Bilateral Electroconvulsive Therapy Research Articles

Response to electroconvulsive therapy in elderly patients with late-onset bipolar disorder: The impact of cerebral small vessel disease.

Cerebral Small Vessel Disease (CSVD) is a chronic, progressive vascular disorder that confers increased vulnerability to psychiatric syndromes, including late-life mood disorders. In this study, we investigated the impact of CSVD on electroconvulsive therapy (ECT) outcomes in patients with late-onset bipolar disorder (BD). A sample of 54 non-demented elderly patients (≥60years) with late-onset BD and treatment-resistant major depression, mixed state, or catatonia who underwent bilateral ECT were included in this naturalistic observational study. A diagnosis of CSVD was established based on brain neuroimaging performed before ECT. All patients were evaluated before and after ECT using the Brief Psychiatric Rating Scale (BPRS), the Hamilton Rating Scale for Depression (HAM-D), and the Clinical Global Impression scale (CGI). Of the total sample, 19 patients were diagnosed with CSVD (35.2%). No significant differences were observed at baseline between patients with and without CSVD. Overall, a response was obtained in 66%-68.5% of patients, with remission in 56.2%. No significant differences in ECT outcomes were found between those with and without CSVD, and both groups exhibited substantial improvements in symptom severity following ECT. The outcome of ECT in late-onset BD was not influenced by the presence of CSVD. This finding aligns with previous research on unipolar depression. Accordingly, ECT should be considered for elderly patients with late-onset BD, regardless of the presence of CSVD.

Treatment outcomes and cognitive function following electroconvulsive therapy in patients with severe depression

BACKGROUND Traditional treatments for major depressive disorder (MDD), including medication and therapy, often fail and have undesirable side effects. Electroconvulsive therapy (ECT) uses electrical currents to induce brief seizures in the brain, resulting in rapid and potent antidepressant effects. However, owing to misconceptions and controversies, ECT is not as widely used as it could and often faces stigmatization. AIM To evaluate the efficacy and safety of ECT compared to those of medication and/or therapy in patients with severe MDD. METHODS This prospective cohort study included 220 individuals with severe MDD who were divided into the ECT and non-ECT groups. The patients in the ECT group underwent bilateral ECT three times a wk until they either achieved remission or reached a maximum of 12 sessions. The non-ECT group received medication and/or therapy according to clinical guidelines for MDD. The primary outcome was the variation in the hamilton depression rating scale (HDRS) score from treatment/ECT initiation to week 12. In addition, patients’ quality of life, cognitive abilities, and biomarkers were measured throughout the study. RESULTS Although both groups showed significant improvements in their HDRS scores over time, the improvement was more pronounced in the ECT group than in the non-ECT group. Additionally, the ECT group exhibited a more substantial improvement in the quality of life and cognitive function than those of the non-ECT group. Compared with the non-ECT group, the ECT group exhibited evi-dently lower variations in the brain-derived neurotrophic factor (BDNF) and cytokine interleukin-6 (IL-6) levels. The side effects were generally mild and comparable between the two groups. ECT is safer and more potent than medication and/or therapy in mitigating depressive symptoms, enhancing well-being, and bolstering cognitive capabilities in individuals with severe MDD. ECT may also affect the levels of BDNF and IL-6, which are indicators of neuroplasticity and inflammation, respectively. CONCLUSION ECT has emerged as a potentially advantageous therapeutic approach for patients with MDD who are unresponsive to alternative treatments.

Electroconvulsive Therapy Reduces Protein Expression Level of EP300 and Improves Psychiatric Symptoms and Disturbance of Thought in Patients with Schizophrenia.

