Continuation Electroconvulsive Therapy Research Articles

Methods for maintaining the effects of electroconvulsive therapy in depression treatment in various parts of the world

Introduction: Electroconvulsive therapy (ECT) is one of the most effective treatments in psychiatry. The aim of this study is to present innovative methods for preventing the recurrence of depression after ECT treatment using continuation ECT (c-ECT), maintenance ECT (m-ECT), and pharmacotherapy, as well as to compare different approaches to the use of these methods across different parts of the world. Materials and methods: A review of the available literature was performed by searching the PubMed and Google Scholar databases using the following keywords: “c-ECT”, “m-ECT”, “continuation electroconvulsive therapy”/”kontynuacja terapii elektrowstrząsowej”, “maintenance electroconvulsive therapy”/”podtrzymująca terapia elektrowstrząsowa”, “major depressive disorder”/”duże zaburzenia depresyjne”, “continuation pharmacotherapy”/”kontynuacja farmakoterapii” for original papers, meta-analyses, and review papers both in Polish and English, published from 1999 to 2023. The SANRA scale was used to maintain the quality of the narrative review. Results: In maintenance treatment, c-ECT and m-ECT achieve effects comparable to those of pharmacological treatment. The most effective method is a combination of pharmacological therapy and c-ECT. c-ECT and m-ECT can reduce the time and cost, and the number of hospitalisations. At the same time, one of the major trends in ECT practice over the past 20 years has been the shift from inpatient to outpatient treatment. Conclusions: c-ECT and m-ECT are underutilised and understudied despite positive clinical experience spanning over 70 years. Although they are used all over the world, there are no specific guidelines or standardised methods for conducting this therapy. Studies that are currently underway should provide recommendations regarding the selection, frequency, and duration of c-ECT and m-ECT.

Correlation Between ECT Quality Measures and Likelihood to Transition From Acute to Continuation and Maintenance ECT.

To evaluate the association between 3 ECT quality measures (seizure duration, Postictal Suppression Index [PSI], and heart rate response) and therapeutic compliance as indicated by transitioning from acute to continuation to maintenance phases of ECT. This was a retrospective chart review of patients who received ECT between July 2016 and July 2019. ECT quality measures were lagged by 1 ECT session to examine the effect of the prior session's quality measure on progressing to a higher ECT phase at the subsequent ECT session. Associations with therapeutic compliance were analyzed using mixed-effects ordinal regression and mixed-effects partial proportional odds models. Seizure duration was associated with 8% higher adjusted odds of progressing to out of the acute phase (95% confidence interval [CI]: 2% to 15%, P = 0.007) and 18% higher adjusted odds of progressing to the maintenance phase (95% CI: 10% to 28%, P < 0.001); PSI was associated with 9% higher adjusted odds of progressing out of the acute phase (95% CI: 3% to 16%, P = 0.005), whereas heart rate response was not statistically associated with therapeutic compliance. Greater therapeutic compliance was also associated with bilateral electrode placement and older age. Longer seizure duration was associated with greater therapeutic compliance across all ECT phases, PSI was associated with progressing out of the acute phase, and heart rate response was not associated with therapeutic compliance. Our findings assist ECT psychiatrists in optimizing ECT quality measures to promote better compliance with ECT.

Continuation or maintenance ECT for schizophrenia: A narrative review of case report data.

This review aimed to address the limited evidence on the efficacy of continuation or maintenance electroconvulsive therapy (C/M-ECT) in schizophrenia, with a focus on international case reports and series due to the scarcity of randomised controlled trials. Electronic database searches were conducted to identify case reports or series evaluating the efficacy of C/M-ECT in patients with schizophrenia or schizoaffective disorder. C/M-ECT treatment span varied from 3 months to 36 years (Median = 30 months; M = 43.9 months; SD = 63.0) and was effective in maintaining remission for most patients with schizophrenia in combination with antipsychotic medication. Reporting of adverse events including cognitive adverse effects was infrequent. Collation of case reports and series data indicated that C/M-ECT, when combined with antipsychotics, appears to be a safe and effective strategy for maintaining remission, even over several years. Caution is warranted due to the potential influence of publication bias.

