT can lead to this unusual movement side-effect. Risk factors for developing Pisa syndrome during neuroleptic therapy include combined pharmacological treatment, old age, female gender, and the presence of organic brain disorder.1 In the present patient, potential risk factors for developing Pisa syndrome included (i) a relatively high dose of clozapine, (ii) old age, (iii) female gender, and (iv) bilateral ECT. Reductions in dose or discontinuation of antipsychotics, and use of anticholinergic agents have been suggested to resolve neuroleptic-associated Pisa syndrome.1 The present patient's Pisa syndrome gradually improved when ECT was stopped, clozapine was tapered and anticholinergic medication was added. We thus think that the Pisa syndrome in the present patient may have been triggered by ECT in the presence of clozapine therapy. Dopaminergic–cholinergic imbalances have been suggested to play a role in the development of antipsychotic-induced Pisa syndrome.1 This raises the possibility that such imbalances are also involved in the underlying mechanisms of ECT-associated Pisa syndrome. Last, we would like to advise that antipsychotic dose should be reduced before use of ECT in the treatment of refractory schizophrenic patients who have risk factors for Pisa syndrome.

Toward Individualized Post-Electroconvulsive Therapy Care

Effective strategies to prolong remission after electroconvulsive therapy (ECT) are urgently needed. Fixed schedules for continuation ECT (C-ECT) cannot adapt to early signs of impending relapse. Symptom-Titrated, Algorithm-Based Longitudinal ECT (STABLE) is proposed as a novel patient-focused approach to individualize the ECT schedule. In STABLE, the ECT schedule adapts to symptom fluctuations to prevent overtreatment of those who do not need it and to recapture response in those who might have otherwise relapsed with a rigid dosing schedule. Here we back-test STABLE to optimize the algorithm for subsequent testing in a prospective trial. Three variations of the STABLE algorithm, differing in cutoff points to trigger or withhold additional ECT, were back-tested in a data set of 89 patients randomized to the C-ECT arm in the CORE (Consortium for Research on ECT) Study comparing C-ECT with combination pharmacotherapy. The selected algorithm identified 100% of patients who ultimately relapsed as requiring additional ECT at an average of 2.2 weeks before relapse, while exposing 20% of sustained remitters to additional ECT. Other variations either failed to capture impending relapse or exposed an unacceptably large percentage of patients to potentially unnecessary ECT. This patient-focused approach to relapse prevention is an attempt to provide the first operationalized guidance to the field regarding how to conduct C-ECT. The effectiveness of this approach should be tested in a randomized controlled trial.