Although electroconvulsive therapy (ECT) has been employed as an effective treatment strategy and to improve mental symptoms in schizophrenia (SCZ), its action mechanisms remain unclear. Our previous study found that some genes and biological pathways were closely related to ECT through genetic technology analysis, such as LTP pathway and EP300. This study combined with healthy controls and symptomatology analysis to further explore the changes of expression of EP300 protein in treatment and related symptoms of SCZ. One hundred and one patients with SCZ and 45 healthy controls (HCs) were enrolled in this study. Patients with SCZ received acute courses of 6 times bilateral ECT. The peripheral blood of patients with SCZ (BECT: before ECT; AECT: after ECT) and the HCs was collected to calculate the changes of expression level of EP300 protein by enzyme-linked immunosorbent assay. The Positive and Negative Symptoms Scale (PANSS) was used to evaluate the severity of symptoms of SCZ patients and the efficiency of the ECT. There was a statistical difference of EP300 protein expression in patients with SCZ (BECT and AECT) (F = 114.5, p < 0.05). ECT reduced plasma expression level of EP300 protein in patients with SCZ, which was not statistically different from that in HCs (t = 4.47, p = 0.20). The change of the expression level of EP300 protein in patients with SCZ (BECT and AECT) has a positive correlation with reduction rate of positive symptoms (r = 0.228, p < 0.05) and disturbance of thought (r = 0.219, p < 0.05). Our study suggests that the expression level of EP300 protein has a significant change in patients with SCZ treating with ECT, and EP300 may have some connections with positive symptoms and disturbance thought of patients with SCZ.

Magnetic Waves vs. Electric Shocks: A Non-Inferiority Study of Magnetic Seizure Therapy and Electroconvulsive Therapy in Treatment-Resistant Depression.

Treatment-resistant depression (TRD), characterized by the failure to achieve symptomatic remission despite multiple pharmacotherapeutic treatments, poses a significant challenge for clinicians. Electroconvulsive therapy (ECT) is an effective but limited option due to its cognitive side effects. In this context, magnetic seizure therapy (MST) has emerged as a promising alternative, offering comparable antidepressant efficacy with better cognitive outcomes. However, the clinical outcomes and cognitive effects of MST require further investigation. This double-blinded, randomized, non-inferiority study aims to compare the efficacy, tolerability, cognitive adverse effects, and neurophysiological biomarkers of MST with bilateral ECT (BT ECT) in patients with TRD. This study will employ multimodal nuclear magnetic resonance imaging (MRI) and serum neurotrophic markers to gain insight into the neurobiological basis of seizure therapy. Additionally, neurophysiological biomarkers will be evaluated as secondary outcomes to predict the antidepressant and cognitive effects of both techniques. The study design, recruitment methods, ethical considerations, eligibility criteria, interventions, and blinding procedures are described. The expected outcomes will advance the field by offering a potential alternative to ECT with improved cognitive outcomes and a better understanding of the underlying pathophysiology of depression and antidepressant therapies.

Prescribing electroconvulsive therapy for depression: Not as simple as it used to be.

In the last century, prescribing electroconvulsive therapy usually involved considering the relative merits of unilateral versus bilateral electroconvulsive therapy, with most other parameters fixed. However, research over the last 30 years has discovered that several parameters of the electroconvulsive therapy stimulus can have a significant impact on efficacy and cognitive side effects. The stimulus dose relative to seizure threshold was shown to significantly affect efficacy, especially for right unilateral electroconvulsive therapy, where suprathreshold doses in the vicinity of 5-6 times seizure threshold were far more efficacious than doses closer to threshold. However, this did not hold for bitemporal electroconvulsive therapy, where near-threshold stimuli were equally effective as suprathreshold stimuli. Then, changes in stimulus pulse width were found to also have a significant impact on both efficacy and side effects, with ultrabrief pulse widths of 0.3 ms having significantly fewer cognitive side effects in unilateral electroconvulsive therapy than standard brief pulse widths of 1.0 ms, with only slightly reduced efficacy. Therefore, choosing the optimum electroconvulsive therapy prescription for an individual patient now requires consideration of placement, pulse width and stimulus dose relative to seizure threshold, and how these three interact with each other. This viewpoint aims to raise awareness of these issues for psychiatrists involved in electroconvulsive therapy practice.

Impact of modeled field of view in electroconvulsive therapy current flow simulations.