A comparative study of electroconvulsive therapy among the elderly and adult patients with depressive disorder

ABSTRACT Aim: The present study aimed to compare the clinical profile, indications for electroconvulsive therapy (ECT), effectiveness of ECT, and complications associated with the use of ECT among elderly and adult patients. Methodology: Using a retrospective study design, data from patients with a diagnosis of unipolar depression, who received ECT between January 2013 and March 2023 was extracted. Based on the age at the time of receiving ECT, the study sample was divided into adult (age &lt;60 years) and elderly (≥60 years) groups and compared. Results: The study included data from 1144 patients with depression. Of them, 371 (32.4%) patients were aged 60 years or above. Compared to the adult group, a significantly higher number of patients in the elderly group were diagnosed with recurrent depressive disorder (P &lt; 0.001), had psychotic symptoms (P &lt; 0.001), and had at least one medical comorbidity. Compared to adult patients, elderly depressed patients had longer total lifetime duration of illness (P &lt; 0.001) and longer duration of current symptoms (P = 0.012). In terms of indications for ECT, the elderly patients had a higher frequency of poor response to the pharmacological treatment (P = 0.003) and a lower frequency of suicidality and attempts at self-harm (P &lt; 0.001). Compared to adults, elderly patients received a higher number of effective ECTs (P = 0.04). There were no differences between the two groups in terms of the reason for stopping ECT and the extent of improvement. However, a higher proportion of the elderly experienced complications related to ECT and received repeat ECT courses (P = 0.003) and continuation ECT (P &lt; 0.001). Conclusion: The present study shows that there are some differences between the elderly and adult patients with depression in terms of indications for ECT, side effects related to ECT, need for multiple courses of ECT, and continuation ECT. However, the efficacy of ECT does not differ between the two groups.

The clinical profile and outcome of patients receiving continuation electroconvulsive therapy (C-ECT): A retrospective study.

There is a lack of data on the use of continuation electroconvulsive therapy (C-ECT) from India. This study aimed to evaluate the clinical profile and outcome of patients receiving C-ECT. The ECT register was used to identify patients receiving C-ECT (ECT after completion of an acute course, to maintain remission or prevent relapse) from 2011 to July 2022. Socio-demographic, clinical, and treatment outcome details were extracted from their treatment records. A total of 72 C-ECT courses were identified that were used in 60 patients. Out of all the patients receiving ECT, only 3.25% of patients receive C-ECT. The majority of the patients were male (60%). The mean age of the patients at the time of starting ECT was around 39 years. The most common diagnosis was schizophrenia (73.3%), followed by recurrent depressive disorder (21.6%). The most common indication was persistent psychotic symptoms poorly responding to multiple antipsychotic trials of 3.09 (SD: 1.39), including clozapine. These patients received a mean of 22.58 (SD: 8.05; range: 10 to 46) ECTs, with 10.0 (SD: 4.83) ECTs for the management of the acute phase of illness and 12.57 (SD: 6.20) ECTs as part of continuation treatment. The majority (61.1%) of the patients received four (once weekly) C-ECTs in the first month, followed by three more in the next month. However, 16 patients received weekly ECTs during the second month too, as symptoms worsened with the lowering of frequencies. Twelve patients received more than one C-ECT course. The majority of the patients maintained the improvement gained during the acute phase or showed further improvement with C-ECT along with ongoing pharmacotherapy as rated on appropriate scales. The Clinical Global Impressions-Severity (CGI-S) difference before and after C-ECTs was 2.94 (SD: 0.88). C-ECT is considered in only in a small proportion of patients. However, when used, it is effective in maintaining the benefits gained during the acute course of ECT and preventing relapse.

The Efficacy and Tolerability of Continuation and Maintenance Electroconvulsive Therapy for Depression: A Systematic Review of Randomized and Observational Studies.

Electroconvulsive therapy (ECT) is a highly effective treatment for severe and treatment-resistant depression, but relapse rates remain high despite maintenance pharmacotherapy. Continuation or maintenance ECT (C/M-ECT) offers the potential to prevent relapses in the most unwell patients, but there remains disagreement among guidelines regarding its efficacy and tolerability. This review aims to summarize and assess the current evidence for the efficacy and tolerability of continuation and maintenance ECT for depression, including data from randomized and observational studies, which included an appropriate control group. Twenty studies were found meeting inclusion criteria. There was evidence from 14 studies suggesting that relapse rates are reduced in those receiving C/M-ECT. There was evidence from 6 studies suggesting that C/M-ECT had no effect on global cognitive function. Detailed neuropsychological testing was limited, but within studies that assessed specific cognitive domains, there was not consistent evidence for deficits in C/M-ECT compared with the control group. The certainty of evidence across outcomes was low or very low because of inclusion of observational studies, heterogeneity of study design, and patient populations. The findings add further weight to evidence suggesting that C/M-ECT is a viable treatment option to prevent relapse in severe depression and provides clinicians with further evidence for the benefits and risks of C/M-ECT when discussing treatment options with patients. Future research should focus on randomized or well-designed prospective studies with sufficient follow-up to determine longer-term outcomes, while including a standardized, detailed neurocognitive battery to assess potential adverse effects.

Comparison of etomidate and methohexital as anesthetic agents for continuation and maintenance electroconvulsive therapy: A retrospective analysis of seizure quality and safety

BackgroundThe ideal hypnotic agent for electroconvulsive therapy (ECT) is still under debate and previous studies comparing etomidate and methohexital have produced conflicting results. This retrospective study compares etomidate and methohexital as anesthetic agents in continuation and maintenance (m)ECT with regard to seizure quality and anesthetic outcomes. MethodsAll subjects undergoing mECT at our department between October 1st, 2014 and February 28th, 2022 were included in this retrospective analysis. Data for each ECT session were obtained from the electronic health records. Anesthesia was performed with either methohexital/succinylcholine or etomidate/succinylcholine. Standard seizure quality parameters, anesthesiological monitoring data, pharmacological interventions and side-effects were recorded. Results573 mECT treatments in 88 patients were included (methohexital n = 458, etomidate n = 115). Seizures lasted significantly longer after using etomidate (electroencephalography: +12.80 s [95 %-CI:8.64–16.95]; electromyogram +6.59 s [95 %-CI:4.14–9.04]). Time to maximum coherence was significantly longer with etomidate (+7.34 s [95 %-CI:3.97–10.71]. Use of etomidate was associated with longer procedure duration (+6.51 min [95 %-CI:4.84–8.17]) and higher maximum postictal systolic blood pressure (+13.64 mmHg [95 %-CI:9.33–17.94]). Postictal systolic blood pressure > 180 mmHg, the use of antihypertensives, benzodiazepines and clonidine (for postictal agitation), as well as the occurrence of myoclonus was significantly more common under etomidate. ConclusionsDue to longer procedure duration and an unfavorable side effect profile, etomidate appears inferior to methohexital as an anesthetic agent in mECT despite longer seizure durations.

The effect of Outpatient Continuation Electroconvulsive Therapy (C-ECT) on the Readmission Risk and Total Direct Cost in Patients with Depressive, Bipolar and Psychotic Disorders: A Naturalistic Retrospective Cohort Study

The effect of Outpatient Continuation Electroconvulsive Therapy (C-ECT) on the Readmission Risk and Total Direct Cost in Patients with Depressive, Bipolar and Psychotic Disorders: A Naturalistic Retrospective Cohort Study

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Background:There is lack of data on use of Continuation Electro Convulsive Therapy (C-ECT) from India.Aim:This study aimed to evaluate the clinical profile and outcome of patients with severe mental illness receiving C-ECT.Method:ECT register was used to identify patients receiving C-ECT (ECT after completion of acute course, to maintain remission/ prevent relapse) during 2011 to 2021. Sociodemographic, clinical and outcome details were extracted from treatment records. Sixty C-ECT courses were identified, used in 49 patients.Results:Majority were male (58.3%), single (56.7%), unemployed (66.7%), belonged to Hindu religion (70%), middle socioeconomic status (91.7%) and urban background (66.7%). Mean age at starting of ECT was around 40 years. Commonest diagnosis was schizophrenia (75%) followed by recurrent depressive disorder (18.3%). Commonest indication was persistent psychotic symptoms despite multiple antipsychotic trials (3.33±1.37), including clozapine. They received a mean of 22.62±8.02 ECTs, of which 9.93±4.41 were acute phase and 12.68±6.52 were for continuation treatment. Majority (66.7%) of them received 4 C-ECTs in the first month, followed by 2 more in the next month. As symptoms worsened with lower frequencies, 16 patients received weekly ECTs during the second month too. CGI-severity scores decreased from 6.50±0.60 to 3.80±0.75 at the end of C-ECT course. Majority of them maintained improvement gained during acute phase or showed further improvement with C-ECT with ongoing pharmacotherapy as rated on appropriate scales.Conclusion:C-ECT is considered only in small proportion of patients but is effective in maintaining benefits gained during acute course of ECT and preventing relapse.