The field of view (FOV) considered in MRI-guided forward models of electroconvulsive therapy (ECT) are, as expected, limited to the MRI volume collected. Therefore, there is variation in model extent considered across simulation efforts. This study examines the impact of FOV on the induced electric field (E-field) due to two common electrode placements: right unilateral (RUL) and bilateral (BL). A full-body dataset was obtained and processed for modeling relevant to ECT physics. Multiple extents were derived by truncating from the head down to four levels: upper head (whole-brain), full head, neck, and torso. All relevant stimulation and focality metrics were determined. The differences in the 99th percentile peak of stimulation strength in the brain between each extent to the full-body (reference) model were considered as the relative error (RE). We also determine the FOV beyond which the difference to a full-body model would be negligible. The 2D and 3D spatial plots revealed anticipated results in line with prior efforts. The RE for BL upper head was ~50% reducing to ~2% for the neck FOV. The RE for RUL upper head was ~5% reducing to subpercentage (0.28%) for the full-head FOV. As shown previously, BL was found to stimulate a larger brain volume-but restricted to the upper head and for amplitude up to ~480 mA. To some extent, RUL stimulated a larger volume. The RUL-induced volume was larger even when considering the neural activation threshold corresponding to brief pulse BL if ECT amplitude was >270 mA. This finding is explained by the BL-induced current loss through the inferior regions as more FOV is considered. Our result is a departure from prior efforts and raises questions about the focality metric as defined and/or inter-individual differences. Our findings highlight that BL is impacted more than RUL with respect to FOV. It is imperative to collect full-head data at a minimum for any BL simulation and possibly more. Clinical practice resorts to using BL ECT when RUL is unsuccessful. However, the notion that BL is more efficacious on the premise of stimulating more brain volume needs to be revisited.

Response rate and factors associated with response in patients with schizophrenia undergoing bilateral electroconvulsive therapy

Schizophrenia is a severe mental illness and a common indication for electroconvulsive therapy (ECT). Research is lacking on the factors that influence response to acute ECT treatment in schizophrenia patients. This study examined the response rate and associated factors in patients with schizophrenia undergoing bilateral ECT. Demographic data, clinical characteristics, ECT data and treatment response were respectively reviewed in patients with schizophrenia undergoing bilateral ECT from January 2013 to June 2022. Forty-six patients were included. Nine responded after the first three sessions, 17 after six sessions, 20 after nine sessions, 25 after 12 sessions and 28 after the last ECT session, cumulatively. The mean of the baseline Brief Psychiatric Rating Scale psychotic symptom subscale score was significantly higher in responders (17.0) than non-responders (10.9) (P < 0.05). The mean of duration of electroencephalogram seizure was significantly longer in responders (53.9) than in non-responders (42.7). There was no association between demographic and ECT data and treatment response. Among 28 responders, 20 responded to ECT after nine sessions (faster responders) and eight responded later (slower responders). The number of failed antipsychotics prior to ECT was 2.8 for faster responders and 4.4 for slower responders (P = 0.02). Nominal logistic regression showed that the number of failed antipsychotics prior to ECT was associated with speed of response to ECT (P = 0.037, odds ratio = 1.77). ECT is an effective treatment for schizophrenia and may be influenced by the number of failed antipsychotics prior to ECT.

Clozapine in Treatment-Resistant Schizophrenia and Its Augmentation with Electroconvulsive Therapy in Ultra-Treatment-Resistant Schizophrenia.

Clozapine is considered the gold standard for patients with treatment-resistant schizophrenia (TRS) who have previously tried other antipsychotics at adequate doses (two or more, with at least one being atypical). However, despite optimal treatment, a subgroup of TRS patients with what is known as ultra-treatment-resistant schizophrenia (UTRS) fails to respond to clozapine, which occurs in 40-70% of cases. The most common approach to manage UTRS involves augmenting clozapine with pharmacological or non-pharmacological interventions, with a growing body of evidence that supports the use of electroconvulsive therapy (ECT) as an augmenter. This prospective non-randomized 8-week study, which followed the TRIPP Working Group guidelines and is one of few that separate TRS from UTRS, aimed to evaluate the effectiveness of clozapine in TRS patients and the efficacy of ECT augmentation of clozapine in UTRS patients. Patients with TRS were assigned to receive clozapine alone (clozapine group), whereas UTRS patients received bilateral ECT in addition to their current medication regimen (ECT plus clozapine group). The severity of symptoms was evaluated using the Clinical Global Impression Scale (CGI) and Positive and Negative Syndrome Scale (PANSS) at baseline and at the end of the 8-week trial. Both treatment approaches resulted in improved CGI and PANSS scores. The results suggest that both clozapine and ECT are effective treatment options for patients with TRS and UTRS, respectively, and that adherence to guidelines should provide a better frame for future clinical studies.