Electroconvulsive therapy in treatment resistant depression

Electroconvulsive therapy (ECT) is a treatment modality for patients with treatment resistant depression (TRD), defined as failure of two adequate antidepressant medication trials. We provide a qualitative review of ECT's effectiveness for TRD, methods to optimize ECT parameters to improve remission rates and side effect profiles, and ECT's proposed neurobiological mechanisms. Right unilateral (RUL) electrode placement has been shown to be as effective for major depression as bilateral ECT, and RUL is associated with fewer cognitive side effects. There is mixed evidence on how to utilize ECT to sustain remission (i.e., continuation ECT, psychotropic medications alone, or a combination of ECT and psychotropic medications). Related to neurobiological mechanisms, an increase in gray matter volume in the hippocampus-amygdala complex is reported post-ECT. High connectivity between the subgenual anterior cingulate and the middle temporal gyrus before ECT is associated with better treatment response. Rodent models have implicated changes in neurotransmitters including glutamate, GABA, serotonin, and dopamine in ECT's efficacy; however, findings in humans are limited. Altogether, while ECT remains a highly effective therapy, the neurobiological underpinnings associated with improvement of depression remain uncertain.

The consortium of Researchers for ECT (CORE) - past, present and future

Abstract The Consortium of Researchers for ECT (CORE) was established in 1996 with the goal to conduct multicenter clinical trials in Electroconvulsive Therapy (ECT). The group comprised of four clinical sites: Medical University of South Carolina (MUSC) in Charleston, SC, Mayo Clinic, Rochester MN, University of Texas SW, Dallas TX, and Hillside Hospital, Glen Oaks NY, NY. The database coordinating center was based at MUSC. The CORE group conducted 3 multicenter clinical trials, all funded by the National Institute of Mental health (NIMH). The first study by the group compared the clinical outcomes of 201 patients who were randomly assigned to receive continuation ECT or continuation pharmacotherapy for 6 months after a successful course of bitemporal ECT for major depression. This is the first randomized controlled trial to establish the clinical effectiveness of continuation ECT. The second study by the CORE group, with the addition of the New Jersey Medical School in Newark, NJ and the subtraction of the clinical site of MUSC, compared the effectiveness and tolerability of the 3 most used electrode placements, i.e. bitemporal, bifrontal and right unilateral (RUL) for the treatment of unipolar depression. The study found only numerical but no statistically significant differences in the efficacy and tolerability of the 3 placements with bitemporal slightly more effective than bifrontal and frontal slightly more effective than RUL. The third study by the group, Preventing Relapse in Depressed Elderly (PRIDE) compared the efficacy and tolerability of continuation ECT plus venlafaxine to venlafaxine alone in preventing relapse after acute ECT in geriatric patients. The combination of venlafaxine and continuation ECT was superior to venlafaxine alone. We’ll discuss in detail the primary results of the above studies, as well as additional analyses that have contributed to the shaping of the current clinical practice of ECT. Keywords: Electroconvulsive, Multicenter, Depression, Research Collaboration

Factors causing a relapse of major depressive disorders following successful electroconvulsive therapy: A retrospective cohort study

BACKGROUNDElectroconvulsive therapy (ECT) is used to treat major depressive disorder (MDD). Relapse is often observed even after successful ECT, followed by adequate pharmaceutical treatment for MDD. AIMTo investigate the diagnostic factors and treatment strategies associated with depression relapse.METHODSWe analyzed the relationships between relapse, the diagnostic change from MDD to bipolar disorder (BP), and treatment after the initial ECT. We performed a 3-year retrospective study of the prognoses of 85 patients of the Shiga University of Medical Science Hospital. The relative risk of relapse of depressive symptoms was calculated based on the diagnostic change from MDD to BP. A receiver operating characteristic (ROC) curve was generated to evaluate the predictive accuracy of diagnostic changes from MDD to BP based on the duration between the first course of ECT and the relapse of depressive symptoms.RESULTSEighty-five patients initially diagnosed with MDD and successfully treated with ECT were enrolled in the study. Compared with the MDD participants, more BP patients experienced relapses and required continuation and/or maintenance ECT to maintain remission (65.6% vs 15.1%, P < 0.001; relative risk = 4.35, 95%CI: 2.19-8.63, P < 0.001). Twenty-nine patients experienced relapses during the three-year follow-up. In 21 (72.4%, 21/29) patients with relapse, the diagnosis was changed from MDD to BP. The duration from the first course of ECT to relapse was shorter for the BP patients than for the MDD patients (9.63 ± 10.4 mo vs 3.38 ± 3.77 mo, P = 0.022); for most patients, the interval was less than one month. The relative risk of depressive symptoms based on diagnostic changes was 4.35 (95% confidence interval: 2.19–8.63, P < 0.001), and the area under the ROC curve for detecting diagnostic changes based on relapse duration was 0.756 (95%CI: 0.562-0.895, P = 0.007).CONCLUSIONIt may be beneficial to suspect BP and change the treatment strategy from MDD to BP for patients experiencing an early relapse.

Effectiveness of maintenance electroconvulsive therapy-Evidence from modifications due to the COVID-19 pandemic.

ObjectiveContinuation and maintenance ECT (c‐/m‐ECT) are effective in the prevention of relapse and recurrence of both affective and psychotic disorders. However, data are scarce concerning the trajectories of severe mental disorders after the end of c‐/m‐ECT. This prospective study investigates the clinical outcome of patients with versus without modifications of their c‐/m‐ECT schedules.MethodsIn the context of the COVID‐19 pandemic, ECT capacities were restricted at many clinics in early 2020. All patients receiving c‐/m‐ECT in March and April 2020 at our department (n = 53, unipolar depression, bipolar disorder, schizophrenia) were followed up for six months to investigate the impact of treatment modifications imposed by the pandemic. Based on individual decisions, c‐/m‐ECT was either (a) continued without modification, (b) continued with reduced frequency, or (c) discontinued.ResultsBoth reduced frequency and discontinuation of c‐/m‐ECT were associated with significant clinical deterioration as measured by CGI‐I (Clinical Global Impression Scale ‐ Global Improvement) during the six‐month follow‐up when compared to the subgroup of patients without any treatment modification (p = 0.005, p = 0.011). Furthermore, patients with discontinued or reduced c‐/m‐ECT showed significantly higher rates of rehospitalizations (p = 0.028) and new acute courses of ECT (p = 0.018).ConclusionDespite the limitations of a heterogeneous and relatively small sample, our study strongly corroborates the effectiveness of c‐/m‐ECT in a real‐world population. Especially, patients with shorter time since index ECT seem to be at high risk for severe clinical deterioration in the case of treatment discontinuation or reduction.

Protocol to maintain ECT in COVID-19 pandemic

IntroductionElectroconvulsive therapy is a highly effective treatment for severe psychopharmacological resistant patients but it is also a procedure that involves open airway management and has been considered as an aerosol generating procedure. The COVID-19 pandemic, has resulted in reduction in ECT services internationally. The COVID-19 pandemic has dramatically and rapidly transformed hospitals in heavily affected areas, decreasing mental health services. The need to locate critical patients in spaces intended for anesthesia, where we usually administered ECT, has forced us to decrease the number of procedures and be highly selective. In the same way, continuation and maintenance ECT (m-ECT) have also been dramatically reduced. The risk of contagion urged us to develop a protocol involving other areas of the hospitalObjectivesTo create a safe circuit from admission to the hospital to the ECT including emergency room and psychiatric WardMethodsReview of the tliterature and published protocols Workshops with Preventive Medicine, Anaesthesia and Emergency Service to elaborate a protocol Submission of the protocol to Management of the HospitalResultsThe protocol (Figure 1) began with the screening for COVID-19 in every patient. If the PCR was (+) the patient was not excluded. We moved treatment from the PACU into the OR and if a patient tested positive It was determined that the ECT was administered in the ORThat was provided with negative pressure. Circuits were established within the Psychiatric Ward and in the areas of the hospital involved to reduce risks and patients remained isolated until negative test was confirmed The number of persons present in the treatment room was kept to the absolute minimum required and appropriate personal protective equipment was used, as prescribed by the WHOConclusionsWe must keep in mind treating the most vulnerable of our patients. ECT should be seen as an essential medical procedure and made availableDisclosureNo significant relationships.