Special Report: Autism Spectrum Disorder and Inflexible Thinking—Affecting Patients Across the Lifespan

Special Report: Autism Spectrum Disorder and Inflexible Thinking—Affecting Patients Across the Lifespan

Clinical characteristics associated with relapse 2 years after electroconvulsive therapy for major depression.

High relapse rates are observed after electroconvulsive therapy (ECT) for major depression. Identifying patients who are at increased risk for relapse to intensify their treatment regimen post-ECT might reduce relapse rates. We aimed to determine clinical characteristics that are associated with relapse within 2 years after successful ECT. Patients who remitted to ECT in a randomised controlled trial comparing adjuvant nortriptyline and placebo during a course of bilateral ECT were followed-up prospectively for 1 year with open-label nortriptyline (Dutch Trial Register NTR5579). Second-year follow-up data were collected retrospectively. Thirty-four patients were included in this follow-up cohort. To examine the association between clinical characteristics and the risk of relapse, unadjusted hazard ratios (HRs) were calculated. At 2 years post-ECT, the overall relapse rate was 50%, and the HRs for relapse in patients with psychotic features, a higher severity of depression, and medication resistance prior to ECT were 0.33 (CI 0.12-0.89; p = 0.029), 0.88 (CI 0.80-0.98; p = 0.014), and 4.48 (CI 1.28-15.73, p = 0.019), respectively. No effect was found for age, sex or episode duration on the relapse rate. Depressed patients with psychotic features, with higher symptom severity and without medication resistance prior to ECT have a significantly decreased risk of relapse after successful ECT. A sustained remission rate of 50% over 2 years in patients with severe major depression who were treated with nortriptyline monotherapy after successful ECT is encouraging.

The cognitive impairments of electroconvulsive therapy

IntroductionElectroconvulsive therapy (ECT) is one of the most controversial treatments in medicine, mainly because of its still unknown mechanism of action and uncertainty about cognitive side effects. ECT is used mainly when antidepressant medications do not result in an adequate response in severe depression, and may also be indicated for other disorders. During the acute phase after electroconvulsive therapy there are better cognitive outcomes with unilateral ECT compared to bilateral ECT.ObjectivesThis literature review aims to analyze the validity of electroconvulsive therapy despite the cognitive impairment and effectiveness of electroconvulsive therapy.MethodsThe method used was a literary review based on articles published in Scielo and Pubmed. Eighteen electronic articles in English were used in a 10-year time frame, using the term electroconvulsive therapy as descriptors in the title, as well as cognitive impairment in all fields.ResultsWe observed that older individuals benefit the most from ECT, with faster response rates and higher remission rates in rapid responders, on the other hand they have a higher risk of cognitive side effects induced by electroconvulsive therapy. Anterograde and retrograde amnesia usually resolve within months. Recovery from retrograde amnesia may be incomplete, resulting in permanent amnesia for events that occurred close to the time of ECT. Right-sided or bilateral electroconvulsive therapy was more effective in treating depression than left-sided. Patients who used right unilateral electroconvulsive therapy had less impairment of verbal memory and post-ictal recovery and faster reorientation compared to left unilateral and bilateral, whereas left unilateral ECT showed a smaller decline in visual memory and non-verbal tests. Bilateral ECT is more effective and faster acting, but is associated with more cognitive impairments compared to unilateral ECT.ConclusionsWe can conclude that ECT is an effective, safe and tolerable treatment, which results in faster and higher remission rates compared to treatment alone with pharmacotherapy. Cognitive effects are largely transient, usually ending within three months. The decision to use unilateral right, left, or bilateral ECT should be made individually for the patient and should be based on a careful assessment of the relative priorities of efficacy versus minimizing cognitive impairment.Disclosure of InterestNone Declared

The silent waitress. A case report of mutism without catatonia

IntroductionMutism, defined as an inability or unwillingness to speak, resulting in an absence or reduction of speech, has a wide differential diagnosis. It rarely presents as an isolated disability and often occurs in association with other disturbances in behavior, thought processes, affect, or level of consciousness. Mutism is typically associated with catatonia, usually in schizophrenia, but also depression, bipolar disorder, intoxication, and neurological conditions.ObjectivesTo describe a case of mutism without catatonia.MethodsWe describe a clinical case of a patient admitted to our psychiatric inpatient unit with mutism as the presenting symptom. The literature on this subject is also selectively reviewed.ResultsA 49-year-old woman was found mute at home by her brother and brought to our emergency room. Not a word had come out of his mouth for the past month. She would show up at the restaurant where she worked as a waitress and do her job, but she didn’t talk. As a result, she had been fired. Her routine daily chores and her vegetative functions were maintained. She had no prior history of medical or psychiatric illness or substance abuse. In addition to the mutism, the patient showed an important psychomotor restlessness and performed repetitive hand movements suggestive of occupational delirium. There was no rigidity, stupor, negativism, catalepsy, echosymptoms or any other catatonic symptomatology.She was then admitted to our inpatient unit, where a complete blood test, EKG, brain CT, brain MRI, EEG and a lumbar puncture with biochemistry and neuroimmunology studies were performed, none of them showing any abnormalities.The clinical presentation suggested the diagnosis of either a psychotic disorder or a major depressive episode.The patient was then started on olanzapine up to 20 mg/d, fluoxetine up to 20 mg/d and lorazepam up to 6 mg/d. Due to persistence of symptomatology despite pharmacological treatment, she was started on Electroconvulsive Therapy (ECT). At the time of issuance of this report, 7 bilateral ECT courses have been carried out and absolute mutism persists. Although she has presented an improvement of the anxiety and the repetitive behaviors noted on admission have disappeared, she hasn´t resumed speaking.ConclusionsMutism occurs in a number of conditions, both functional and organic, and an accurated diagnosis is important for the management. One must perform a thorough physical and systemic examination to rule out organic causes for mutism. An observation for some time period may be warranted and should be done to reach final diagnosis in our case.Disclosure of InterestNone Declared

A Brief History of Transcranial Magnetic Stimulation

A Brief History of Transcranial Magnetic Stimulation

Clinical Practice Guidelines for the Use of Electroconvulsive Therapy.

Clinical Practice Guidelines for the Use of Electroconvulsive Therapy.

A Study on the Differences in Adverse Reactions and Reorientation Ability between Right Unilateral and Bilateral Electroconvulsive Therapy for Severe Depressive Disorder

A Study on the Differences in Adverse Reactions and Reorientation Ability between Right Unilateral and Bilateral Electroconvulsive Therapy for Severe Depressive Disorder

Factors Associated with Response in Patients with Schizophrenia Undergoing Bilateral Electroconvulsive Therapy: Retrospective Study

Factors Associated with Response in Patients with Schizophrenia Undergoing Bilateral Electroconvulsive Therapy: Retrospective Study

Emerging Catatonia and Psychosis in Resolving COVID-19 Infection in an Adolescent