Repetitive enhancement of serum BDNF subsequent to continuation ECT.

IntroductionContinuation electroconvulsive therapy (c‐ECT) is highly effective for the prevention of depressive symptom relapse. There is a lack of understanding, about how c‐ECT works in humans, particularly with regard to its effects on brain derived neurotrophic factor (BDNF) concentrations. Here, we aimed to close a gap in the literature by evaluating BDNF levels in patients receiving c‐ECT.MethodsWe included 13 patients with either unipolar or bipolar depression (mean age ± SD: 55.5 ± 17.1; f/m: 10/3; unipolar/bipolar: 10/3) who received between one and four c‐ECT (average per patient: 2.8). Serum BDNF (sBDNF) levels were assessed before and after each c‐ECT sessions. Clinical assessments were also administered both before and after treatment.ResultsOur analysis revealed a significant increase in sBDNF after each treatment (c‐ECT 1‐3: P < 0.001, c‐ECT 4: P = 0.018). The application of multiple c‐ECT treatments was not, however, associated with further sBDNF enhancements. Psychometric scores were not significantly altered following c‐ECT.DiscussionAn increase in sBDNF concentrations subsequent to c‐ECT parallel data from the animal literature, which has linked regularly applied electrical stimulation to neuroplastic processes. This finding suggests a relationship between ECT‐induced sBDNF concentrations and (sustained) remission status, considering a stable clinical condition across c‐ECT.

Lithium for suicide and readmission prevention after electroconvulsive therapy for unipolar depression: population-based register study.

Electroconvulsive therapy (ECT) is effective for unipolar depression but relapse and suicide are significant challenges. Lithium could potentially lower these risks, but is used only in a minority of patients.AimsThis study quantifies the effect of lithium on risk of suicide and readmission and identifies factors that are associate with readmission and suicide. This population-based register study used data from the Swedish National Quality Register for ECT and other Swedish national registers. Patients who have received ECT for unipolar depression as in-patients between 2011 and 2016 were followed until death, readmission to hospital or the termination of the study at the end of 2016. Cox regression was used to estimate hazard ratios (HR) of readmission and suicide in adjusted models. Out of 7350 patients, 56 died by suicide and 4203 were readmitted. Lithium was prescribed to 638 (9%) patients. Mean follow-up was 1.4 years. Lithium was significantly associated with lower risk of suicide (P = 0.014) and readmission (HR 0.84 95% CI 0.75-0.93). The number needed to be treated with lithium to prevent one readmission was 16. In addition, the following factors were statistically associated with suicide: male gender, being a widow, substance use disorder and a history of suicide attempts. Readmission was associated with young age, being divorced or unemployed, comorbid anxiety disorder, nonpsychotic depression, more severe symptoms before ECT, no improvement with ECT, not receiving continuation ECT or antidepressants, usage of antipsychotics, anxiolytics or benzodiazepines, severity of medication resistance and number of previous admissions. More patients could benefit from lithium treatment.Declaration of interestNone.

Continuation Electroconvulsive Therapy for Patients With Clozapine-Resistant Schizophrenia: A Pilot Study.