IntroductionCOVID-19 infection may lead to encephalopathy and various neurotrophic effects which can result in neuropsychiatric complications. Here, an asymptomatic adolescent female developed acute onset catatonia and psychosis manifesting during the resolution of Covid-19 infection.ObjectivesDiscuss differential diagnosis, medical workup, and initial treatment optimization for acute stabilization.MethodsThis 15-year-old female with no previous psychiatric history nor prodromal symptomatology was hospitalized secondary to Covid -19. During the immediate three-month recovery phase following resolution of Covid-19, the patient exhibited gradually increasing anxiety, paranoia, delusions, disorganized behavior, and weight loss leading to re-hospitalization secondary to catatonia. Negative workup included rapid strep test, urinalysis, chest and abdominal x-ray, EEG, and brain MRI. Lumbar puncture revealed elevated WBC of 18 but was unremarkable for NDMA receptor antibodies, CSF HSV, and encephalitis panel. IV steroids, IVIG, and Anakinra were all given without benefit. Inadequate response to olanzapine, clonidine, and lorazepam led to an Index Series of bilateral electroconvulsive therapy (ECT).ResultsThe provisional diagnosis of psychotic disorder secondary to COVID-19 infection responded robustly regarding sleep, behavior, and affect by session #6, yet positive symptoms of psychosis persist. Ongoing ECT, psychopharmacology, and narrowing of the differential diagnosis continue.ConclusionsAs more COVID-19 cases evolve during the pandemic, potential post-infectious neuropsychiatric complications should be considered as potentially contributory and kept in a thoughtful differential diagnosis. Regardless of ultimate causation, the acute symptom profile responded robustly to an initial Index Series of ECT.DisclosureNo significant relationships.

Something inside my head

IntroductionElectroconvulsive therapy (ECT) is a medical treatment for those patients with high suicide risk or refractory psychiatric disorders. It is currently a safe technique, and its effectiveness has been widely demonstrated.ObjectivesPresentation of a clinical case about a patient with drug-resistant delusional disorder and high suicide risk, who eventually received ECT treatment.MethodsBibliographic review including the latest articles in Pubmed about ECT procedure, effects and use.ResultsWe present a 45-year-old man, who visited different doctors several times by reporting he had the feeling of “having a brain tumor or a vascular disorder”, so he requested imaging tests (computed tomography and magnetic resonance). These tests were absolutely normal, but he kept thinking something was wrong, and eventually attempted suicide by hanging (his family founded him before it was too late). The patient was admitted to hospital, and started psychopharmacological treatment, with minimal response. He desperately insisted that he had “something inside his head”. At this point, it was proposed to start ECT, and the patient accepted. After 6 bilateral ECT sessions, he was visibly more relaxed and less worried, and he no longer presented autolytic ideation. He was still a little bit suspicious about the feeling of having a neurological disease. Currently, the patient runs a follow-up consultation.ConclusionsElectroconvulsive therapy is a safe and effective technique for those patients with high suicide risk. It may be useful to perform imaging tests in certain cases, for detecting intracranial pressure, acute hemorrhage, tumors… A follow-up of these patients must be performedDisclosureNo significant relationships.

An Examination of Electroconvulsive Therapy and Delivery of Care in Delirious Mania.

Delirious mania is a severe life-threatening syndrome, often misdiagnosed, and eminently treatable as a variant of catatonia. Our aim is to provide a comprehensive examination of electroconvulsive therapy (ECT) parameters and clinical features, as well as describe the delivery of care of the patients with delirious mania. A retrospective study was conducted of the ECT records at Stony Brook University Hospital from years 2014 to 2021. We characterized demographic and clinical variables, including psychiatric diagnoses and ECT parameters of patients identified with delirious mania. We identified 8 cases (3 women) of delirious mania with 8 corresponding acute treatment series. The mean age was 43.2 ± 12.6 years (range, 23-59 years). There were a total of 55 sessions performed with an average of 6.9 ± 2.6 (range, 5-13); 45 (82%) were bilateral (bifrontal or bitemporal) and 10 (18%) were right unilateral electrode placement. In 40 (73%) of the sessions, a high-energy stimulus was used (>60%, or 302 millicoulombs). Seizure duration measured on electroencephalogram was 47.4 ± 25.9 seconds (range, 0-143 seconds). Motor seizure duration measured on electromyogram was 32.7 ± 14.9 seconds (range, 0-66 seconds). In 6 cases, ECT was delayed for 10 days, and patients were given inappropriate treatments. High-dose antipsychotics caused worsened aggression and hemodynamic instability requiring physical restraints in 50% of cases. The clinical presentation of delirious mania remains poorly recognized, and its treatment is often delayed, which may result in negative outcomes. Bilateral ECT with high-energy dosing yielded a rapid remission of symptoms.

CPNP 2022 Annual Meeting Poster Abstracts

CPNP 2022 Annual Meeting Poster Abstracts