The risk of relapse after a successful acute course of treatment is a clinical challenge in electroconvulsive therapy (ECT) practice, particularly in patients with a history of marked resistance to previous treatments. Research suggests that a gradual decrease of ECT or its long-term continuation might be the best strategy. Notwithstanding, current studies do not address the role of continuation ECT in the truly refractory cases, that is, the clozapine-resistant patients. Our group published a randomized controlled trial of ECT augmentation of clozapine in clozapine-resistant patients with schizophrenia, where the augmentation was vastly superior in efficacy for the acute treatment. The aim of the current study is to evaluate the efficacy of continuation ECT for patients who showed response to the combination of acute ECT and clozapine for treatment-resistant schizophrenia. Continuation ECT was offered to all patients who completed the acute study and who met response criterion. We followed a tapered schedule of 4 weekly ECT sessions, followed by 4 ECT sessions every 2 weeks and 2 monthly ECT sessions for a total of 10 sessions. Patients sustained the gains achieved with the acute course of ECT, and no individual patient presented with clinically relevant worsening of symptoms. Moreover, the long-term use of ECT was not associated with added adverse effects. This is an open pilot study with a small sample size, and results should be interpreted accordingly, but this report offers a relevant starting point for much needed future studies.

Electroconvulsive therapy for treatment-resistant schizophrenia.

This is the protocol for a review and there is no abstract. The objectives are as follows: Our primary objective is to assess the effects (benefits and harms) of ECT for people with treatment-resistant schizophrenia. Our secondary objectives are to determine whether ECT produces a differential response in people: who are treated with unilateral compared to bilateral ECT; who have had a long course of ECT (more than 12 sessions) or short course of ECT; who are given continuation or maintenance ECT; who are diagnosed with well defined treatment resistant schizophrenia as opposed to less rigorously defined treatment-resistant schizophrenia (who would be expected to have a greater affective component to their illness).

Commentary on Braga et al: The Potential of Large Simple Trials to Determine the Real-World Effectiveness of Combined Electroconvulsive Therapy and Antipsychotics in Treating Patients With Treatment-Resistant Schizophrenia.

This commentary reflects upon the study of Braga et al of open-label continuation electroconvulsive therapy (ECT) plus clozapine in treatment-resistant schizophrenia (TRS), as reported in this issue of The Journal of ECT. The evidence base for ECT in TRS is scant, and the study of Braga et al is a step forward. However, their report raises other important questions including (1) what is the proper frequency of continuation ECT in TRS, and (2) should TRS patients, even TRS patients who have failed clozapine, receive acute ECT + clozapine, or is ECT + conventional antipsychotics sufficient? In this commentary, we examine these questions and outline a future research strategy for TRS that includes large simple trials.

Acute and subsequent continuation electroconvulsive therapy elevates serum BDNF levels in patients with major depression

IntroductionThe induction of brain-derived neurotrophic factor (BDNF) release and subsequent restoration of neuroplastic homeostasis may underlie the effects of electroconvulsive therapy (ECT). ObjectivesWe aimed to assess serum and plasma BDNF levels during the course of acute ECT, as well as before and after subsequent continuation ECT, in patients with depression. MethodsWe included 24 patients with major depressive disorder (mean age ± SD: 54.5 ± 13.7; f/m: 17/7; baseline 17-item Hamilton Depression Rating Scale score of 26.79 ± 4.01). Serum and plasma BDNF (sBDNF, pBDNF) levels were assessed at nine time-points before, during, and after acute ECT series. Data were analysed using linear regression and linear mixed models, which were adjusted for multiple comparisons via Bonferroni correction. Five patients received continuation ECT subsequent to the acute ECT series. In these patients, BDNF levels were assessed before and after each two continuation ECT sessions using Wilcoxon signed-rank tests. ResultsRelative to baseline (mean ng/ml ±SD: 24.68 ± 14.40), sBDNF levels were significantly higher 1 day (33.04 ± 14.11, p = 0.013, corrected), 1 week (37.03 ± 10.29, p < 0.001, corrected), and 1 month (41.05 ± 10.67, p = 0.008, corrected) after the final ECT session, while pBDNF levels did not significantly differ (p > 0.1). Furthermore, our results indicated that sBDNF levels increased after each continuation ECT session. There was no significant association between sBDNF levels and clinical parameters or treatment response. ConclusionThe absence of an association between changes in sBDNF levels and depressive symptoms challenges the proposed concept of sBDNF/pBDNF as key markers of the effects of ECT.